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CHILD EMERGENCY MANAGEMENT OF INJURIES SUSTAINED DURING CHILD SEXUAL ASSAULT

The emergency management of the acutely injured child is demanding and stressful for the practitioner and the entire health care team.

Although child sexual assault has always been a dark and often painstakingly concealed fact of our human condition, the incidence of severe injury associated with these attacks appears to be increasing.1 Child victims have a higher incidence of genital injury than their adult counterparts.2 In addition, children are becoming victims at a younger age, with incidences of attempts at penetrative vaginal rape being well documented — even in young infants under one year of age.3 These severe and brutal assaults can result in serious and sometimes life- threatening injury to the young child.4 A systematic approach to the care of these individuals is essential in order to achieve a satisfactory outcome. Traditionally the management of child rape victims has focused on the forensic, psychosocial GRAEME J PITCHER and transmissible disease aspects of the attack, but the child with a severe and MB BCh, FCS (SA) sometimes life-threatening injury needs to be detected and promptly treated. Senior Specialist and Adjunct Professor Children with severe injuries after sexual assault are usually referred to tertiary referral centres or specialists for their definitive care, but most cases initially pres- Division of Paediatric Surgery ent to general practitioners or district surgeons. In this article I concentrate on the Johannesburg Hospital and emergency management of injuries sustained by child victims of . Els University of the Witwatersrand et al.5 have published a more thorough description of the approach to the overall Johannesburg management of the sexually abused child in the South African context.

It is mandatory that all medical practitioners have a working knowledge of the Graeme Pitcher trained at the University of approach to this problem. In addition, it is the doctor's ethical and societal duty the Witwatersrand. After becoming a to take responsibility for the accurate and complete collection of forensic evi- Consultant Surgeon, he trained in paedi- dence and to be willing to participate in the medicolegal process in its entirety. atric surgery. He is currently Adjunct Professor and Deputy Head of the GOALS OF MANAGEMENT Department of Paediatric Surgery at Wits. The goals of management of these patients can be summarised as follows: He is an ATLS instructor, and his interests • acute phase management of injuries sustained include transplantation and injury preven- •prevention of transmissible diseases and tion. • collection of forensic evidence • management of social circumstances • physical, social and psychological rehabilitation.

Referral of patient The correct emergency care of the seriously injured child or infant sexual assault victim is vitally important. The patient should be referred to the closest tertiary care centre capable of dealing with the severely injured child and providing holistic care. This includes resuscitation, medical, surgical, psychological, social and rehabilitation components of care. This must include the ability to resuscitate and treat children with life-threatening injury. Unstable or ill patients should be transferred without delay. It is preferable that a senior practitioner experienced in the management and assessment of child abuse cases should be in charge of

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The correct emergency care and exsanguination this should be fol- injuries vary with the sexual assault of the seriously injured lowed by administration of whole and the age of the child. blood or packed red cells. child or infant sexual These injuries are usually graded according to the traditional ‘obstetric assault victim is vitally Any source of external bleeding classification’ (Table I). In older child- important. should be controlled by the applica- ren, in whom there is less dispropor- tion of a gauze dressing and local tion between the size of the assailant’s pressure. Plugging the , penis and the child’s genital structures, Ateam approach, combin- or any wound is not advisable as the minor injuries usually result. These ing the expertise of paedia- injury can be exacerbated and evi- include vulvar bruising and abrasions, tricians, paediatric sur- dence can be altered, and it creates mucosal tears of the introitus, geons and gynaecologists, the opportunity for lost swab foreign and vaginal walls, or bruising of the bodies. Definitive genital examination is optimal. and mucosal tears (first- should be deferred until the patient is degree tears). In more severe cases, stable. Most patients are in pain and usually in younger children or in more Definitive genital examina- distressed. The administration of intra- brutal attacks, the vaginal injury may venous such as tion should be deferred extend into the adjacent tissue and (0.1 mg/kg) or an equivalent greatly until the patient is stable. may involve the perivaginal and trans- facilitates the assessment and resusci- verse perineal muscles but spares the tation. It should be given as soon as sphincter complexes (second-degree the patient is sufficiently stable. Little Approximately 40% of tears). Most girls presenting with credence is given to the notion that the perineal injuries in South severe perineal injuries after sexual administration of renders the assault are under 5 - 6 years of age. African children are due to examination of the unreli- In the infant subjected to a concerted sexual abuse. able. Indeed, the treatment of pain attempt at penile penetration or forced usually makes the child more co-opera- insertion of a foreign body, rectovagi- tive and enhances the clinical exami- nal disruption usually occurs. In these nation of the abdomen. and responsible for the examination of cases there is complete disruption of these cases and the adequate collec- the posterior fourchette, perineal body Perineal and genital tion of evidence. A team approach, and anal sphincters, with a tear examination combining the expertise of paediatri- extending for a variable distance into cians, paediatric surgeons and gynae- Most child rape victims can be satis- the vagina and rectum. Once these cologists, is optimal. factorily examined without the need muscular defences are breached there for or administra- is a serious risk of vaginal vault, proxi- Acute phase management of tion of powerful sedatives. In certain mal rectal and intra-abdominal injuries sustained cases where the examination cannot injuries.6 The initial assessment should focus on be deferred, a sedative such as mida- 5 Most first-degree tears will heal satis- the patient’s general condition. Signs zolam (0.1 mg/kg IVI) is acceptable. factorily without the need for suture. In of shock, such as tachycardia, pallor, Infants are best examined in the knee- selected circumstances, definitive pri- poor peripheral perfusion and chest supine position and older child- mary suture will provide quicker and hypotension, should be sought. Life- ren in the lateral knee-chest position. superior healing and is probably war- threatening bleeding can occur in the Where there are extensive perineal ranted. Iodine vaginal douches are not abdominal cavity. When hypo- tears, ongoing unexplained bleeding, recommended for treatment or prophy- volaemic shock is diagnosed, urgent a suspicion of a foreign body or laxis in prepubertal girls. restoration of intravascular fluid vol- abnormal abdominal signs, examina- tion under general anaesthesia may ume and resuscitation according to the Second-degree tears can be sutured, be necessary. principles of Advanced Trauma Life either primarily (if presenting early) or Support (ATLS) should be carried out. secondarily, without the need for cov- Standard peripheral venous access Perineal injuries ering . with an appropriate sized catheter Approximately 40% of perineal should be obtained. In the event of injuries in South African children are The most critical decision involves the severe shock and cardiovascular col- due to sexual abuse.6 Most serious need to perform diverting colostomy. lapse it may be necessary to obtain injuries in paediatric rape or sexual Colostomy is usually indicated in the intraosseous access. Crystalloid resus- assault victims are genital. The young following circumstances: citation in up to 3 boluses of child is easily subdued and serious • complete perineal disruption with 20 ml/kg body mass can be adminis- non-genital injury is uncommon. The common rectovaginal channel tered. In the event of severe shock nature and distribution of genital • all third-degree tears

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after anal and vaginal penetrative Table I. Grading of perineal injuries rape in early life. Compared with the vagina, the anorectum appears to have greater elasticity and compliance First degree Skin lacerations involving the introitus, or perineal and it seems that attempts at anal pen- skin etration, even in young children, can occur without the victim suffering any Second degree Lacerations extending onto perirectal or vaginal tissues, severe disruptive injury. Boys do suffer sparing anal sphincters anal tears (usually mucocutaneous Third degree Compound lacerations involving anal and/or vaginal walls without major sphincter injury) after and sphincters anal rape but very rarely require diverting colostomy and perineal repair. Table II. Prophylactic antibiotics after sexual assault Prevention of transmissible diseases and pregnancy In postmenarchal females, a careful Erythromycin suspension 30 - 60 mg/kg/day po in 4 doses for 7 days menstrual history and baseline preg- and cephalexin 100 mg/kg/day po in 4 doses for 7 days nancy test should be performed to exclude pre-existing pregnancy, espe- or cially in sexually active adolescents. Ceftriaxone 60 mg/kg IMI stat Emergency contraception using a and metronidazole 7.5mg/kg/dose po 8-hourly for 7 days progesterone-only regimen is recom- mended in cases of unprotected vagi- nal rape. Table III. Antiretroviral prophylaxis after child rape It is widely recommended that antibi- otics are administered after a sexual assault, although even these are not Zidovudine 180 mg/m2/dose po twice daily for 28 days reliably administered by emergency department staff.9 Most experts agree and that treatment directed towards Lamivudine 4 mg/kg/dose po twice daily for 28 days Neiserria gonorrhoeae and Chlamydia trachomatis is necessary. Acceptable • injuries presenting late with estab- sufficiently sensitive to detect signs of antibiotic regimens are shown in Table II.5 lished sepsis or evidence of necro- intraperitoneal injury. In cases where tising fasciitis there is abdominal tenderness, a plain The use of antiretroviral therapy direct- • late occurrence of rectovaginal fis- radiograph and examina- ed towards the prevention of HIV and tula. tion are recommended. Prompt refer- viruses is much more contro- ral to a surgeon for or versial.10 Adherence to 28-day anti- In cases where a colostomy is indicat- exploratory is essential. retroviral prophylaxis regimens is low11 ed, definitive surgical repair is per- and the benefit has not been clearly formed when the perineal wounds Injuries in males defined by scientific study. Many have have healed completely and inflamma- Boys are, without doubt, frequently the called for a reasonable approach to tion has subsided. It is usually per- victims of various forms of sexual this problem, determined by the formed approximately 2 - 4 months abuse, but most large studies in differ- degree of perceived risk. South Africa after the injury. ent countries show that girls are the is undoubtedly a high-prevalence area victims of rape 1.5 - 3 times more fre- and international research has shown Abdominal injuries quently than boys.7 In the study by the that the prevalence of sexually trans- Injury to intra-abdominal organs is Red Cross Children’s Hospital group, missible diseases and hepatitis virus rarely a result of a sexual assault, but only 13% of victims were male.3 In a positivity is higher in convicted sex if not detected can cause from large French study 14% of victims offenders than in the general popula- blood loss or later from septic intra- were male.8 Anal rape in a male tion.12 The greater degree of tissue abdominal sequelae. We treated a infant causing severe injury with damage occurring in child rape vic- rape victim with an injury to the poste- sphincter disruption is rare. All infants tims must also predispose to greater rior fornix of the vagina, with multiple requiring perineal repair seen at the risk of HIV . Real rates of loops of small bowel prolapsing Johannesburg University hospital com- HIV transmission in paediatric rape through the perineum. In experienced plex have been female. This may be a are unknown but in the study of child hands abdominal examination is usually reflection of different patterns of injury rape victims at Red Cross Children’s

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Hospital a 1% seroconversion rate The most senior person available, Rehabilitation 3 was noted. This occurred despite the preferably one experienced in the The physical, social and psychological fact that in the early part of the series examination of these cases, should be rehabilitation of these unfortunate patients were not tested and in the lat- responsible for this essential task. New children will continue for the duration ter half of the study most victims kits allowing for more efficient and of their lives, often with little formal or 13 received antiretroviral prophylaxis. secure collection of these specimens institutional support. It is vital for The real risk in our environment is are now available. Great care must be health care practitioners to facilitate therefore much higher than 1%. It taken to ensure that the chain of evi- this process as much as possible. seems prudent therefore to provide dence is not broken and that labelling antiretroviral prophylaxis to all chil- and transportation of specimens is References available on request. dren suffering penetrative rape, espe- meticulous. It is essential to report the cially if accompanied by severe injury case to your local Child Protection IN A NUTSHELL or if multiple offenders were responsi- Unit of the South African Police. ble for the attack (Table III). This treat- Awareness of the spectrum of injury Management of social ment should be supervised and moni- is the single most important factor. tored by a practitioner familiar with circumstances the administration of these to Frequently the perpetrator of these A systemic approach is essential. small children. A baseline HIV anti- offences is a family member or known Manage acute injuries first according body test should be performed to to the victim’s family. Disrupted fami- to ATLS principles. exclude pre-existing infection. If nega- lies are so common as to be almost Institute therapy for prevention of tive, the test should be repeated in 3 - the norm. Under these circumstances transmissible disease and pregnancy. 6 months. the child’s safety cannot be assured. Early involvement of social workers Collect the necessary forensic evi- Collection of forensic and other community organisations is dence. evidence essential. The child should be dis- Manage the social circumstances. The proper collection of forensic evi- charged only when a safe receiving dence after child sexual assault is too environment can be assured. Institute long-term support and reha- complex to consider for this article. bilitation.

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