CHILD SEXUAL ASSAULT 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 rape 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 sexual abuse. 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 pregnancy 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 378 CME July 2004 Vol.22 No.7 CHILD SEXUAL ASSAULT 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 vagina, rectum 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, hymen geons and gynaecologists, the opportunity for lost swab foreign and vaginal walls, or bruising of the bodies. Definitive genital examination is optimal. anal canal 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 analgesics such as morphine 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 opioids renders the assault are under 5 - 6 years of age. African children are due to examination of the abdomen 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 general anaesthesia 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 colostomy. 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 July 2004 Vol.22 No.7 CME 379 CHILD SEXUAL ASSAULT 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, anus 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