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Sexual Assault / Abuse

Category: Trauma Sources: raw/protocols/nm-sop-guidelines-treatment-2022.pdf Last updated: 2026-04-04

Overview

Sexual assault and abuse patients require compassionate, non-judgmental care combined with meticulous attention to evidence preservation. The EMT-B's priorities are: treat life-threatening injuries, preserve forensic evidence, provide emotional support, and transport to an appropriate facility. Sexual assault nurse examiner (SANE) programs at receiving hospitals provide the comprehensive forensic examination — the EMT-B's job is to get the patient there safely.

Special attention is required for victims who report being choked or strangled — these patients are at high risk for delayed neurological complications and internal vascular injury even when they appear asymptomatic initially.

Key Points

  • Do not investigate the crime — obtain only information needed to provide medical care; law enforcement handles the investigation
  • Evidence preservation is critical: encourage patient not to bathe, urinate, defecate, or change clothes before hospital evaluation; avoid unnecessary contact with the patient or scene
  • Minimize personnel: only those essential for patient care should have contact with the patient or scene
  • Strangulation is a high-lethality mechanism — a patient who was choked or strangled must be transported even if they appear fine; internal carotid dissection, laryngeal fracture, and neurological injury can be delayed in presentation
  • Approach with calm, direct, non-judgmental communication — one provider communicates with the patient; reduce stimulation
  • Document all statements, injuries, and physical findings thoroughly on the patient care report
  • The patient's emotional state may fluctuate widely — provide psychological support and maintain privacy

Assessment Relevance

History (history-taking): - Obtain only the history required for medical treatment — do not conduct a forensic interview - Document chief complaint and mechanism as reported by patient - If strangulation is reported: determine if there was loss of consciousness, seizures, vision changes, speech changes, incontinence, neurological symptoms; these indicate transport to trauma center - SAMPLE: Relevant medical history; medications; last meal (relevant for potential surgical intervention); current medications - Note: do NOT ask the patient to describe the assault in detail — this is law enforcement's role

Physical exam (secondary-assessment): - Primary survey: airway, breathing, circulation; treat all life threats - Neck examination if strangulation reported: look for ligature marks, contusions, petechiae, subcutaneous emphysema (air under the skin from laryngeal injury) - Facial: petechial hemorrhage in conjunctivae or facial skin (from increased venous pressure during strangulation) - Overall trauma assessment: other injuries from physical violence; bruising, lacerations, fractures - Do not perform a genital examination prehospital — this is the SANE examination at the hospital; genital exam prehospital destroys forensic evidence - Mental status: anxiety, dissociation, shock response

Strangulation red flags (indicators for trauma center transport): - Loss of consciousness (any duration) - Seizures - Altered mental status - Amnesia - Vision changes (spots, flashing lights, tunnel vision) - Facial or conjunctival petechial hemorrhage - Ligature marks or neck contusions - Soft tissue neck swelling or tenderness - Incontinence of bladder or bowel during strangulation - Difficulty speaking or loss of voice - Shortness of breath from upper airway swelling - Subcutaneous emphysema

Procedures

  1. Scene size-up (scene-size-up): ensure scene safety; coordinate with law enforcement; minimize personnel on scene
  2. Primary assessment (primary-assessment): treat all life threats; airway priority if strangulation injury
  3. Preserve evidence: do not remove clothing unless medically necessary; if removed, bag clothing separately and give to law enforcement; do not allow patient to bathe, brush teeth, or change clothes
  4. Provide emotional support: assign one provider to communicate with the patient; maintain privacy; allow patient to make decisions where possible
  5. Secondary assessment (secondary-assessment): focused on life threats and trauma; do NOT perform pelvic/genital examination
  6. If strangulation with any red flag signs: high priority transport; c-spine consideration if neck injury suspected
  7. Transport to appropriate facility (SANE center or designated sexual assault receiving center when available)
  8. Document: patient care report must clearly document assessment findings, statements, and all actions taken
  9. Maintain chain of custody for any evidence collected

NM Protocol Notes

From NM EMS Treatment Guidelines (2022) — Sexual Abuse/Assault:

EMT-B and all levels scope: - Primary assessment; airway, breathing, circulation; treat all life threats - History, physical exam, vital signs - Treat all life threats as indicated - Protect the scene and preserve evidence in cooperation with law enforcement - Encourage patient not to bathe, douche, or change clothes - Allow only necessary personnel for patient care contact with patient and scene - This may be a highly emotional and volatile situation — clearly document physical exam findings and treatments on the patient care report - Obtain only information needed to treat the patient — do not attempt to investigate the crime

Strangulation/choking victims: Patients who report being choked or strangled during the assault AND have any of the following should be transported to the nearest appropriate medical facility, preferably a trauma center: - Loss of consciousness or other neurological signs/symptoms (seizures, AMS, amnesia, visual changes, stroke-like symptoms) - Visual changes (spots, flashing lights, tunnel vision) - Facial or conjunctival petechial hemorrhage - Ligature marks or neck contusions - Soft tissue neck injury or swelling and/or tenderness - Incontinence of bladder or bowel - Difficulty speaking or loss of ability to speak - Shortness of breath from upper airway swelling/trauma - Subcutaneous emphysema

Transport decisions: Should be patient dependent; have a high index of suspicion for internal injuries; consider spinal immobilization, IV access and fluid resuscitation, and/or pain management as indicated by the clinical situation.

NREMT Relevance

  • Evidence preservation: no bathing/changing/urinating before hospital evaluation
  • Only personnel needed for medical care should have patient contact
  • No pelvic/genital examination prehospital
  • Strangulation patients require transport even if asymptomatic — delayed neurological injury
  • One provider communicates with patient throughout
  • Documentation of all findings and statements is critical

Sources

  • raw/protocols/nm-sop-guidelines-treatment-2022.pdf — Sexual Abuse/Assault protocol (p. 77)