A LIFE-THREATENING CASE OF SEXUAL ASSAULT

The case presents a victim of sexual assault who suffered a stab wound which required life-saving surgical intervention to repair a laceration to the myocardium. The case report analyzes the appropriate protocol for a sexual assault victim with life threatening injuries. It summarizes the operative note for the surgical repair and uses medical references to comment on the method of treatment used. While immediate evaluation of trauma remains the primary focus in the emergency room, it is important to arrange follow up and psychological counseling for complete recovery. Purpose (a): Once reported to police, cases of sexual assault must be assessed by appropriate hospital staff who are trained in gathering biologic evidence of the sexual encounter and examining the patient for possible injuries. According to the Bureau of Justice Statistics, "Seventeen percent of the 135,550 completed or attempted sexual assaults annually against females ages 12 or older resulted in injury"5. Victims of sexual assault who are injured are more likely to receive medical treatment if reported to police. The case presented exemplifies the importance of seeking medical attention after sexual assault because it involved life-threatening injuries. Methods (b): Assessment - A 28-year-old woman who had suffered sexual assault presented to the emergency department with a total of nineteen stab-wounds to the face, neck, anterior chest, upper abdomen, back, both upper extremities and lower extremities. A primary and secondary survey of the patient was completed and the patient presented hemodynamically stable. A Sexual Assault Nurse Examiner completed a thorough medical forensics exam, collected evidence of assault and treated patient prophylactically for possible infection and pregnancy. A Computed Tomography was completed which showed concern for a hemopneuothorax. The patient remained in stable condition in the emergency department for three hours. Treatment - A right tube thoracostomy was placed for the patient's hemopneumothorax. Next, a diagnostic laparoscopy was performed. Exploration of the abdomen was initiated and a laceration to the diaphragm was noted through which the patients beating heart could be seen. A decision was made to convert to an open exploratory laparotomy. A pericardial window was made in the preperitoneal space below the xiphoid. A 1.5 to 2 cm laceration in the apex of the heart was seen. The laceration was repaired. The laceration to the diaphragm was repaired. All stab wounds were thoroughly irrigated and closed with staples. Finally, a flexible esophagoscopy and sigmoidoscopy was performed to screen for any other possible injuries. Results (c): Literature Review - The assessment and treatment of the present case proved to be effective in identifying an underlying heart laceration. The necessary steps were taken to evaluate a hemodynamically stable stab wound patient. Berardoni et al, explain, "Although it is widely accepted that patients demonstrating signs of hemodynamic instability, peritonitis or evisceration should undergo timely exploratory laparotomy, the proper conservative evaluation in hemodynamically stable patients with AASWs remain indefinable despite the multitude of proposed clinical pathways"1. Another study by Paydar et al, comparing the use of conservative management versus exploratory laparotomy found that "of the patients in the CM group, 11% needed delayed laparotomy"4. When an anterior abdominal stab wound patient is hemodynamically stable, it can be difficult to determine the proper course of management for that patient as shown by the statistical evidence of these studies. The conversion to exploratory laparotomy in this case was therapeutic in providing surgical intervention for a myocardial stab wound. Conclusions (d): In conclusion, it is important to fully evaluate victims of violent sexual assault both surgically and psychologically. A study by Koss et al. stated, "Findings indicated that severely victimized women, compared with nonvictims, reported more distress and less well-being, made physician visits twice as frequently in the index year, and had outpatient costs that were 2.5 times greater…long-term deleterious effects suggest that criminally victimized women's needs for medical treatment transcend the traditional focus on emergency care and forensic evaluation."3. After a victim of rape recovers physically, the need for emotional, spiritual and psychological healing is indicated. it is important to treat the whole patient; keeping in mind that complete healing occurs when all aspects of human disease are treated.