Forensics, Abuse and Sexual Assault in the ED

In depth

The one-page summary above is what the PDF prints. These sections go further.

Trauma-informed interviewing

Victims of violence often arrive with a partner, relative, employer or trafficker who controls what they can say. The first job is a private conversation: take the patient alone for a routine reason, such as a urine sample, imaging or the private part of the examination, so the companion is not alerted. Use a professional interpreter in person, by phone or by video. A family member, partner, caregiver, employer or co-worker can filter answers, block a disclosure or retaliate afterward. The DOJ protocol asks for a qualified interpreter for patients with limited English proficiency, at no cost to them.

Ask directly and neutrally ('Has anyone hurt you?', 'Do you feel safe at home?'), listen without writing while the patient talks, and avoid leading or blaming questions such as what the patient wore or drank. A patient who is shaking, tearful or cannot recall parts of the event is having an expected acute stress response: give short explanations of each step, offer choices, let them control the pace and stop when they ask. Consent is an ongoing process; the DOJ protocol says the patient may decline any part of the examination and withdraw consent at any time, and verbal consent is sought throughout even after a written form.

Tell the patient at the start which disclosures you are required to report and what happens next. Make no promises outside your control. For an adult, the goal of the visit is safety and choice, not a disclosure or a police report.

Documentation that holds up

The record may be used in protective-order hearings and criminal trials. The DOJ protocol notes that statements made to clinicians, including paramedics and EMTs, may be admissible and can corroborate the patient's testimony, while statements to police generally are not. Record the patient's own words in quotation marks, including the name of the person and the object they identify, and the patient's demeanor. Words such as 'alleges' or 'claims' imply doubt; labels such as 'domestic violence victim' or 'aggressor' are conclusions, not observations.

Describe each injury by site, size, shape, color and pattern, mark it on a body diagram and photograph it with consent according to policy. Describe colors but do not assign an age to a bruise from its color; this is long-standing forensic teaching. When a forensic examiner is available, they document injuries with measurements and photographs and give injury-specific discharge instructions (Stellpflug 2022).

Child maltreatment: what the ED nurse owns

The full child abuse content (sentinel injuries, fracture specificity, immersion burns, abusive head trauma, skeletal survey timing) is on Pediatric Emergencies. The ED nurse's part is to recognize the pattern, keep the child safe, document and report. TEN-4-FACESp, validated in children younger than 4 years at five pediatric EDs, flags bruising of the torso, ear, neck, frenulum, angle of the jaw, fleshy cheeks, eyelids or subconjunctivae, any bruise in an infant 4.99 months or younger, and patterned bruising (Pierce 2021: sensitivity 95.6%, specificity 87.1%). A positive rule calls for an abuse evaluation, not proof.

Every state has mandated child-abuse reporting, but who must report, and how, varies by state: health professionals including nurses are named reporters in most states, and some states make every person a reporter. The trigger is suspicion or reason to believe, not proof. The duty belongs to the individual: if the physician disagrees or a supervisor declines, the nurse still reports to child protective services or police as state law directs. State counts and immunity rules are on Legal and Ethical Terms (RN Basics) and Pediatric Emergencies. HIPAA permits child abuse reports to the authority that receives them without the family's agreement (45 CFR 164.512(b)).

If a caregiver demands to take a child home during a work-up for abuse or trafficking, do not argue or reveal the concern. Alert security and follow the institution's child-protection policy while the report is made; protective services or police decide on custody.

Intimate partner violence

CDC defines intimate partner violence as physical violence, sexual violence, stalking or psychological aggression by a current or former partner. More than 1 in 3 US women and more than 1 in 6 US men report contact sexual violence, physical violence or stalking by a partner in their lifetime, and over half of female homicide victims are killed by a current or former male partner (CDC, updated August 2026). Men are victims too: screen whoever presents with an unexplained or poorly explained injury.

The USPSTF (June 2025, grade B) recommends screening women of reproductive age, including pregnant and postpartum women, and notes that screening works best in a safe, private setting; brief tools include HITS, HARK and WAST. Benefit comes from multicomponent interventions with ongoing support over several visits, with the strongest evidence in pregnancy and the postpartum year, while brief counseling alone generally has not shown benefit. For older or vulnerable adults the evidence is insufficient (I statement), so clinicians use judgment.

A competent adult who chooses to go home is not showing impaired judgment. Respect the decision, build a safety plan (a safe place to go, people who can help, an emergency bag with documents, money and medicines, how to reach help), connect with an advocate, give the National Domestic Violence Hotline (800-799-7233, or text START to 88788) in a form the patient can hide, and arrange follow-up. Do not invite the partner to a joint talk and do not push the patient to leave on your timetable.

HIPAA allows a report about an adult victim of abuse or domestic violence to a government authority when the law requires it, when the patient agrees, or in narrow cases where a statute authorizes it to prevent serious harm, and the patient must be told promptly unless that would put them at risk (45 CFR 164.512(c)). Some states require clinicians to report certain injuries, such as weapon wounds, strangulation or serious bodily injury, whatever the adult wants (DOJ protocol); know your state.

Strangulation

Prior non-fatal strangulation by a partner is one of the strongest warning signs of later homicide. In a case-control study, it was reported by 10% of abused women who were not attacked lethally, 45% of attempted-homicide victims and 43% of homicide victims (odds ratios 6.70 and 7.48; Glass 2008). Ask about it directly in every IPV history and include it in a danger assessment.

Injury can be internal and delayed. About half of victims have no visible neck injury (Stellpflug 2022; the Training Institute on Strangulation Prevention reports the same in police-report series). Findings that point to significant injury include loss of consciousness, urinary incontinence, confusion, seizure or a focal deficit, vision loss, hoarseness or loss of voice, stridor, dysphagia or painful swallowing, facial or conjunctival petechiae, ligature marks and neck swelling. Arterial dissection can cause an ischemic stroke, and airway or laryngeal injury can compromise breathing, so reassess rather than rely on a single normal look.

CT angiography of the neck is considered the gold standard for structural vessel, laryngeal and bony injury; MRI may be more sensitive for subtle vascular or brain injury but is less available, and no symptom-based decision rule is validated. Advanced imaging is reasonable for GCS under 15, focal neurologic symptoms, signs of airway injury or dysphagia (Stellpflug 2022). An asymptomatic patient can usually be discharged with strict return instructions (new weakness, numbness, vision or speech change, breathing trouble, voice change, painful swallowing) and close follow-up; a symptomatic patient with a negative work-up is observed.

Abuse of older and dependent adults

CDC defines abuse of older persons (60 or older) as an intentional act or failure to act by a caregiver or other trusted person that causes or risks harm: physical, sexual, emotional or psychological abuse, neglect, and financial exploitation. About 1 in 10 older adults living at home experience abuse, and most cases go unreported. Risk rises when the perpetrator has substance use, mental illness, high stress or poor caregiving preparation, or depends financially or emotionally on the older adult (CDC 2024).

Accidental bruises in older adults are mostly on the extremities over bony areas. In adults referred to adult protective services, abused participants more often had large bruises (over 5 cm) and bruises on the face, the lateral right arm and the posterior torso, and 89.6% could say how they were bruised, compared with 23.5% of non-abused older adults (Wiglesworth 2009). Bruises encircling wrists or ankles suggest restraint. Ask the patient, alone, how each bruise happened, and compare the answer with the caregiver's separate account.

Neglect is a caregiver's failure to meet basic needs: food, fluids, hygiene, shelter, medical care or safety. A bedbound patient with hypernatremic dehydration, weight loss, soiling, a neglected pressure injury and an undetectable level of a prescribed drug points to neglect by the caregiver rather than self-neglect or 'normal aging'. Financial exploitation is the improper use of the older adult's money, benefits or property; clues include a relative newly added to an account, unexplained withdrawals and unpaid bills or stopped medications despite enough income.

Many states require health workers to report suspected abuse, neglect or exploitation of older or dependent adults to adult protective services, but who must report, and what counts, varies by state (know yours); proof and the patient's permission are not required where reporting is mandatory. Adult protective services offers services, and a capable adult may decline them. Tell the patient a report is made, explain what the agency does, and plan safety with them. Legal detail: Legal and Ethical Terms (RN Basics).

Human trafficking

US law defines trafficking as using force, fraud or coercion to compel a person into commercial sex or labor. The Hotline's action-means-purpose model asks whether someone recruited, harbored, transported, provided or obtained the person (action), by force, fraud or coercion (means), for commercial sex or labor (purpose). Any child under 18 in commercial sex is a trafficking victim whatever the means and whatever the child says about choice. Trafficking does not require any movement; people are trafficked in their hometowns, by partners and family members, and in legal industries such as restaurants, construction, cleaning and factories. Smuggling, by contrast, is an illegal border crossing.

• Labor indicators (Hotline): pressure to stay in a job, debt to an employer or recruiter, unpaid wages, employer holds passport or ID, isolated or employer-provided overcrowded housing, monitored conversations, threats of deportation, unsafe work
• Sex indicators: wants to stop but feels unable to leave, has a 'manager', lives where they work, escorted between home and work, controlled spending and phone
• ED clues (bank and classic teaching, not from the Hotline pages): companion who speaks for the patient and will not leave, no stable address, a story that changes, STI or pregnancy, fear, and a patient who keeps checking a phone

Interview the patient alone with a neutral professional interpreter, aiming at safety rather than forcing a disclosure. A minor is reported to child protective services or police as state law and policy direct; explain to the teen that you must report rather than promising secrecy. An adult keeps the right to decide whether to report, leave or accept services: treat the medical problem, offer a safety plan and the National Human Trafficking Hotline (1-888-373-7888, text 233733) discreetly. You may call the Hotline for advice with general, non-identifying information; sharing the patient's identity needs her permission unless a law requires a report (health information that cannot identify a person is not protected health information, 45 CFR 164.514(a)).

If the patient wants to leave the trafficker today and he is in the building, safety comes first: move her somewhere he cannot reach or watch, follow the protocol for notifying security and law enforcement, and do not have him confronted or escorted out before she is safe. Then social work, the response team or the Hotline arranges shelter, legal and social services.

Sexual assault: the medical forensic examination

The DOJ National Protocol for Sexual Assault Medical Forensic Examinations (Adults/Adolescents, 3rd edition, September 2024) is the national guide. The examination, ideally done by a clinician with forensic training such as a sexual assault nurse examiner (SANE), includes the medical forensic history, a head-to-toe examination, treatment of injuries, documentation, collection of samples for the evidence kit with consent, and information, treatment and referrals for STIs, pregnancy, suicidal ideation and substance use, with an advocate present if the patient wishes (OVW). The ED's part is triage, stabilization, privacy, calling the examiner and advocate, and protecting the patient's options.

The protocol asks EDs to triage sexual assault patients as priority patients (a higher ESI level because of the time and resources needed), to treat acute injuries before any sample collection, and to tell patients they can receive medical care regardless of whether they report. Except where the law mandates a report, the decision to report to police is the patient's. States that receive STOP Violence Against Women Act funds must make the examination free to the patient whatever their level of participation with the justice system, and many communities allow anonymous or delayed reporting while the kit is stored.

Timing: DNA evidence degrades, so examine promptly, but samples may be collected up to 5 days after the assault or longer, and the protocol says timeframes are a benchmark that must never be used to deny care. Samples are collected whatever the patient has done since the assault; patients who are able can be asked to hold off urinating, eating or drinking, but never at the cost of being retraumatized or made ill. Clothing worn during or after the assault may be kept as evidence, so offer replacement clothing.

Alcohol- or drug-facilitated assault: suspect it with memory loss, waking somewhere without knowing how, a report of being drugged, or unexplained drowsiness, dizziness or impaired coordination. Routine toxicology is not recommended. With specific consent, collect urine if under 120 hours have passed (the first available sample is ideal) and blood if under 24 hours, even if the patient has not decided about reporting; if the patient must void before the examiner arrives, collect that urine and keep chain of custody. Forensic toxicology goes to a forensic laboratory, not the hospital lab. Voluntary drug or alcohol use never lessens the seriousness of the assault or the standard of care.

Chain of custody in general terms: the person who collects a sample keeps it in their control, sealed and labeled, until it is handed to an authorized person, and every transfer is recorded with date, time and identity so the court can trust that nothing was lost or altered. Patients, advocates and family members do not handle evidence. Detailed drying, packaging and storage rules are jurisdictional and belong to the forensic examiner.

Sexual assault: pregnancy, STI and HIV prevention

Pregnancy: discuss the risk with anyone who could become pregnant, test with consent, and offer emergency contraception to every patient who wants it (DOJ: standard of care; a clinician who objects must hand the patient to another). Levonorgestrel 1.5 mg is one tablet within 72 hours (Plan B label: the sooner the better; if vomiting within 2 hours, ask whether to repeat). Ulipristal 30 mg is one tablet within 120 hours; it is contraindicated in known or suspected pregnancy, the dose may be repeated if the patient vomits within 3 hours, hormonal contraception should not start for 5 days, a barrier method is used until the next period, and CYP3A4 inducers such as rifampin, carbamazepine or St John's wort reduce its effect (ella label). DOJ calls ulipristal more effective than levonorgestrel and notes the copper IUD cuts pregnancy risk by more than 99% when placed within 5 days. Emergency contraception does not end an existing pregnancy and does not prevent STIs.

STIs: CDC (2021) recommends presumptive treatment because follow-up after assault is poor. Women: ceftriaxone 500 mg IM once, doxycycline 100 mg orally twice daily for 7 days and metronidazole 500 mg orally twice daily for 7 days. Men: ceftriaxone and doxycycline. Ceftriaxone is 1 g for patients weighing 150 kg or more. Warn about gastrointestinal effects (DOJ suggests an antiemetic such as ondansetron), and advise no intercourse until treatment is complete. Hepatitis B: unvaccinated survivors start the vaccine (with HBIG if the assailant is known HBsAg positive); vaccinated survivors without post-vaccination testing get one booster. HPV vaccine for unvaccinated survivors aged 9 to 26.

HIV: CDC's 2025 nPEP recommendations (replacing 2016) say to give the first dose as soon as possible, ideally within 24 hours and no later than 72 hours, without waiting for results, for a 28-day course. Preferred adult regimens are bictegravir/emtricitabine/tenofovir alafenamide, or dolutegravir plus tenofovir (TAF or TDF) plus emtricitabine or lamivudine. Baseline: HIV antigen/antibody test, creatinine, ALT, AST, hepatitis B testing and a pregnancy test. Follow-up: a check within 24 hours on access and side effects, HIV testing at 4 to 6 weeks and at 12 weeks (antigen/antibody plus NAT), and an offer of PrEP to anyone with ongoing risk. CDC finds the evidence insufficient to choose between a full 28-day supply, a starter pack or a prescription; starter packs were linked to lower completion in some studies, so follow the local protocol and make sure the patient leaves with medication in hand. After 72 hours CDC finds the evidence insufficient to recommend starting nPEP: test for HIV, counsel (including PrEP) and repeat testing.

Patients in police custody

Handcuffs and other devices applied by law enforcement for custody are not governed by the CMS hospital restraint rule; the officers who keep custody and direct supervision are responsible for applying and monitoring them (71 FR 71389, 2006). The hospital still owes the patient safe and appropriate care, so the nurse assesses and treats the injury, checks circulation and skin under the cuffs and asks the officer to adjust them when needed. A restraint applied by hospital staff for clinical reasons follows the restraint rule and needs its own order (see Mental Health: Meds and Communication).

Exam pearls

• First action with a controlling companion: get the patient alone, with a professional interpreter.
• Child or trafficked minor: report on suspicion; disagreement from a physician or the teen's wish for secrecy does not change it.
• Competent adult with IPV or adult trafficking: respect the choice, safety plan, hotline; police only if the patient wants it or the law requires it.
• Strangulation: highest-lethality history; no marks does not mean no injury; CTA of the neck for symptoms.
• Elder bruises over 5 cm, on the face, lateral arm or back, or a patient who cannot explain them: interview alone and report.
• Sexual assault: injuries first, examiner and advocate early, every part optional, ask but do not insist on no bathing, first urine with chain of custody if drugging is suspected.
• Ulipristal to 120 h, levonorgestrel to 72 h; nPEP no later than 72 h; ceftriaxone plus doxycycline, plus metronidazole for women.
• Handcuffed patient: the officers manage the cuffs; the nurse still assesses and treats.