Emergency med unit 2 outside source

what are the structural causes of AUB?

HINT: PALM

- polyps

- adenomyosis

- leiomyoma

- malignancy and hyperplasia

what are the non-structural causes of AUB?

HINT: COEIN

- coagulopathy

- ovulatory dysfunction

- endometrial

- iatrogenic

- not otherwise classified

39-year-old female presents to the ED c/o abdominal pain for the last three days. Intermittent pain that comes in waves. LMP was 3 weeks ago but recently her cycles have been abnormal and she endorses spotting in between cycles. Given the most likely dx, what tx do you recommend for the patient?

surgical resection

(dx = polyps)

42-yr-old female presents to ED complaining of painful menstrual bleeding for the past 4 days. States her periods have been regular in timing but have recently become heavier and more painful. what is the most likely dx?

what tx would you recommend initially? if it persists?

adenomyosis

med management, but may need hysterectomy

what are the typical sxs seen w/ leiomyomas?

asyx or painful w/ bleeding

what is the tx for leiomyomas?

NSAIDs, hormonal agents in consult w/ GYN, hysterectomy

53-yr old female presents to ED complaining of vaginal bleeding for last 2 days. she is post-menopausal w/ an intact uterus. last pap was 78 years ago and was negative at that time. given pt presentation, what is the next best step in dx?

what are you concerned for?

refer for outpatient US and bx

malignancy

what is the MCC of uterine bleeding in adolescents with non-structural AUB

von Willebrand's disease

what is the typical tx for stable pts w/ AUB?

- d/c and f/u with GYN

- tx based on underlying eti

- short term hormonal therapy for bleeding

- NSAIDs to reduce bleeding

what is the tx for hemodynamically unstable pts presenting w/ massive uterine bleeding

- immediate resuscitation and emergent GYN consult

- IVF resus, blood transfusion

- correction of underlying coagulopathy

- 1st line = conjugated estrogen IV q4-6hrs until bleeding stops

- tranexamic acid IV

- surg if med management fails

- admit

what are the clinical features of a ruptured ovarian cyst?

- classic = sudden onset u/l lower abd pain

- often following strenuous physical activity

- palpable ovarian mass

- possible hypotension, tachycardia, and acute abdomen

what are the risk factors a/w ovarian torsion

- ovarian mass

- pregnancy (enlarged CL)

- polycystic ovaries

- chemical induction of ovulation (ovarian hyperstimulation syndrome)

- tubal ligation

what is the primary diagnostic modality to assess for ovarian torsion?

what is the most common finding?

TVUS w/ doppler

ovary >4cm in size (d/t cyst, tumor, edema)

what is the outpt tx for PID?

ceftriaxone 500mg IM + doxy 100mg BID x14 days +/- metro 500mg BID (if BV +)

what is the inpatient tx for PID?

ceftriaxone IV + doxy PO/IV + metro IV/PO OR

cefotetan IV + doxy PO/IV

this is a complication of PID consisting of an inflammatory or purulent mass involves the fallopian tube or ovary; serious and potentially life-threatening d/t risk of rupture and sepsis

tubo-ovarian abscess

what are the clinical features of a Bartholin gland abscess?

- cysts may be asyx

- redness, swelling, pain

- tender, fluctuant, cystic mass w/ surrounding labial edema

what is the ED management for a Bartholin gland abscess?

- simple I&D + sitz baths

- word catheter for 6 weeks to prevent recurrence

- GYN referral for definitive tx

- broad spectrum abx (polymicrobial infx)

what is the leading cause of maternal death in the 1st trimester of pregnancy?

ectopic pregnancy

what are some s/sx of an ectopic pregnancy?

- abd or pelvic pain

- vaginal spotting/bleeding

- unexplained s/sx of hypovolemia

what are the risk factors assoc/w an ectopic pregnancy

- PID or hx of STI

- hx of tubal surgery or sterilization

- conception w/ IUD in place

- maternal age 35-44

- assisted reproduction techniques

- previous ectopic pregnancy

- cigarette smoking

- prior pharm-induced abortion

T/F: lack of abd pain rules out an ectopic pregnancy

false; lack of abd pain does not r/o an ectopic pregnancy

1 multiple choice option

what diagnostic test can either confirm or exclude an ectopic pregnancy?

transvaginal US

what b-hCG levels correspond to the transvaginal US discriminatory zone, where an IUP would be present on US?

> 1500 mIU/mL

what is the tx for ectopic pregnancy in unstable pts?

- ABCs

- 2 large bore IVs w/ rapid infusion of crystalloid or packed RBCs

- anti-Rho immunoglobulin

- emergent OBGYN consult for surg

in patients with severe nausea and vomiting in pregnancy, the presence of what other symptom is highly unusual and should suggest a diagnosis other than hyperemesis gravidarum

abdominal pain

what is the management for hyperemesis gravidarum?

- IV fluids (containing 5% glucose in NS or LR)

- antiemetics

what is the tx for mild preeclampsia?

- outpt after consult w/ OB

- BP control (labetalol, nifedipine, hydralazine)

- close f/u monitoring of mom and fetus

when BP s less than…

what is the tx for severe preeclampsia?

- emergent OB consult

- mag sulfate IV to prevent seizure

- BP >160 mmHg = labetalol or hydralazine IV or PO immed release nifedipine

what is the definitive tx for preeclampsia?

delivery of fetus

what are the clinical features of HELLP syndrome

- malaise, RUQ/epigastric pain, n/v

- less common = HA, visual changes, HTN, jaundice

what is the management for HELLP syndrome

- administer magnesium for seizure prophylaxis

- tx HTN if present (labetalol or hydralazine IV)

- emergent OB consult for admission and prompt delivery

what exams do you NOT perform on a patient w/ suspected placenta previa

digital or speculum exam

what is the management for placenta previa?

- 2 large bore IVs for fluid resus

- CBC and coags, type and cross match

- consult OB for management options

- admit for observation and fetal monitoring

what is the management for placental abruption?

- what is the - 2 large bore IVs, CBC, B/CMP, coags, fibrinogen, type and cross match

- emergent OB consult, fetal monitoring

- RhoGAM if mom is Rh-

- immediate delivery for severe abruption

what is the definitive tx for testicular torsion?

detorsion and fixation of both testes (done by urology)

what is the management for epididymitis?

- abx to cover STIs or urinary pathogens

- scrotal support, NSAIDs

what is the curative tx for phimosis?

what are alternative tx?

circumcision

topical steroid application for 1-2 mos to foreskin and daily manual retraction

which is a true urologic emergency

paraphimosis (glands can not be pulled back down

1 multiple choice option

what is the tx for paraphimosis

- compress glans for several mins to reduce edema

- tightly wrap glans w/ 2" elastic bandage

- reduce smaller glans through foreskin

- urology referral for dorsal slit reduction

what is the management for priapism

- narcotic analgesia

- emergent urology consult for corporal aspiration, irrigation, and alpha-adrenergic agonist injection (SNS actvaton

what is the management for penile fracture?

surgery w/in 8 hrs to evacuate hematoma and repair tunica albuginea

why do we perform a retrograde urethrogram when diagnosing a penile fx?

to ensure urethral integrity

what is the management for acute prostatitis?

- FQ (cipro) for 2 wks

- tx for STI if RF

when would we admit a pt with acute prostatitis?

signs of sepsis, major comorbidities, urinary retention (cath)

polymicrobial necrotizing infection of perianal subcutaneous tissues that often begin as a benign skin infection or abscess

Fournier gangrene

what are the clinical features of Fournier gangrene?

- genital pain, lethargy, fever, hypotension

- perineal erythema and edema

- crepitus and ecchymosis of inflamed tissue

what is the tx for Fournier gangrene

- aggressive fluid resus and IV abx (piperacillin/tazobactam or imipenem)

- urgent urologic consult for surg debridement

what important aspects of pt history do we want to obtain in pts who present w/ N/V? (8)

- onset and duration, frequency

- content of vomitus

- associated sxs

- ill contacts

- travel hx

- meds (any ADE of n/v)

- prior abd surgeries

- hematemesis

given that n/v has an extensive differential dx, what is the purpose of obtaining labs?

what are some labs we check in pts c/o n/v?

identifying consequences of n/v and looking for underlying cause

CBC, BMP, LFTs, lipase; hCG if female of childbearing age

in pts w/ n/v needing IV fluid hydration, what is the typical bolus for adults?

for peds?

for elderly pts?

500 mL IV bolus

20 mL/kg IV bolus

caution in elderly

what is the "4-2-1" rule for maintenance fluids?

- 0-10 kg = +4 mL/kg/hr

- 10-20 kg = +2 mL/kg/hr

- >20 kg = +1 mL/kg/hr

using the 4-2-1 rule, a patient who weighs 72 kg would need how many mL of fluid per hr?

112 mL/hr

what is the first line antiemetic given?

what are some alternative antiemetics?

ondansetron

promethazine, metoclopramide, prochlorperazine

which fluid is used for dehydration?

normal saline

which fluid is similar to human plasma and is therefore used for aggressive fluid replacement (burns, sepsis)

lactated ringers

LR can have ____________________ precipitations, so it is not used w/ some IV meds or blood transfusions

calcium

most common acid-base disturbance assoc/w vomiting; due to loss of hydrochloric acid, leading to an increase in serum bicarb

what electrolyte abnormalities would be seen with this?

metabolic alkalosis

hypokalemia, hypochloremia

diarrhea is most often assoc/w what type of infection?

viral

what aspects of pt hx do we want to obtain in pts presenting w/ diarrhea? (7)

- bloody or melenic

- food hx or association

- water source, travel

- small or large volume

- fever or abd pain

- meds (abx, laxatives)

- IBD

lab testing for diarrhea that is rarely helpful in ED and used more for pt follow up; not needed if onset is less than 24 hrs

stool eval

most common acid-base disorder assoc/w diarrhea; occurs d/t loss of sodium bicarb

- if severe hypovolemia, reduced tissue perfusion can lead to lactic acidosis

what electrolyte abnormality may be seen?

metabolic acidosis

hypokalemia

what is the basic tx for diarrhea?

supportive care, rehydration

abx may be warranted for diarrhea under what circumstances?

which abx are used?

severe illness, inflammatory diarrhea, high risk pt

azithro or FQ

antibiotics should NOT be prescribed for diarrhea if there is concern for what causative organism?

Shiga toxin-producing E. Coli

occurs when toxins interact to cause illness from diarrhea; inflammatory bowel disorder w/ plaques of exudate that overlap and replace necrotic intestinal mucosa

pseudomembranous colitis

what are the clinical features of C. diff diarrhea and colitis?

- onset 7-10 days after starting abx

- mild = frequent, watery, mucoid stools

- severe = profuse diarrhea, crampy abd pain, feer, hypotension, shock, possible toxic megacolon

when should C. diff be considered in pts? (2)

- 3+ loose stools in 24 hrs w/ recent abx use

- presence of C. diff toxin in stool

what is the tx for mild C. diff?

if severe?

d/c offending abx and monitor; if no response start metro 500mg TID x14 days

admit, vanco or fidaxomicin PO

chronic, granulomatous IBD that occurs as segmental transmural ulceration of any part of GI tract

Crohn's Disease

clinical features of Crohn's disease

- recurrent episodes of fever, abd pain, diarrhea (+/-)

- weight loss

- tachycardia, hypotension may be present

- abd tenderness

what are some complications assoc/w crohn's disease?

obstruction, abscess, fistulas, toxic megacolon

what are some extraintestinal sxs assoc/w crohn's disease?

arthritis, uveitis, nephrolithiasis, biliary disease, skin disease

what are the components of diagnosing Crohn's disease and ulcerative colitis?

- clinical dx (confirmed by colonoscopy)

- lab tests = CBC (leukocytosis, anemia), CMP, elevated ESR/CRP

- abd XR if suspected bowel obstruction

what is the management for Crohn's disease and ulcerative colitis?

- IV fluids, analgesia, bowel rest, electrolyte correction

- consult gastroenterologist for alterations in therapy

- corticosteroids to induce flare remission (not long term)

- 5-ASA meds (anti-inflammatory)

- abx for anal disease or severe colitis (Crohn's only)

when should pts w/ Crohn's disease be admitted to the hospital?

fulminant colitis, obstruction, severe dehydration, or failed outpatient management

what is the most common form of inflammatory bowel disease?

ulcerative colitis

ulcerative colitis is an idiopathic chronic inflammatory and ulcerative disease of the colon and rectum that is limited to what areas of organ structures?

mucosa and submucosa

what are the clinical features of ulcerative colitis?

- intermittent episodes of crampy abd pain, bloody diarrhea, tenesmus

- weight loss, fever, fatigue, tachycardia

what are the extraintestinal manifestations of ulcerative colitis?

- arthritis

- ankylosing spondylitis

- uveitis

- hepatobiliary disease

- skin disease

- nephrolithiasis

what are the complications a/w ulcerative colitis

- GI hemorrhage

- abscess

- fistula

- obstruction

- perforation

- toxic megacolon

when should a pt with ulcerative colitis be admitted to the hospital?

admit to GI and/or surg for GI hemorrhage, toxic megacolon, bowel perforation

total or segmental nonobstructive colonic dilatation w/ systemic toxicity

toxic megacolon

what conditions/pathogens can lead to toxic megacolon

- IBD, C. diff

- salmonella, shigella, campylobacter colitis

what are the clinical features of toxic megacolon

- severe bloody diarrhea refractory to therapy

- toxic appearance

- AMS, fever, tachycardia, hypotension

- distended tender abdomen +/- peritoneal signs

- n/v/d

what criteria need to be met in order to diagnose toxic megacolon?

- radiographic evidence of colonic dilatation >6cm AND

- 3 of: fever, HR 120+, anemia, leukocytosis >10.5 PLUS

- 1 of: dehydration, AMS, hypotension, electrolyte alteration

is the management for toxic megacolon

- ICU admission and supportive therapy; consult surg

- if IBD = IV steroids + IV abx (broad spectrum)

- if C. diff colitis = stop inciting abx;treat as fulimant: vanc NG and metro IV

acute constipation is diagnosed by the presence of 2 or more of what complaints?

- < 3 BM/wk

- straining

- hard stools

- incomplete evacuation

what components of pt hx are important when evaluating a pt w/ acute constipation?

- new meds (narcotics, antihistamines) or supplements (calcium, iron)

- decrease in fiber or fluid intake, immobility, sedentary lifestyle

- hypothyroidism, diverticulitis

what physical exam findings might be seen in a pt w/ acute constipation

- bowel sounds, hernias, abd masses, ascites, rectal bleeding

- DRE to r/o mass, fecal impaction, blood, anal fissure, abscess

what are the red flags assoc/w acute constipation

- rapid onset, n/v

- obstipation, severe abd pain, distension

- unexplained weight loss, rectal bleeding

what diagnostic eval can be done with a flat and erect abd XR?

assess stool burden and r/o obstruction

what diagnostic eval can be done w/ a CT abd/pelvis

assess for obstruction, carcinoma, impaction

what is the first step in treating acute constipation in the ED?

rule out any serious cause (bowel obstruction, AAA, colon cancer, etc.)

what is the treatment for constipation after ruling out serious causes?

- fecal digital disimpaction

- enema

- meds (if mild cases)

- recommend diet and exercise!

what medications are used for tx of mild constipation?

- osmotic laxatives (docusate, mag citrate, milk of magnesium, PEG)

- stimulant laxatives (bisacodyl)

what are the clinical features of hemorrhoids?

- hx of straining or constipation, pregnancy, sedentary lifestyle

- painless, bright red blood after defecation

- thrombosed = painful, bluish-purple firm mass

how to dx external hemorrhoid?

internal hemorrhoid?

visible on exam

use anoscope

what is the management for hemorrhoids

- sitz bath 15 min TID, high fiber diet, stool softeners, increase fluid intake

- topical steroids and analgesics short term

- thrombosed <48-72hrs = local anesthesia and elliptical clot exicison

- surg referral for definitive tx

superficial linear tear at the anal canal, usually a result of local trauma, constipation, and/or passage of hard stool

anal fissure