Avery- phimosis and paraphimosis

Conditions presenting in uncircumcised or partially circumcised males.

Phimosis-

Inability to retract the foreskin

This is not an emergency. It is present physiologically at birth but most males can retract by age 5-7.

Becomes pathological when a constricting band forms between glans and foreskin.

Do not retract forcefully- treat with topical steroids and gentle daily traction, admit to urology if there is urinary obstruction

Paraphimosis-

Inability to protract the foreskin

Can cause necrosis within hours to days

Tx is manual reduction-

• Pretreat with ice/mannitol/sugar
• Dorsal penile nerve block
• Hold foreskin between index and middle finger of both hands, use both thumbs to push the glans whilst pulling the foreskin
• If this fails can consider protraction using forceps, multiple need punctures to foreskin to allow improvement edema, or aspirate glans
• As a last resort, to be performed if the above techniques fail AND urology is not available, incise a dorsal slit using scalpel, protract foreskin and then suture the inflicted wound

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Dan- Testicular torsion-

Usually caused by an abnormal fixation of the testicle within the tunica vaginalis (when present this is usually bilateral)- most commonly the bell-clapper deformity

Bimodal distribution- perinatal and at puberty. Can occur at any age but is less common over 40.

HPI/Exam

• Unilateral testicular/flank/lower abdominal pain. This is not usually positional. May be atypical or colicky pain
• In children commonly presents only as vomiting or abdominal pain
• Testicle is usually firm, elevated and in transverse lie
• Unilateral loss of cremasteric lie may increase suspicion but is not specific and is not always present/easy to identify

Differential-

• Appendiceal torsion- isolated torsion of the testicular appendix- presents with more focal pain on the posterior portion of the testicle- ‘blue dot sign’ may be seen
• Epididymitis/epididymo-orchitis- inflammation, most commonly infectious of the epididymis and/or testicle. Most commonly cause by STI in those <35, UTI in those >35 (though this is not a hard/fast rule). Look for isolated tenderness over the epididymis, symptoms of infection, prehn’s sign

Mx-

• If the diagnosis is clear contact urology immediately
• In the meantime provide supportive care
• If urologist is delayed or not available can attempt manual detorsion- manually rotate the affected testicle externally- ‘open the book’. Most testicles torse internally (internal rotational) and so the opposite motion is used to detorse. However, not all testicles torse internally, so this could worsen the patient’s condition. When effective, 540 degrees of external rotation is usually required

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Austin- Hernias-

Abnormal exit of tissue or an organ through the wall of a cavity within which it normally resides

Most common-

• Inguinal hernia- presents as groin mass. Direct inguinal hernias pass through the transversalis fascia in the Hesselbach triangle (triangle formed by inguinal ligament, rectus abdominis and the inferior epigastric vessels). Indirect inguinal hernias pass through the internal and external inguinal rings
• Ventral hernias- bowel passes through a defect in the anterior abdominal wall- can be umbilical, epigastric, incisional
• Femoral- bowel protrudes through the femoral canal. These are much more prone to strangulation and incarceration, and require urgent f/u, even if not currently incarcerated/obstructed/strangulated
•     Protrusion of the stomach through the diaphragm and into the thorax- often presents as ‘heartburn’/epigastric discomfort

Hernias should be soft, non-tender and reducible.

• Incarceration is the inability to reduce the hernia back into the cavity within which it should reside. This term is used when blood flow to the herniated section of bowel is maintained. Symptomatic hernias should be reduced in the ed to avoid strangulation.

• Strangulation is when blood flow to the hernia is impaired- this causes ischemia, necrosis, perforation, sepsis. These should NOT be reduced as this makes the ischemic portion of bowel difficult to find and moves potentially necrotic tissue back into the abdomen, causing infection. Strangulation should be suspected in a pt with significant pain, tenderness, any skin change or findings of ischemia on ct/elevated lactic acid.

Reduction-

• Grasp and elongate the hernia neck with one hand whilst applying steady pressure to the proximal portion of the hernia at the neck of the fascial defect. Pushing on the most distal portion of the hernia simply causes the hernia to bulge more proximally, preventing reduction through the fascial defect

Complications of reduction-

• Risk of reducing strangulated bowel
• Reduction en masse- this is reduction of the majority of the hernia, often with improvement in symptoms. However small portions of bowel can remain incarcerated and remain at risk for strangulation. Watch hernia patients post reduction to ensure complete resolution of symptoms- consider ct/ultrasound/surgical review if any ongoing symptoms

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Dr McGee Renal Emergencies-

Indications for emergent hemodialysis-

A- Acidosis- dialyze for pH <7.1

E- Significant electrolyte abnormality- especially hyperkalemia

I- Intoxications

O- Overload/oxygenation

U- Symptomatic uremia

Consider rhabdomyolysis as a cause for renal failure, especially in pts unable to provide good history. Tip offs are hepatitic pattern LFTs and dipstick hematuria without blood on micro.

Hyperkalemia-

Weakness, symptoms of causative pathology, AMS.

EKG changes with peaked T waves, prolonged QRS à sine wave

EKG changes do not always progress smoothly through the above stages- pts can go from NSR with narrow qrs to asystole very quickly.

Mx-

• Stabilize the membrane- with calcium. Gluconate if stable, chloride if unstable or if pt has central access
• Move the potassium back into the cells- Insulin and glucose, fluids, albuterol, bicarb if acidotic
• Typically 10 units of insulin in 1 amp of d50 is use, but this depends on the pt. if they are normoglycemic consider 2 amps of d50. If they are very hyperglycemic may consider not giving glucose. REGARDLESS, IT IS IMPERATIVE THAT BLOOD GLUCOSE IS CHECKED REGULARLY TO MONITOR FOR HYPOGLYCEMIA
• Give fluids- LR does contain potassium but the amount is negligible and not clinically significant. LR is a better choice than normal saline as the NAGMA caused by NS will increase potassium more than the minimal potassium contained in LR
• If acidotic- can bolus bicarbonate and then use 2-3 amps of bicarbonate in d5w for fluid resuscitation/maintenance
• If the patient is volume overloaded use furosemide. If normovolemic give fluids and furosemide. Can discuss diuretic use with renal if pt is hypovolemic/dry.
• Dialysis if all else fails

Drug intoxications-

Many drugs can be dialyzed out of the blood stream-

• LEMS mnemonic
• Lithium
• Ethylene glycol
• Methanol
• Salicylates
• (and others- these are the most commonly encountered clinically)

Discuss with poison control

Uremia-

End organ damage-

• Pericarditis or uveitis
• Uremic encephalopathy
• Bleeding- uremia causes platelet dysfunction

Hemodialysis access-

• Short term dialysis access- shiley/trialysis catheter- a necessary skill for EM
• Medium term- Tunneled dialysis catheters
• AV fistulas- most commonly brachiocephalic
• Peritoneal dialysis catheters

Complications of AV fistulas-

• Acute bleeding- direct pressure with a finger may stop bleeding. TXA soaked gauze may help. Avoid tourniquet placement if possible. Figure of 8 sutures can be placed if necessary, though above options should be exhausted prior. Note that heparin is given during hemodialysis- if bleeding is hard to control can give protamine, though risk of allergic reaction is common. DDAVP can improve platelet function in pts with azotemia.

• Call vascular for any fistula or graft issues

• Infected HD catheters can cause sepsis. Look at the site. Metastatic infection from the catheter is also common and can cause septic arthritis, osteomyelitis etc

• PD patients should always have clear peritoneal fluid. Abdominal pain/fever in a PD pt can be a sign of peritonitis. Dx for PD related peritonitis is different than SBP when assessed with fluid microscopy. >100 PMNs or >50% PMNs is suggestive of infection

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SANE lecture

Sexual Assault Nurse Examiner

Purpose is to evaluate and treat victims of sexual assault, collect evidence and document injuries

See male and female victims of sexual assault age 12 or older

Injury terminology-

Contusions- These are bruises. Either term is acceptable. Do not attempt to date bruises, though it can be stated that bruises are in different stages of healing

Abrasions- Scrapes/grazes/road rashes are abrasions. Vaginally, these are most common at 5 and 7 o clock.

Petechiae- burst capillaries, appearance like paint splatter. Can be the result of direct pressure or of strangulation

Incised wounds are not lacerations and should not be documented as such. Incised wounds are inflicted by sharp objects such as a knife or a piece of glass. When these are described as lacerations it may cast doubt on the mechanism of injury/use of weapons. Simple puncture wounds should be described as such – ‘puncture wound’.

Pattern injuries are bruises/contusions whose shape is suggestive of a specific mechanism (eg a bat, a bite mark). Describe these injuries as pattern injuries and document the patient reported mechanism of injury. Photographs and forensic experts will determine mechanism

GSWs- Describe as GSW or penetrating injury. Do not document entry/exit wounds- photographs and expert review will determine this