1. Volume repletion most patients 3-6L down. When sugars < 250 include dextrose containing fluids.
2. Electrolyte repletion K<3.5 consider stopping insulin, K3.5 to 5.5, consider adding K to fluids 20-30meq/L. <5.5 no need to add potassium. Check Mg, Phos levels as well.
Insulin drip >1units/kg dose. Switch to subQ after gap normalized and bicarbonate normalized.
Hyperosmolar hyperglycemic state
Triad
Severe hyperglycemia (> 600 usually)
Elevated serum osmolality (>320 osm/kg)
Altered mental status
Treat similarly to DKA, usually require more fluids as patients more dehydrated.
Resuscitative Hysterotomy (Ben Turner and Harrison Brown)
Indications to do
Maternal cardiac arrest without ROSC within 4 minutes
Estimated gestational age of infant >20 weeks (fundus > 20 cm)
Physical with pelvic with possible cervical motion tenderness Lower abdominal tendernes, Uterine and or adnexal tenderness, Mucopurulent discharge, Fever
DX: Sexually active women with lower abdominal pain without other cause found with PE with CMT, Adnexal tenderness, or uterine tenderness
Tubo-ovarian Abscess
Dx via ct or US
Needs admission for IV antibiotics and OB/GYN Consult. Can have IR drainage.
Predictors of failure of antibiotic treatment: WBC 16k or abscess > 5.2 cm
Outpatient management
Rocephin 250mg IM + Doxycyclin 100mg Po BID x 14 days with Metronidazole 500mg Po BID x 14 days
Dispo
Admit of they have TOA, pregnant, cannot tolerate po, septic, failed outpatient antibiotics
Ovarian Torsion (Tyler Bayers)
Ovary can rotate around suspensory ligaments or utero-ovarian ligament, compression of ovarian vein with leads to obstructed venous outflow leading to ischemia and necrosis
Risk factors mass >5cm, hx of cyst, ovarian malignancy, TOA, pregnancy
Presentation
90% with pelvic pain, Adnexam mass, nausea and vomiting
Pearl- Right sided torsion more common due to presence of sigmoid colon on left
Ultrasound- Evaluate for decreased venous/arterial flow
2/3rd might have normal flow
Can see enlarged unilateral ovarian volume
Lpelvic free fluid
Loss of echogenicitiy
Whirlpool sign
CT
Can be used for evaluation of suspected torsoin,
Sensitive for secondary findings in torsion
Can find ovarian enlargement, ovarian mass, distended pedical, lack of enhancement
Management
Pain and nausea control, transabdominal/transvaginal US, Emergent OBGYN consult
Definitive diagnosis by direct visualization
Bartholin Gland Cyst/Abscess (Dan Fischer)
Ducts of the glands drain into posterior vestibule at 4 oclock and 8oclock positions. See mass near the posterior introitus medial to labia minora
Usually sterile initially but can become infected
Abscess- erythema, fluctuance, severely painful
Dx- Clinical consider sti testing
Tx: Word catheter placement
Make small incision so that word catheter will not fall out
Drain abscess, explore wound
Place word catheter and inflate balloon with 2-4cc of water with blunt kneedle
Keep in place for 4-6 weeks
Fllow up with gyn
HTN emergencies in Pregnancy (Joshua Sennets)
Can occur from 20 weeks gestation to 6 weeks post partum
Definition- new onset htn and proteinuria
With severe features- new onset htn and signs of end organ dysnfucntion after 20 weeks gestation and up to 6 weeks gestation
A 26-year-old G1P0 38 weeks and 4 days female presents as a Code Green to the ambulance circle. The patient brought back to Room 9 for assessment. The patient states her “water broke” and it soaked through her pants. She is feeling contractions. Vitals are HR 120 BP 128/78 RR 24 SPO2 100% and T 97.6 F. On external vaginal exam you palpate a pulsating vessel in the vaginal canal and fetal head at 0 station.
● What is the diagnosis? Umbilical cord prolapse
● What is the most important next step in the management of this patient? Elevate presenting part to reduce compression and transport to OR for emergent c-section
● What positions can you place the patient in to alleviate pressure on the protruding part? Knee to chest position, no pushing or Valsalva
A 27-year-old G1P0 at 37 weeks and 4 days is presenting in active labor to the emergency department. She is endorsing painful contractions that began within the last hour. Contractions are occurring every 2 minutes. Vitals are HR 106 BP 136/68 RR 18 SPO2 98% and T 98.8 F. Physical exam reveals fetal head crowning and bloody show. During delivery, you are able to advance the posterior shoulder, however as you attempt to advance the posterior shoulder the fetal head retracts. An episiotomy is made; however, you are still unable to advance the anterior shoulder.
● What is the diagnosis? Shoulder dystocia
● What is the most appropriate next course of action?HELPERR pneumonic. Chall for Help, Evaluate for episiotomy, Legs flex (Mcroberts maneuver), Pressure (suprapubic pressure), Entry maneuvers (Wood’s corkscrew or Rubin II maneuver, Remove posterior arm by sweaping it across chest, R Roll on all fours
● What are some risk factors for this condition?Preterm labor, macrosomia, small materanal pelvis, prolonged labor
● Failure to recognize this condition and correct it can have what damaging results? Fetal demise
● Which of these three maneuvers is the most effective in relieving this condition? Roll on all four
Case 3:
A 21 year-old G4P3 woman presents to your Rural Emergency Department in Ashland, KY in active labor and has a spontaneous vaginal delivery in the emergency department. Prenatal care was appropriate and the patient’s blood type is O-positive. The infant is full-term and well. An intact placenta passes shortly thereafter, followed by vaginal bleeding. There are no obvious lacerations to repair, and the bleeding appears to be originating from the cervical os. Vital signs are within normal limits. The patient continues to have oozing of blood from the vagina several minutes after birth.
What is the diagnosis? Post partum hemorrage
What is the most common cause of this diagnosis? Uterine atony
What is your next step in management? Bimanual massage,
What medications (and in what order) would you use to stop the bleeding? Pitocine 80units bolus IV or 10units IM, Misoprostol 600mcg SL or 1000mcg rectally
What is a rare complication of this diagnosis that results in high fetal and maternal death?Uterine rupture
Review of the Basics of Cognitive Error in Emergency Medicine and Updates: Still No Easy Answers by Hartigan et al, 2020.
Despite research, Cognitive Error remains a source of frustration
Rapid decision making in the ED relies on a combination of intuition and analytic reasoning, both based on experience and training.
Reviews studies on Cognitive Error interventions and assesses applicability in ED. Not much statistical data to support that these interventions translate into productive changes in clinical practice, but studies are limited and further research is needed.
Contrast-Associated Acute Kidney Injury by Mehran et al, 2019.
Proposes change of nomenclature from “Contrast-Induced” AKI to “Contrast-Associated” AKI
Historical significance of Contrast-Associated Acute Kidney Injury may be overstated
Reviewed historical interventions for preventing CAAKI
Recommend fluids and follow-up for patients at high risk of renal injury (those with known renal dysfunction)
Deaths in ED and 72 Hour Returns
Excellent work last month, Team.
Reviewed palliative care in ED, post-traumatic growth, and toolkits for dealing with trauma.
Unexpected decompensation in ED with subsequent PEA arrest
Reviewed traditional ACLS algorithm as well as updated literature discussing potential for treating PEA based on its morphology (i.e., wide complex vs narrow complex)
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