Conference 8/31/2022

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Ovarian Torsion, Garrett Stults D.O.:

  • R > L ovary due to increased length of utero-ovarian ligament and no sigmoid colon to stabilize
  • Incidence unknown, often missed, majority of cases in reproductive cases, peds cases around 15%
  • Risk factors: previous torsion, ovary >4cm, 85% have ovarian mass
  • Acute onset of moderate/severe pain, n/b, fever, mass, can have peritoneal signs but this should raise concern for adnexal necrosis
  • CT noninferior to ultrasound, if CT is concerning then do not delay gyn consult for ultrasound
  • Definitive diagnosis is made by direct visualization of ovary
    • Can de-torse or may have to do oophoropexy

Hyperemesis Gravidarum, Dominic Aiello, M.D.:

  • Nausea/vomiting of pregnancy: normal vitals, normal physical, normal labs, 60-80% of pregnancies in first trimester
  • Hyperemesis has increased incidence in lower socioeconomic class and non-Caucasian populations
  • Complications: orthostatic hypotension, electrolyte abnormalities, transaminitis, Mallory Weiss tears, Wernicke encephalopathy, increased risk of pre-e, abruption, and low birth weight if in 2nd trimester
  • Treatment:
    • Nonpharmacologic: avoid triggers, small meals, avoid stress, ginger, P6 acupressure wristbands
    • Pharmacologic: pyridoxine, doxylamine. If persistent can add dimenhydrinate (Dramamine), Benadryl, prochlorperazine, promethazine,
    • No dehydration: metoclopramide, ondansetron, promethazine, trimethobenzamide
    • Dehydration: D5NS If ketonuria is present, can add in methylpred taper

Trauma in Pregnancy: the 2 for 1 plan, Melissa Platt, M.D.:

  • Trauma is #1 cause of hospitalization for pregnant women (7-8% including falls)
    • MVA 2/3
  • Respiratory changes:
    • Upper airway: mucosal edema, epistaxis, estrogen induced
    • Lungs: multiple changes related to capacity, increasing RR by 2-3 breaths/min
      • Oxygen consumption increased, respiratory alkalosis—pay attention if you get a gas
  • Cardiovascular changes:
    • Cardiac output rises 30-50%
      • ½ of this occurs by 8w of pregnancy
      • Influenced by posture
    • Preload increased due to rise in blood volume, afterload reduced due to decline in SVR, HR increased by 15-20 BMP, EF remains unchanged (reliable indicator of LV function)
    • Appears enlarged on CXR, different projection/rotation
    • Apex at 4th intercostal space instead of 5th
    • EKG with LAD, ST depression, 28% PVC
    • BP typically falls but later returns to baseline
  • Placenta
    • Low resistance circulation, no neuronal input
    • Vascular resistance is determined more by things like endothelin, NO, not epi
    • Placental flow 400-600cc/min
      • Blastocyst implants in innermost uterine wall, uterine blood supply is rich
  • Other changes:
    • higher diaphragm
    • chest becomes more barrel shaped with increased diameter
    • slowed GI motility, slowed gastric emptying
    • normal to have small amounts of intraperitoneal fluid
    • widened symphysis pubic and sacroiliac joints
    • renal changes
  • plasma volume expands, peaks at 28-34 weeks
  • physiologic anemia with decreased blood viscosity
  • Trauma general principles:
  • Focus initially on ABCs, management dictated by severity initially geared toward maternal stabilization, what’s best for mom is going to be what’s best for baby
  • Do not under diagnosis or under treat secondary to unfounded fears of fetal effects
  • Place on O2 early due to decrease in FRC and increased O2 consumption
  • Recognize shock early
  • Four factors in maternal trauma/surgery that predict fetal morbidity/mortality: hypoxia, drug effects, infection, preterm labor
    • Decreased maternal hematocrit >50% or decreased MAP 20% or paO2 <60 à fetal hypoxia
    • Anesthesia-surgery is best between weeks 13-23
  • Secondary survey:
    • Examine for non-obstetric injury, fetal heart tones, speculum exam to r/o SROM or VB
  • Chest tubes need to be one intercostal space higher
  • Weigh risk/harms of CT
  • Shared decision making between Ob-Gyn, trauma, EP, and patient
  • Most gestational ages: check fetal heart tones
  • Continuous fetal monitoring is appropriate only if OB is willing to act on it (viable fetus)
  • If heart tones are absent regardless of gestational age, no fetal resuscitation
  • During acute phase, uterine contraction monitoring is appropriate
    • Remember you cannot r/o abruption with ultrasound (50% accurate or less)
  • Abruption:
    • Can occur with no sign of injury externally
    • Maternal mortality 1-2%, fetal 20% +
    • VB, abdominal cramps, uterine tenderness, amniotic fluid leakage, change in FHT, maternal hypotension
  • Labs:
    • Fibrinogen/KB test
    • Any patient who is Rh negative with abdominal trauma should receive Rhogam
  • Utilize ultrasound, MRI as needed
  • Penetrating trauma:
    • Remember intraabdominal organs change position
  • Electrical burns: fetus has lack of resistance to current = high fetal mortality
  • Other burns: silver sulfadiazine cream- used sparingly due to risk of kernicterus
  • Pelvic fractures:
    • Increased risk of shock, bladder, urethra injuries
    • Fetal skull fracture, fat embolism, vaginal lacerations
    • Is pelvic fracture an absolute contraindication for vaginal delivery? NO, depends on severity/type and compromise of pelvic inlet
  • Seat belt: lap belts alone increase abruption due to forward flexion and uterine compression, educate to wear low across pelvis

Pauline Thiemann, PharmD- Ketamine Music Trial Starting tomorrow, 9/1!!

EM Oral Boards, Jenny McGowan, M.D.:

  • Randomly assigned to dates
  • Format 7 cases, 15 min each, 2023 changing to 5 single patient, 2 structured interview
  • Practice practice practice
    • Review books, courses, online resources and practice cases
  • Structured interview: intended to assess clinical judgement and though process for decision making
    • Expect “why did you do xyz” question
    • What are you looking for
    • Interpret labs
  • Initial case stimuli with brief history, vitals.
    • Take note of all abnormal vitals, must be addressed
  • Labs
    • If certain lab is unavailable, move on
    • Should not be borderline
    • Occasionally may be given results you did not ask for, standardized results for all applicants, not that you missed something
  • Imaging
    • Usually clear, not designed to be tricky/subtle
    • All static
    • If unavailable, may need to stabilize or find alternative means of diagnosis
  • Talk to patient as if they are present
  • Ask for whatever you need
    • Pharmacy, poison control, family, EMS, etc
  • If someone says no or disagrees with you- you are allowed to argue
    • However, if you have tried to convince and they still refuse, you may be going down wrong path
  • If you receive prompting of “anything else you would give/anyone else you would call?”, pause and reconsider
  • Approach: HAVE A SYSTEM, if you don’t, you will skip steps and miss important findings
  • HPI: generally, answers are direct enough that you can get a thorough history quickly
  • Think level 5 charting: ask med, surgical, family, social hx. Ask meds. Ask allergies.
  • Exam: head to toe on all cases, keep list, take notes, practice to move through efficiently
  • Give orders clearly at a speed in which your examiner can keep up
  • Be aware of scoring system, look at ABEM website
  • ABC survey first in unstable patients, then interventions to stabilize, then secondary survey, gather more history to supplement along with additional medical info
  • ABC interventions: accucheck, bil IV, cardiac monitor (supplemental O2 PRN, cont pulse ox, BP), draw rainbow of labs, EKG, family/EMS hang around, gown/expose, “hello” introduce to patient, immobilization/isolation
  • You are provided with reference labs for normal ranges
  • Level of care generally increased from typical clinical cases, patients rarely go home
    • If questioning, admit up a level

Substance Use Disorders in the ED, Richard Cales, M.D.

  • Dependence- reliance on a substance to prevent withdrawal
    • Easily managed with medication, can be resolved with slow taper,
    • Not a unique property for many substances, but rather a normal and expected distraction from the real problem of addiction
  • Addiction: unlike physical dependence, is abnormal and classified as a disease
    • Primary condition associated with uncontrollable cravings, inability to control use, compulsive use, continued use despite harm to self or others.
    • Currently characterized as substance use disorders
  • Polysubstance use is the rule as opposed to exception for patients with severe substance use disorder (frequently nicotine and alcohol, also methamphetamines in this area)
    • Always think- what else are they taking?
  • Diagnosis:
    • Severity groups based off of specific criteria associated with impaired control, social impairment, risky use, drug dependence
  • POC urine drug testing has been used widely and remains appropriate for screening low risk populations (workplace, schools, military, etc).
    • Massive number of false positives, negatives
    • Should not be used for management, use as red flag to refer/obtain additional testing such as mass spectrometry
  • ED options for OUD:
    • New term is MOUD (medication for opioid use disorder) rather than MAT (medication assisted treatment)
    • Buprenorphine slowly replacing methadone as standard of care
      • Available as daily sublingual tablets/films or monthly depot injections
    • Most common ED presentations:
      • Overdose requiring admission- managed with Narcan, admission, eventual referral
      • Overdose not requiring admission: managed with symptomatic treatment and referral
      • OUD patient in withdrawal: managed with buprenorphine induction and referral
      • OUD patient not in withdrawal seeking treatment: managed with referral only
  • Vulnerability to addiction is 50% genetic (derived from twin studies)
  • Addiction (defined as severe SUD) is chronic
    • Subject to acute exacerbation, similar to severe COPD, CHF
    • Requires lifelong treatment (as opposed to tapering, which is often used for mild SUD)

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