Conference notes 12/6

• Ovarian cysts, rupture, and torsion (Dr. Williams)
  • Ovarian cysts: If cyst size is greater than 10cm consider OB consult for potential surgery
  • Infundibulopelvic ligament (suspensory ligament) contains the ovarian aa, vv, nn and is cause of ovarian torsion
  • If concerned for torsion and US inconclusive can get MRI
• PID (Dr. Mattingly)
  • Most common in 18-44 yo F
  • Physical exam findings: lower abdominal tenderness, cervical motion tenderness, cervical purulent drainage, adnexal tenderness or mass
  • Admission criteria: severe n/v, fever, pelvic abscess ruptured TOA, need for invasive diagnostic eval, unable to tolerate PO, concern for nonadherence
  • IP Tx: ceftriaxone and doxycycline+ flagyl, OP: ceftriaxone 1x then doxycycline + flagyl x 14d
• Perimortem C Section (Dr. Boland)
  • Gravid uterus can compress IVC impeding venous return> compressions w L lateral uterine displacement can alleviate this pressure
  • If fundus height at or above the umbilicus and ROSC is not achieved> recommend perimortem c-section (estimated gestational age >24wks)
  • Should be considered at 4 minutes after the onset of maternal cardiac arrest or resuscitative efforts
  • Do not attempt to take to the OR for the procedure
• Operations Update (Dr. Ross)
  • If an abortion presents to ED and ‘fetal tissue’ is removed, a series of forms regarding remains, cremation, and ‘death certificate’ must be completed by nursing staff.
  • Minors cannot give consent for cremation/disposal of fetal remains. If the patient refuses to tell their guardian about the pregnancy and abortion- ULH will manage tissue. ** Dr. Ross is in the process of confirming this.
  • ‘Fetal tissue’ must be sent to pathology.
  • CAR T-Cell Therapy Adverse Events: CRS (cytokine release syndrome- patients appear septic, fever, tachy, hypoxic, dyspneic, hypotensive) vs ICANS (Immune-effector cell-associated neurotoxicity syndrome- AMS, seizures, cerebral edema). Will be admitted to BMT. BMT Cytokine release syndrome and ICANS management order set on Cerner
• Preeclampsia and Eclampsia (Drs. Huttner and Stults)
  • HTN in pregnancy = >140/90 (gestational = diagnosed >20wks gestation and resolves after 12 wks post partum)
  • Pre-eclampsia: HTN w proteinuria (protein/Cr ratio >0.3 or 2+ protein on urine dipstick) or evidence of end-organ damage
    • PLT< 100,000
    • Cr> 1.1
  • Ecclampsia:
  • Pathophys- abnormal placentation leading to poor placental perfusion and hypoxia-reperfusion injury. Inflammatory markers target maternal endothelium.
  • Sxs: elevated BP, SOB, rapid weight gain, pitting edema (hands/face), decreased UOP, AMS, RUQ/epigastric pain, HA
  • Labs: thrombocytopenia, incr Cr/AST/ALT (HELLP), LDH (hemolysis), coagulopathy
  • Severe Pre-E management:
    • Seizure ppx: Magnesium
    • BP management
      • Labetalol, hydral, nifedipine
    • BP goal: decrease MAP by 20% in the first several hours
    • Labetalol 20 mg IV  q30 min total 300 mg
    • Hydral 10 mg IV q 20 min total 30 mg
    • Mag 4-6 g IV
    • Deliver at 37 weeks if regular pre-e; if severe: deliver at 34 wks
  • Eclampsia management
    • L Lat decubitus position
    • RSI if needed
    • Seizure treatment
      • Mag 4-6g bolus (over 20 min) followed by 1-2 g/hr infusion
      • Benzos if refractory
    • Delivery of fetus
  • Complications: pulmonary edema, MI, stroke, ARDS, coagulopathy, renal failure, retinal injury
  • Dispo: pre-e wo severe features likely dc, severe or eclampsia: admit

Conference 12/13

• Hyperemesis Gravidarum (Dr. Taylor)
  • Severe nausea/vomiting
  •  Weight loss >5% of pre-pregnancy weight
  • Onset <9 weeks gestation
  • Occurs in 0.3-3% of pregnant patients
  • Symptoms resolve 20-22 weeks
  • Risk factors
    • Family hx
    • Prior pregnancy with hyperemesis gravidarum
    • Hx of motion sickness, migraines
    • N/v related to estrogen medications
  • PUQE score to determine severity, based on duration, number of episodes of emesis
  • Complications
    • Dehydration
    • Electrolyte derangements
    • Mallory Weiss tear/esophageal injury
  • Treatment
    • For DC: Pyridoxine +/- doxylamine
    • In ED: IVF, diphenhydramine, metoclopramide, promethazine, prochlorperazine, Zofran is controversial
• Labor (Dr. Blair)
  • Shoulder Dystocia
    • HELPERR mnemonic
      • Help (call for help)
      • Empty bladder
      • Leg- McRoberts
      • Pressure- Suprapubic
      • Enter- Rotational maneuver
      • Remove posterior arm
      • Roll the patient onto her hands and knees
  • Umbilical cord prolapse
    • Have mom stop pushing
    • Use hand to elevate presenting part and decrease compression of cord
    • Attempt to not manipulate cord> can lead to vasospasm
  • Post-Partum Hemorrhage
    • Most common> uterine atony
      • Fundal massage
      • Oxytocin 10u IM/40 u in 1 L
      • Misoprostol 800-1000 mcg rectal or buccal
      • Methergine 0.2 mg IM/IV q2-4hr PRN
• Neonatal (Dr. Bhargava)
  • Neonatal conjunctivitis
    • Often without fever, just discharge
    • Ddx: gonorrhea vs chlamydia
      • Gonorrhea- first week of life
      • Chlamydia- day 7-14 of life
        • Pneumonia is common complication
    • Management:
      • Admit for abx
  • Neonatal mastitis
    • Etiology staph aureus
    • Dispo: admit for abx, drain abscess if present
    • Peak incidence at 2wks of life
    • Complications: cellulitis, necrotizing fasciitis, osteomyelitis
  • Neonatal seizures
    • Often focal- lip smacking or leg pedaling
    • Causes: hypoxic-ischemic encephalopathy, infection, ICH, metabolic abnormality, meningitis
    • First line tx is phenobarbital
  • Inconsolable infant
    • Easily consoled without source of crying> can be discharged
    • IT CRIES, causes for crying infant
      • Intussusception
      • Trauma
      • Cardiac
      • Rectal/anal fissures/reflux
      • Ingestion
      • Exposure, eyes (corneal abrasion, FB)
      • Sepsis, strangulation (hernia)
    • Hair tourniquet
      • Try application of Nair (less than 10 mins)
      • If color of extremity/ physical exam does not improve> cut down to bone with scalpel
  • Newborn rashes
    • Erythema toxicum neonatorum:
      • papules, pustules, erythema
    • Herpes simplex:
      • lesions are vesiculopustular on ill appearing neonate
    • Milia:
      • 1-1 mm pearly keratin plugs
    • Neonatal cephalic pustulosis:
      • unclear etiology, can be inflammatory reaction.
      • Tx daily cleaning with soap and water ***
    • Seborrheic dermatitis
      • Yellow flaky, often starts in scalp
      • Typically resolves in weeks to month
      • Can use emollient or low potency steroid
      • Ketoconazole shampoo if severe
  • Hypoglycemia
    • Rule of 50s
      • < 1 year old use D10 (5 mL/kg)
      • 1-8 years old use D25 (2mL/kg)
      • Greater than 8 years old D50 (1mL/kg)
  • Jaundice
    • ABO incompatibility: first day of life. Typically, mother’s blood type is O and Baby is A or B
    • Physiologic jaundice: seen at day 2-3 due to decreased conjugation of bilirubin due to immature liver
    • Severe neonatal hyperbilirubinemia
      • T bili > 25 mg/dL
      • Bili crosses BBB and causes neurologic dysfunction
  • Lower GI bleed
    • Meckel diverticulum is most common cause at 2y of age
    • Milk protein allergy should be suspected after introduction of new formula
    • NEC is complication of premature infants and presents with. Abdominal distension, bloody stools and feeding intolerance
    • To eval for swallowed mother’s blood as cause of blood in stool can use Apt Test
  • Pediatric vital signs
    • For children >1 y old SBP= 70+2x age (lower limit of normal)
  • Abdominal wall defects
    • Omphalocele
      • Often with other congenital defects
      • Membranous covering over abdominal contents
    • Gastroschisis
      • Direct exposure of abdominal contents
  • Omphalitis
    • Most often cause s. aureus
    • Presents before 14 days of life
    • Can become necrotizing fasciitis or sepsis
    • High morbidity and mortality rates
  • Intestinal malrotation
    • AXR: double bubble sign
    • Upper GI series: corkscrew sign
    • AIR in biliary tree is most often seen with NEC