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 2^nd 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 4^th intercostal space instead of 5^th
  • 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)