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)

SANE, Amanda Corzine:

• Purpose: medical eval and treatment, evidence collection, documentation of injuries, male/female victims of sexual assault age >12, “rape kit” collection in <96h, sane room in back hallway has full shower and bathroom
• Benefits: detailed written and photo documentation, expedited visit, referrals to appropriate f/u care and community resources, integrated care with advocacy/law enforcement. SANEs can testify as expert witnesses in legal proceedings.
• Sexual assault nurse examiners: RN with specialized training in medical forensic exam
• Reporting may occur at time of exam or prior to arrival or victim may chose to have kit collected without reporting, kept for 1 year and then destroyed, only tested for DNA if report made
• Level of alertness required for exam, search warrant required for unconscious patients
• Can also see patients in EPS
• Neurobiology of trauma
  • Difficulty in recalling facts in linear format
  • Emotional presentation
  • Sometimes sensory memory is more well preserved
• Patient history guides the exam
• Important to write declined rather than refused
• SANEs will document bodily and genital injuries and obtain photographs as possible
• Will generally order prophylactic meds and notify physician
  • Specific protocol built for NPEP
• HIV risk by exposure:

Perimortem c-section, Drs. Royalty and Newcomb:

• Anatomic and physiologic changes in pregnancy
  • Airway: narrowing of upper aspect in third trimester, intubated using ETT 1 size smaller than usual
  • Breathing: elevation of diaphragm -> decrease in residual capacity, poor toleration of apnea. Give supplemental O2 rapidly.
  • Circulation: by 28w, blood volume and cardiac output increase by 30-40%, compression of IVC, displace uterus to L (rotate 15-30 degrees), aggressive fluid resuscitation.
• PRIMARY BENEFIT: MATERNAL RESUSITATION
  • Secondary benefit: fetal viability
• Indications:
  • Cardiac arrest- medical or trauma (ideally within 4 minutes, have been reports of saves up to 15 min post arrest)
  • >/= 24w or fundus is above umbilicus on your exam
• Contraindications:
  • ROSC within two cycles of compression
  • Gestational age <20 weeks
• ACLS considerations for pregnant patients:
  • Provider performing ACLS is separate from physician performing procedure
  • Fetal assessment should not be done.
  • Hand placement is the same as nonpregnant patients, same dose of meds. Cardioversion and defibrillation are not contraindicated
  • Continuous lateral uterine displacement while performing CPR with patient supine
• Need:
  • Bare minimum: scalpel, scissors, gloves. Chest tube kit can be a good start.
  • Other supplies: definitive airway, O2, two large bore IVs, end tidal CO2, c/s delivery kit/trauma lap kit, no 10 scalpel, hemostats, large scissors, gauze sponges/surgical towels, retractors, infant warmer, bulb suction, pediatric airway kit
• Very basic process

1. Large vertical incision from xyphoid process to pubic symphysis

2.  Expose uterus

3. Inferior small vertical incision (around 2 fingers size) to uterus, insert fingers and lift uterus away from fetus, use scissors to make incision directed superiorly

4. Deliver infant, pass infant to someone else

5. Pack uterus/abdomen,

• Complications:
  • Bladder/bowel injury, injury to fetus, arterial injury
• ROSC considerations:
  • Broad spectrum PRN or cephalosporin
  • Consider oxytocin, can cause arrhythmias and risk repeat arrest
  • Why did patient arrest?

Documentation update:

• Big changes coming in early 2023, stay aware and will have continued updates
• Make sure to document discussion with other physicians, brief summary
  • Radiology
• Any history obtained from someone other than patient
  • Friend/family, EMS, police, nursing home
  • Make sure to say “Per ___,”
• Review and summarization of old records
  • Cannot just copy and paste. Must make comment.
  • Try to say specifically what you reviewed, when/where that visit was, and what you took from it that was relevant.
  • Don’t just say- reviewed outside records. This does not add anything to the record.
• Conversation with other specialists, what you discussed, outcome/recommendations
• Document independent interpretation of imaging

Medical Mimickers of Psychotic Disorders: A Review of Secondary Psychosis, Drs. Reske and Marcellus:

• Condition affecting cognition and causing distorted perception or loss with reality
• Psychotic presentations are seen in many different syndromes/disease processes
• Primary psychiatric
  • Little/never develops over short period or in older patients, except potential for first break psychosis in post-menopausal women
  • Usually subacute, variable attention, generally alert, both episodic and chronic, episodes can resolve but repeated episodes can lead to chronic symptoms, in general cognition (orientation) should be intact
• Secondary psychosis
  • Mnemonic: TACTICS MDS USE
  • Substance intoxication: stimulants (symptoms can become permanent), hallucinogens, dissociants. Usually sudden onset, changes in vitals. Auditory, tactile hallucinations, paranoid delusions. Commonly with hyperkinetic body movements. Manage with benzos, antipsychotics, aggressive hydration.
  • Substance withdrawal:  GABAergics (benzos, barbs, baclofen, EtOH), opiates less frequently
  • Dementia with behavioral disturbance: in late stage, baseline psychosis is not uncommon. Consider frontotemporal dementia. Lewy Body Dementia and Parkinsons can have complex visual hallucinations. However, acute worsening of confusion or deviation from baseline should raise concern for underlying medical condition. Can be very distressing for patient but frequently can be calm and even soothed by these hallucinations, sometimes patients are aware that these perceptions are not real.
  • Infection: UTI most often, also meningitis, cerebritis, HIV, neurosyphilis
  • Delirium
  • What is atypical? Later onset, primarily confused/disoriented, visual/multimodal hallucinations.
  • Less common but can be easy to test: thyroid disease, b12/folate deficiency, hypo/hypernatremia, hypercarbia/hypoxic (can have visual hallucinations), calcium, hepatic encephalopathy (sometimes can present even before jaundice), infections (RPR, HIV), space occupying lesions, stroke, seizure
  • **Try to get a thorough history and physical**
• Primary vs secondary investigation:
  • Is presentation of psychosis atypical?
  • Is medical condition or substance use temporally related?
  • Is the psychosis not better explained by primary psychotic disorder or other mental illness?
  • Is psychosis a direct physiological consequence of a medical illness of substance use?
• Secondary: Treat underlying cause if known, avoid benzos if possible, can worsen delirium and disinhibition, avoid anticholinergic meds
• Primary: best to use antipsychotics if possible
  • Multiple medications exist in PO, IM forms with different MOA, onset times, etc

Sepsis Update, Marianne Kreuger

• RN can initiate triage-initiated sepsis alert if patient has 2+ SIRS criteria and suspected/confirmed infection with or without organ dysfunction
  • Patient can flag for sepsis while in waiting room- time zero is triage
• Multiple sepsis power plans exist
• Three hour bundle and six hour bundle have different requirements.
  • 3h: IV abx, fluid bolus, lactic with reflex
  • 6h: repeat lactic if initial was >2, vasopressors if not responsive to IV fluids, tissue perfusion reassessment (echo, cap refill, periph pulses eval, etc)
• 30cc/kg bolus required when patient has two or more hypotensive episodes or lactic >4
  • If withholding full sepsis fluids, please document reason why
• .sepsisreassessment is helpful dot phrase in cerner
• Effort is being made to track patients in the waiting room to help meet compliance and goals
• Also: new hyperkalemia power plan exists specifically for insulin/dextrose treatment
  • Protocol for repeat poc glucose afterward for 6 hours, BMP Q1h x4

Pediatric Trauma, Dr. Klensch:

• Trauma Stat (generally more severe) vs Trauma Alert
• Trauma Role assignments: team leader, airway, assessor, procedure physicians
  • Specific roles prior to arrival and then after arrival
• Airway considerations:
  • Small mouth, larger tongue, large adenoid, floppy epiglottis
  • Larynx more cephalad and anterior
  • Increased vagal response, use atropine PRN
  • ET Tube: (age/4)+4
  • Depth: ETT x3
• Breathing:
  • Compliant ribcage makes fracture less likely
  • Pulm contusion is most common ped thoracic injury
  • Mobile mediastinum: less aortic disruption, more tracheobronchial injuries, earlier compromise from tension ptx
• Circulation
  • Long bone fracture generally won’t have as much blood loss as adults
    • Ex: if hypotensive with femur fx, should look into chest, abdomen, etc for other causes
  • ICH with open fontanelle can contain large amount of blood
  • No sternal IO in kids <12yo
  • Hypotension: 70 + (2x age)
  • Pay close attention to mentation in evaluating shock
• Disability:
  • Modified GCS exists for infants and children
  • Prevent secondary injury in TBI: avoid hypoxia, hypercapnia, hyperthermia, hyponatremia
  • Linear skull fracture are typically benign unless depression exists, overlying vascular channel, a diastatic fracture, or over area of MMA
  • Closed head injury: PECARN <2
• Exposure:
  • Expose entirely to eval for other injuries
  • At risk for hypothermia, keep exposure time brief
    • Due to large BSA, thin skin, minimal fat
• NAT:
  • KY has highest child abuse rate in the country
    • ~20/1000 kids in the state
  • IN has highest child abuse death rate nation wide
  • Up to 25% of severe child abuse cases have previous sentinel injuries
  • Red flags:
    • No hx of trauma, mechanism does not fit, history inconsistent with age/development, history changes, delay in seeking care
  • Use TEN-4-FACESp for bruising clinical decision rule for children <4
• Cervical Spine:
  • Generally uncommon, 1-2% of all trauma admissions
  • High risk: Down Syndrome, Ehlers Danlos, NAT
  • Most common site of fracture varies with age
  • Why not CT?
    • More expensive, more radiation
    • Less likely to define injury in infants and small children with only ligamentous injury
  • Ok to clear clinically in low risk (no distracting injury, normal neuro exam, etc), also make sure to examine for tenderness/ROM
  • Conscious, not meeting low risk criteria: okay to get plain XR, CT if XR unclear or high suspicion for injury
  • Unconscious or obtunded, obtain CT head and c spine
  • SCIWORA: neuro deficits or symptoms that may be transient w/ normal imaging, get MRI and NES consult, admit, can be delayed up to 30min-4days
• FAST
  • Data mixed
  • Several studies demonstrate lower sensitivity than for adults

Clinical Pathway- Complicated Delivery, Drs. Boland and Hill-Norby:

• ED deliveries higher risk than those on labor floor
  • Often little or no prenatal care
  • Higher perinatal mortality
  • Need to expect the unexpected
• Shoulder dystocia:
  • Clinical diagnosis when gentle traction is insufficient to deliver shoulders after delivery of head
  • General Mgmt: stop pushing, align buttocks flush with edge of bed to provide optimal access, cath bladder for decompression, suprapubic pressure
  • HELPERR (Ob, empty bladder, legs flexed (McRoberts), pressure to suprapubic area, enter vagina (Rubin or Woods), remove posterior arm (Barnum), roll to all 4s (Gaskin))
    • Pressure should be applied just above pubic symphysis, not fundal
    • Rubin, Woods, and Barnum generally all require adequate anesthesia, making their use more challenging in ED deliveries
  • Maneuvers of last resort:
    • Fracture of fetal clavicle
    • Zavanelli maneuver requires immediate availability of surgeon and anesthesiologist: push fetal head back up into pelvis and c/s performed
  • Breech presentation
    • 4% of live births
    • Prone to problems with cervical dilation and umbilical cord prolapse
    • Frank, complete, incomplete breech
    • Call for help, if fetus not yet emerged, tell mom not to push
    • Consider uterine relaxants
    • Allow spontaneous delivery, support fetus but do not apply traction
    • Fetus should be delivered within 10 min as cord will be compressed causing acidosis
    • Mauriceau-Smellie-Veit maneuver
  • Umbilical Cord Prolapse
    • 50% are associated with malpresentations
    • OB should be called, prep for c/s but if delivery is imminent facilitate as possible
    • Cord manipulation can induce vasospasm and hypoxia
    • Position mom in knee chest position
    • Any presenting parts should be manually elevated with provider’s hand to reduce pressure
  • CODE GREEN: imminent delivery
  • *** See Clinical Pathway Section for Malpositions Complicating Precipitous Delivery Flowchart***

The Clench Test, Dr. Martinez:

• Nerve innervations and why the clench test is useless in assessing for true spinal cord injury
• Glutes are innervated by L5-S2 where ankle flexion is innervated by S1-2 meaning if they can plantar flex, their buttcheeks can squeeze
• S3-4 control bowel and bladder function
• Pudendal nerve supports rectal tone, urethral and anal sphincters, made up of nerve fibers from S2-S4
• Trauma neuro exam
  • GCS/pupils/mentation, gross sensory, gross motor (PF and DF ankles), digital rectal exam
• Isolated damage to S1-5 can happen with sacral fractures depending on location, more medial fractures are higher risk for neurologic injury mostly involving bowel, bladder, and sexual dysfunction
• Reasons to do a proper DRE in trauma: clued in early to severe sacral fractures, blood, high riding prostate
• Always make sure to notify patient prior to DRE

Postpartum Hemorrhage, Dr. Shaw:

• Definition: >1000cc of blood loss or any blood loss with systemic signs of hypovolemia
  • Up to 24h postpartum
• Leading cause of maternal death worldwide, 1-5% of US deliveries
• Uterine atony most likely cause also laceration, retained POC
• DDx: tone, trauma, tissue, thrombin
  • Use physical exam to differentiate
    • Fundus should be below umbilicus
    • Inspect perineum for lacs
    • Uterine sweep for retained tissue, use ultrasound, look at placenta to verify that it appears intact
    • Coagulopathy: CBC, CMP, PT, PTT< fibrinogen, dimer, type/screen
• Bimanual uterine massage: one hand compresses fundus, one hand intravaginally compressing body of uterus
• Oxytocin first line
  • 10U IM, or 10-40U per 500-1000cc bag of saline as continuous infusion wide open
• Misoprostol: PO sublingual, rectal
• Uterine inversion:
  • Risks/causes: excessive cord traction, short umbilical cord, uterine relaxants during labor, previous inversion, placental attachment
  • Management: requires reduction of uterus
    • Provide adequate analgesia, likely procedural sedation
    • Nitroglycerine is potent uterine relaxant, onset 30 seconds, dose 50-100mcg bolus over 1-2 min, half life 2.5 minutes
• Retained Products of Conception
  • Eval with ultrasound for normal endometria stripe, inspect placenta, manual removal
  • Hemorrhagic shock: blood products ASAP
    • 1g bolus TXA = decreased risk of death by bleeding, evidence based practice
  • Tamponade with uterine packing, or Bakari balloon if available
    • Other options: Blakemore, condom cath

Peer Perspective on Addiction, Dr. McMurray:

• Make an effort to attempt to treat those with Opioid Use like you would anyone else, connect with them, ask them about their families, hobbies, things that make them happy Disorder
• Louisville area addiction resources guide to be posted in EXI and able to handout to patients with updated information
• Buprenorphine: partial opioid agonist
  • Subutex: buprenorphine only
  • Suboxone: buprenorphine and naloxone (attempts to decrease misuse or diversion)
  • Ceiling effect for euphoria/pain relief
  • Use caution when other CNS depressants are on board or patient has liver impairment
• X wavier: free, takes 3-4 min to apply, must have DEA number
  • Use link to apply https://www.samhsa.gov/medication-assisted-treatment/become-buprenorphine-waivered-practitioner
  • Enter licensing state, medical license number, and DEA number
  • “starting at the 100 patient level” select “no” for both questions
  • Select “I wish to apply for the 30 patient level with exemption”
  • Recheck in ~1 week to make sure your application was approved
• 3 day rule is for those without an x-wavier
• Resources: California Bridge Buprenorphine Pathway, Clinical Pathway on room9er by Dr. Kuzel
• Dot phrase for resources: ,dcaddict
• Prescribe Narcan kit at discharge

Pharmacy- Eclampsia/Pre-E, Josh Senn, PharmD:

• Important to quickly identify and treat these patients in a timely manner
• Hypertensive disorders of pregnancy are one of the leading causes of maternal and perinatal mortality worldwide
• 20-26% of eclampsia cases occur 48h-6weeks postpartum
  • 78% of these patients had no BP issues in pregnancy
• ACE-I and ARBS are contraindicated in pregnancy
• Preeclampsia: new onset hypertension and proteinuria
  • >160 systolic or >110 diastolic x1 or >140 and >90 x2 four hours apart
• Pre-e with severe features: new onset hypertension and signs of end organ dysfunction after 20 weeks gestation and up to 6 weeks postpartum
• Eclampsia: convulsive manifestation
  • Maintain airway, establish IV access, fetal monitoring and assessment, BP control, Mg therapy, obtaining pertinent labs
• Magnesium:
  • Do not wait on labs to initiate treatment with Mag!!
  • MOA possible cerebral vasodilation + blocking Ca entry + entry in neural cells and altering neurotransmission
  • Multiple studies validate use
  • Dosing: 4-6g IV over 15-20 min, repeat 2-4g loading dose PRN
  • Maintenance 1-2g/hr
  • **NO IV ACCESS: 5gm x2 IM in each buttock**
  • Monitoring: respiratory dive, patellar reflexes, for reversal can give Ca Gluconate 1g IV over 5-10 min, +/- 40mg Lasix (renal excretion of Mg)
• Blood pressure control otherwise: no difference in efficacy or safety in hydralazine, labetolol, nifedipine
• Initiate treatment for any SBP >160 or DBP >110
• Refractory HTN: nicardipine gtt (5-15 mg/hr) titrated to goal BP
• Stay up to date on ED protocol

Lightning Lectures:

• HELLP, Dr. Beard:
  • In pregnancy: multiple normal physiologic changes
  • HELLP 0.1-1% of all pregnancies
  • Questionably represents a severe form of pre-e
  • 15-20% do not have antecedent HTN or proteinuria
  • Pathogenesis: inadequate placental perfusion, induces platelet aggregation, endothelial dysfunction & arterial hypertension, fibrin released, microangiopathic hemolytic anemia
  • Risks: previous hx, multiparous women (>50%), COVID
  • Clinical manifestations: HTN, RUQ or epigastric pain, jaundice, nausea/vomiting, headaches, vision changes
  • Haptoglobin, LDH, coags in addition to other labs
  • Maternal stabilization and then prompt delivery if possible
  • Multiple pregnancy related disparities exist: black and Hispanic women are at significantly higher risk for pre-e and HELLP
• PID/TOA, Dr. Kushner:
  • PID: Proportion of cases caused by CT/GC is decreasing
    • Multiple other nontraditional organisms are surfacing and becoming more common
  • Risk factors: multiple partners, <25 yo, prior hx of PID or STI, partner with STI
  • Can occur acutely over several days or over weeks/months
  • S/s: lower abdominal or pelvic pain, pain with intercourse, abnormal uterine bleeding, urinary freq, vaginal discharge
  •  No single historical, physical or lab finding is both sensitive and specific
  • Special population: transgender patients- ask pronouns and ask about patient’s anatomy/organs
    • Very common (21%) for these patients to avoid ED care due to fear of discrimination
    • 4x higher rates of HIV, also higher rates of extreme poverty, sexual assault, sex work
    • Be cognizant of this
  • Maintain low threshold for clinical diagnosis of PID
    • Even mild or asymptomatic cases may be at risk of infertility
    • Presumptive treatment should be initiated for sexually active women: experiencing pelvic or abdominal pain, no other cause for illness can be identified or if one or more of the following criteria are present on pelvic exam: CMT, uterine tenderness, adnexal tenderness
  • Workup: pregnancy test, microscopy of vaginal discharge, HIV, syphilis, UA (in addition to other labs including inflammatory markers, CBC if more severe presentations)
  • Stay up to date on CDC guidelines
  • TOA: inflammatory mass involving fallopian tube, ovary, sometimes other adjacent organs like bowel/bladder
  • Not all are associated with PID
  • Pathophys: ascending lower genital tract infection
  • Not all have fever and acute abdominal pain
    • 23% have normal WBC count
  • CT > US if need to exclude GI tract involvement
  • Need at least 24h of inpatient observation

Research Updates, Dr. Huecker:

• Residents should understand how research is conducted, evaluated, explained to patients, and applied, participate in scholarly activity, have appropriate resources to accomplish these goals
•  ULDEM has a full time PhD faculty member who performs stats and also designs and serves as PI on studies: Dr. Jacob Shreffler

• Think, Do, Write
• Travel to conference is sponsored by the university if you are presenting
• Plan ahead, use available resources, expect delays, something you are passionate about

Suturing 101, Dr. Eisenstat:

• Resource: thelacerationcourse.com, also closing the gap
• “The best suture for a given laceration is the smallest diameter suture, which will adequately counteract static and dynamic tension forces on the skin” -Brian Lin
• Sizes and removal: please always discuss with patient and make sure to document in discharge instructions
• There is a difference between how long an absorbable suture supports the wound vs how long it actually stays in the skin
• Absorbable (fast gut) is completely appropriate for facial sutures in regards to scarring and patient satisfaction
• Utilize undermining when wound edges are too far apart to get good closure
• Vertical mattress sutures are good in high tension wounds: can make a big difference even with 1-2 placed in the middle of the wound
• Elderly, thinner skin: use steri-strips along edges and put sutures through steri strips