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Grand Rounds - June 1, 2016

6/1/2016

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Grand Rounds June 1st:
  • Intern Board Review with Marie-Eve
  • Sepsis Update with Alex
  • Nausea & Vomiting in Pregnancy by Jared
  • Evidence-Based Updates by Dr. Pourmand
  • The Pelvic Exam by Annabel
  • Specialty Conference: Ob/Gyn - by Michelle and Dr. Anna BuAbbud, chief Ob/Gyn resident

Board Review: Ob/Gyn by Marie-Eve

HELLP Syndrome
  • increased risk of intracranial bleeding
  • criteria for Preeclampsia: BP >140/90 beyond 20weeks gestation, severe preeclampsia BP >160/110
  • tx: Mg and antihypertensives
Endometritis
  • sx: fever, abd pain, foul-smelling, profuse blody d/x, uterine and adneal tenderness
  • cesarean (70%)
Tubo-ovarian Abscess
  • polymicrobial: chlamydia, gonorrhea, gram neg orgs, anaerobes
  • mgmt: IV abx (amp, gent, clinda)
    • if >10cm -> drain
Post-Partum Cardiomyopathy/Pericarditis
  • rare, but mortality as high as 30%
  • clinical presentation similar to CHF
  • mgmt: inotropes, after load reduction (hydralazine and labetalol), rest
  • on echo, all 4 chambes enlarged with decreased systolic LV dysfunction
  • RF: maternal age, multi-parity, twin pregnancies
Spontaneous Abortion
  • up to 80% of women with first trimester SAB complete the abortion without intervention
  • threatened AB should avoid anything in the vagina temporarily
  • Rhogam - anytime RH - pt exposed to fetal bleeding (if father Rh + or unkown)
    • 50 ug in first trimester
    • 300 ug after first trimester (counteracts up to 15mL RBCs or 30mL whole blood)
Kleihaur-Betke Test (KBT)
  • detects fetal cells in maternal circulation
  • not sensitive - requires 5mL of fetal cells (as little as 0.1mL can sensitize the mother)
  • KBT not useful in most pregnancies, but can help if >30mL
Fetal Heart Monitoring
  • VEAL
  • CHOP
    • Variable decels - Cord compression
    • Early decels - Head compression
    • Accelerations - (normal)
    • Late decels - Placental/uteroplacental insufficiency
Ulcerative STDs
  • HSV 2
    • multiple small grouped vesicles, shallow ulcers, recurr, painful
    • can have lymphnode involvement
    • dx by cx of PCR
    • mgmt: first episode - Acyclovir 400mg PO TID 7-10 days
      • can also take suppressive therapy
  • Syphilis
    • treponema pallidum
    • indurated, sharply demarcated with red smooth base, not painful
    • firm, rubbery lymph nodes
    • dx: dark field exam (scrap lesion or use fluid)
      • serology for screening: RPR, then confirm with MHA-TP or FTA-ABS
    • tx: Penicillin G, one time does of 2.4 mil units IM (must be long-acting!)
  • Chancroid
    • hemophilus ducreyi
    • irregular, sharply demarcated, painful
    • tx: ...
  • Lymphogranuloma Venerum
    • chlamydia
    • usually single lesion, papule, or ulcer, transient, frequently not noticed, not painful. lymph nodes unilateral, firm, tender, fized, may form fistulas
    • tx: Doxy or erythromycin x 21 days
  • Granuloma Inguinale
    • Klebsiella, chronic, hard, irrgular, clea-based granulomatous ulcer, highly vascular and bleed easily, not painful. no lymph node involvement. 
Vulvovaginitis
  • Bacterial Vaginosis: tx: Metronidazole x 7 days
  • Trichomonas: dx on wet mount, Metronidazole
  • Candida: white, curdy discharge, budding and hyphae. Fluconazole 150mg PO x 1 or intravginal agents. oral -azoles contraindicated in pregnancy
Bartholin's Gland Cyst
  • typically polymicrobial
  • tx: Word catheter should be placed for 6-8 weeks (2-4 weeks in other sources?)
    • drainage by fistulization or marsupializataion
    • local anesthesia, scapel incision, break up septations with hemostat, place cathether (fill with 2-3mL of saline)
    • once, drained, abx not of value unless surrounding cellulitis
  • located at 5 and 7 o'clock, normally NOT palpable
  • older women should have elective excision b/c more likely to be adenocarcinoma


Shoulder Dystocia
  • tx:
    • can be relieved by extreme lithotomy position (McRobert maneuver)
    • apply moderate suprapubic traction and apply moderate traction to fetal head
    • can drain bladder with foley to create more room
    • episiotomy
  • RFs: fetal macrosomia, GD
  • fetal complicationsL brachiala plexus injuries, clavicle fxs, cord compression
Earliest Sign of Pregnancy
  • gestational sac
    • can be seen at level of BhCG 1,500 for TVUS and 6,500 for TAUS
  • double decidual sign is gestational sack with ecogenic outer...
  • yolk sac - first structure seen WITHIN gestational sac
    • first definitive evidence of IUP
  • fetal pole - seen after yolk sac. once reaches 0.5cm, cardiac activity should be seen

Sepsis Update by Alex

Mortality from sepsis has decreased to 5%, which is the 5th percentile nationally. In pts with septic shock, studies show that each hour of delay of abx was a/q decrease in survival of 7.6%. 80% survival if abx w'in first hour
  • Algorithm
    • triage nurse identifies 2 SIRS and possible source
    • calls Senior Resident of Attending, who evaluates
    • bundle to be initiated in 15 minutes
  • UHS 3+ SIRS criteria, no organ dysfunction = sepsis
  • Improved time to abx, but still avg 160 mins
  • 22% of pts who fire sepsis sun have final dx of sepsis (picks up all severe sepsis and septic shock)
  • time from abx order to admin ~60 mins
    • reasons for delay: most have delay in IV access, 1 with delay in blood culture, 1 with vancomycin given first

Sepsis 3.0 (Third International Consensus Definitions for Sepsis and Septic Shock)
    • sepsis - organ dysfunction caused by dysregulated host response to infection
      • organ dysfunction = SOFA >=2 (many variables, better for ICU, made to be mortality predictor)
      • in-hospital mortality 10%
    • septic shock...
    • screening with q-SOFA
      • resp >= 22
      • AMS
      • SBP <= 100

Nausea and Vomiting during Pregnancy

DDx:
    • NVP usually manifest <9 weeks GA
    • if >9 weeks, consider appy, choley, pyelo, DKA< preeclampsia
    • ROS: abd pain, fever, hepatitis, goiter
  • Hyperemesis Gravidarum
    • prevalence 0.3-3% of all pregnancy
    • no criteria, look for electrolyte abnormalities
  • maternal complications:
    • Wernicke's, splenic avulsion, esophageal rupture, PTX, ATN, psyclsocial impact
Treatment
    • assess for dehydration, IVF PRN
    • treat pt's view of condition
    • first line: B-6: 10-25mg Q8H
      • plus doxylamine
      • combined pill previously accused of birth defects, but subequently exonerated
        • now reissued as Diclegis (10mg/10mg)
        • reduced sx from 49% to 33% - clinically significant
      • very expensive: can try combining OTC B6 and doxylamine (anecdotally, another resident's wife had bad NVP and OTC didn't help but Diclegis did)
    • Zofran 4-8mg ODT Q6H
      • watch for prolonged QTc
      • serotonin syndrome - use cautiously in pts taking SSRIs
      • HA, weakness, drowsiness (less than others)
      • one study showed increased risk of fetal cardiac septal defect
      • ACOG says it is category B
    • Phenergan (promethezine)
      • 12.5-25mg PO or IM Q4-6H (do not given IV, a/w tissue necrosis)
      • SEs: dry mouth, sedation
      • category C
    • Reglan
      • 10mg IM or PO Q6H
      • SEs: tardive dyskinesia
        • avoid high doses or treatment for >12 weeks
      • category B
    • Other
      • Benadryl
      • Tigan
      • Dramamine
      • Mecliine
      • NO SCOPALAMINE - a/w teratogenicity
      • Steroids last resort b/c can cause increased rate of cleft palate
    • Non-pharma options
      • multivitamins 3 months prior to preg, a/w decreased incidence
      • ginger capsules shown to reduce N but not V
      • dietary modifications
        • small meals
        • avoid spicy fatty foods
        • eating more protein
      • avoid sensory stimuli
      • psychotherapy does not help
      • accupuncture :(
  • Dispo:  admit if AMS, can't tolerate liquids, ketonuria, unstable VS

Evidence-Based Update

"Does This Patient With Chest Pain Have Acute Coronary Syndrome?" systematic review in JAMA Nov, 2015
  • 10% of pts with CP in ED have ACS
  • Accuracy of clinical exam in dx of ACS
    • radiation to both arms - 96% specificity; LR 2.6
    • pain similar to prior ischemnia - 79% specificity, LR 2.2
    • RFs: hx of abnl prior stress test and PAD most important (fam hx, tobacco use not as significant)
    • PE: HTN, rales, tachypnea, tachycardia most important
    • EKG findings: STD, ischemic EKG, TWI
    • decision rules: HEART misses 2.9%, TIMI misses 4.4% of ACS

"Postural modification to the standard Valsalva maneuver in SVT" Lancet 2015
  • cardioversion in clinical practice 5-20% (ACLS Guideline 2010 says 25%)
  • pts blew at 40mmHG for 15 seconds, then laid supine with leg elevation
  • 43% using modified maneuver converted
  • CEs: unstable c-spine, hip dislocation
  • no reported serious SEs


"A Randomized Controlled Noniferiority Trial of Single Dose Oral Dexamethazone vs 5 Days of Oral Prenisone for Acute Adult Asthma" Annals of EM 2015
  • 12mg dex vs 5 days of 60mg pred
  • similar or slightly inferior to dex

The Pelvic Exam

Undifferentiated Abdominal Pain (not pregnant)
  • Torsion
    • 29% had NO tenderness on pelvic exam
    • 53% had NO palpable mass on pelvic exam
  • PID
    • tenderness on bimanual exam
      • sensitivity 91-99%
      • low specificity - max 20%
    • CDC recs empiric tx for sexually active woman w pelvic/abd pain and pelvic tenderness (CMT, adnexal, or uterine) and no other explanation
    • cultures?
      • self-collected vaginal swabs are equal in sensitivity and specificity to clinician collected

First Trimester Abdominal Pain/Bleeding
  • DDx:
    • Ectopic
      • pelvic exam is not that sensitive:
        • CMT - OR 3.3 (45% had this)
        • lateral or bilateral adnexal tenderness - OR 2.4 (61% had this)
        • adnexal mass - OR 2.2 (14% had this)
      • still need U/S
    • Abortion
    • Normal IUP
    • Abnormal IUP
    • Trauma/Cervical lesion
  • Can you skip the pelvic if pt is getting U/S?
    • No change in mgmt when U/S shows IUP
      • TVUS can predict cervical length and open/closed os (put in comments, "Please assess cervix")
      • consider self-collected specimen for STD testing
      • still need to r/o active/massive hemorrhage
    • If TVUS indeterminate, need pelvic exam for tenderness and open/closed os
      • tenderness keeps ectopic on ddx
    • Study at GW Brown et al in Western Journal of Emergency Medicine 2011
      • 6% of pts with findings on pelvic exam that changed mgmt
  • On study in Western Journal of Medicine 2001 showed that "The findings of bimanual pelvis examinations performed by emergency physicians are unreliable." Previous studies show the ob/gyn practitioners have similar degree of unreliability

Specialty Conference

Specialty Conference: Ob/Gyn - by Michelle and Dr. Anna BuAbbud, chief Ob/Gyn resident
First Trimester Vaginal Bleeding/Pain
  • exam: abdominal exam for peritoneal signs
  • pelvic exam: os opened or closed? clots? POC?
  • TVUS - should see something if beta >3000 (upper discriminatory zone)
  • indeterminate: non-specific fluid collection, gestational sac with no yolk sac, echogenic material, enlarged cul-de-sac
  • Patient counseling:
    • worsening pain, bleeding, fever
    • "pelvic rest" to reduce risk of infection to reduce risk of infection (and guilt)
    • emotional support (not their fault, would have happened anyway, usually genetic problem with baby, 1 in 3 early pregnancies result in miscarriage)
  • ACEP guidelines:
    • even if beta is below discriminatory zone, get pelvic U/S (can have ectopic even if beta is low)
    • if TVUS is indeterminate, DO NOT use beta value to EXCLUDE ectopic
      • obtain specialty consultation or close outpatient f/u for all pts with indeterminate U/S


Consulting Ob/GYN
  • Useful information before calling:
    • Age, G's and P's
    • Where they are seen?
    • How many pads filling with blood?
    • LMP
    • VS
    • blood type
    • beta level
    • pelvic exam
    • U/S results
  • Should we do a pelvic if you're likely going to?
    • highly variable, ok to ask
    • make sure to do it if brisk bleeding - removal of POC from OS can stop bleeding
      • use ring forceps and keep for pathology
  • What happens when we call to put someone in the "beta book"?
    • new policy that ob/gyn resident needs to come down and see pt
  • What triggers surgical tx of ectopic?
    • unstable/abnl vitals
    • low Hct
    • possibly for unreliable pt
    • heart beat in tube
  • Ob/Gyn clinic does take Medicaid but does not take uninsured pts (they can go to Unity or Planned Parenthood)


Pregnancy Induced Hypertension
  • gestational HTN (after 20 weeks): >140/90, resolves postpartum
  • preeclampsia
    • vasospastic disease
    • gestational HTN +proteinuria (or AMS, signs of end-organ damage: elevated LFTs, RUQ TTP, thrombocytopenia, headaches, visual changes)
    • spot urine protein to creatinine ratio (24 hour protein collection no longer needed)
      • cutoff 0.3
    • cure is delivery of placenta
  • HELLP
    • hemolysis
    • elevated liver enzymes
    • low platelets (<100,000)
    • Pt/Ptt/fibrinogen - normal
  • Eclampsia
    • preeclampsia + seizure
    • don't forget to feel for fundus if unknown PMH and pt unable to provide
    • increased total leukocyte count, creatinine, or AST - a/w increased morbidity
    • can happen up to 6 weeks postpartum
    • MC sx is headache - remember to ask if they have new infant at home if BP is >140/90
    • testing:
      • fetal monitoring
      • CBC, BMP, LFT, coags, Mg, (UA, U Cr, U prot), [LDH, uric acid - can be added on to CMP]
      • if seizures, check blood glucose
      • if no hx of preeclampsia or refractory seizures -> CT head
    • Mgmt:
      • Mild/Moderate
        • close f/u
        • accurate gestational age on U/S
        • bed rest to reduce BP, allow pregression of pregnancy
        • hospitalization if BP >140/90
      • Severe (BP >160/110)
        • control seizures -> Mg sulfate (6g over 10-15 minutes, then 1-2g/hr)
          • watch for hypotension, but expect it - it's one of hte goals
        • control BP if DBP >105
          • hydralazine or labetalol
          • DO NOT USE ACEI
        • maintain UOP <25mL/hr
        • limit IVF
        • avoid diuretics, hyperosmotic agents
        • CT head if AMS, persistent seizures, lateralization
        • delivery baby
      • Imaging as needed
        • give pts ACR handout on radiation in pregnancy and lactation


Fetal Monitoring
  • blunt body trauma
    • preg >24 weeks -> send for 4hrs of fetal monitoring if no other treatment needed
    • preg <20 weeks -> fetus not viable, no monitoring indicated as no obstetric intervention will alter outcome


Medications
  • NSAIDs - increase risk of spontaneous abortions, birth defects, neonatal pHTN, fetal death
  • opiates ok until nearing delivery
  • usual RSI meds ok or unknown
    • just do it if needed
    • previously considered avoiding propofol for possibly fetal hypotension
  • no fluoroquinolones, tetracyclines
  • cephalosporins, penicillins ok
  • nitrofurantoin CI'd in 3rd trimester (theoretic risk if fetus has G^PD)
  • metronidazole contraindicated in 1st T
  • cardiac and neuro meds are often class C or D
  • Phenylephrine is vasopressor of choice

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​Please refer to our Terms of Use. 
  • Clinical
    • Discharge Macros
    • Procedure Macros
    • Exam Macros
    • Pediatric Macros
    • Antibiogram
    • Follow Up
    • 2023 MDM
    • Heart Pathway
    • Jeromy's Macros
  • Education
    • EM Education
    • Critical Care
    • FOAM
  • Orientation
    • Dept Orientation
    • Cerner
    • Dragon
  • Links
    • Clinical Links
    • StatMacros
    • ICU Bootcamp
  • Private
    • MCS
    • GWU Contacts & Map