>EM Reflections – April 2018

Thanks to Dr. Joanna Middleton for leading the discussions this month

Edited by Dr David Lewis 

 


 

Top tips from this month’s rounds:

 

Ondansetron (Zofran) and QTi

Globe Rupture

Ovarian Torsion

 


 

Ondansetron (Zofran) and QTi

  • Ondansetron prolongs QTi in a dose-dependent manner
  • Patient is most at risk for an arrhythmia when peak serum levels are reached
    • Largest difference in QTi was found at 15 minutes (IV), but has seen to persist up to 120 min in heart failure patients.
  • Arrhythmia after a single dose is EXCEEDINGLY RARE
    • No reports of arrhythmia after a single dose of oral ondansetron.
    • Consider ECG monitoring (or use another anti-emetic agent) in patients who are receiving IV ondansetron with other arrhythmogenic factors such as QTi prolonging agents or electrolyte abnormalities

Ondansetron and QTc Prolongation: Clinical Significance in the ED

 


 

Globe Rupture

  • When should you suspect?
    • Mechanism – severe blunt, penetrating, metal-on-metal
  • Signs of open globe include:
    • penetrating lid injury,
    • bullous subconjunctival hemorrhage
    • shallow anterior chamber
    • blood in the anterior chamber (hyphema),
    • peaked pupil
    • iris disinsertion (iridodialysis)
    • lens dislocation, and
    • vitreous hemorrhage. Loss of red reflex can indicate vitreous hemorrhage or retinal detachment.

The EyeRounds.org website has some useful tutorials.

 

Management 

  • Stop Examination
  • NO PATCH – Use Eyes Shield
  • Consult Ophthalmology immediately
  • NPO, Tetanus, IV Antibiotics, analgesia and antiemetics

Download (PDF, 181KB)

 


 

Ovarian Torsion

  • Uptodate:  It is one of the most common gynecologic emergencies and may affect females of all ages
  • Most common ages 20-50 years
  • Acute onset pain with adnexal mass
  • As size of mass increases, risk of torsion increases
    • #1 RF is ovarian mass >5 cm
    • benign > malignant
  • Increased risk during pregnancy, fertility treatments
  • U/S test of choice, although normal doppler does not rule out torsion
  • CT not diagnostic, although if you had a CT that didn’t show an ovarian mass of >5cm, unlikely it was torsion…
  • 86-95% of patients with torsion have a mass (exception – pediatric population – more likely to have torsion with normal ovaries)
  • Pediatric patients – early surgical detorsion more likely to be successful
  • >36 hours – non-viable

A useful recent review can be viewed here

CoreEM provides another useful summary (as well as a huge amount of other EM Topics)

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