EM Reflections – June 2019 – Part 1

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

Edited by Dr David Lewis 


Discussion Topics

  1. When is a pregnancy not a pregnancy?
  2. Caustic Ingestions
  3. Transient Ischemic Attack – Emergency Medicine (see part 2)

When is a pregnancy not a pregnancy?

Molar Pregnancy

Hydatidiform mole (molar pregnancy) is a relatively rare complication of fertilization with an incidence in the United States of 0.63 to 1.1 per 1000 pregnancies, although rates vary geographically. It is included in the spectrum of gestational trophoblastic diseases and is comprised of both complete molar pregnancies (CM) and partial molar pregnancies (PM).

The most well characterized risk factor for CM is extreme of maternal age. Maternal ages less than 20 or greater than 40 years have been associated with relative risks for CM as high as 10- and 11-fold greater respectively. Other potential risk factors include oral contraceptive use, maternal type A or AB blood groups, maternal smoking, and maternal alcohol abuse.

Molar pregnancy typically presents in the first trimester and may be associated with a wide array of findings, including vaginal bleeding (most common), uterine size larger than expected according to pregnancy date (CM), uterine size smaller than expected according to pregnancy date (PM), excessive beta-human chorionic gonadotropin (β-hcg) levels, anemia, hyperemesis gravidum, theca lutein cysts, pre-eclampsia, and respiratory distress.Studies comparing modern clinical presentations of CM with historical presentations have demonstrated a significant reduction in many of the classic presenting signs and symptoms such as vaginal bleeding and excessive uterine size. This reduction is attributed to early detection by transvaginal ultrasound and increasingly sensitive β-hcg assays. Numerous studies evaluating the efficacy of ultrasound in detecting molar pregnancy demonstrate a 57–95 percent sensitivity for the detection of CM compared to only 18–49 percent sensitivity for PM.

More here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2791738/

PoCUS – Normal Early Pregnancy

Arrow = Yolk sac (YS) within Gestational sac (GS), note the hyperechoic decidual reaction surrounding GS, Arrow head = Fetal Pole

PoCUS – Molar Pregnancy

 

PoCUS SIgns:

  • enlarged uterus
  • may be seen as an intrauterine mass with cystic spaces without any associated fetal parts
    • the multiple cystic structures classically give a “snow storm” or “bunch of grapes” type appearance.
  • may be difficult to diagnose in the first trimester 6
    • may appear similar to a normal pregnancy or as an empty gestational sac
    • <50% are diagnosed in the first trimester
  • More on Radiopedia.org

Useful post from County EM blog- click here

 


Caustic Ingestions

 

 

Hydrochloric Acid – pH 1-2

Dangerous if pH <2 or >11.5-12

For alkaline – higher percent, shorter time to burn – 10%NaOH – 1 min of contact to produce deep burn, 30% within seconds

 

Acid – painful to swallow so usually less volume, bad taste so more gagging/laryngeal injury, more aqueous so less esophageal injury, pylorospasm prevents entry into duodenum producing stagnation and prominent antrum injury.  Food is protective.  Acid ingestion typically produces a superficial coagulation necrosis that thromboses the underlying mucosal blood vessels and consolidates the connective tissue, thereby forming a protective eschar.  In enough amount – perforation.

Alkali – burns esophagus more, neutralized in stomach.  Liquefaction necrosis.

Management

Decontamination: Activated charcoal / GI decontamination / neutralisation procedures are contraindicated

Obtaining meaningful info from endoscopy after treatment with charcoal is very difficult

If asymptomatic – observe, trial of oral intake at 4 hours after exposure, earlier if low suspicion or likely benign ingestion after discussion with Poisons Centre

Symptomatic patients or those with a significant ingestion

(high-concentration acid or alkali or high volume [>200 ml] of a low-concentration acid or alkali)

Upper GI endoscopy should be performed early (3 to 48 hrs) and preferably during the first 24 hrs after ingestion to evaluate extent of esophageal and gastric damage and guide management.  Endoscopy is contraindicated in patients who have evidence of GI perforation. (Ingestion of >60 mL of concentrated HCl leads to severe injury to the GI tract with necrosis and perforation, rapid onset of MODS and is usually fatal – endoscopy within 24 hours (unless asymptomatic at 4 hours)

Complications – 1/3 develop strictures – directly related to depth/severity of injury, years later

 


 

TAKE HOME POINTS

  1. PV Bleed, Hyperemesis, PoCUS = bunch Grapes or Snowstorm – consider Molar Pregnancy
  2. Don’t use Activated Charcoal for Caustic Ingestions
  3. Discuss Caustic Ingestions with Poisons Centre
  4. Consider early endoscopy
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An approach to the unexpected pregnancy

Resident Clinical Pearl (RCP) – March 2019

Renee Amiro – PGY2 FMEM Dalhousie University, Saint John NB

Reviewed by Dr. David Lewis

 

As Emergency Physicians we perform a number of pregnancy tests on women of childbearing age presenting to our care. It is an important part of our practise to screen for life threatening conditions like ectopic pregnancy and also avoid giving medications or preforming investigations that could be harmful to a fetus.

As with any medical test that we do, there are sure to be surprise results that we, or the patients, were not expecting.

A positive BHcG is not always a positive result for a patient we are treating. It is important as medical providers to handle this situation in an empathetic way and be armed with information to help the patient with this potentially life changing information.

An approach to an unexpected pregnancy result:


1. Ensure that the patient either has a support person with them, or if they wish, is alone. This is still confidential information and should be treated as such.
2. After informing the the patient of the pregnancy test result, it can be helpful to assess whether this is a wanted pregnancy. This can help you to assess what information you are going to provide her.
3. If it is an unwanted/surprise pregnancy it is helpful to inform her of her options.
      a. Continue the pregnancy to term
      b. Abortion
      c. Adoption


Since continuing with the pregnancy and adoption will be a long-term navigation and not necessarily time sensitive these discussions are better carried out in primary care / family practice. However, the options for pregnancy termination that are available in Canada and specifically New Brunswick are time sensitive.

It is crucial that patients who are considering these options be provided with accurate and timely information about their legal choice to end a pregnancy. Physicians who are unable to provide this information, for whatever reason, are expected to pass this responsibility on to a physician who can in a time sensitive manner.

Abortion options available in Canada:

 


Information for Patients considering termination of pregnancy


Surgical Abortion:
Abortion is decriminalized. There is no actual legal limit on the gestational age on which abortions can be performed.
Most intuitions in Canada have their own gestational age cut offs and the majority of abortions done in Canada are before 20wks.
The early on in the pregnancy generally the safer the procedure.

Advantages: once you’ve had the procedure it is done.
Disadvantages: you have had to have a d&c (dilation and curettage) and although relatively safe, there are always risks associated with surgical procedures.

 

Medical Abortion:
Medications used are Mifepristone and Misoprostol.
Mifepristone blocks progesterone which is a hormone responsible for maintaining a pregnancy.
Misoprostol is a medication taken up to 48 hours after the mifepristone and causes uterine contractions that empty the uterus.
The process is often described as like having a really heavy and crampy period.
Advantages: No surgical procedure, so can be done in your own home.
Disadvantages: more prolonged, may require more follow up with physicians, can’t be done past 9 weeks.

In New Brunswick: the drug can only be obtained with a prescription from a doctor who has completed the six-hour training required to prescribe it. It’s unclear how many New Brunswick doctors have the training.
You must have a valid health card and an ultrasound showing your gestational age to have the drug covered by the province.

 

Options available in New Brunswick:

Clinic 554 (Fredricton NB)
Able to self refer
Phone Number 506-261-7355
Patients can expect a 5-10-minute intake appointment over the phone.
Counselling, ultrasound and doctor’s exam are all done in the same visit as the abortion so you would only have to travel once.
Surgical are preformed up to 15wks and 6days.
Medical up to 9 weeks.
Cost between 700-850$ for surgical abortion.
Medical abortions are free.

Bathurst Chaleur Regional Hospital (Bathurst)
Able to self refer
Phone number 506-544-2133
Surgical abortions are available up to 13wks 6days.
Hospital based surgical abortions are free of charge.

Dr. Georges Dumont University Hospital Center (Moncton) – French
Able to self refer
Phone number 506-862-2770
Surgical abortions are available up to 13wks and 6days.
Hospital based surgical abortions are free of charge.


The Moncton Hospital- English
Able to self refer
Phone number 1-844- 806- 9205
Surgical abortions are available up to 13wks and 6days.
Hospital based surgical abortions are free of charge.
For options available in every province in Canada please see this list:
http://www.arcc-cdac.ca/list-abortion-clinics-canada.pdf

 

Copyedited by Dr. Mandy Peach

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What’s the word? Insertion of Word catheter for Bartholin’s cysts

Resident Clinical Pearl (RCP) February 2019

Renee AmiroPGY3 FMEM Dalhousie University, Saint John NB

Reviewed by Dr. David Lewis. Copyedited by Dr. Mandy Peach

Bartholin gland are located in the vulva and are a common cause of vulvar masses.
The normal function of the Bartholin gland is to secret mucus to lubricate the vagina. These ducts can get blocked and cause fluid accumulation can cause a cyst or abscess.

Anatomy of the vagina (2)
Identifying a bartholin gland cyst (3)

Treatment:
The mainstay of management is incision and drainage with insertion of a ward catheter. The ward catheter allows the cyst to continue to drain and allow re-epithelization of the Bartholin gland allowing the duct to stay patent in future.

Indications:
Presence of an uncomplicated Bartholin’s cyst.

Contraindications:
Latex allergy – the ward catheter is made with latex.

Materials:
Alcohol swabs or other solution to clean the area.
Sterile gloves
Local anesthetic
Scalpel with an 11 blade
Gauze (+++)
Haemostat to breakup loculations
Culture swab
Ward Catheter
Syringe filled with H2O to fill the ward catheter.

Procedure

  1. Sterilize area with sterilizing solution.
  2. Inject local anesthetic in to the area that you are going to stab for the incision ~1-3cc.
  3. Stab the cyst or abscess. Make the incision about 5mm big and 1.5cm deep. Too big an incision could cause the ward catheter to fall out.
  4. Drain the cyst/abscess and breakup any loculations with the haemostat.
  5. Place the ward catheter into the incision and inflate with 2-3cc of water.
  6. Tuck the end of the ward catheter in to the vagina to minimize discomfort.
Technique for insertion of word catheter (4)

Follow up:
Pelvic rest for the duration of the time the ward catheter is in place.
Sitz baths and mild analgesia (Tylenol/Advil)

Duration of ward catheter placement is on average four weeks.

If the ward catheter falls out prior to the tract being re-epithelialized or the cyst or abscess remains the patient may need another placement of the ward catheter or follow up marsupialization procedure (obstetrics). If the area looks well healed, the ward catheter can be kept out.

Role of antibiotics:
In uncomplicated skin abscesses there has been no benefit shown from antibiotic treatment. Using an antibiotic without and I and D will not heal the Bartholin glad cyst.

Antibiotics indicated in:
High risk of complicated infection – surrounding cellulitis, pregnancy, immunocompromised.
Culture positive MRSA
Signs of systemic infection

Bottom Line:

  1. Ward catheter placement is essential if you are going to drain a Bartholin’s abscess. If you don’t the patient may loose patency of the duct which could have long term consequences such as dyspareunia.
  2. Antibiotics alone will not cure a Bartholin’s abscess. Only indicated in limited situations.

References

  1. Uptodate: Bartholin gland masses: Diagnosis and Management https://www.uptodate.com/contents/bartholin-gland-masses-diagnosis-and-management?search=bartholin%20cyst&source=search_result&selectedTitle=1~10&usage_type=default&display_rank=1
  2. Bartholin Gland Cysts: https://www.health.harvard.edu/a_to_z/bartholins-gland-cyst-a-to-z
  3. Bartholin Gland Cysts: https://www.merckmanuals.com/en-ca/home/women-s-health-issues/noncancerous-gynecologic-abnormalities/bartholin-gland-cysts
  4. Bartholin Gland Abscess or Cyst Incision and Drainage: https://accessemergencymedicine.mhmedical.com/content.aspx?bookid=683&sectionid=45343783

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EM Reflections – November 2018

Thanks to Dr. Paul Page for leading the discussions this month

Edited by Dr David Lewis 


Top tips from this month’s rounds:

1. Severe Metabolic Acidosis

2. Ovarian Torsion

3. Acetaminophen Overdose


Severe Metabolic Acidosis with Unexplained Anion Gap

Case: Female presents with reduced LOC, found with large empty bottle of gin. Smells of alcohol. Hypothermic. VS otherwise stable.

VBG: pH – 6.89, pCO2 – 28, bicarb – 6, Lactate – 21

Anion Gap

Anion Gap = Na+ – (Cl- + HCO3-)

An elevated anion gap strongly suggests the presence of a metabolic acidosis. The normal anion gap depends on serum phosphate and serum albumin concentrations. The normal AG = 0.2 x [albumin] (g/L) + 1.5 x [phosphate] (mmol/L)

MDCalc Anion Gap Calculator

Common Causes (MUDPILES):

  • Metformin, Methanol
  • Uremia
  • DKA
  • Pyroglutamic acidosis, paracetamol, phenformin, propylene glycol, paraladehyde
  • Iron, Isoniazid
  • Lactic acidosis
  • Ethylene glycol
  • Salicylates

Dr. Pages’s Tips: Keep toxic alcohols in the differential.  Early antibiotics for possible sepsis. Remember for sick patients to consult early to appropriate services to expedite disposition.  Sick patients take up a lot of nursing resources so also be aware of impact on nursing care and resources with these patients.


Ovarian Torsion

This is a gynae/surgical emergency, delayed diagnosis may lead to loss of ovary. Early diagnostic ultrasound is recommended.

Ovarian torsion is a rare but emergency condition in women. Early diagnosis is necessary to preserve the function of the ovaries and tubes and prevent severe morbidity. Ovarian torsion refers to complete or partial rotation of the adnexal supporting organ with ischemia. It can affect females of all ages.

Presents with acute onset severe lower abdominal pain, with nausea and vomiting.

Benign ovarian cyst > 5cm is the usual cause. Torsion can also occur in normal ovaries, however, particularly in premenarchal girls who have elongated infundibulopelvic ligaments 

Dr. Page’s Tips: Increased risk with large cysts but can occur without cysts as well.Time sensitive dx so need to be vigilant with assessment. When considering as dx need to get U/S arranged and gynaecology consultation. Remember we have 24 hour U/S coverage but we have to ask for the U/S.


Acetaminophen Overdose

Survival from a acetaminophen overdose is generally considered to be 100% in cases receiving NAC within 8 hours of exposure. Efficacy declines after this point. Therefore early recognition is paramount. Don’t miss the treatment window by not considering.

This post from LITFL does a great job outlining the management of Acetaminophen (Paracetamol) toxicity:

Also with have discussed Acetaminophen toxicity in EM reflections in June 2018:

and also in December 2016:

Dr. Page’s Tips: Correlate presentation with timeframe to see if adds up regarding time of OD. When patient being assessed by other services (with primary resident assessment) we need to keep in mind these are still our patients and review to make sure the plan seems appropriate.

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Gravidology for the Emergency Physician

Gravidology for the Emergency Physician

Resident Clinical Pearl – April 2017

Luke Taylor, PGY1 iFMEM, Dalhousie University, Saint John, New Brunswick

Reviewed by Dr. David Lewis

 

 

Many adaptations take place in the gravid female, the end goal of each being to provide optimal growth for the fetus, as well as to protect the mother from the potential risks of labour and delivery. It is very important to understand these changes when assessing an unwell pregnant patient in the ED.


Vital Signs:

 

BP: Blood pressure falls earlier in pregnancy with nadir in second trimester (mean ~105/60 mmHg). In the third trimester BP increases and may reach pre pregnancy levels at term. BP is related to a reduction in SVR and multiple hormonal influences that are not fully understood.

 

HR: CO=HRxSV. The increase in CO is attributed mainly to the increase in circulating volume (30-50% above baseline). HR increases by 15-20 beats/min over non pregnant females.

*Supine position in the gravid female can lower CO by 20-30% due to a reduction in venous return which reduces stroke volume.

 

RR: State of relative hyperventilation. NO change in RR, however there is an increase in tidal volume resulting in a 50% increase in minute ventilation. Increased O2 consumption and demand with hypersensitivity to chances in CO2.

*60-70% of women experience a sensation of dyspnea during pregnancy

 

 


Diagnostic Imaging and ECG:

 

Must ensure imaging is necessary for management and explain risks well.

** 1 rad increases the risk of childhood malignancy by 1.5-2x above baseline.

 

CXR: Minimal changes to CXR in normal pregnancy but may have; prominence of the pulmonary vasculature and elevation of the diaphragm.

 

PoCUS: FAST doesn’t perform well in pregnant patient. Small amount of physiologic free fluid in the pelvis (posterior, lower portion of uterus), all else should be considered pathologic. Physiologic hydronephrosis and hydroureter (mostly R-sided).

 

CT-A: When required to r/o PE, capable of being completed at very low rad (below teratogen cut off, CT of 1-3rad is under the teratogenic cutoff of 5-10rad = 10,000 cxr or 10x CT chest

 

ECG: Various changes occur, may include ST and T wave changes, and presence of Q waves. The heart is rotated toward the left, resulting in a 15 to 20º left axis deviation. Marked variation in chamber volumes, especially left atrial enlargement. This can lead to stretching of the cardiac conduction pathways and predisposes to alterations in cardiac rhythm.

 

 


Routine Laboratory Tests:

 

CBC: Physiologic Anemia – Increased retention of Na and H2O (6-8L) leading to volume expansion combined with a slightly smaller increase in red cell mass.

Leukocytosis – Due to physiologic stress from the pregnancy itself, creates a new reference range from 9000, to as high as 25000 in healthy pregnant females (often predominately neutrophils)

 

PTT: Various processes result in 20% reduction of PTT and a hypercoagulable state (also helps to protect from hemorrhage during labour).

 

Urinalysis: Very common to have 1-3+ leukocytes, presence of blood, as well as ketones on point of care testing. Not considered pathologic unless Nitrite positive.

 

Creatinine: Pre-eclamptic patients may have a creatinine in the normal range, but have a drastic reduction in GFR (40%).

 

B-HCG: Every female of childbearing years should be considered to: Be pregnant, RH-, and have an ectopic until proven otherwise. Draw a beta HCG on every critically ill or injured women of childbearing years regardless of reported LMP.

 


ACLS:

 

Remember, most features are the same as when resuscitating a non-pregnant patient.

Some things to remember:

 

Higher risk of aspiration – Progesterone relaxes gastroesophageal sphincters and prolongs transit times throughout the intestinal tract. = Careful bag mask ventilation, do not overdo it.

Left uterine displacement (LUD)– While patient supine to provide best chest compressions possible

Medications and Dosages– Remain the same in pregnancy, vasopressors like epinephrine should still be used despite effect on uterus perfusion

Defibrillation OK-  Fetus is not effected by defibrillation, low risk of arc if fetal monitors in place, do not delay.

Four minute rule– For patients whose uterus is at or above the umbilicus, prepare for cesarean delivery if no ROSC by 4mins. ** In a case series of 38 perimortem cesarean delivery (PMCDs), 12 of 20 women for whom maternal outcome was recorded had ROSC immediately after delivery.

Etiology:  Must continue to think broadly, however common reasons for maternal cardiac arrest are: bleeding, heart failure, amniotic fluid embolism (AFE), and sepsis. Common maternal conditions that can lead to cardiac arrest are: preeclampsia/eclampsia, cerebrovascular events, complications from anesthesia, and thrombosis/thromboembolism.

 


REFERENCES

Cardiac Arrest in Pregnancy – A Scientific Statement From the American Heart Association

Up To Date – Respiratory Tract Changes in Pregnancy

Merk Manual – Physiology of Preganacy

https://radiopaedia.org/cases/chest-x-ray-in-normal-pregnancy

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