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)