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Clinical Pathway for Emergency Department Management of Abnormal Uterine Bleeding in Adolescent Patients February 18, 2019

Posted by Andy Jagoda, MD in : Feature Update , add a comment

In the emergency department, gynecologic complaints are common presentations for adolescent girls, who may present with abdominal pain, pelvic pain, vaginal discharge, and vaginal bleeding. The differential diagnosis for these presentations is broad, and further complicated by psychosocial factors, confidentiality concerns, and the need to recognize abuse and sexual assault.

This clinical pathway will help you improve care in the management of abnormal uterine bleeding in adolescent patients. Download now.

Clinical Pathway for Emergency Department Management of Abnormal Uterine Bleeding in Adolescent Patients

Clinical Pathway for Emergency Department Management of Subarachnoid Hemorrhage February 17, 2019

Posted by Andy Jagoda, MD in : Feature Update , 1 comment so far

Headache is the fourth most common reason for emergency department encounters, accounting for 3% of all visits in the United States. Though troublesome, 90% are relatively benign primary headaches –migraine, tension, and cluster headaches. The other 10% are secondary headaches, caused by separate underlying processes, with vascular, infectious, or traumatic etiologies, and they are potentially life-threatening.

This clinical pathway will help you improve care in the management of patients with subarachnoid hemorrhage. Download now.


Adolescent Gynecologic Emergencies. What do you do? February 14, 2019

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 1 comment so far

You are then called to the resuscitation room for a 17-year-old girl who was found unresponsive at home. On examination, she is ill-appearing, lethargic, has cool distal extremities, normal heart sounds, and clear lungs, and her abdomen is soft but tender in the left lower quadrant. Her vital signs are: blood pressure, 80/40 mm Hg; heart rate, 130 beats/min; respiratory rate, 25 breaths/min; and oxygen saturation, 95% on room air. What are the immediate first steps in managing this patient? What testing is needed for evaluation and management? What is the appropriate disposition?

Case Conclusion:
The 17-year-old girl presented in shock. IV access was obtained quickly for fluid resuscitation. Bedside abdominal ultrasound revealed free fluid on the suprapubic view. The following laboratory tests were sent: hCG, CBC, complete metabolic panel, type and screen, and blood culture. Her hCG resulted positive, raising concern for ectopic pregnancy. After she was resuscitated, gynecology was consulted and noted an empty uterus and free peritoneal fluid on ultrasound, in spite of a serum hCG of 10,000 mIU/mL. The patient was quickly transferred to the operating room where an ectopic pregnancy complicated by hemoperitoneum was found.

Would you have done it different? Tell us how you would have handled this case.

Life-Threatening Headache. What do you do? February 12, 2019

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 2comments

A 55-year-old man with history of nonsmall cell lung cancer who is on cisplatin presents with an acute headache and lethargy for 6 hours. His vital signs are remarkable for a blood pressure of 210/120 mm Hg, heart rate of 70 beats/min, and a temperature of 36.7°C (98°F). His physical exam reveals a lethargic patient with no localizing neurologic signs and no meningismus. You order a noncontrast CT of the head and consider lowering this patient’s blood pressure, though you wonder how much and how fast it should be reduced…

Case Conclusion:
You recognize that this cancer patient’s change in mental status and severely elevated blood pressure was likely the result of PRES. You obtained a CT of the head, which revealed white-matter changes in the posterior cerebral hemispheres. Utilizing IV nicardipine, you lowered the patient’s MAP by 25% over the first hour. In addition, you temporarily discontinued his chemotherapy medication. He subsequently became more alert and responsive.

Would you have done it different? Tell us how you would have handled this case.

Secondary hypothermia in patients with sepsis and trauma — Brain Teaser. Do you know the answer? January 26, 2019

Posted by Andy Jagoda, MD in : Brain Tease , add a comment

Test your knowledge and see how much you know about treating and managing hypothermia and peripheral cold Injuries in pediatric patients.

Did you get it right? Click here to find out!

The correct answer: C.

Earn CME for this topic by purchasing this issue. 

Using anti-D immune globulin in first trimest of pregnancy — Brain Teaser. Do you know the answer? January 24, 2019

Posted by Andy Jagoda, MD in : Brain Tease , 1 comment so far

Test your knowledge and see how much you know about treating and managing first trimester pregnancies in the ED.

Did you get it right? Click here to find out!

The correct answer: D.

Earn CME for this topic by purchasing this issue. 

 

Treatment Pathway for the Management of a Pediatric Patient With Hypothermia January 19, 2019

Posted by Andy Jagoda, MD in : Uncategorized , add a comment

Hypothermia occurs when the core body temperature falls below 35ºC (95ºF) due to primary exposure (eg, environmental exposure) or secondary to other pathologies. Infants, children, and adolescents are at higher risk for primary cold injuries due to a combination of physiologic and cognitive factors, but quick rewarming and appropriate disposition can result in survival and improved neurological outcomes. Treatment for cold injuries is guided by severity and can include passive or active measures.

This clinical pathway will help you improve care in the management of patients who preset with hypothermia. Download now

Treatment Pathway for the Management of a Pediatric Patient With HypothermiaTreatment Pathway for the Management of a Pediatric Patient With Hypothermia

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Treatment Pathway for Emergency Department Management of Nausea and Vomiting of Pregnancy January 17, 2019

Posted by Andy Jagoda, MD in : Feature Update , 1 comment so far

Timely management of patients presenting to the ED while in their first trimester of pregnancy can improve outcomes for both the patient and the fetus. Common obstetric problems encountered include vaginal bleeding and miscarriage, ectopic pregnancy and pregnancy of undetermined location, and nausea and vomiting of pregnancy, including hyperemesis gravidarum.

This clinical pathway will help you improve care in the management of patients who preset with nausea and vomiting in the first trimester. Download now

Treatment Pathway for Emergency Department Management of Nausea and Vomiting of PregnancyTreatment Pathway for Emergency Department Management of Nausea and Vomiting of Pregnancy

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Skiing with no gloves. How do you handle these cold injuries? — Management of Pediatric Hypothermia January 14, 2019

Posted by Andy Jagoda, MD in : What's Your Diagnosis , add a comment

Case Recap:
A 17-year-old boy comes into your ED complaining of numbness and hardening of his fingers. He is a previously healthy foreign exchange student who is staying with a host family. The symptoms started yesterday after he went snow skiing for the first time. He says he wore gloves, but he was having a hard time holding the ski poles, so he took them off midway through the day. On examination, the fingertips on both of his hands are firm to the touch, have a dark discoloration, and are without sensation. The firmness and discoloration extend only to the distal interphalangeal joint in most of the fingers, but to the proximal interphalangeal joint in the middle finger of his left hand. The thumb on his right hand has a sizeable blister. As you step out of the room, you contemplate the next steps.

How do you classify the severity of his cold injuries? Does his thumb need debridement? Should you consult a hand surgeon and/or the burn center? What is the long-term prognosis for his injuries?

Case Conclusion:
The hands of the 17-year-old boy who did not wear gloves while skiing were placed in a warm water bath at 38°C (100.4°F) and gently rewarmed for 30 minutes. The pain did increase in his hand secondary to reperfusion, and all of his tissues softened except for his thumbs. You left his thumb blister intact, as it was not causing any restriction in movement and was filled with clear fluid. You placed aloe vera gel on all of his digits and loosely wrapped his hands in nonadhesive dressing. You gave him instructions to follow up at the burn center for continued outpatient therapy. He did not lose any digits, but the decreased sensation in his left thumb remained.

Intrauterine pregnancy presenting with fever. What do you do? — First Trimester Pregnancy Emergencies in the ED January 12, 2019

Posted by Andy Jagoda, MD in : What's Your Diagnosis , add a comment

Case Recap:
Late in your shift, you evaluate a 26-year-old woman who has a confirmed intrauterine pregnancy at 11 weeks’ gestation and presents for fever, dysuria, and right flank pain. An ultrasound was performed in triage that showed bilateral mild hydronephrosis.

Several questions flood your mind. What do you make of that finding, which antibiotics would be safe for treatment, and can she be managed as an outpatient?

Case Conclusion:
You diagnosed your patient with pyelonephritis. Since there are not good data supporting routine outpatient management of pyelonephritis in pregnancy, you consulted her obstetrician to discuss admission. She received ceftriaxone 1 g IV, was admitted to the hospital, and recovered uneventfully. The hydronephrosis was symmetric and bilateral, which is typical during pregnancy, so no further workup for this was undertaken. She was discharged on cephalexin after sensitivities resulted.

 

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Last Modified: 02-23-2019
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