Lecture 11 (GI/GU/GYN) Flashcards
(220 cards)
1
Q
A
2
Q
A
3
Q
A
4
Q
GI Emergencies (overview)
A
5
Q
GI Emergencies
A
6
Q
Gastrointestinal Emergencies
* What are two types of assessments?
A
Life threatening condition that may require immediate surgery (AAA, peritonitis, trauma)
Vs.
Time to work-up the patient (may have a little time to work up if ruptured appendix)
7
Q
Gastrointestinal Emergencies
* What is disposition?
A
8
Q
Emergency
* If the patient is hemodynamically compromised?
* You don’t always have the luxury of what?
* This is why you need to have good skills at what?
* You should use your tests, in general, only to do what?
* Do not deley what?
A
- If the patient is hemodynamically compromised, you need to treat presumptively
- You don’t always have the luxury of time to do a diagnostic work up
- This is why you need to have good skills at obtaining a history and doing an exam
- You should use your tests, in general, only to confirm your suspicion; you should know your working diagnosis when you leave the patient’s bed
- Don’t delay consultation in sick patients
9
Q
Associated symptoms:
* GI:
* GU:
A
- GI: Anorexia, nausea, vomiting, diarrhea, constipation, bleeding, weight loss
- GU: Dysuria, hematuria, frequency, urgency, hesitation, incontinence, polyuria, nocturia
10
Q
Associated symptoms:
* GYN:
* Vascular:
A
- GYN : Menstrual history, contraception, fertility, sexual activity, STD’s, vaginal discharge, dyspareunia
- Vascular (think mesenteric ischemia if postprandial pain): Any ischemic disease, A fib, anticoagulation, CHF, AAA (including family history)
11
Q
Approach to the Patient
* What information do you need to collect from patient?
A
12
Q
Physical Exam
* What is first?
* What do you need to inspect?
* What do you hear with auscultation
A
As always: Vital Signs after ABC
Inspection
* Pt moving about (kidney stones) or lying completely still (peritonitis)
* Jaundice/manifestations of chronic liver disease
* Scars, distention, masses, fluid state
Auscultation – not helpful
* Hypoactive or Absent, Normoactive, or Hyperactive “Rushes of gas”
13
Q
Physical
* What is percussion for?
* What is palpation for?
* What are the special tests?
A
- Percussion – fluid and to test rebound tenderness
- Palpation - guarding
- Special Tests (psoas, rovsign, obturator, murphys, carnett, Cullen, grey-terner etc.)
Carnett sign – abd wall tenderness (hematoma in muscle) or abd cavity pain (peritonitis). Sit up and see if pain occurs -muscle pain.
14
Q
PE Always Includes:
* What are you looking for in pelvic or male gential exam? Do not forget what?
* What do you look for in rectal exam?
A
15
Q
Abdominal pain can be REFERRED pain
* Consider what?
* Think of hernia when?
A
- Consider Cardiopulmonary Etiology
- Consider GU, GYN Etiology
- Think of Hernias with SBO (2nd common most cause)
16
Q
Abdominal pain can be REFERRED pain
* Remember what?
* Consider what?
* Always think about what?
A
- Remember Toxic-Metabolic Etiologies (DKA)
- Consider Neurogenic Causes
- ALWAYS think of Vascular Causes
* ALWAYS consider AAA, mesenteric ischemia/infarct
17
Q
Elderly Patients
* How many of elderly patients presenting with abdominal pain die? Why?
A
- 11-14% of elderly patients presenting with abdominal pain die->This doubles if the ED makes an incorrect diagnosis
- Poor historians, delayed presentation, decreased pain perception, decreased signs/symptoms, decreased febrile response to infection.
18
Q
Elderly Patients
* What might be missed?
* Higher what?
A
- Volume depletion may be missed if a normally hypertensive patient is normotensive
- Higher surgical risk and increased comorbidities
19
Q
Elderly Patients
* What should you be thinking about? (4)
A
- Acute mesenteric ischemia
- Abdominal aortic aneurysm
- Diverticulitis
- Sigmoid volvulus
20
Q
Elderly Patients
* What are the sxs of acute mesenteric ischemia?
A
“Pain out of proportion to exam,” or postprandial pain. Anion gap lactic acidosis. On PE – normal abdomen that’s soft but they say they have 10/10 pain.
21
Q
What lab work do you need to do?
A
- CBC – WBC count is of limited value
- Serial H&H – in GI bleeds
- CMP-fairly routinely done-may indicate metabolic abnormality related to present illness
- UA
- Hepatic Panel (part of CMP)
- PT, PTT
- Amylase, Lipase
- Pregnancy – any female of child-bearing age (6-60)
22
Q
Imaging: X-rays
* Use of xrays for what?
* What series should you do to see free air?
* What x-ray if good for obstruction or constipation?
A
See free air-> Surgery
23
Q
What is going on here and what does it suggest?
A
- Air under diaphragm
- Suggests perforation
24
Q
What is going on here? Recall what rules?
A
- AF Levels
- Recall diameter of bowel, i.e. 3(small intestine)/6 (large intestine) /9 (cecum) rule.
25
* When is Ultrasound useful?
* When is Abdominal CT with contrast useful?
* When is Ultrasound useful? Looking for fluid, trauma, cholecystitis, pregnancy, pancreas/biliary tree. Good with lower or normal BMI.
* When is Abdominal CT with contrast useful? Not for unstable patients. Use for most internal organs pathology-> under BMI of 21.5 the use oral constrast
26
Resuscitation:
* What fluids do you give?
* Give what if indicated?
* What meds should you give?
* Crystalloid fluids
* Blood if indicated
* Pain meds (avoid opiods because decrease bowel mvts)
27
Resuscitation:
* When do you give antibiotics/
* What should you cover?
* Suspected abdominal sepsis
* Peritonitis
* Cover suspected organism: Gram (-) aerobes, anaerobes, flagellates
* Metro
* Pip/tazo
* Ceftri+metro
* Bactrim +metro
* E.coli: in perf->Amoxicillin
28
Where is an upper GI bleed and Lower one?
* Upper: proximal to the Ligament of Treitz (duo, stomach)
* Lower: distal to Ligament of Treiz
## Footnote
Ligament of treitz: separates duo from jeju-> RUQ medial portion
29
GI bleeds: Historical clues
* What should you be looking for?
* Recent what?
* Melena (dark stool) vs Hematochezia (bright red stool)
* Recent vomiting and retching followed by hematemesis->Mallory-Weiss (boerhaave rarely present with bleeding – goes to mediastinum).
30
GI bleeds: historical clues
* When should you think about varices?
* When should you think about peptic ulcers?
* What do you need to order with a patient taking coumadin?
* Cirrhotic patient w/ portal HTN presenting with hematemesis? Stigmata of liver disease? Varices.
* History of NSAID/ASA use? Peptic Ulcers
* Patient taking Coumadin? Do PT/INR
31
Upper GI Bleeding
* What are major examples of upper GI bleeds?
* Peptic Ulcer Disease
* Erosive Gastritis, Esophagitis (irritants like ASA)
* Esophageal & Gastric Varices (portal HTN)
* Mallory-Weiss Tears
32
What are examples of other upper GI bleeds?
* Stress Ulcer
* AV malformation
* Malignancy
* Aortoenteric fistula
* Spurious (ENT)
33
Lower GI Bleeding
* What are examples of lower gi bleeds? What are the sxs with it?
* Diverticulosis
* Carcinoma (usually not massive bleeding)
* Hemorrhoids (diagnosis of exclusion)
* Polyps, IBD, Infectious gastroenteritis (rarely massive bleeding)
* Meckel’s Diverticulum
* Angiodysplasia (AV malformation)->Often associated with HTN and aortic stenosis
34
Primary Management of GI bleeds
* _
* 2 what?
* What should you get?
* Labs including what?
* ABCs
* 2 large bore IVs and Monitor
* EKG
* Labs including coagulation studies & serial H&H
35
Primary Management of GI bleeds?
* What should you do early and why?
* NGT with what?
* Type and Crossmatch blood early
* Transfuse with asymptomatic Hgb <7, symptomatic <8.
* NGT with gentle gastric lavage* (room temperature water) . None if facial trauma
## Footnote
* “Concerns that an NG tube may provoke bleeding in patients with varices are unwarranted”
36
Secondary Management of GI bleeds
* Get what?
* Early what for UGIB?
* What is occuring more frequently for LGIB? What are examples (2)
Get type and screen
Early Therapeutic Upper Endoscopy for UGIB
Earlier Therapeutic Colonoscopy for LGIB is now occurring more frequently.
* Technetium-labeled red cell scans may help locate site of bleeding if EGD and Colonoscopy are unrevealing
* Angiography may localize site with massive bleeds (requires active bleeds)
37
Secondary Management of GI bleeds
* What drugs do you give?
* What do you if drugs fail?
Drugs
* IV PPI (Protonix) for UGIB 2/2 PUD (EVERYONE BESIDES VARICES)
* IV Somatostatin (Octreotide) and prophylactic ABX for UGIB 2/2 **esophageal varices** (hx of alcoholism, nose varices, voimiting blood)
Surgical intervention if pt fails medical tx.
38
What can you give someone with warfran OD and why?
* Kcentra – has all Vit. K dependent factors (2,7,9,10).
* FFP, Vit. K
39
OD reversals:
* heparin+LMWH
* Warfrain
* Dabigatran
* Rivaroxaban and apixaban
* Heparin and DOACs
* Protamine for heparin & partially LMWH
* Kcentra, Fresh frozen plasma and Vitamin K for warfarin
* Idarucizumab for the reversal of dabigatran (Pradaxa)
* Andexanet alfa for the reversal of rivaroxaban (Xarelto) and apixaban (Eliquis)
* Ciraparantag, a potential “universal” reversal agent (Covers heparin and DOACs)
40
Esophageal Emergencies: Dysphagia
* Protect what and why? Who is NPO?
* What is the progress of handling Structural/Obstructive causes?
* Protect the airway: Aspiration is a major concern
* All CVA patients are NPO until cleared by normal swallow study
* Structural/Obstructive causes: Most are worked up as outpatients as they are progressive in nature….BUT, If the patient is drooling or unable to swallow their own secretions, they need an EGD now.
41
Chest Pain secondary to GERD& Chest Pain secondary to diffuse esophageal spasm
* Difficult to distinguish from what?
* Err on the side of what?
* Difficult to distinguish from ischemic CP
* Err on the side of the patient: Rule OUT ACS first and then consider GI etiology
42
Esophageal Perforation
* What are all the causes of esophageal perforation?
43
What is going on here?
boerhaave syndrome-> perforation
44
Esophageal perforation:
* high what?
* What is the management?
45
What is going on here?
Mediastinitis
* Note superior mediastinum
46
47
What is this? What should you do?
Battery – 2hr window from swallowing to erosion of esophagus – do EGD.
48
What things must be removed?
* sharp objects
* multiple foreign bodies
* Most button batteries
* objects present more than 24 hours
* objects causing airway obstruction
* children with coins at level of cricopharyngeus muscle
49
What is this? what do you do?
* Packing – smuggling of drugs.
* Don’t stick anything up to butt. Do laxative
50
What is this? Put what?
Bottle in rectum. Bad because it creates suction – put the tube in
51
UGI Bleeding
* What are the sxs?
* What is the work up?
* What is the management?
* Sxs: Abd pain, hematemesis, melena, etc
* Work up: Ct with IV contrast of ab + pelvis
* Management: EGD, Octreotide (in ETOH)/PPI otherwise, PRBC if hgb is less than 7
52
Perfortion
Sxs: - (just happen, no inflammation to spilled content)/+ pain, peritonitis signs if late
Management: ABCs, 2 large IVs, surgery, labs, type and screen, fluids, anx
53
Acute Appendicits:
* Causes?
* Most common in who?
* Cause: Obstruction of the appendix by a fecalith (most common), inflammation, foreign body, or neoplasm
* Most common between age of 10-30 years old.
54
Acute Appendicitis
* How do you dx?
* What patients are at risk for misdiagnosis?
Clinical Diagnosis
* Describe the typical history
* Typical Exam of abdomen-> Typical signs found on exam
* Start with periumbilical pain. Appendicitis pats don’t have Diarrhea (GE does), but do anorexia (hamburger sign), N/V etc.
* Patients at risk for misdiagnosis: <6 y/o, elderly patients, pregnant patients, & anatomic variations of the location of the appendix
* Pregnants can have pain in RUQ and not always localizes
55
Acute Appendicitis
* What tests?
* WBC doesn’t help
* CT scan if you are unsure
* May risk stratify child with Pediatric Appendicitis score (look up on MDCalc)
56
What is the management of acute appendicitis
57
Constipation:
* What do you need to rule out?
## Footnote
Obstruction: not passing gas + vomiting
58
Intestinal obstruction
* SBO most common in who and when?
* What is the second MCC?
* What are the typical sxs?
SBO in Adults
* Most commonly caused by adhesions after abdominal surgery
* Second most common cause is incarceration of a groin hernia
* Don’t get BURNED! ALWAYS do a hernia exam in a patient with SBO
* Typical symptom progression: vomiting food, then bile, then fecal matter
59
Intestinal Obstruction: LBO
* MC caused by what?
* What do you need to do and why?
* Most commonly caused by neoplasms
* Fecal Impaction – Always do a rectal exam
60
Intestinal Obstruction
* Think about what in children and elderly?
Think about intussusception in children and volvulus in elderly
61
Intestinal Obstruction
* SBO: imaging and hx?
* LBO: hx?
* SBO – on KUB cant always see normal gas pattern. Hx wise – vomiting food, then bile, then feces.
* LBO – usually no nl haustra and is lower in pelvis. Primary problem is constipation.
62
Intestinal obstruction
* Sxs?
* Exam findings?
* Work up?
* belly pain, rigidity, N/V, -/+ fever
* Work up: x-ray, ABCS, IV fluids, labs, anx, pain, N/V control, NG tube needs to be placed
63
What is the management of intestinal obstruction?
## Footnote
SBO – do fluids and do NG tube.
64
Sigmoid Volvulus
* Colon does what?
* Typical in who?
* Recall what?
* Colon twists on mesentery and forms closed loop obstruction & torsion
* Typical in elderly or psych
* Recall coffee bean sign
65
Hernias: ingunial
* more common in who?
* What is indirect and direct?
Inguinal (more common in males)
* Indirect passes through internal inguinal ring
* Congenital, incarcerate frequently in 1st year of life
* Direct passes through Hasselbach’s Triangle
* Acquired, rarely strangulate or incarcerate
66
Hernias: femoral
* more common in who?
* Where does it go through?
Umbilical: Rarely what?
* What is it?
What are other hernias? (2)
## Footnote
Strangulation – cut off BS. Sx emergency.
Incarcerated – non reducible.
67
Terminology & Clinical Applications
* What does reducible mean? How do you do it?
* What does incarcerated mean?
* Reducible – can be returned to its normal anatomic position of manipulation
* Place pt in Trandelenburg, apply ice to area and give them some morphine. With constant gradual pressure, attempt to reduce hernia
* Incarcerated – cannot be reduced->This can be acute or chronic
68
Terminology & Clinical Applications
* What is strangulation?
Strangulation – there is vascular compromise and development of gangrene in an incarcerated hernia
* This is an emergency; patient may be toxic, may have a bowel obstruction or perforation
69
Inflammatory Bowel Disease
* Sxs?
* What is the work up?
* Signs/Symptoms: Pain and Diarrhea are predominant symptoms
* Work-up: CBC/CMP/Stool studies
## Footnote
Diarrhea is a predominant Sxs. Always r/o infection – do CBC/CMP and stool studies.
70
Inflammatory Bowel Disease
* What is the management?
71
What is this? What can this be a complication of?
toxic megacolon-> UC or C.diff complication
72
Toxic Megacolon
* What is it?
* What is the dx criteria? (3)
Nonobstructive colonic dilatation larger than 6 cm & signs of systemic toxicity.
Diagnostic criteria.
* Radiographic evidence of colonic dilatation
* Any 3 of the following: fever (>101.5°F), tachycardia (>120), leukocytosis (>10.5), or anemia.
* Any 1 of the following: dehydration, altered mental status, electrolyte abnormality, or hypotension
73
Toxic Megacolon
* What is the management?
Consult Sx and GI. Can treat with Prednisone but really have to deal with Sx.
74
Pseudomembranous colitis
* What is it caused by? (bacteria)
* When should you suspect it?
* What can can cause the bacteria to overgrow?
* Must test for what?
75
Pseudomembranous colitis
* What is the txt?
* What are the sxs of severe diarrhea?
* Admit to hospital and RX PO vancomycin or fidaxomicin – 1st line
* PO flagyl (2nd line tx if no access to vanco)
* Severe diarrhea: volume depletion, electrolyte imbalance; systemic response (fever, leukocytosis, severe abdominal pain); failed outpatient management
76
Ischemic Colitis
* What is the sign of mucosal edema with mesenteric ischemia?
Thumbprinting – projections – best CT is Mesenteric Angiography to see vessels.
77
Ischemic Colitis
* Common in who?
* What are the sxs?
* What is the management?
* What are the Blood test?
* Imaging?
* Elderly patients & patients at risk for vascular disease
* Signs/Symptoms: Pain disproportional to exam findings
* Management: IVF, ABX, NPO, Surgery
* Blood test: Lactic acid (If Lactic level is normal, it is not IC)
* Imaging test: CTA Abd/Pelvis
78
Ischemic Colitis
* What is the txt?
Tx by IV fluids, NPO, consult GI/Sx.
79
Diverticulitis
* What are the sxs?
* What does the PE show?
* SXS: LLQ pain, fever, diarrhea or constipation, RLQ pain with ascending colonic diverticulitis.
* PE: low grade fever may be present, localized tenderness and guarding, occult blood may be present. Peritoneal signs with perforation
80
Diverticulitis
* What is the imaging of choice?
* What was historically avoided but now it is good for you?
* CT is imaging test of choice if indicated
* Avoidance of nuts/seeds/popcorn is refuted, its actually beneficial
81
Diverticulitis Management
* What is the outpatient management?
* Bowel rest and low-residue foods added to diet when symptoms improve.
* Antibiotics: metronidazole (Flagyl) + Keflex or Bactrim
## Footnote
If mild – can send home with soft diet as tolerated. Add cipro or keflex or bactrim to cover E. coli.
82
Diverticulitis Management
* What is the inpatient txt?
Admit, NPO, IV broad-spectrum, abx and surgical consult if any signs of systemic infection, presence of abscess, signs of peritonitis, or failed outpatient management
83
Txt:
* Acute, painful, recently thrombosed external hemorrhoids
* Anal fissure
Acute, painful, recently thrombosed external hemorrhoids
* excision of the clot w/ elliptical skin incision
Anal Fissure
* WASH treatment, topical analgesics
84
Treatment:
* Anorectal Abscess
* Pilonidal Abscess
## Footnote
I&D in the ER – only perianal abscessess. All others have to go to OR (like supralevator).
85
Management of vomiting and diarrhea
* _
* Give and study what?
* Control what?
* ABC’s
* Fluid replacement, electrolytes, stool studies
* Control vomiting (Zofran, promethazine; metoclopramide {pregnancy})
86
Management of vomiting and diarrhea
* What do you give for infectious diarrhea?
* What do you not give? What is safe?
* Infectious diarrhea: ciprofloxacin, metronidazole
* Antimotility agents: Do NOT RX with bloody/infectious acute diarrhea. Loperamide (Immodium) may be safe; Lomotil is not well studied; be cautious
87
Acute Jaundice
* What are three causes?
Massive Hemolysis
Fulminant Hepatic Failure
Ascending Cholangitis
88
Hepatic Disorders & Hepatic Failure
* What is Fulminant Hepatic Failure:?
* What are the labs?
* Fulminant Hepatic Failure: acute hepatocellular necrosis with rapid encephalopathy and liver failure developing in less than 8 weeks
* Labs: CBC,CMP, PT/inr, Hep panels, Admit to ICU, Ammonia
89
Hepatic Disorders & Hepatic Failure
* What is the txt?
TX – admit to ICU and consult hepatology, aggressive support & monitoring. Correct hypoglycemia and coagulopathy if present. Lactulose for encephalopathy
90
Acute Jaundice
* Abrupt onset abdominal pain, jaundice, fever, RUQ pain, vomiting…..worry about what? (2)
choledocholithiasis and ascending cholangitis
* usually complications of billary stone
91
choledocholithiasis and ascending cholangitis
* Low or high mortality?
* What needs to be drained?
* What ist he charcot's triad?
High mortality
“Pus under pressure” that needs to be drained
Charcot’s Triad: All three= ascending cholangitis, jaundice+ RUQ pain=Choledocholithiasis, stone in common bile duct
* High Fever
* Jaundice
* RUQ Pain
92
ED Treatment of Portal HTN Complications
* How do you txt refractory ascites?
93
ED Treatment of Portal HTN Complications
* how do you treat esophageal variceal hemorrhage?
UGIB management + **IV octreotide, fluoroquinolone** prophylaxis, Admission, balloon tamponade only for temporary measure if needed, GI consult, TIPS procedure if needed.
94
ED Treatment of Portal HTN Complications: Subacte bacterial peritonitis
* Suspect with what?
* Dx with what?
* What is the txt?
* Suspect with: Fever, abdominal pain, worsening ascites, functional decline, or encephalopathy
* DX w/ paracentesis C&S
* Treatment: Admit to hospital, IV cefotaxime (3rd generation celphalosporin) . PO Ofloxacin may be used in pts without vomiting, shock, hepatic encephalopathy, or without serum creatinine greater than 3 mg/dL.
95
ED Treatment of Portal HTN Complications: Hepatic Encephalopathy
* Consider what?
* What is the best test ot evaluate liver disease
* What will be high?
* What is the txt?
* Consider other causes: R/O intracranial hematoma (End-Stage Liver Disease patients have coagulopathies); Sepsis, SBP, poor clearance of liver-metabolized drugs, don’t forget about hypoglycemia (ABCs and accucheck in AMS!)
* Best test to evaluate liver disease?
* NH3 level will be high
* TX: Admit to hospital, **Lactulose** (PO, NGT, or enema) and LOW protein diet
96
Admission for these patients
* What liver patients need to be admitted?
* Acute liver failure w/ prolonged PT, hypoglycemia, coagulopathy, encephalopathy, marked jaundice, etc.
* Cirrhotic patient who is not clinically stable
* Decompensated cirrhosis, fever, hypothermia, infection, SBP, GI bleeding, encephalopathy, and acute or worsening renal function
97
Cholecystitis & Biliary Colic
* How does the patient with cholecystitis present?
* What is the managemnt?
* When do you need early anx
* RUQ pain radiates to scapula. (Risk factors: 5Fs)
* Management: Labs, US, Surgical consultation with hospital admission-> Cholesystectomy within 2 weeks.
* Early broad spectrum ABX and HIDA (give CCK, then monitor gallbladder with constract)/ERCP with suspected choledocholithiasis and ascending cholangitis
98
What is the pathway of billary system?
Liver → 2. Bile Canaliculi → 3. Intrahepatic Bile Ducts → 4. Left and Right Hepatic Ducts → 5. Common Hepatic Duct → 6. Cystic Duct (to/from Gallbladder) → 7. Gallbladder (storage) → 8. Common Bile Duct → 9. Ampulla of Vater → 10. Sphincter of Oddi → 11. Duodenum (small intestine).
99
Pancreatitis:
* What are tyical causes? (4)
* What is the typical tests?(2)
* Typical causes: Etoh, gallstones, trigs>1000, scorpion bites
* If ETOH withdrawal is a concern, add benzodiazepine ie chlordiazepoxide
* Typical tests: Amylase/lipase
100
Pancreatitis
* What is the txt?
* What criteria is used to try and identify the 10% of patients who may develop severe pancreatitis?
Treatment: ABC, etoh withdrawal, IV fluids and lots of them, NPO, pain meds. Consider ICU
* If ETOH withdrawal is a concern, add benzodiazepine ie chlordiazepoxide
What criteria is used to try and identify the 10% of patients who may develop severe pancreatitis?
* Ranson or Apachi II criteria
101
Specialty Patients in ER (post-bariatric)
* Musst consider what?
Must consider Wernicke’s for at least 6 months following surgery in any altered patient
102
Bariatric patient
* Evaluate based on what Criteria ? Explain
* If greater than 2, give what?
103
Post bariatric patient:
* What is the work up?
104
Post bariatric patient:
* Rapid weight loss can increase chance of what?
* Consider increase incidence of what? (2)
105
Acute Renal Failure
* What is it?
* What is community acquired vs hospital?
* ARF: deterioration of renal function over hours or days
* Community acquired ARF is generally due to volume depletion and tends to be reversible/ Rx’s
* Hospital acquired ARF usually occurs in critically ill patients with Severe sepsis/MSOF and there is a very high mortality rate (up to 70%)
106
What is the difference btw AKI and ARF?
107
ARF
* Prerenal causes? BUN and cr?
108
ARF
* Renal: What is it, Cause?
109
Causes of post renal ARF?
110
ARF
* Asymp. until when?
* What are the features?
Asymptomatic until uremia develops
* Multiple features involving neurologic (uremic encephalopathy, asterixis), cardiovascular, hematologic, GI and bone disease
111
ARF
* What is the BUN:cr?
* What are the types?
* Always check?
* When to dialyze?
* BUN:Cr 100:10
* Oliguric versus Non-oliguric (better prognosis)
* Always check K+
* When to dialyze: When you suspect uremia
112
Creatinine
* Cr 1 = _% GFR
* Cr 2 = _% GFR
* Cr 4 = _% GFR
* Cr 8 = _% GFR
* When Cr 8, cannot get rid of what? Must do what?
113
Emergencies
* Dialysis patients have multiple complications from dialysis and their disease. What are they?
They have Subdural hematomas (2x risk of non-HD patients), pericardial tamponade, dialysis dementia, hypertension, anemia, bleeding diathesis, metabolic abnormalities, vitamin deficiencies and more
114
If they missed a dislysis appointment, worry about what?
worry about hyperkalemia(Deadly) and volume overload (CHF)
115
Ongoing Problems- Dialysis
* What is the issue with vascular access?
* What can happen durign dialysis?
Vascular Access (Hemodialysis)
* Infection (due to ports), Bleeding, Patency (thrombosis and stenosis), Pseudoaneurysm
During Dialysis: hypotension, air embolism, electrolyte abnormalities
116
Ongoing Problems- Dialysis
* What can happen at the end of dialysis?
Dialysis disequilibrium
* (nausea, vomiting, hypertension, seizure, coma, death – always a Dx of exclusion)
* Large fluid shifts/brain forms organic acids
117
Peritoneal Dialysis
* What is a complication?
* Also get what?
* When they present with abdominal pain, they will have peritoneal signs and must be presumed to have what?
* Bacterial Peritonitis
* Also get infections at access site and abdominal wall hernias
* When they present with abdominal pain, they will have peritoneal signs and must be presumed to have SBP until proven otherwise
## Footnote
SBP – spontaneous bacterial peritonitis.
118
Peritoneal Dialysis
* What should be studied? How should that be txt?
Cloudy dialysate fluid should be studied (cell count, gram stain, culture, amylase)
* Empiric antibiotic coverage
* Vancomycin (IP)
* If Systemic S&S give IV
119
CHF
* Change what?
* What happens when you increase dialysate/
* Patients are educated on what?
* Life saving especially in who?
* Give what if not anuric?
## Footnote
Give Lasix IV
CAPD – continuous peritoneal dialysis.
120
CAPD/CCPD
* Continuous what?
* Dialystate what? Give example
* patient will change % dialysate based on what?
121
CHF hemodialysis patients:
* What should you give to tx??
122
UTI
* What ist he spectrum?
* What are special at risk population?
* Spectrum: Uncomplicated to fulminant sepsis
* Special at-risk populations include neonates , elderly, pregnant women, immunosuppressed, obstructed, and patients with co-morbidities
123
Urinary Tract Infections
* Typical symptoms (Cystitis) lower tract:
* Upper tract :
* Typical symptoms (Cystitis) lower tract: dysuria, hematuria, increased frequency, urgency, hesitation, suprapubic discomfort
* Upper tract – observe CVA tenderness
124
Pyelonephritis
* What type of disease?
* What are the sxs?
Upper tract disease
Fever, chills, CVAT, nausea, vomiting, possible hemodynamic instability
* WBC casts
* **Proteinuria**
125
Pyelonephritis
* Can be complicated by what?
* Latter is gas-forming infection, usually in who? txt how?
* Can be complicated by acute bacterial nephritis, renal abscess and emphysematous disease
* Latter is gas-forming infection, usually in diabetics, requiring nephrectomy
126
How do we txt Acute Cystitis in a young, healthy, non-pregnant female adult ?
outpatient oral antibiotics with Bactrim/Keflex/Macrobid etc
127
how do we tx healthy elderly patient with uncomplicated cystitis?
Outpatient ciprofloxacin/Bactrim/Keflex etc, culture, close follow up
* C. Difficile always a risk
* May add probiotics
128
Txt of Patient with kidney stone obstruction?
Will become septic – do IV ABX
129
Pyelonephritis: who gets admitted?
* Debilitated, immunosuppressed
* Pregnant women
* 1-3% of patients with pyelonephritis will die!
130
UTI
* What is Acute urethral syndrome in women?
* who must we treat with asymptomatic bacteriuria? Why does it happen?
* Acute urethral syndrome in women – lower than traditional bacterial counts on culture
* Asymptomatic bacteriuria – must be treated in pregnant women
* Incomplete bladder emptying due to uterus compression
* Only with PO meds if they are asymptomatic, NO need for IV
131
UTI
* What anx are safe in preg?
* What is avoided?
* Antibiotics such as beta-lactams, vancomycin, nitrofurantoin, **metronidazole**, clindamycin, and fosfomycin are generally considered safe and effective in pregnancy.
* Fluoroquinolones and tetracyclines are generally avoided in pregnancy.
132
Male GU:
* Do a complete exam after you obtain what?
* Any testicular lumps that you find should be considered what?
* Look for what?
* When is the clock ticking?
* Do a complete exam after you obtain consent and get a chaperone
* Any testicular lumps that you find should be considered cancer until proven otherwise
* Look for hernias and torsion(age between 10-25yo)
* Clock is ticking: Fournier Gangrene (20% mortality)
133
Testicular Torsion
* What is cut off?
* What happens in testicular death?
* What reflex can you do?
Testicle cuts off it’s blood supply
Testicular death
* Decreased sperm production
* Decreased fertility
Bell Clapper’s/Cremasteric Reflex
134
Testicular Torsion
* What can you do for dx? Does not completely do what?
* What is DDX?
* Flow on ultrasound does not completely r/o torsion, use clinical judgement
* Indirect inguinal hernia DDX
* Doppler U/S
135
Clinically, a reflex arc termed the cremasteric reflex can be demonstrated by what?
by lightly stroking the skin of the inner thigh downwards from the hip towards the knee. This causes the cremasteric muscle on the same side to rapidly contract, raising that testicle.
136
Fournier Gangrene
* What is it?
*
* Polymicrobial, synergistic, necrotizing infection of perineal subcutaneous fascia and male genitalia in diabetic men
* Women affected as well
137
What is phimosis? Not an emergency when/
* Phimosis – inability to retract the foreskin proximally over the glans penis
* Not an emergency if they can easily urinate-> just give betamethasone and have them do stretching excerises or Definitive is circumcision.
138
What is paraphimosis?
inability to reduce the foreskin distally over the glans penis (swelling, venous engorgement, arterial compromise, gangrene….emergency circumcision)
139
Fractured Penis (rupture of corpus cavernosa tunica albuginea); “snapping sound”; hematoma evac & repair
140
Peyronie Disease
* Associated with that?
* What is it?
* Associated with Dupuytren’s contractures of hand
* Plaque on dorsum of penis
* Not an emergency
141
Priapism
* Common in who?
* What is the txt?
Priapism-common in SCD/vasoactive drugs/spinal injury
* Phenylephrine injection intrapenally
## Footnote
Priapism => 4hrs; commonly seen in cervical spine fracture.
142
What is this? Higher chance of what?
Inflatable penile prosthesis: higher chance of infection
143
Epididymitis and Orchitis
* usually what? What does the doppler show?
* Malignancy – work up any what? What is a risk factor?
Epididymitis and Orchitis – usually infectious (STDs)
* Doppler: increased blood flow
Malignancy – work up any testicular mass urgently
* Hydrocele is a risk factor
144
Prostatitis
* What is it?
* What are the sxs?
* What is the txt?
145
* Urethritis: cause?
* Stricture: Causes (2)
Urethritis
* STD’s (chlamydia)
Stricture
* Frequent STD’s
* Post-op prostatectomy 2nd to cancer
146
Urinary retention:
* Ask for hx of what?
* Causes?
Urinary Retention – ask for Hx of CA
* Prostate Hypertrophy
* Medications (anti-depressants notorious)
* Spinal Cord Pathology
147
Urologic Stone Disease
* May not have what?
* What is a DDX?
* What labs/ imaging do you need to do?
* Kidney Stone Belt (may not have blood/WBC in urine)
* DDX: AAA DO NOT MISS THIS!!!!!!!!!!!!!!!!!!
* Urine
* Imaging:CT UROGRAM IS THE STANDARD (will see AAA)
148
Urologic Stone Disease
* What is important to control?
* Who do you admit?
* What passes on own?
* Pain Control (important)
* Whom to admit? PAIN,EMESIS,INFECTED – don’t send them home.
* Which ones will pass on their own?—LESS THAN 5mm
149
Hematuria
* What are the two types?
* Can be caused by what?
* Beware of what?
* Gross and Microscopic
* Caused by: Infections, neoplasms, kidney stones, glomerulonephritis, injury/trauma, coagulopathy, others
* Beware: Beets!
150
What are the Complications of Catheters?
## Footnote
In male hard to catheterize with BPH. Place 10cc of KY jelly into urethra and slide catheter.
151
Renal Transplant Patients
* Chronically what?
* Always at risk for what?
* Very what?
* Chronically immunosuppressed
* Always at risk of graft rejection
* Very complex to manage
152
Renal Transplant Patients
* What are two questions you need to ask?
* Always get help from who?
## Footnote
Place on ABX (c.diff is complication)
153
Vaginal Bleeding (in the non-pregnant patient)
* What are common causes in adolescents and adults?
154
Vaginal Bleeding (in the non-pregnant patient)
* Post-menopausal patient: Common Causes?
Exogenous estrogen (30%)
Atrophic vaginitis or endometrial polyp (30%)
Endometrial lesion (30%)
Endometrial CA is a major concern; close GYN follow-up
* Postmenopausal bleeding – think endometrial malignancy – MUST HAVE ENDOMETRIAL BIOPSY.
155
Vaginal Bleeding (in the non-pregnant patient)
* What is a common cause if the exam is normal?
* What are the two ages?
* What is anovulatory cycles?
Dysfunctional Uterine Bleeding (DUB) is a common cause if the exam is normal
Age
* Peri-menarchal
* Peri-menopausal
Anovulatory cycles -> irregular shedding of thickened endometrium
## Footnote
Dysfunctional – not in nl cycle and not due to anatomical cause – just outgrows the BS too fast and sloughes off.
156
Vaginal Bleeding: Management
* What do you do if hemodynamically stable?
* Gyn consult, usually outpatient
* IV or oral estrogen, done by OBGYN
* Medroxyprogesterone
* Consult for bx in peri/postmenopausal pt (no hormone therapy-> because if HR + mass, it will increase malignacy)
157
Vaginal Bleeding: Management
* What do you for hemodynamically unstable?
* Standard resuscitation
* Inpatient OBGYN consult
* Prompt D&C (if indicated)
* IV estrogen + progesterone
158
159
Pelvic Pain (in the non-pregnant patient)
* Interview adolescents without who?
* Chaperone for what?
* Most states allow treatment of what?
* Interview adolescents without the parent present to elicit an accurate sexual history
* Chaperone for pelvic exam
* Most states allow treatment of STDs without parental consent
160
Pelvic Pain (in the non-pregnant patient)
* What are some causes?
* Bartholin gland cyst
* Ovarian cysts
* Ovarian torsion
* PID/ Tuboovarian Abscess
161
Bartholin Gland Cyst
* Where are they?
* What is the size?
* usually what?
* Bartholin's duct cysts
* Average 1 to 3 cm
* Usually unilateral and asymptomatic-> Can form an abscess
162
Bartholin Gland Abscess
* how do this happen?
* What are the sxs?
* Abscess is what?
* Some do not contain what?
An obstructed Bartholin's duct can become infected and form an abscess
* Severe pain and swelling; patients are unable to walk, sit, or have sexual intercourse
* Abscess is a warm, tender, soft or fluctuant mass in the lower medial labia majora
* Some do not contain pus but rather clear jelly-like substance
163
What is this?
Bartholin gland abscess
164
Bartholin Gland Abscess
* What is the management?
* Immediate pain relief occurs upon drainage of pus
* Initial treatment of abscess is incision and drainage supplemented by placement of a Word catheter
* Excision is definitive treatment esp if recurrent
165
What is the word catheter?
166
how do you place a word cath?
Will be left in place to help tissue grow and prevent abscess formation
167
Ovarian Cysts
* Rupture will cause what? What is a DDX in a young patient?
* What is the imaging?
* What size cyst tend to cause torsion?
Mostly are benign and asymptomatic until rupture
168
Ovarian Cysts management:
* Unruptured cysts < 5cm txt?
* Self-limited
* NSAIDs
* GYN follow-up
169
Ovarian Cysts management:
* Unruptured cysts > 5 cm (or solid instead of cystic) txt?
* Neoplastic until proven otherwise (Ovarian CA)
* Needs urgent f/u to prevent torsion
170
Ovarian Torsion
* What are the sxs?
* What does it cause?
* Urgent what?
* Typically fertility isnt affected until?
* Severe, acute pelvic pain, nausea and vomiting
* Ovary twists on pedicle cutting off blood supply necrosis
* Urgent Sx consult
* Typically fertility isnt affected until older age
171
Ovarian Torsion
* What do you need to evaluate for?
* What may help you dx? What does it show?
* Urgent what?
172
Pelvic Inflammatory Disease (PID)
* Cause?
* poly_
* What are the risk factors? (3)
* What is the sequelae? (2)
173
What is the clincial presentation of PID?
174
PID
* Culture for what?
* Wet mount for what?
* What to do if wet prep is not available (urgent care)?
Cultures for Chlamydia and gonorrhea
Wet mount (BV, trichomonas, Candida)
What to do if wet prep is not available (urgent care)? pH paper
* Normal pH 4.5-5.0: organism to cause problem is candida
* pH>5 will indicate BV, Trichomonas, Lichenoid vaginitis, inflammatory/atrophic vaginitis
175
PID
* What imaging?
* What Abx should you give?
Pelvic U/S for possible tubo-ovarian abscess (TOA)
ABX:
* Cefotetan or cefoxitin plus doxycycline
* Cindamycin plus gentamicin
176
What are the Indications for Admission with a pt with PID?
177
Ectopic Pregnancy
* leading cause of what?
* Think of this if any what?
* What will be positive?
* Leading cause of first trimester pregnancy-related maternal death
* Think this if any pelvic pain
* Quantitative pregnancy will be positive, qualitative may not be
178
Ectopic Pregnancy
* What are the risk factors?
* h/o PID/chlamydia
* Previous ectopic pregnancy - scarring
* IUD presence (if pregnancy occurs)
* BTL
179
Ectopic Pregnancy
* Consider in who?
* What ist he classic triad?
* What is highly variable?
## Footnote
They don’t always bleed
180
Ectopic Pregnancy
* What labs/imaging should you do?
* Urine HCG
* Serum HCG if urine negative and high clinical suspicion
* Transvaginal U/S -> empty uterus with adnexal mass esp if UHCG+/QHCG is >2000
181
Ectopic Pregnancy
* OBGYN consult prior to what?
* What is the txt?
182
Heterotopic Pregnancy
* What is it?
* What are the sxs?
Presence of simultaneous pregnancies at two different implantation sites
Symptoms include:
* abdominal pain,
* adnexal mass,
* peritoneal irritation if rupture
* enlarged uterus
## Footnote
PT+ and lots of abd pain – suspect this
183
Heterotopic Pregnancy
* What is contraindicated?
* What is the txt?
* Methotrexate is contraindicated in the presence of a viable intrauterine gestation
* Tx is surgical if viable intrauterine pregnancy.
184
What are emergenices during prenancy?
185
Special considerations in evaluating the pregnant patient...
* EVERY woman of childbearing age gets what?
* Consider PE in who?
* Get MRI if high concern for what?
* Treat what?
* Always place what?
186
Special considerations in evaluating the pregnant patient…
* When considering imaging studies? (3)
* What is not contraindicated in pregnancy?
When considering imaging studies:
* Risk vs. benefit
* Performed if mother is in eminent danger
* Consult radiology if any question
Tetanus is NOT contraindicated in pregnancy
187
Special considerations in evaluating the pregnant patient…
* Prior to 20 wks gestation efforts are focused on who?
* After 20 wks gestation, once mom is in asystole x4-5 min, what needs to happen?
* Prior to 20 wks gestation efforts are focused on saving mom
* After 20 wks gestation, once mom is in asystole x4-5 min, EMERGENT c-section is performed in the ED
188
Abortion
* What is threatened and inevitable abortion?
* Threatened – vaginal bleeding, closed os and no passage of tissue (very common in early pregnancy)
* Inevitable – vaginal bleeding, dilated os, and no passage of tissue
189
Abortion
* What is incomplete and complete?
* Incomplete – vaginal bleeding, dilated os and passage of some tissue
* Complete – vaginal bleeding, closed os and passage of tissue
190
Abortion
* What is the txt?
* What imaging do you need to do?
Rapid infusion of IV crystalloid or packed RBCs plus 1 amp oxytocin if hemodynamically unstable 2nd to blood loss
* Sometimes use methergine, but look for consult from OBGYN
U/S to confirm that all products of conception have passed, If not – do D&C
* Complications associated with retained products-> Choriocarcinoma
191
What do you give anytime of bleeding during pregnancy in Rh negative mothers? How long is it effective for?
What is for incomplete abortion?
## Footnote
Anytime at amniocentesis or any pregnant woman with vaginal bleeding
192
Hyperemesis Gravidarum
* What is it?
* What are the SE?
* What can happen if Loss of more than 5% weight?
* Discharge when?
* Intractable vomiting
* SE: Weight loss, volume depletion, hypokalemia or ketonemia
* Loss of more than 5% weight: IUGR and low birth weight infants
* Discharge when ketonuria clears (not before)
193
Hyperemesis Gravidarum
* What is the txt?
* Admit if what?
Rehydrate: 5% dextrose in normal saline
Antiemetics:
* Diclegis/Bonjesta
* Metoclopramide
* Promethazine
* Zofran (gray area of pregnancy risk classification)
Admit if persistent ketonuria, electrolyte abnormalities or weight loss > 10%
194
Abruptio Placentae
* What is it? what is Subchorionic hemorrhage ?
* Premature separation of placenta from uterine wall > 20 weeks
* Subchorionic hemorrhage before 20 weeks (about 50% leads to miscarriage)
195
Abruptio Placentae
* What is the avg onset?
* What is the clincial presentation?
* What may be necessary?
Average onset at 25 weeks
Clinical Presentation:
* Vaginal bleeding (mild or severe), painful
* Uterine tenderness
* Fetal distress
Emergency delivery may be necessary
196
Placenta Previa
* What is this?
* What is the clinical presentation?
* Implantation of the placenta over cervical os (marginal, incomplete and complete) > 20 weeks
* Clinical presentation: Painless vaginal bleeding
197
Placenta Previa
* What should you not do?
Diagnosis:
* U/S – NO TRANSVAGINAL US
* NO DIGITAL EXAM PRIOR TO U/S
198
Placenta Previa
* Admit for what?
* When can you consider outpatient care?
199
# under notes
At 20 weeks and PP ?
At 20 weeks and PP – no worry as placenta will probably migrate up away from os as pregnancy advances
200
PROM
* What is it?
* What is the clinical presentation?
PROM – Premature rupture of membranes, i.e. rupture of membranes prior to labor
* Another variant is PPROM (under 37 weeks)
Clinical presentation:
* Rush of fluid or constant leakage of fluid from the vagina (not incontinence
201
Prom
* how do you dx it?
* Admit to who?
Diagnosis:
* Nitrazine test: pH of amniotic fluid is greater than 7.0 (by sterile speculum exam)
* Ferning on smear of fluid
Admit to OBGYN
202
Pre-term Labor
* When does this occur?
* Viability is possible before when?
* Consult OB for what?
Labor: before 37 weeks
* Viability is possible before 23 weeks but high morbidity and mortality
Consult OB for admission and decision regarding tocolytics (delay labor to get time for steroids to mature lungs)
203
Tocolytics
* What does it give?
* What is an example?
* Offers an opportunity to give what?
* Buy a little time (few days)
* E.g. Terbutaline
* Offers an opportunity to give mother glucocorticoids to try to mature fetal lungs
204
Tocolytics
* At 25 weeks gestation, delaying delivery for 2 days and giving steroids can do what?
* Defer to what?
* At 25 weeks gestation, delaying delivery for 2 days and giving steroids can increase neonatal survival by 10%
* Defer to OBGYN for specific therapy
205
Preeclampsia and Eclampsia
* What is it?
HTN in pregnancy (<20W): BP > 140/90 mmHg or increase from normal baseline of 20 mmHg (systolic) or 10 mmHG (diastolic)
206
Preeclampsia (>20W + up to 6 weeks following birth): (3)
* HTN
* Proteinuria (≥ 0.3gm in 24hrs)
* Usually accompanied by peripheral edema (esp hands and face) Ankle edema is common in all pregnants – dependant edema.
207
What is Eclampsia?
Eclampsia: above plus seizures
208
Preeclampsia and Eclampsia
* What is the txt for preeclampsia and eclampsia
209
HTN in Pregnancy:
* What medications can you use to tx HTN?
Treatment: along with Mg Sulfate which prevents seizures.
* Hydralazine – 5 mg IV followed by additional 5 – 10mg IV depending on initial response; OR
* Labetalol – 20mg IV bolus; repeat 20 – 80mg bolus as needed to max of 300mg
* Nifedipine – 30mg loading bolus; 10-20mg Q6hrs as maintenance
210
HTN in Pregnancy
* What meds are contraindicated?
Contraindicated meds include ACEI/ARBS, diuretics, most BBs (except Labetalol), and most CCBs (except nifedipine)
211
HELLP
* What is it?
* Characterized by what?
* Variant of preeclampsia; may present w/o HTN
* Characterized by: hemolysis, elevated liver enzymes and low Platelets
212
HELLP
* Clinical presentation?
* What are complications?
* Clinical presentation: RUQ pain and Preeclampsia, can present for up to 6 weeks following delivery of fetus
* Complications: hepatic and splenic hemorrhage, end organ failure, abruptio placentae, ICH, death of the fetus, death of mother from hemorrhage
213
Complications of Delivery
* What do you feel with a cord prolapse? What do you need to do?
214
Postpartum Emergencies
* What are two examples?
* Postpartum Hemorrhage
* Postpartum Endometritis
215
Postpartum Hemorrhage
* When does it occur?
* What are causes?
Hemorrhage-usually in first 24 hours; **can occur in days to weeks**
* **Uterine atony – most common cause (muscles cant contract back to normal after prolonged labor)**
* Uterine rupture
* Laceration of genital tract
* Retained placental tissue
* Uterine inversion
* Coagulopathy
216
Postpartum Hemorrhage
* What does the PE show?
Uterus is enlarged and “boggy/doughy”
217
Postpartum Hemorrhage
* Stabilize the patient with what?
* What labs do you need to do?
* What is the uterine atony txt?
* Stabilize the patient with crystalloid IV fluids and/or packed RBCs w/ 1 amp oxytocin
* CBC, clotting studies, type and crossmatch
* Uterine atony treatment: Oxytocin 40 units/L NS at 200mL/h
218
Postpartum Hemorrhage
* What do you repain in the ED? What do you need to educate on?
* What requires obstetric consult for emergent surgery
Repair minor lacerations in the ED
* If secondary to torn episiotomy, emphasize importance of refraining from intercourse
Retained POC, uterine inversion and uterine rupture require obstetric consult for emergent surgery
219
Postpartum Endometritis
* What are teh clinical features?
* What are the physical exam findings?
Clinical features:
* Foul smelling lochia (rubra or alba)
* Abdominal pain
* Fever
Physical Exam Findings:
* Uterine or cervical motion tenderness
* Discharge
220
Postpartum Endometritis
* Poly_
* Admission for what? What do you give?
Polymicrobial
Admission for ABX
* clindamycin (900 mg every eight hours) plus gentamicin(1.5 mg/kg every eight hours or 5 mg/kg every 24 hours
