Asynchrony EM: GYN Sampler

BLEEDING, TWISTING AND INFECTION

...in the non-pregnant female patient

New to Asynchrony EM? It's an asynchronous learning course in its third year at Brown EM, with digital content curated into topic modules following our curricular calendar. In the spirit of #FOAMed, we've started putting it out there for the EM professional community at large. Check out the theme song, the 'extras', and the discussion questions -- and leave us your thoughts in the comments section. Click here for more about us and for other curated teaching modules!

Note: Brown EM residents must complete the modules (including discussion/quiz) in Canvas to obtain credit hours.

A very interesting ornament....tis the season!

A very interesting ornament....tis the season!

  

This week in our OB/GYN block, we're surveying a smattering of GYN conditions in the non-pregnant patient. Bleeding, torsion, PID/TOA, and a little bit on newer long-term contraception methods.  At the end we've got a little blurb on STIs and expedited partner therapy. 

Do we have a theme song? Of course we do!

Here's Chaka Khan with her famous "I'm Every Woman."  A reminder to not be biased by age or socioeconomic status in your differential diagnoses of gyn pathology...e.g., she may look like your Nonna, but she could still have chlamydia. (See the extras below!)

 

OK, let's get some knowledge flowing. ;)

1) First question up for discussion: Is Pelvic Exam in the Emergency Department Useful? From ALiEM, 1/30/14, by Salim Rezaie, MD.  Please read the comments that follow the post. For practical purposes, I like the notion of treating the pelvic exam as a test one orders judiciously. Most seasoned ED docs will be able to tell you a story about when their pelvic exam actually changed their management, so don't throw it out. My two cents: you're much more likely to be faulted in hindsight for skipping it than being diligent, so when it could add to my differential in a woman with significant symptoms, I do it. (Also, the more we use bedside Gyn ultrasound, the more this will just become one exam, right?)

 

2) "Not Pregnant and Vaginal Bleeding for Two Weeks."   Even more awesome than the title makes it sound! From FreeEmergencyTalks.net, featuring the 2012 AAEM Scientific Assembly -- lectures in podcast form. Did you know tampons are approved as medical devices?  Me neither!

You'll want to jot some notes on the various regimens for temporizing bleeding (put them in your phone for access on your next shift.) You can skip the first minute in which the speaker (Dr. Joelle Borhart) collects a speaking award from a previous lecture. (We only pick award-winning speakers for lectures on vaginal bleeding.) And you can skip the last 4 minutes of Q&A, too.  So about 20 minutes on menorrhagia, and things we can do about it in the ED, besides checking a CBC and telling patients to follow up with their gynecologist. Some very useful tips in the latter half.

 

3) EM Lyceum has a nice review of answers to your torsion questions. Because you definitely had torsion questions. 

 

4) And you also definitely had questions about PEDIATRIC ovarian torsion, didn't you?  (Such as: "Um, that really happens?!') FromPediatric EM Morsels -- a quick blog post. I love how, in the twisted (pun intended) way of the universe, pediatric torsion is more often right sided.  As if the diagnosis were not difficult enough. The universe does not seem to be concerned with making our job any easier.

 

5) Put 3 and 4 together to review, and then add in tubo-ovarian abscess and a tad on PID for a nice podcast review from CORE EM (March 7, 2016).  (Ever heard of in utero ovarian torsion? Now you have.) Thirteen minutes. Ovarian Pathology, Episode 37.0

 

6a)  Pelvic Inflammatory Disease: Pearls and Pitfalls from EM Docs (November 21, 2016.) Brings us back to part 1: don't dump the pelvic exam entirely. 

b) Because you might never see it, but you'll definitely be asked about it: a tad more on Fitz-Hugh-Curtis syndrome, from Radiopaedia. 

c) We're not doing a full STI review today, but just FYI: Expedited Partner Therapy (i.e., prescribing antibiotics for sexual partners without seeing them as a patient) is LEGAL in many states and encouraged by the CDC, particularly for treatment of male partners of women with chlamydial infection or gonorrhea.  Expedited Partner Therapy

Here's a map of where it's legal (last updated October 2016): http://www.cdc.gov/std/ept/legal/ 

(Check out the discussion question at the end.)

 

7) Just a little primer on long acting birth control methods, which you may or may not be familiar with, and which are becoming increasingly more popular. 

a) From Medscape: Long-Acting Reversible Contraception: Comparing Methods

b) It is true that, as stated in part A, the risk of 'injury' from a Nexplanon implant is very small -- but if someone says they have a birth control implant, and you can't feel it, perhaps you should go look for it. You might just find a Nexplanon pulmonary embolus. FDA Safety Information: Nexplanon Implants

c) One more thing you might incidentally find on pelvic exam: you don't see IUD strings when the patient says you should. Again, you should consider looking for them. From Radiopaedia: IUCD related uterine perforation. Amazingly, patients can be asymptomatic! This recommends US as first choice for testing, although I have found extra-pelvic IUDs on a gyn-recommended KUB in the past.

 

And now...The OPTIONAL OB/GYN EXTRAS:

MRI safety, Transgendered Patients, and "Aliens" with an HCG > 1 million, and Grammies with Chlamydia.

1) Recent JAMA (2016 Sep;316(9):952-961) article on safety of MRI in early pregnancy. Bottom line: so far MRI seems safe, but gadolinium doesn't, so avoid the contrast.  https://www.ncbi.nlm.nih.gov/pubmed/27599330

2) Health Issues to Consider in the Transgender Patient from ACEP Now, March 6, 2014.

3) "There's An Alien Inside Me!"  Just when you think you've seen everything. An interestingly layered OB/Gyn case from EP Monthly with valuable teaching points. 

4) She might remind you of your Nonna, but it doesn't mean she can't have chlamydia. Sex and the Single Senior; NYT 1/18/24. 

THAT'S IT! (Brown EM residents, remember you have to complete the discussion section and quiz in Canvas in order to receive credit.)

Tell us in the comments:

  • Expedited Partner Therapy is LEGAL in many states. Is this your practice, if you are in a state where it is legal (it's legal where we are in Rhode Island)? If not -- why not?
  • Any interesting relevant cases to share?
  • Any other #FOAMed resources on these topics that you find helpful?

Click, engage, learn, comment, query, teach, share.  See you next time!

 

 

 

POCUS: Shoulder Dislocation

Case:

An 18-year male with a history of a left shoulder dislocation presents with a chief complaint of “my shoulder is out of place.” Prior to arrival, the patient fell during a soccer game and felt his shoulder dislocate. He is neurovascularly intact.

Introduction:

The glenohumeral joint is the most commonly dislocated major joint in the body. The glenoid is shallow, with only a small portion of the humeral head articulating with it. While this allows for a wide range of motion, this makes the shoulder an unstable joint. Anterior dislocations account for 95 to 97% of all glenohumeral dislocations. Posterior dislocations account for most of the remainder, whereas inferior and superior dislocations are rare [i]. It is important that the dislocation is reduced as soon as safely possible since neurovascular complications increase with time.

A common practice is to obtain radiographs before reduction of a shoulder dislocation to confirm the diagnosis and exclude fractures. Recent literature has demonstrated the advantage of point-of-care-ultrasound (POCUS) in detecting both anterior and posterior shoulder dislocations. However, further investigation is necessary to assess the ability of ultrasonography in detecting fractures associated with dislocation [ii]. Factors associated with fractures include age over 40, first-time dislocation, and traumatic mechanism. When all three factors were absent, the negative predictive value for the presence of a fracture was 96.6 percent (95% CI 88.3-99.6) [iii]. If none of the aforementioned criteria are met and the clinician feels that this is an uncomplicated anterior shoulder dislocation, pre-reduction radiographs are unnecessary.  

X-rays are often taken following a reduction to confirm successful reduction and exclude any fracture caused by the procedure. Post reduction films are time consuming and need to occur after any sedating medications have worn off. Imagine discovering that the reduction was unsuccessful? This patient may need to undergo sedation again, the length of stay is dramatically increased, and your patient is probably not thrilled!

Don’t worry, there is another option! Ultrasound is a cost-effective, portable, safe, and real-time tool that can be used in this situation. POCUS allows for a dynamic evaluation of the glenohumeral joint, immediately informing you of a successful reduction or the need for additional shoulder manipulation. Additionally, ultrasound can also be used to guide intra-articular local anesthetic. As good as this sounds, there are some limitations to using POCUS. Ultrasound is highly operator-dependent, it is not sensitive for a labral or rotator cuff tears, and fractures can be difficult to assess.

Let’s Scan

Figure 1: Getting set up

Figure 1: Getting set up

Grab a high-frequency, linear-array probe or the curvilinear probe. Depending on patient habitus and personal preference, either probe is a fine choice. Position the probe in the transverse orientation, behind the shoulder and over the scapular spine. Move the probe laterally until you can visualize the glenoid. Continue to move laterally until you have a good view of the humeral head.

Normal Shoulder:

Figure 2: Normal Shoulder Anatomy on POCUS

Figure 2: Normal Shoulder Anatomy on POCUS

Figure 3: Normal Shoulder Anatomy on POCUS.  Photo Source: https://sonostuff.com/2016/08/23/msk-pocus-2nd-installment-muscles-tendons-and-bones-oh-my-foamed-foamus-meded-ultrasound/

Figure 3: Normal Shoulder Anatomy on POCUS. 
Photo Source: https://sonostuff.com/2016/08/23/msk-pocus-2nd-installment-muscles-tendons-and-bones-oh-my-foamed-foamus-meded-ultrasound/

Figure 4: Normal Shoulder Anatomy on POCUS Photo Source: http://www.foamem.com/2014/06/05/shoulder-ultrasound-intra-articular-injection-and-reduction-2/

Figure 4: Normal Shoulder Anatomy on POCUS
Photo Source: http://www.foamem.com/2014/06/05/shoulder-ultrasound-intra-articular-injection-and-reduction-2/

If the shoulder is in appropriate anatomical position, the shoulder joint should be immediately adjacent to the glenoid. If the shoulder is not dislocated, the patient should be able to internally and externally rotate the shoulder while adducted, and the rotational articulation between the humeral head and glenoid fossa will be seen clearly on the ultrasound screen.

Abnormal Shoulder:

With an anterior dislocation, the humeral head will be deep on the screen, while with a posterior dislocation, the humeral head will be more superficial on the screen (closer to the probe).  A hyperechoic hemarthrosis is often seen in the joint when shoulder is dislocated.

Figure 5: Anterior Shoulder Dislocation 

Figure 5: Anterior Shoulder Dislocation 

Figure 6: Posterior Dislocation [iv]

Figure 6: Posterior Dislocation [iv]

Figure 7: Comparing Anterior Dislocations to Posterior Dislocations. Photo Source: http://www.emdocs.net/wp-content/uploads/2014/06/shoulderDislocation.png

Figure 7: Comparing Anterior Dislocations to Posterior Dislocations. Photo Source: http://www.emdocs.net/wp-content/uploads/2014/06/shoulderDislocation.png

Pain Control:

Another advantage to ultrasound is that it can be used to guide an intra-articular lidocaine injection. Systematic review articles have found that complication rate, length of stay, and cost were significantly lower in patients who received intra-articular lidocaine when compared with those who received intravenous sedation [i],[ii],[iii]. Sterilize the skin over the shoulder and place local anesthetic with a small bore needle. Use the ultrasound transducer to locate the glenoid and humeral head. Using a long axis or in-plane technique guide a 20-gauge spinal needle into the joint and inject 20 mL of 1% lidocaine into the joint space [iv]. Give the medication 10-20 minutes to kick in and proceed with your reduction.

Figure 8: Representation of intra-articular lidocaine injection

Figure 8: Representation of intra-articular lidocaine injection

Video source: Dr. Shirley Wu

Take Home Points:

  • Position the probe in the transverse orientation, behind the shoulder and over the scapular spine. Move the probe laterally until you can visualize the glenoid and the humeral head.
  • With an anterior dislocation, the humeral head will be deep on the screen, while with a posterior dislocation, the humeral head will be more superficial on the screen (closer to the probe). 
  • Complication rate, length of stay, and costs were significantly less in the intra-articular lidocaine group when compared with the intravenous sedation group

If you want to see more, here is a helpful 6 min video by Mike Stone on ultrasound for dislocation and tips on intraarticular lidocaine injections using US guidance.

Resident Reviewer: Dr. TJ Ye

Faculty reviewers: Dr. Otto Liebmann

References:

[i] Marx, John A, Robert S. Hockberger, Ron M. Walls, Michelle H. Biros, Daniel F. Danzl, Marianne Gausche-Hill, Andy Jagoda, Louis Ling, Edward Newton, Brian J. Zink, and Peter Rosen. Rosen's Emergency Medicine: Concepts and Clinical Practice. , 2014. Chapter 53, 618-642.e2

[ii] Abbasi S, Molaie H, Hafezimoghadam P, Zare MA, Abbasi M, Rezai M, Farsi D. Diagnostic accuracy of ultrasonographic examination in the management of shoulder dislocation in the emergency department. Ann Emerg Med. 2013 Aug;62(2):170-5. doi:10.1016/j.annemergmed.2013.01.022. Epub 2013 Mar 13.

[iii] Emond M, Le Sage N, Lavoie A, Rochette L. Clinical factors predicting fractures associated with an anterior shoulder dislocation. Acad Emerg Med. 2004Aug;11(8):853-8.

[iv] Mackenzie DC, Liebmann O. Point-of-care ultrasound facilitates diagnosing a posterior shoulder dislocation. J Emerg Med. 2013 May;44(5):976-8. doi: 10.1016/j.jemermed.2012.11.080. Epub 2013 Mar 13.

[v] Waterbrook AL, Paul S. Intra-articular Lidocaine Injection for Shoulder Reductions: A Clinical Review. Sports Health. 2011;3(6):556-559. doi:10.1177/1941738111416777.

[vi] Hunter, B, Wilbur, L MD.  Can Intra-articular Lidocaine Supplant the Need for Procedural Sedation for Reduction of Acute Anterior Shoulder Dislocation?  Ann Emerg Med 59(6): 513-4; 2012.

[vii] Ng VK, Hames H, and Millard WM: Use of intra-articular lidocaine as analgesia in anterior shoulder dislocation: a review and meta-analysis of the literature. Can J Rural Med 2009; 14: pp. 145-149

[viii] Custalow, Catherine B, James R. Roberts, Todd W. Thomsen, and Jerris R. Hedges.Roberts and Hedges' Clinical Procedures in Emergency Medicine. Philadelphia, PA: Elsevier/Saunders, 2013. Internet resource.

 

 

CITW 20: Flashing Lights

HPI/ROS: 47 year old female presents to the ED with a change in her vision. The patient states she was doing laundry about an hour prior when “all of a sudden” she experienced “flashing lights” in the right side of her vision. This was associated with “hundreds of black specks” appearing predominately in the right side of her visual field. She denies any changes in her overall clarity of vision as well as no eye pain, photophobia, headache, dizziness, hearing changes, numbness, weakness, or trouble speaking and swallowing. This has never happened before. No history of trauma to the head. She’s been otherwise well recently.

Vital Signs: T: 98.6, HR: 91, BP: 152/73, R: 16, SpO2: 99% on room air

Visual Acuity: R 20/35 L 20/25

Physical Examination: The patient is alert and oriented. Normocephalic, atraumatic head. Tympanic membranes are clear. Oropharnyx clear and moist. Cranial nerves II-XII are intact. Pupils are 4 mm and reactive bilaterally. Extra-ocular movements are intact. Peripheral vision is intact. Patient accommodates appropriately. Neck is supple. Lungs are clear to auscultation. Heart is regular rate and rhythm without murmurs, rubs, or gallops. Abdomen is soft, non-tender, non-distended. No other pertinent exam findings.

A bedside globe ultrasound of the right eye is performed, and the following image is obtained:

Figure 1: Ultrasound imaging of the right globe

Figure 1: Ultrasound imaging of the right globe

What is the diagnosis?

Retinal Detachment

The ultrasound image above demonstrates a retinal detachment in which the retina pulls away from supporting tissue in the back of the eye. In the image below, you can see what a large retinal detachment would look like on ophthalmoscopic examination:

Figure 2: Retinal detachment as seen on ophthalmoscopic exam. Borrowed from http://emedicine.medscape.com/article/798501-overview

Figure 2: Retinal detachment as seen on ophthalmoscopic exam. Borrowed from http://emedicine.medscape.com/article/798501-overview

This is one of few ocular emergencies along with globe rupture, endophthalmitis, acute angle glaucoma, retrobulbar hematoma, and central retinal artery occlusion. Let’s review the pathology:

  • This refers to the separation of the inner layers of the retina from the underlying retinal pigment epithelium (RPE).
Figure 3: Anatomy of the eye. Borrowed from http://www.aafp.org/afp/2004/0401/p1691.html

Figure 3: Anatomy of the eye. Borrowed from http://www.aafp.org/afp/2004/0401/p1691.html

  • Occurs when a tear in the neuronal layer allows vitreous to collect between the neuronal layer and RPE, in the setting of traction from the vitreous membrane on the retinal layer (seen with proliferative retinopathies such as diabetic retinopathy or scarring from previous surgeries/trauma), or in the setting of exudative build up of fluid in the space between the neuronal layer and RPE (such as severe hypertension, central retinal vein occlusion, vasculitis, papilledema).
Figure 4: Anatomic depiction of retinal detachment. Borrowed from http://www.aafp.org/afp/2004/0401/p1691.html

Figure 4: Anatomic depiction of retinal detachment. Borrowed from http://www.aafp.org/afp/2004/0401/p1691.html

  • Patients typically present with photopsia (flashing lights), the sudden onset of floaters, and more ominously will describe a “dark curtain” falling over their vision or blurred vision, which would be indicative of macular involvement.
  • It is important to consider a broad differential:
Table 1: Differential diagnoses of retinal detachment. Borrowed from http://www.aafp.org/afp/2004/0401/p1691.html

Table 1: Differential diagnoses of retinal detachment. Borrowed from http://www.aafp.org/afp/2004/0401/p1691.html

  • Risk factors include age greater than 40, a history of trauma, previous ophthalmologic surgery (particularly cataract surgery), extreme myopia (typically >6 diopters), prior retinal detachment/uveitis/retinal hemorrhage, or a family history of retinal detachment.
  • On examination, it is important to assess for signs of trauma, pupillary function, visual acuity (to assess for macular involvement), ophthalmoscopy (although this may be inadequate in and of itself given poor sensitivity to detect peripheral/smaller detachments), and slit lamp exam.

Figure 5: A) Weiss ring visualized under ophthalmoscopy indicative of vitreous detachment from the optic nerve resulting in an out-of-focus optic disc, nerve, and retina. B) Shafer’s sign on slit lamp examination of the vitreous demonstrating pigmented cells. Borrowed from http://webeye.ophth.uiowa.edu/eyeforum/cases/196-pvd.htm

  • Emergent/urgent ophthalmology consultation is paramount, especially in patients with blurred vision or visual field defects (implying macular involvement).
  • With modern surgical approaches to management, prognosis is favorable. Studies seem to indicate that the faster the repair the better the outcome (re: visual recovery) regardless of whether the macula is involved or not, ideally within the first week.
  • The most important predictor of visual recovery is the visual acuity prior to repair. Younger age also plays a role.
  • Consider utilizing ultrasound to make the diagnosis at the bedside! 

Case Conclusion: The patient had an emergent ophthalmology consultation. In the absence of visual acuity loss, she was taken to the OR two days later with successful repair and visual recovery. 

Special thanks to Dr. Sarah Joseph for help in putting this together!
Faculty Reviewer: Dr. Alyson McGregor

References: 

Gariano R, Chang-Hee K. Evaluation and Management of Suspected Retinal Detachment. Am Fam Physician. 2004 Apr 1;69(7):1691-1699. 

Gauger E, Chin EK, Sohn EH. Vitreous Syneresis: An Impending Posterior Vitreous Detachment (PVD). Oct 16, 2014. <http://eyerounds.org/cases/196-PVD.htm>. 

Hemang, P. Retinal Detachment. Oct 20, 2015. <http://emedicine.medscape.com/article/798501-overview>.

Mayo Clinic. Retinal Detachment. 2016. <http://www.mayoclinic.org/diseases-conditions/retinal-detachment/home/ovc-20197289>.

National Eye Institute. Facts About Retinal Detatchment. Oct, 2009. <https://nei.nih.gov/health/retinaldetach/retinaldetach>.