Rosen & Barkin's 5-Minute Emergency Medicine Consult (20 page)

• Patients requiring abdominal surgery
  
• Observe the following patients for at least 8 hr:
  
  • Patients with negative findings on diagnostic peritoneal lavage, CT, or US. During hospitalization, the following are necessary:
    
    • Frequent abdominal exam
      
    • Repeated hematocrit levels at regular intervals
      

Patients with stab wounds without fascial penetration may be discharged after observation in the ED.

Permissive hypotension is gaining support as a resuscitative principle:

• Avoid normal or near normal BP.
  
• Avoid overaggressive resuscitation with crystalloids.
  
• Completely exposing the patient will minimize overlooking an injury.
  
• Spinal immobilization is unnecessary unless there is an obvious spinal cord injury.
  

• Goodman CS, Hur JY, Adajar MA, et al. How well does CT predict the need for laparotomy in hemodynamically stable patients with penetrating abdominal injury? A review and meta-analysis.
  AJR Am J Roentgenol
  . 2009;193(2):432–437.
  
• Kirkpatrick AW, Sirois M, Ball CG, et al. The hand-held ultrasound examination for penetrating abdominal trauma.
  Am J Surg
  . 2004;187:660–665.
  
• Oyo-Ita A, Ugare UG, Ikpeme IA. Surgical versus non-surgical management of abdominal injury.
  Cochrane Database Syst Rev
  . 2012;14(11):CD007383.
  
• Sebesta J. Special lessons learned from Iraq.
  Surg Clin North Am
  . 2006;86(3):711–726.
  

CODES

868.10 Injury to other intra-abdominal organs with open wound into cavity, unspecified intra-abdominal organ

BASICS

• Spontaneous termination of a <20 wk intrauterine pregnancy
  
• Synonyms: Early pregnancy loss, miscarriage
  
• Occurs in up to 15–20% of recognized pregnancies (most common complication of early pregnancy)
  
• Vaginal bleeding in the 1st trimester seen in about 25% of pregnant patients:
  
  • 50% of these women will eventually mis-carry
    
• Definitions:
  
  • Threatened abortion:
    Vaginal bleeding, cervical os is closed, viable intrauterine pregnancy confirmed:
    
    • 50% of women seen in the ED for threatened abortion will eventually miscarry
      
  • Inevitable abortion:
    Vaginal bleeding, cervical os is open; products of conception (POC) have not been expelled
    
  • Incomplete abortion:
    Vaginal bleeding, cervical os is open with partial passage of some POC and some retained POC
    
  • Complete abortion:
    Vaginal bleeding, cervical os closed, complete passage of POC; no surgical or medical intervention
    
  • Missed abortion:
    Fetal demise with no uterine activity to expel
    
  • Septic abortion:
    Spontaneous abortion complicated by intrauterine infection
    
  • Recurrent spontaneous abortion:
    3 or more consecutive pregnancy losses
    

• Chromosomal abnormalities of the fetus
  
• Uterine abnormalities
  
• Risk factors include:
  
  • Increased age of both the mother and father
    
  • Increased parity
    
  • Alcohol use
    
  • Cigarette smoking
    
  • Cocaine use
    
  • Conception within 3–6 mo after delivery
    
  • Chronic maternal disease:
    
    • Poorly controlled diabetes
      
    • Autoimmune disease
      
    • Celiac disease
      
  • Intrauterine device
    
  • Maternal BMI < 18 or >25 kg/m
    ²
    
  • Maternal infections:
    
    • Bacterial vaginosis
      
    • Mycoplasmosis
      
    • Herpes simplex
      
    • Toxoplasmosis
      
    • Listeriosis
      
    • Chlamydia/gonorrhea
      
    • HIV
      
    • Syphilis
      
    • Parvovirus B19
      
    • Malaria
      
    • CMV
      
    • Rubella
      
  • Medications:
    
    • Misoprostol
      
    • Methotrexate
      
    • NSAIDs
      
  • Multiple previous elective abortions
    
  • Previous early pregnancy loss
    
  • Toxins
    
  • Uterine abnormalities (e.g., leiomyoma, uterine adhesions, congenital anomalies)
    

DIAGNOSIS

• Last menstrual period (LMP)
  
• Obstetric history:
  
  • Parity
    
  • Risk factors for pregnancy loss
    
  • Prenatal care
    
• Abdominal pain, cramping
  
• Vaginal bleeding:
  
  • Duration
    
  • Amount of bleeding (quantify by number of pads used, compare with normal menstrual period for patient)
    
  • Passage of clots
    
• Dizzy, syncope
  

• Determine hemodynamic status of patient:
  
  • Pregnant patients in late 1st trimester have an increased blood volume
    
  • Can lose substantial amount of blood before having abnormal vital signs
    
• Pelvic exam:
  
  • Determine whether the internal cervical os is opened or closed
    
  • Amount of bleeding
    
  • Presence of POC
    
  • Presence of adnexal tenderness or peritoneal irritation can be consistent with an ectopic pregnancy
    
• Bimanual exam to determine the size of the uterus:
  
  • Size of an orange: 6–8 wk
    
  • Fundus at the symphysis pubis: 12 wk
    
  • Fundus at the umbilicus: 16–20 wk
    

• Pregnancy test as below
  
• Imaging as below
  

• Confirm pregnancy with a urine or serum test:
  
  • Urine pregnancy test: Most are positive at β-hCG levels of 25–50 mIU/mL ∼1 wk gestational age and remain positive 2–3 wk after induced or spontaneous abortions
    
• CBC
  
• Rapid hemoglobin determination: Type and Rh
  
• Type and cross-match for woman with low Hct or signs of active blood loss
  
• Quantitative β-hCG
  
• Any POC passed should be sent to pathology for confirmation
  

• Transvaginal ultrasound (TVS):
  
  • Gestational sac seen at 5 wk
    
  • Cardiac activity seen at 6.5 wk
    
• Transabdominal ultrasound (TAS):
  
  • Gestational sac at 6 wk
    
  • Cardiac activity seen at 8 wk
    
• Discriminatory zone: Level of β-hCG where a normal IUP should be detected:
  
  • 1,500–2,000 for TVS
    
  • 6,500 for TAS
    

• Positive pregnancy test with vaginal bleeding:
  
  • Cervicitis
    
  • Ectopic pregnancy
    
  • Molar pregnancy
    
  • Pregnancy of unknown location (PUL)
    
  • Septic abortions
    
  • Subchorionic hemorrhage
    
  • Trauma
    
• 2nd- and 3rd-trimester vaginal bleeding:
  
  • Placenta previa
    
  • Placental abruption
    

TREATMENT

• IV fluids, oxygen, and cardiac monitor
  
• Monitor vital signs and transport
  
• Cautions:
  
  • Patients with spontaneous abortion/vaginal bleeding can have severe hemorrhage and present in shock, especially at >12 wk
    
  • BP drops during the 2nd trimester of pregnancy with an average of 110/70
    

• Stable patients:
  
  • IV
    
  • Pelvic exam
    
• Unstable patients:
  
  • Oxygen, IV fluids via 2 large-bore IVs, cardiac monitor
    
  • Transfuse PRBC if patient does not stabilize after 2–3 L of crystalloid
    
  • Gynecologic consultation immediately
    
  • Oxytocin or methylergonovine may be necessary to control hemorrhage
    
  • These patients are at high risk for having ruptured ectopic pregnancies and may need emergent operative intervention
    

• Threatened abortion:
  
  • Pelvic rest, close follow-up with obstetrics
    
  • Patients <6.5 wk pregnant with no documented cardiac activity by vaginal US need to be followed with serial β-hCG to assess the viability of the fetus and to rule out ectopic pregnancy
    
• Inevitable and incomplete abortions:
  
  • Expectant management:
    
    • Successful in up to 85%
      
    • Increased risk of unplanned surgical intervention and blood loss as compared to surgical management
      
  • Medical management:
    
    • Misoprostol
      
    • Successful in up to 85%
      
  • Surgical management:
    
    • Dilation and curettage (D&C) or evacuation, removal of POC at the cervical os to help decrease bleeding and cramping
      
    • Less unplanned hospital admissions, curettages, and blood transfusions
      
    • The confirmation of POC by pathology rules out ectopic pregnancy
      
• Complete abortion:
  
  • May treat with methylergonovine or oxytocin if bleeding is heavy
    
  • If quantitative β-hCG is <1,000 and the US is negative, may follow-up with obstetrics for serial β-hCG to confirm the levels are decreasing
    
• Missed abortion:
  
  • These patients are at risk for disseminated intravascular coagulation (DIC), especially if fetus is retained >4–6 wk
    
  • Obtain CBC, PT/PTT, fibrin-split products (FSP), and fibrinogen levels
    
  • These patients may be followed closely as outpatients if stable with an early, confirmed IUP and no evidence of DIC
    
  • Patients may choose to have a D&C at a later date or miscarry at home with medication or no intervention; this decision should be made in consultation with OB/GYN