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Toronto Notes 2019 Approach to Common ED Presentations
Management
• NPO,IV,NGtube,analgesics,considerantibioticsandanti-emetics
• growingevidencethatsmallamountsofopioidanalgesicsimprovediagnosticaccuracyofphysicalexam
of surgical abdomen
• consultasnecessary:generalsurgery,vascularsurgery,gynecology,etc.
Disposition
• admission:surgicalabdomen,workupofsignificantabnormalfindings,needforIVantibioticsorpain control
• discharge:patientswithanegativelabandimagingworkupwhoimproveclinicallyduringtheirstay; instruct the patient to return if severe pain, fever, or persistent vomiting develops
Acute Pelvic Pain
Etiology
• gynecological
■ ovaries: ruptured ovarian cysts (most common cause of pelvic pain), ovarian abscess, ovarian
torsion (rare, 50% will have ovarian mass)
■ fallopian tubes: salpingitis, tubal abscess, hydrosalpinx
■ uterus: leiomyomas (uterine fibroids) – especially with torsion of a pedunculated fibroid or in a
pregnant patient (degeneration), PID, endometriosis
■ other: ectopic pregnancy (ruptured/expanding/leaking), spontaneous abortion (threatened or
incomplete), endometriosis and dysmenorrhea, sexual or physical abuse • non-gynecological(seecausesoflowerabdominalpainabove)
History and Physical Exam
• pain: OPQRST
• associatedsymptoms:vaginalbleeding,discharge,dyspareunia,boweland/orbladdersymptoms • pregnancyandsexualhistory
• vitals
• gynecologicalexam:assessforcervicalmotiontenderness/“chandeliersign”(suggestsPID)
• abdominalexam
Investigations
• β-hCGforallwomenofchildbearingage
• CBCanddifferential,electrolytes,glucose,Cr,BUN,G&S,PTT/INR
• urinalysistoruleouturologiccauses
• vaginal and cervical swabs for C&S during physical exam
• pelvicandabdominalU/S:evaluateadnexa,thicknessofendometrium,pregnancy,freefluidormasses
in the pelvis
• Dopplerflowstudiesforovariantorsion
Management
• general:analgesia,determineifadmissionandconsultsareneeded • specific:
■ ovariancysts
◆ unruptured or ruptured, and hemodynamically stable: analgesia and follow-up ◆ ruptured with significant hemoperitoneum: may require surgery
■ ovarian torsion: surgical detorsion or removal of ovary
■ uncomplicated leiomyomas, endometriosis, and secondary dysmenorrhea can usually be treated on
an outpatient basis, discharge with gynecology follow-up
■ PID: broad spectrum antibiotics
Disposition
• referral:gynecologicalorobstetricalcausesrequiringsurgicalintervention,requiringadmission,or oncological in nature
• admission:patientsrequiringsurgery,IVantibiotics/painmanagement
• discharge:negativeworkupandresolvingsymptoms;giveclearinstructionsforappropriatefollow-up
Altered Level of Consciousness
Definitions
• alteredmentalstatus:collective,non-specifictermreferringtochangeincognitivefunction,behaviour, or attentiveness, including:
■ delirium (see Psychiatry, PS19)
■ dementia (see Psychiatry, PS21)
■ lethargy: state of decreased awareness and alertness (patient may appear wakeful) ■ stupor: unresponsiveness but rousable
■ coma: a sleep-like state, not rousable to consciousness
Emergency Medicine ER19
Gynecological Causes of Pelvic Pain
• Ovarian cyst
• Dysmenorrhea
• Mittelschmerz
• Endometriosis
• Ovarian torsion
• Uterine fibroids/neoplasm • Adnexal neoplasm
• PID+cervicitis
U/S is the preferred imaging modality in the assessment of acute pelvic pain