Page 220 - TNFlipTest

ER40 Emergency Medicine
Gynecologic/Urologic Emergencies Toronto Notes 2019 Epistaxis
• seeOtolaryngology,O26
• 90%ofnosebleedsstemfromtheanteriornasalseptum(Kiesselbach’splexuslocatedinLittle’sarea) • canbelife-threatening
Etiology
• mostcasesofepistaxisarecausedbytrauma(digital,blunt,foreignbodies)
• othercauses:barometricchanges,nasaldryness,chemicals(cocaine,Otrivin®),orsystemicdisease
(coagulopathies, HTN, etc.)
Investigations
• bloodwork:CBC,PT/PTT(asindicated) • imaging:X-ray,CTasneeded
Treatment
• goalsoftreatment:localizebleedingandachievehemostasis
• first-aid:ABCs,clearclotsbyblowingnoseorsuctioning,leanforward,pinchcartilaginousportionof
nose for 20 min twice
• assessbloodloss:vitals,IVNS,crossmatch2unitspRBCifsignificant
• iffirstaidmeasuresfailtwice,proceedtopacking
• applyananteriorpack
■ clear nose of any clots
■ apply topical anesthesia/vasoconstrictors (lidocaine with epinephrine, cocaine, or soaked pledgets) ■ insert either a traditional Vaseline® gauze pack or a commercial nasal tampon or balloon
■ if bleeding stops, arrange follow-up in 48-72 h for reassessment and pack removal
■ if packing both nares, prophylactic anti-staphylococcal antibiotics to prevent sinusitis or toxic shock
syndrome
■ if bleeding is controlled with anterior pressure, cautery with silver nitrate can be performed if the
site of bleeding is identified (only cauterize one side of the septum because if both are cauterized this
can lead to septal perforation)
• ifsuspectposteriorbleedoranteriorpackingdoesnotprovidehemostasis,consultENTforposterior
packing and further evaluation
■ posterior packing requires monitoring; can cause significant vagal response and posterior bleeding
source can lead to significant blood loss, therefore usually requires admission
Disposition
• discharge:dischargeduponstabilizationandappropriatefollow-up;educatepatientsaboutprevention (e.g. humidifiers, saline spray, topical ointments, avoiding irritants, managing HTN)
• admission:severecasesofrefractorybleeding,andmostcasesofposteriorpacking
Gynecologic/Urologic Emergencies
Vaginal Bleeding
• seeGynecology,GY9andObstetrics,OB13
Etiology
• pregnantpatient
■ 1st/2nd trimester: ectopic pregnancy, abortion (threatened, incomplete, complete, missed,
inevitable, septic), molar pregnancy, implantation bleeding, friable cervix (most common cause)
■ 2nd/3rd trimester: placenta previa, placental abruption, premature rupture of membranes, preterm
labour
■ other: trauma, bleeding cervical polyp, passing of mucous plug
• postpartum
■ postpartum hemorrhage, uterine inversion, retained placental tissue, endometritis
• non-pregnantpatients
■ structural (PALM- polyps, adenomyosis, leiomyoma, malignancies/hyperplasia) ■ non-structural (COEIN - coagulopathy, ovulatory, endometrial, iatrogenic, NYD)
History
• characterizebleeding(frequency,duration,numberofpads/tampons,typesofpadsused,cyclicity)
• pain,ifpresent(OPQRSTUV)
• menstrualhistory,sexualhistory,STIhistory,syncope/pre-syncope,malignancyhistory,familyhistory,
hematological history, cardiac history, abdo history
• detailsofpregnancy,includinggushoffluidandfetalmovement(>20wk)
Thrombocytopenic patients – use resorbable packs to avoid risk of re-bleeding caused by pulling out the removable pack
Complications of Nasal Packing
• Hypoxemia
• Toxic-shock syndrome
• Aspiration
• Pharyngeal fibrosis/stenosis • Alar/septal necrosis