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Friday, December 29, 2023

Disease Control and Prevention data now reflect that the current rate of occult bacteremia is < 1%. Furthermore, approximately 80% of pneumococcal bacteremia will resolves

spontaneously without intervention. Thus several acceptable

variations in management exist for this patient cohort.

The evaluation of well-appearing children age

3-36 months includes urinalysis and urine culture for girls

<2 years of age and boys < 1 year of age, particularly if they

are uncircumcised. A CXR may be performed if there are

signs of lower respiratory infection. If no source is

identified after this focused evaluation, reassurance and

CHAPTER 48

Table 48-1. Rochester, Philadel phia, and Boston criteria comparison.

heart rate, and location of the placenta.

MEDICAL DECISION MAKING

Delivery of a fetus is best done by obstetricians in a labor

and delivery unit. If time allows, the emergency physician

should attempt to transfer the patient to an appropriate

setting. In a hospital with no obstetric services, a precipitously delivering mother must be delivered by the emer

gency physician. If delivery is not imminent, the patient

may be transferred. If a patient needs to be transferred to

another hospital, she should be sent by an advanced life

support-equipped ambulance, as a patient in labor is c onsidered medically unstable (Figure 46-1).

.AFigure 46-1 . Emergency del ivery diagnostic algorithm.

CHAPTER 46

TREATMENT

If the decision is made to deliver the child in the ED, call

for obstetric and pediatric support if available. Large-bore

intravenous (IV) access should be obtained and fluids

started. Oxygen by nasal cannula is given to the mother,

especially if there are any signs of fetal distress. The infant

radiant warmer should be set up and in the room. Delivery

equipment should be set up including cord clamps,

scissors, suction, forceps, and neonatal resuscitation

equipment.

The mother is placed in the dorsal lithotomy position,

and the perineum is cleaned with povidone-iodine solution. Time permitting, the physician should be dressed in

gown, sterile gloves, hat, and mask. When the mother is

fully dilated, and the head is at + 3 station, the examiner

uses a towel and supports the perineum by gently putting

pressure on the fetal chin. The other hand is used to control the fetal occiput (Figure 46-2A). Slight pressure on the

occiput ensures a smooth delivery of the fetal head and

reduces tearing.

Once the fetal head is delivered, the physician should

suction the nose and mouth and check for a nuchal cord.

The mother should stop pushing at this point. If a nuchal

cord is present, it is pulled over the fetal head. If unable to

pull the cord over, it should be clamped in two places and

cut in the middle.

Next, the anterior shoulder is delivered by guiding the

head inferiorly with gentle traction. The posterior shoulder

is delivered next by traction upwards. This will also deliver

the rest of the infant (Figures 46-2B and 46-2C). If the

shoulders are not easily delivered, the physician should

consider shoulder dystocia as a complication. Once the

infant is delivered, the cord is clamped in 2 locations and

cut in the middle. The infant is wrapped, cleaned, and

taken to the infant warmer for evaluation.

Ideally, a second physician or experienced practitioner

can care for the newborn while the delivering physician

Figure 46-2. A. Del ivery of the head while putting pressure over the peri neum. B. Del ivering the anterior

shoulder. c. Del ivery of the posterior shoulder is performed with gentle upward traction, while su pporting the

head. Reprinted with permission from VanRooyen MJ, Scott JA. Chapter 1 05. Emergency Del ivery. In: Tintina IIi

JE, Stapczynski JS, Ma OJ, Cline OM, Cyd ulka RK, Meckler GO, eds. Tintinolli's Emergency Medicine: A

Comprehensive Study Guide. 7th ed. New York: McGraw-Hill, 201 1.

EMERGENCY DELIVERY

Table 46-1 . APGAR scoring.

Appearance Blue-gray or pale

Respiration Absent

treats the mother. The newborn should be warmed, given

oxygen, and stimulated. The APGAR is performed at 1 and

5 minutes (Table 46- 1). Neonatal intubation should be

considered for poor tone, shallow respirations, and cyanosis. Once the infant is assessed, attention is directed back

to the mother, to deliver the placenta. The placenta should

deliver spontaneously, but it can be assisted with uterine

massage while pulling gently on the umbilical cord.

Pulling too forcefully can result in uterine inversion.

Complications of delivery include postpartum hemorrhage, shoulder dystocia, and breech presentations.

Although rare, these complications generally require the

assistance of an obstetrician.

Postpartum hemorrhage can occur immediately after

delivery or up to a few hours after delivery. The physician

should check for retained products, uterine atony, uterine

inversion, or vaginal lacerations that are contributing to the

blood loss. In the case of uterine atony, oxytocin can be given,

20 units in 1 L of Lactated Ringer's solution. Additionally,

misoprostol 1 mg can be given per rectum.

Shoulder dystocia is present when the fetus's anterior

shoulder becomes caught under the mother's pubic bone.

It is more common in diabetic mothers, obesity, and postmaturity of the fetus. The first clue to the physician that

shoulder dystocia is occurring is a retraction of the fetal

head toward the vagina immediately after it is delivered.

This is called the "turtle sign." In the event of a shoulder

dystocia, the mother's legs are flexed to a knee-chest position (McRobert maneuver). This rotates the pubic bone

over the anterior fetal shoulder. Second, an assistant provides firm suprapubic pressure to further disengage the

Normal, except extremities

Sneeze, cough, pulls away

Normal over entire body

Good, crying

anterior shoulder. If this does not resolve the dystocia, an

episiotomy should be performed to enlarge the opening

and provide access to the posterior shoulder.

Breech presentations are ideally delivered by cesarean

section. Rapid bedside ultrasound can determine whether

the fetal head or another part is presenting. Breech presen

ous abortion. In the United States, about 2% of all pregnancies are ectopic pregnancies. Mortality in these women is due

to shock from intra-abdominal hemorrhage. In postmenopausal women with vaginal bleeding, 10% will be diagnosed

with cancer, the majority being endometrial cancer.

Ectopic pregnancy is one of the most important causes

of vaginal bleeding. Ectopic pregnancy occurs when a

1 81

• Ruptured ectopic pregnancy is a surgical emergency

requiring prompt intervention and gynecologic consultation.

• Patients with postmenopausal bleeding should be

referred to a gynecologist for endometrial biopsy to

exclude malignancy.

trophoblast implants at a site outside of the endometrium.

In most cases, the ectopic site is within the lateral two

thirds of the fallopian tube. Other sites include the medial

third of the fallopian tube, cornu (junction of the tube and

uterus), ovary, fimbria, cervix, and abdomen (Figure 43-1).

Risk factors for ectopic pregnancy include a history of salpingitis, use of an intrauterine device, a prior ectopic pregnancy, increased maternal age, use of fertility drugs, and

history of tubal ligation. Up to 42% of women with an

ectopic pregnancy have no risk factors.

CLINICAL PRESENTATION

..... History

A detailed history is essential. Determine the onset of bleeding, the date and duration of the last normal menstrual

period, the number of previous pregnancies, and the presence of any prior history of abnormal vaginal bleeding. Pain

may or may not be present. If pain is present, determine pain

characteristics such as location, quality, and duration.

Approximately 1 0% of patients with ectopic pregnancy will

present with bleeding only. Attempt to have the patient

quantify the amount of bleeding. Although variable, a

tampon or pad absorbs approximately 30 mL of blood. The

presence of clotted blood suggests brisk vaginal bleeding.

Inquire about previous gynecologic problems and

assess the risk factors for ectopic pregnancy.

CHAPTER 43

Tubal 95-96%

Interstitial and

£. Figure 43-1. Frequency of sites of ectopic pregnancy. Repri nted with permission from

Cunningham FG, Le�eno KJ, Bloom SL, Hauth JC, Rouse OJ, Spong CY. Chapter 1 o. Ectopic

Pr�g nancy. In: Cunnmgham FG, Leveno KJ, Bloom SL, Hauth JC, Rouse OJ, Spong cv, eds.

WJ/Iwms Obstetrics. 23rd ed. New York: McGraw-Hill, 201 0.

Symptoms of weakness, lightheadedness, shortness of

breath, or syncope suggest anemia from significant blood

loss. Determine the presence of other medical conditions

(eg, coagulopathies) or medications (eg, anticoagulants)

that may exacerbate vaginal bleeding.

� Physical Examination

Note the patient's blood pressure and pulse, specifically to

identify hypotension or a resting tachycardia. Look for

other signs of anemia such as general, mucosal, or nail bed

pallor. Before performing a pelvic examination, perform a

focused general examination, including the heart, lungs,

abdomen, and flank. Assess the abdomen for the presence

of tenderness, masses, guarding, and rebound. Peritoneal

signs may suggest infection or intraperitoneal blood.

For the pelvic examination, obtain the patient's consent

and ensure her privacy during the exam. Explain what you

are going to do. Ideally, both male and female examiners

should request that a chaperone be present. Perform the

exam with the patient in the lithotomy position. First, inspect

the external genitalia. Then, using a warmed, lubricated, and

appropriately sized vaginal speculum, determine the presence of blood, blood clots, tissue (products of conception), or

discharge in the vaginal vault. Visually inspect the cervix.

On bimanual examination, determine whether the cervical os is open or closed. An open os is present when the

tip of the examiner's index finger can easily pass through

the cervix. Women with a closed internal os should be

Table 43-1. Classification of spontaneous abortion.

Type Internal Cervical Os Products of Conception

Threatened Closed Not passed

Inevitable Open Not passed

Incomplete usually open Partially passed

Complete Closed Completely passed

considered to have a closed os, even if the external portion

of the os is open. The internal os and the presence of products of conception will allow classification of different

types of spontaneous abortions ( Table 43-1).

Next, estimate the size of the uterus (12 weeks at the

symphysis, 20 weeks at the umbilicus) by palpating the

uterine fundus on the abdomen with one hand and palpating the cervix with the index and middle fingers on the

other hand. Assess the cervix, uterus, and adnexa for tenderness or masses. Tenderness on pelvic examination is

present in more than 80% of patients with a ruptured

ectopic pregnancy.

DIAGNOSTIC STUDIES

� Laboratory

Urine pregnancy test is 99.4% sensitive for diagnosing

pregnancy at the time that a woman "misses" her period.

VAGI NAL BLEEDING

It detects the presence of the beta subunit of human

chorionic gonadotropin hormone ( �-hCG) produced by

the trophoblast in the patient's urine. A serum �-hCG

level is also obtained. In a normal pregnancy, �-hCG

levels double approximately every 2 days, peaking at

1 00,000 rniU/mL. Higher levels suggest trophoblastic

disease. An ectopic pregnancy can be present at any

�-hCG level; therefore, the initial �-hCG level cannot be

used to exclude ectopic pregnancy. Patients with repeat

�-hCG levels that decrease by >50% are at low risk for

ectopic pregnancy, whereas those with levels that do not

increase >66% are at high risk.

A serum hemoglobin is indicated in most patients with

vaginal bleeding, but especially those with a resting tachycardia, lightheadedness, or prolonged duration of bleeding

(2:3 weeks). Rh status should be obtained in pregnant

patients with vaginal bleeding.

� Imaging

In pregnant patients with vaginal bleeding, the presence of

an ectopic pregnancy must be excluded with a pelvic ultrasound performed by an emergency medicine physician or

radiology personnel. Ectopic pregnancy is excluded when

an intrauterine pregnancy (IUP) is visualized on pelvic

ultrasound. A heterotopic pregnancy (a simultaneous IUP

and an ectopic pregnancy), traditionally considered rare, is

more common in women receiving treatment for infertility. Patients with pelvic ultrasounds that demonstrate a

noncystic adnexal mass, moderate-large fluid in the culde-sac, an extrauterine gestational sac, or an empty uterus

(with �-hCG > 1,000 rniU/mL) should be considered high

risk for ectopic pregnancy. In 1 5-20% of patients, the initial pelvic ultrasound will be indeterminate (no evidence

of an IUP or an ectopic pregnancy). Of these indetermi

nate ultrasounds, 20% eventually will be diagnosed with

an ectopic pregnancy.

MEDICAL DECISION MAKING

In a patient with vaginal bleeding, the most essential information to determine is the hemodynamic status and a

urine pregnancy test. In the pregnant patient, the most

important role of the emergency department is to exclude

an ectopic pregnancy (Figure 43-2).

In patients with vaginal bleeding during the first

trimester of pregnancy, the diagnostic possibilities

include continuation of what will be a normal

pregnancy or an abnormal pregnancy ( ie, spontaneous

abortion; ectopic pregnancy; trophoblastic disease). In

nonpregnant patients, diagnostic possibilities include

dysfunctional uterine bleeding, uterine fibroids, malig

rostomy tubes. Patients with a solitary kidney, history of

renal transplant, or renal dysfunction should be discussed

with urology and admitted.

..... Discharge

Most patients with nephrolithiasis can be successfully

managed in the ED and safely discharged. They should

have adequate pain control and the ability to tolerate oral

NEPHROLITHIASIS

intake before discharge. Follow-up is recommended with

a primary care provider within 1 week for small ( <6 mm),

uncomplicated kidney stones in patients with a known

history of nephrolithiasis. Urology follow-up is recommended for patients with first time stones and large (>6

mrn) proximal stones, as these stones have a low likelihood ( < 1 Oo/o) of spontaneous passage. Patients should be

given prescriptions for opioid analgesics and a urine

strainer with instructions to strain all urine until stone

passage and to bring passed stones to their follow-up

appointment. Alpha blockers (tamulosin, terazosin, or

doxazosin) are prescribed for up to four weeks to relax

ureteral smooth muscles and increase the rate of stone

passage and decrease pain. Lastly, patients should be given

clear and specific discharge instructions to return to the

ED if they have fever, persistent vomiting, intractable pain,

or inability to urinate.