Book Review Drew Paulson, MD Chap. 112-116

“Whinee Gynee” Complications of Gynecologic Procedures

The most common reasons for ED visits during the postoperative period following gynecologic procedures are (3)…

Pain Fever Vaginal Bleeding

After laparoscopy, patients may have pain radiating to their shoulder for several days because of remaining…

CO2 Bubbles

The major complications associated with laparoscopy are…

Thermal injury of the bowel Perforation of a viscus Bleeding/Vascular injury Bladder/Ureteral injury Incisional Hernia Wound dehiscence

Complications of Hysteroscopy include…

Fluid Overload Uterine Perforation Infection Toxic Shock Syndrome Postoperative Bleeding Embolism (CO2) Anesthesia Reaction

The entry of _______ into the circulation can lead to pulmonary edema & DIC

Dextran No more than 500ml should be used during the procedure

Early postoperative infections, especially cellulitis, are treated with what class of antibiotics?

Penicillins (parenteral)

Septic Pelvic Thrombophlebitis consists of the following signs/symptoms…

Fever Tachycardia GI Distress Unilateral Abdominal Pain Palpable Abdominal Cord (50-67%)

Treatment of Septic Pelvic Thrombo-phlebitis consists of…

Antibiotics (Clindamycin) Heparin Antibiotics (Clindamycin) Coverage against heparinase-producing Bacterioides species Treatment for 7-10 days

What should be avoided in a female patient presenting to the ED with abdominal pain/distention, weight gain, & ovarian enlargement, & a history of assisted reproductive therapy?

Abdominal Examination Pelvic Examination Defer these exams until consulting a GYN Due to extremely fragile ovaries that are at high risk of rupture &/or hemorrhage, & torsion

“Don’t be a PUS…” Pelvic UltraSonography

Transabdominal US is best performed with a _________ Bladder, while a Trans-vaginal US is best performed with a _________ Bladder.

Transabdominal = filled bladder Transvaginal = empty bladder

The first sonographic finding in early pregnancy is what?

Gestational Sac 4-5 weeks BhCG 1000

Gestational Age can be determined by measuring (3)…

Gestational Sac Diameter Crown-rump Length Biparietal Diameter

Gestational Age (GA) Mean Sac Diameter (MSD) MSD = (L + W + D)/3 GA (days) = MSD (mm) + 30

Gestational Age (GA) GA (wks) = CRL (cm) + 6.5

After the 1st trimester, gestational age should be measured by which technique?

Biparietal Diameter

The best initial test to rule out an ectopic pregnancy is…

Transvaginal Ultrasound

The inability to visualize a yolk sac or embryo in a large gestational sac is referred to as a…

Blighted Ovum

Bleeding in the endometrial cavity between the chorionic membranes & the uterine wall during pregnancy is called…

Subchorionic Hemorrhage/Hematoma

Sensitivity of US for evaluating placenta previa is ______________, while Sensitivity of US for evaluating placenta abruption is _______________...

Placenta Previa = highly sensitive Placenta Abruption = not very sensitive

“I Ain’t Queer & Stuff” The Normal Child

How do you approach a child in the ED?

In a positive & gentle manner First impressions count Be honest & tell them what to expect

True or False: When a parent states, “This is not my child”, it is best to assume he/she is over-reacting.

False!

How do you estimate the weight of a child between 1 & 12 years of age?

Weight (kg) ~ (2 x Age) + 10

What vaccination is given at birth?

Hepatitis B Vaccine

What vaccine is given at 11-12 years of age?

Td

What are the milestones of early infancy (0-6 months)? Motor Verbal Social

Motor = lifts head, reaches Verbal = cooing Social = responsive smile

A minor (under 18) should be evaluated but not receive treatment in the emergency department without consent obtained from a parent or legal guardian, with the following exceptions:

Life or Limb-threatening emergency State-Protected right to treat Child abuse Pregnancy-related complaints STD’s Substance abuse Outpatient mental health (some states)

State-defined “emancipated minor” status Married Member of armed forces Self-supporting & living independently

“I’ve Got a Fever, and the only Cure is More Cow Bell”

What is the Rochester Criteria for low-risk bacteremia in infants < 3 months of age?

Nontoxic appearance No soft tissue infections WBC 500-15,000 Normal Urinalysis Stools < 5 WBC/hpf with diarrhea

Risk of serious bacterial infection in the absence of these variables is 0.2%

The body looses heat in 4 ways:

Radiation (60%) Evaporation (25%) Convection (10%) Conduction(5%)

“I think She’s Sick, & I want some too?!” Bacteremia, Sepsis, & Meningitis in Children

What are the top pathogens in neonates (0-28 days)?

Group B Strep E. Coli Listeria Enterococcus sp.

What are the top pathogens in older infants (3-36 months)?

Neisseria Meningitidis Strep Pneumonia Neisseria Meningitidis H. Flu Group A Strep E. Coli (pyelonephritis) Salmonella (gastroenteritis) Staph Aureus (osteomyelitis)

If the kid looks sick, the kid is probably…

Sick.

True or False: The finding of a minor focus of infection (URI, UTI, OM) excludes the possibility of bacteremia or serious bacterial infection

False

What are general comments in the History that suggest a febrile infant is at Low-Risk for a SBI?

Full Term (>37 weeks gestation) No prior infection or medical problems No current antibiotics

What are some indications for obtaining blood cultures in children?

Unexplained ill appearance (fever or not) Febrile neonates Febrile infants up to 90 days Febrile children with immune deficiency Clinical sepsis Clinical meningitis Pneumonia requiring admission

Pyelonephritis (<6 months or admission) Bacterial enteritis (<24 months) Facial cellulitis Septic arthritis Osteomyelitis

Antibiotics for Neonatal Sepsis & Meningitis

Ampicillin 100mg/kg plus: Cefotaxime 50mg/kg or Ceftriaxone 50mg/kg

Antibiotics for Children with Sepsis & Meningitis

Cefotaxime 50mg/kg, or Ceftriaxone 50mg/kg Consider Vancomycin 15mg/kg

Response to IV fluids given in sepsis should be monitored &/or titrated to what?

Urine output of 1-2mL/kg per hour

What is a positive Kernig Sign?

Neck pain elicited with passive knee extension

What is a positive Brudzinski Sign?

Involuntary lower extremity flexion elicited with passive neck flexion

CSF fluid should be sent for…

Culture & Sensitivity Glucose Protein Cell Count Gram Stain

La Hacienda Del Paulson

Gardening/Pool/Home Protection…

The END… A Tribute/Toast to Harry Frederick: