WikEM - User contributions [en]

Alcohol ketoacidosis

2014-01-15T03:56:46Z

Tdeboyes: New content

== Background ==
*Seen in pts with recent h/o binge drinking with little/no nutritional intake
**Starvation leads to excess glucagon and decreased insulin
**Elevated NADH:NAD+ ratio due to ETOH metabolism
**Volume depletion from emesis & poor PO intake
*Characterized by high serum ketone levels and an elevated AG
**Consider other causes of elevated AG, as well as co-ingestants
**Concomitant metabolis alkalosis can occur from dehydration (volume depletion) and emesis

== Treatment ==
Consider associated diseases (ie pancreatitis, rhabdo, hepatitis, infections)
#Hydration
##IVF should include 5% dextrose since there is a lack of glucose
##Note: Thiamine (100mg IV/PO) prior to glucose to decrease risk of Wernicke encephalopathy or Korsakoff syndrome
#Oral nutrition if able to tolerate
#Electrolyte replacement - K, Mag and Phos
#Monitor for signs of alcohol withdrawal
#Consider bicarb if life-threatening acidosis (pH <7.1) unresponsive to fluid therapy

== Disposition ==
#Most go home after treatment
#Consider admission for those with severe volume depletion and/or acidosis
*Hypoglycemia is poor prognostic feature

Subarachnoid hemorrhage

2014-01-15T03:23:40Z

Tdeboyes: New content

== Background ==

=== Pearls ===

#Obtain GCS before intubation
#If intubate prevent HTN (rebleeding)
##Pretreatment
###Lidocaine 1-1.5mg/kg (100mg) (blunts incr in BP)
###Fentanyl 200mcg (sympatholytic)
##Sedation
###If pt has high BP - use propofol
###If pt has adequate BP - use etomidate
##Treat pain
###Prevents incr catacholamines / incr BP

=== Epidemiology ===

*Of All pts in ED who p/w HA:
**1% will have SAH
**10% will have SAH if c/o worst HA of life
**25% will have SAH if c/o worst HA of life + any neuro deficit

=== Risk Factors ===

#Genetics (polycystic kidney disease, Ehler-Danlos, family hx)
#Hypertension
#Atherosclerosis
#Cigarette smoking
#Alcohol
#Age >50
#Cocaine use
#Estrogen deficiency

=== Etiology of Spontaneous SAH ===

#Ruptured aneurysm (85%)
#Nonaneurysmal (15%)
##Perimesencephalic hemorrhage (10%) - lower risk of complications
##Other: tumor, coagulopathy, dissection, vasculitis, SCD, venous sinus thrombosis

== Clinical Features ==

#Sudden, severe headache that reaches maximal intensity within minutes (97% of cases)
##Sudden onset is more important finding than worst HA
#May be a/w syncope, seizure, nausea/vomiting, meningismus
##Meningismus may not develop until hrs after bleed (blood breakdown -> aseptic meningitis)
#Retinal hemorrhage
##May be the only clue in comatose patients
#Sentinel bleed/HA 6-20d before SAH (30-50% of pts)

== DDX ==

#Other intracranial hemorrhage
#Drug toxicity
#Ischemic stroke
#Meningitis
#Encephalitis
#Intracranial tumor
#Intracranial hypotension
#Metabolic derangements
#Venous thrombosis
#Primary headache syndromes (benign thunderclap headache, migraine, cluster headache)

== Diagnosis ==

'''If concerned for SAH and CT normal strongly consider LP'''

#Non-Contrast Head CT
##Sensitivity
###Within 12hr of onset of symptoms: 98% Sn
###Within 24hr of onset of symptoms: 93% Sn
###Within 5d of onset of symptoms: 50% Sn
###Not as sensitive/specific for minor bleeds
##Findings
###SAH due to aneurysm - look in cisterns (esp. suprasellar cistern)
###SAH due to trauma - look at convexities of frontal and temporal cortices
#Lumbar Puncture
##Findings:
###Elevated RBC count that doesn't decrease from tube one to four
####Note: decreasing RBCs in later tubes can occur in SAH; only reliable if RBC count in final tube is nl
###Opening pressure >20 (60% of pts)
####Can help differentiate from a traumatic tap (opening pressure expected to be normal)
####Elevated opening pressure also seen in cerebral venous thrombosis, IIH
###Xanthrochromia
####May help differentiate between SAH and a traumatic tap
####Takes at least 2hr after bleed to develop (beware of false negative if measure early)
####Sn (93%) / Sp (95%) highest after 12hr
##If unable to obtain CSF consider CTA
###CTA also highly sensitive for predicting delayed cerebral ischemia

== Treatment ==
Physiologic derangements, such as hypoxemia, metabolic acidosis, hyperglycemia, BP instability, and fever, can worsen brain injury and has been independently associated with increased M&M, but no studies showing benefit of corrections.

#BP control
##No consensus on HTN (incr BP may maintain CPP but may also increase rate of bleeding)
###If pt is alert this means CPP is adequate so consider lowering SBP to 120-140
####If pt has history of HTN consider lowering SBP to ~160
###If pt is ALOC consider leaving BP alone as the ALOC may be 2/2 reduced CPP
##If BP control is necessary use nicardipine, labetalol, or esmolol
###Avoid vasodilators such as nitroprusside or NTG (incr cerebral blood volume -> incr ICP)
##Avoid hypotension
###Maintain MAP >80
####Give IVF
####Give pressors if IVF ineffective
#Discontinue/reverse all anticoagulation
##Coumadin - (Prothrombin complex conc or FFP) + vit K
##Aspirin - DDAVP
##Plavix - Platelets
#Nimodipine
##Prevents vasospasm (a/w improved neuro outcomes and decreased cerebral infarction)
##Give 60mg q4hr PO or NGT only (never IV) within 96hr of symptom onset. NNT 13 to prevent one poor outcome
##Keep an eye on BP for fluctuations
#Magneisum
##Controversial; prevents vasospasm acting as NMDA antagonist and a calcium channel blocker; maintain b/w 2-2.5 mmol/L
#Seizure prophylaxis
##Controversial; 3 day course may be preferable
##Phenytoin, levetiracetam, carbamazepine and phenobarb. Phenytoin can be a/w worse neurologic & cognitive outcome
#Glucocorticoid therapy
##Controversial; evidence suggests is neither beneficial nor harmful
#Glycemic control
##Controversial; consider sliding scale if long pt stay in ED while awaiting ICU bed
#Keep head of bed elevated
#Aneurysm Tx
##Surgical clipping and endovascular coiling are definitive tx
##Antifibrinolytic - Controversial; if delayed aneurysmal tx, consider short term therapy (<72 hrs) with TXA or aminocaproic acid

== Complications ==

#Rebleeding
##Risk is highest within first 24 hours (2.5-4%), particularly within first 6 hours
##Usually diagnosed by CT after acute deterioration in neuro status
##Only aneurysm treatment is effective in preventing rebleeding
#Vasospasm
##Leading cause of death and disability after rupture
##Typically begins no earlier than day three after hemorrhage
##Characterized by decline in neuro status
##Aggressive treatment can only be started after aneurysm has been treated
###Tx for symptomatic vasospasm: Triple-H therapy (hemodilution + induced hypertension (pressors) + hypervolemia), ballon angioplasty, or intra-arterial vasodilators.
####Studies have not provided strong evidence of benefit Triple-H therapy
#Cardiac abnormalities (?2/2 release of catecholamines due to hypoperfusion of hypothalamus)
##Ischemia
###Elevated troponin (20-40% of cases)
###ST segment depression
##Rhythm disturbances
###Torsades, A-fib/flutter
##QT prolongation
##Deep, symmetric TWI
##Prominent U waves
#Hydrocephalus
##Consider ventricular drain placement for deteriorating LOC + no improvement w/in 24hr
#Hyponatremia
##Usually due to SIADH
###Treat via isotonic, or if necessary, hypertonic saline (do not treat via H2O restriction)
##Rarely due to cerebral salt-wasting
###Volume depleted, so treat with isotonic saline

== Prognosis ==

=== Hunt and Hess ===
Subjective terminology, but good interobserver variability
*Grade 0: Unruptured aneurysm
*Grade 1: Asymptomatic or mild HA and slight nuchal rigidity
**Grade 1a: No acute meningeal/brain reaction, with fixed neurological def
*Grade 2: Moderate to severe HA, stiff neck, no neurologic deficit except CN palsy
*Grade 3: Mild mental status change (drowsy or confused), mild focal neurologic deficit
*Grade 4: Stupor or moderate to severe hemiparesis
*Grade 5: Coma or decerebrate rigidity

<br>

*Grade 1 or 2 have curable disease
*Add one grade for serious systemic disease (HTN, DM, severe atherosclerosis, COPD)

=== World Federation of Neurosurgical Societies (WFNS) ===
Objective terminology, and fair interobserver variability
*Grade 1: GCS of 15, no motor deficits
*Grade 2: GCS of 13 or 14, no motor deficits
*Grade 3: GCS of 13 or 14, with motor deficits
*Grade 4: GCS of 7–12, with or without motor deficits
*Grade 5: GCS of 3–6, with or without motor deficits

Other scales are also available, including the Ogilvy and Carter scale (comprehensive, yet complex), and the Fisher scale or Claassen grading system (vasospasm index risk).

Note: First-degree relatives are at 2-5 fold increase in SAH, so screening is considered on individual basis.

== See Also ==
*[[Intracranial Hemorrhage (Main)]]
*[[Head Trauma]]

== Source ==
*UpToDate
*EB Emergency Medicine, July 2009
*EMCrit Podcast 8
*Tintinalli
*www.epmonthly.com/features/current-features/lp-for-subarachnoid-hemorrhage-the-700-club

[[Category:Neuro]]

Subarachnoid hemorrhage

2014-01-15T03:06:54Z

Tdeboyes: New edit

== Background ==

=== Pearls ===

#Obtain GCS before intubation
#If intubate prevent HTN (rebleeding)
##Pretreatment
###Lidocaine 1-1.5mg/kg (100mg) (blunts incr in BP)
###Fentanyl 200mcg (sympatholytic)
##Sedation
###If pt has high BP - use propofol
###If pt has adequate BP - use etomidate
##Treat pain
###Prevents incr catacholamines / incr BP

=== Epidemiology ===

*Of All pts in ED who p/w HA:
**1% will have SAH
**10% will have SAH if c/o worst HA of life
**25% will have SAH if c/o worst HA of life + any neuro deficit

=== Risk Factors ===

#Genetics (polycystic kidney disease, Ehler-Danlos, family hx)
#Hypertension
#Atherosclerosis
#Cigarette smoking
#Alcohol
#Age >50
#Cocaine use
#Estrogen deficiency

=== Etiology of Spontaneous SAH ===

#Ruptured aneurysm (85%)
#Nonaneurysmal (15%)
##Perimesencephalic hemorrhage (10%)
##Other: tumor, coagulopathy, dissection, vasculitis, SCD, venous sinus thrombosis

== Clinical Features ==

#Sudden, severe headache that reaches maximal intensity within minutes (97% of cases)
##Sudden onset is more important finding than worst HA
#May be a/w syncope, seizure, nausea/vomiting, meningismus
##Meningismus may not develop until hrs after bleed (blood breakdown -> aseptic meningitis)
#Retinal hemorrhage
##May be the only clue in comatose patients
#Sentinel bleed/HA 6-20d before SAH (30-50% of pts)

== DDX ==

#Other intracranial hemorrhage
#Drug toxicity
#Ischemic stroke
#Meningitis
#Encephalitis
#Intracranial tumor
#Intracranial hypotension
#Metabolic derangements
#Venous thrombosis
#Primary headache syndromes (benign thunderclap headache, migraine, cluster headache)

== Diagnosis ==

'''If concerned for SAH and CT normal strongly consider LP'''

#Non-Contrast Head CT
##Sensitivity
###Within 12hr of onset of symptoms: 98% Sn
###Within 24hr of onset of symptoms: 93% Sn
###Within 5d of onset of symptoms: 50% Sn
###Not as sensitive/specific for minor bleeds
##Findings
###SAH due to aneurysm - look in cisterns (esp. suprasellar cistern)
###SAH due to trauma - look at convexities of frontal and temporal cortices
#Lumbar Puncture
##Findings:
###Elevated RBC count that doesn't decrease from tube one to four
####Note: decreasing RBCs in later tubes can occur in SAH; only reliable if RBC count in final tube is nl
###Opening pressure >20 (60% of pts)
####Can help differentiate from a traumatic tap (opening pressure expected to be normal)
####Elevated opening pressure also seen in cerebral venous thrombosis, IIH
###Xanthrochromia
####May help differentiate between SAH and a traumatic tap
####Takes at least 2hr after bleed to develop (beware of false negative if measure early)
####Sn (93%) / Sp (95%) highest after 12hr
##If unable to obtain CSF consider CTA
###CTA also highly sensitive for predicting delayed cerebral ischemia

== Treatment ==
Physiologic derangements, such as hypoxemia, metabolic acidosis, hyperglycemia, BP instability, and fever, can worsen brain injury and has been independently associated with increased M&M, but no studies showing benefit of corrections.

#BP control
##No consensus on HTN (incr BP may maintain CPP but may also increase rate of bleeding)
###If pt is alert this means CPP is adequate so consider lowering SBP to 120-140
####If pt has history of HTN consider lowering SBP to ~160
###If pt is ALOC consider leaving BP alone as the ALOC may be 2/2 reduced CPP
##If BP control is necessary use nicardipine, labetalol, or esmolol
###Avoid vasodilators such as nitroprusside or NTG (incr cerebral blood volume -> incr ICP)
##Avoid hypotension
###Maintain MAP >80
####Give IVF
####Give pressors if IVF ineffective
#Discontinue/reverse all anticoagulation
##Coumadin - (Prothrombin complex conc or FFP) + vit K
##Aspirin - DDAVP
##Plavix - Platelets
#Nimodipine
##Prevents vasospasm (a/w improved neuro outcomes and decreased cerebral infarction)
##Give 60mg q4hr PO or NGT only (never IV) within 96hr of symptom onset. NNT 13 to prevent one poor outcome
##Keep an eye on BP for fluctuations
#Seizure prophylaxis
##Controversial; 3 day course may be preferable
##Keppra preferred. Phenytoin a/w worse neurologic & cognitive outcome
#Glucocorticoid therapy
##Controversial; evidence suggests is neither beneficial nor harmful
#Glycemic control
##Controversial; consider sliding scale if long pt stay in ED while awaiting ICU bed
#Keep head of bed elevated
#Aneurysm Tx
##Surgical clipping and endovascular coiling are definitive tx
##Antifibrinolytic - Controversial; if delayed aneurysmal tx, consider short term therapy (<72 hrs) with TXA or aminocaproic acid

== Complications ==

#Rebleeding
##Risk is highest within first 24 hours (2.5-4%), particularly within first 6 hours
##Usually diagnosed by CT after acute deterioration in neuro status
##Only aneurysm treatment is effective in preventing rebleeding
#Vasospasm
##Leading cause of death and disability after rupture
##Typically begins no earlier than day three after hemorrhage
##Characterized by decline in neuro status
##Aggressive treatment can only be started after aneurysm has been treated (surgery or intraluminal tx)
###Tx for symptomatic vasospasm: Triple-H therapy (hemodilution + induced hypertension (pressors) + hypervolemia), ballon angioplasty, or intra-arterial vasodilators.
####Studies have not provided strong evidence of benefit Triple-H therapy
#Cardiac abnormalities (?2/2 release of catecholamines due to hypoperfusion of hypothalamus)
##Ischemia
###Elevated troponin (20-40% of cases)
###ST segment depression
##Rhythm disturbances
###Torsades, A-fib/flutter
##QT prolongation
##Deep, symmetric TWI
##Prominent U waves
#Hydrocephalus
##Consider ventricular drain placement for deteriorating LOC + no improvement w/in 24hr
#Hyponatremia
##Usually due to SIADH
###Treat via isotonic, or if necessary, hypertonic saline (do not treat via H2O restriction)
##Rarely due to cerebral salt-wasting
###Volume depleted, so treat with isotonic saline

== Prognosis ==

=== Hunt and Hess ===

*Grade 0: Unruptured aneurysm
*Grade 1: Asymptomatic or mild HA and slight nuchal rigidity
**Grade 1a: No acute meningeal/brain reaction, with fixed neurological def
*Grade 2: Moderate to severe HA, stiff neck, no neurologic deficit except CN palsy
*Grade 3: Mild mental status change (drowsy or confused), mild focal neurologic deficit
*Grade 4: Stupor or moderate to severe hemiparesis
*Grade 5: Coma or decerebrate rigidity

<br>

*Grade 1 or 2 have curable disease
*Add one grade for serious systemic disease (HTN, DM, severe atherosclerosis, COPD)

=== World Federation of Neurosurgical Societies (WFNS) ===

*Grade 1: GCS of 15, no motor deficits
*Grade 2: GCS of 13 or 14, no motor deficits
*Grade 3: GCS of 13 or 14, with motor deficits
*Grade 4: GCS of 7–12, with or without motor deficits
*Grade 5: GCS of 3–6, with or without motor deficits

First-degree relatives are at 2-5 fold increase in SAH, so screening is possibility.

== See Also ==
*[[Intracranial Hemorrhage (Main)]]
*[[Head Trauma]]

== Source ==
*UpToDate
*EB Emergency Medicine, July 2009
*EMCrit Podcast 8
*Tintinalli
*www.epmonthly.com/features/current-features/lp-for-subarachnoid-hemorrhage-the-700-club

[[Category:Neuro]]

Palpitations

2014-01-13T00:53:08Z

Tdeboyes: added content

==Background==
Insert

==Diagnosis==
Insert

==Work-Up==
#CBC
#Chem
#ECG
#CXR
#?Trop

==DDx==
Arrhythmias:
*AFib or Flutter
*VTach
*Sick sinus syndrome
*MAT
*PVCs
*WPW
*Sinus node dysfunction
*AV Block
Non-arrhythmic cardiac causes:
*Cardiomyopathy
*CHF
*Mitral valve prolapse
*Congenital heart disease
*Pericarditis
*Valvular disease
*Pacemaker malfunction
Psychiatric causes:
*Anxiety disorder
*Panic attack
Drugs and Medications:
*Alcohol
*Caffeine
*Meds (i.e. digitalis, theophylline)
*Street drugs (i.e. cocaine)
*Tobacco

==Treatment==
Insert

==Disposition==
Insert

==See Also==
Cards: Atrial Fibrilation

[[Category:Cards]]

Palpitations

2014-01-13T00:46:46Z

Tdeboyes: added content

==Background==
Insert

==Diagnosis==
Insert

==Work-Up==
#CBC
#Chem
#ECG
#CXR
#?Trop

==DDx==
Arrhythmias:
*AFib or Flutter
*VTach
*Sick sinus syndrome
*MAT
*PVCs
*WPW
*Sinus node dysfunction
*AV Block
Psychiatric causes:
*Anxiety disorder
*Panic attack
Drugs and Medications:
*Alcohol
*Caffeine
*Meds (i.e. digitalis, theophylline)
*Street drugs (i.e. cocaine)
*Tobacco

==Treatment==
Insert

==Disposition==
Insert

==See Also==
Cards: Atrial Fibrilation

[[Category:Cards]]

Palpitations

2014-01-13T00:38:50Z

Tdeboyes: added content

==Background==
Insert

==Diagnosis==
Insert

==Work-Up==
#CBC
#Chem
#ECG
#CXR
#?Trop

==DDx==
Arrhythmias:
*AFib or Flutter
*VTach
*Sick sinus syndrome
*MAT
*PVCs
*WPW
*Sinus node dysfunction
*AV Block
Psychiatric causes:
*Anxiety disorder
*Panic attack

==Treatment==
Insert

==Disposition==
Insert

==See Also==
Cards: Atrial Fibrilation

[[Category:Cards]]

Palpitations

2014-01-13T00:17:43Z

Tdeboyes: added content

Trauma in pregnancy

2014-01-12T00:56:17Z

Tdeboyes: added content

==Background==
*Concern for trauma, premature labor, and abruption
*Viable = >23-24wk (~fundus above umbilicus)
*nl FHR = 110-160 beats/min
*The leading cause of death in women during their reproductive years
*The leading non-obstetric cause of death and disability in pregnant women
*Trauma or accidental injury complicates up to 7% of all pregnancies
*For maternal vitals see [[Maternal Vitals and Labs in Pregnancy]]

==Diagnosis (Abruption)==
Symptoms
#Vag bleed 70% (may be absent if retroplacental)
#Cramps/contractions
#Uterine tenderness
#Hypovolemia
#Abnl fetal HR

US only 50% accurate

Signs of fetal distress on toco monitor are often the earliest indicator
#decelerations, tachycardia, bradycardia, and loss of variability

==Treatment & Disposition==
#Nonviable fetus (<23-24wks)
##Standard treatment for trauma
##Consider RhoGAM 50mcg in rh neg
#Viable fetus (>23-24wks)
##Consider RhoGAM 300mcg in rh neg
##Avoid pressors - compromises blood flow to uterus leading to decreased fetal O2 delivery
##Monitor (fetal) all for 4-6hrs -->
##Extend Monitoring to 24hrs, if risk factor or abnormal 6hr monitoring

===Risk Factors (ATLS)===
#Maternal heart rate > 100
#Injury Severity Score > 9
#Evidence of placental abruption
#Fetal heart rate > 160 or <120
#Ejection during a motor vehicle crash
#Motorcycle or pedestrian collisions

===Abnormal Monitoring===
#>3 contractions/hr
#Persistent uterine TTP
#Worrisome strip
#Vag bleed
#PROM
#Serious maternal injury

Partial abruption w/ stable mom/fetus and <32wk may have expectant care (with easy access to emergent C-section)

Abruption = risk DIC

==See Also==
*[[Fetal Maternal Hemorrhage (RhoGAM)]]
*[[Perimortum C-Section]]
*[[Abruption]]
*[[Maternal Vitals and Labs in Pregnancy]]

==Sources==
<references/>

[[Category:Trauma]]
[[Category:OB/GYN]]

Maternal vitals and labs in pregnancy

2014-01-12T00:30:23Z

Tdeboyes: added content

==Vitals==
{| border="1" cellpadding="1" cellspacing="1" width="200"
|-
| <br/>
| '''Nonpreg'''
| '''T1'''
| '''T2'''
| '''T3'''
|-
| HR
| 70
| 78
| 82
| 85
|-
| SBP
| 115
| 112
| 112
| 114
|-
| DBP
| 70
| 60
| 63
| 70
|-
| Hcrt
| 40
| 36
| 33
| 34
|-
| WBC
| 7.2k
| 9.1k
| 9.7k
| 9.8k
|}

==Labs==
*Increased ESR ~78
*Decreased PaCO2 ~30
*ECG w/ Qs in III & aVF, L axis
*[[Beta-HCG Levels]]
*Decreased Hct
*Decreased BUN and creatinine
*Decreased Bicarb
*Increased WBC count
*Decreased PLTs
*Increased D-dimer and Fibrinogen

==Source==
3/29/09 DONALDSON (adapted from Rosen)

[[Category:Airway/Resus]]
[[Category:OB/GYN]]

Perimortum C-Section

2014-01-09T23:22:37Z

Tdeboyes: added content

==Background==
*70% success at <5min loss vitals of mother
*Continue CPR during C-section
*Correct maternal acidosis

==Indications==
# Fundus higher than umbilicus or >23 weeks
# Fetal heart tones present
# Loss of maternal vital signs

==Procedure==
# Full BSI
# Large vertical abdominal incision down to uterus
# Vertial placental incision
# Delivery infant from mother
# Have NICU team with warmer standing by

[[Category:OB/GYN]]
[[Category:Procedures]]

Perimortum C-Section

2014-01-09T23:19:22Z

Tdeboyes: edit

==Background==
*70% success at <5min loss vitals of mother
*Continue CPR during C-section
*Correct maternal acidosis

==Indications==
# Fundus higher than umbilicus
# Fetal heart tones present
# Loss of maternal vital signs

==Procedure==
# Full BSI
# Large vertical abdominal incision down to uterus
# Vertial placental incision
# Delivery infant from mother
# Have NICU team with warmer standing by

[[Category:OB/GYN]]
[[Category:Procedures]]

Perimortum C-Section

2014-01-09T23:18:30Z

Tdeboyes: added content

==Background==
70% success at <5min loss vitals of mother
Continue CPR during C-section
Correct maternal acidosis

==Indications==
# Fundus higher than umbilicus
# Fetal heart tones present
# Loss of maternal vital signs

==Procedure==
# Full BSI
# Large vertical abdominal incision down to uterus
# Vertial placental incision
# Delivery infant from mother
# Have NICU team with warmer standing by

[[Category:OB/GYN]]
[[Category:Procedures]]

Trauma in pregnancy

2014-01-09T23:12:17Z

Tdeboyes: added content

==Background==
*Concern for trauma, premature labor, and abruption
*Viable = >23-24wk (~fundus above umbilicus)
*nl FHR = 110-160 beats/min
*The leading cause of death in women during their reproductive years
*The leading non-obstetric cause of death and disability in pregnant women
*Trauma or accidental injury complicates up to 7% of all pregnancies
*For maternal vitals see [[Maternal Vitals and Labs in Pregnancy]]

==Diagnosis (Abruption)==
Symptoms
#Vag bleed 70% (may be absent if retroplacental)
#Cramps/contractions
#Uterine tenderness
#Hypovolemia
#Abnl fetal HR

US only 50% accurate

Signs of fetal distress on toco monitor are often the earliest indicator
#decelerations, tachycardia, bradycardia, and loss of variability

==Treatment & Disposition==
#Nonviable fetus (<23-24wks)
##Standard treatment for trauma
##Consider RhoGAM 50mcg in rh neg
#Viable fetus (>23-24wks)
##Consider RhoGAM 300mcg in rh neg
##Avoid pressors
##Monitor (fetal) all for 4-6hrs -->
##Extend Monitoring to 24hrs, if risk factor or abnormal 6hr monitoring

===Risk Factors (ATLS)===
#Maternal heart rate > 100
#Injury Severity Score > 9
#Evidence of placental abruption
#Fetal heart rate > 160 or <120
#Ejection during a motor vehicle crash
#Motorcycle or pedestrian collisions

===Abnormal Monitoring===
#>3 contractions/hr
#Persistent uterine TTP
#Worrisome strip
#Vag bleed
#PROM
#Serious maternal injury

Partial abruption w/ stable mom/fetus and <32wk may have expectant care (with easy access to emergent C-section)

Abruption = risk DIC

==See Also==
*[[Fetal Maternal Hemorrhage (RhoGAM)]]
*[[Perimortum C-Section]]
*[[Abruption]]
*[[Maternal Vitals and Labs in Pregnancy]]

==Source==
3/29/06 DONALDSON (adapted from Rosen)

[[Category:Trauma]]
[[Category:OB/GYN]]

Trauma in pregnancy

2014-01-09T23:05:27Z

Tdeboyes: edit

==Background==
*Concern for trauma, premature labor, and abruption
*Viable = >23-24wk (~fundus above umbilicus)
*nl FHR = 110-160 beats/min
*The leading cause of death in women during their reproductive years
*The leading non-obstetric cause of death and disability in pregnant women
*Trauma or accidental injury complicates up to 7% of all pregnancies
*For maternal vitals see [[Maternal Vitals and Labs in Pregnancy]]

==Diagnosis (Abruption)==
Symptoms
#Vag bleed 70%
#Cramps/contractions
#Uterine tenderness
#Hypovolemia
#Abnl fetal HR

US only 50% acurrate

==Treatment & Disposition==
#Nonviable fetus (<23-24wks)
##Standard treatment for trauma
##Consider RhoGAM 50mcg in rh neg
#Viable fetus (>23-24wks)
##Consider RhoGAM 300mcg in rh neg
##Avoid pressors
##Monitor (fetal) all for 4-6hrs -->
##Extend Monitoring to 24hrs, if risk factor or abnormal 6hr monitoring

===Risk Factors (ATLS)===
#Maternal heart rate > 100
#Injury Severity Score > 9
#Evidence of placental abruption
#Fetal heart rate > 160 or <120
#Ejection during a motor vehicle crash
#Motorcycle or pedestrian collisions

===Abnormal Monitoring===
#>3 contractions/hr
#Persistent uterine TTP
#Worrisome strip
#Vag bleed
#PROM
#Serious maternal injury

Partial abruption w/ stable mom/fetus and <32wk may have expectant care (with easy access to emergent C-section)

Abruption = risk DIC

==See Also==
*[[Fetal Maternal Hemorrhage (RhoGAM)]]
*[[Perimortum C-Section]]
*[[Abruption]]
*[[Maternal Vitals and Labs in Pregnancy]]

==Source==
3/29/06 DONALDSON (adapted from Rosen)

[[Category:Trauma]]
[[Category:OB/GYN]]

Trauma in pregnancy

2014-01-09T23:02:55Z

Tdeboyes: edits

==Background==
*Concern for trauma, premature labor, and abruption
*Viable = >23-24wk (~fundus above umbilicus)
*nl FHR = 110-160 beats/min
*The leading cause of death in women during their reproductive years
*The leading non-obstetric cause of death and disability in pregnant women
*Trauma or accidental injury complicates up to 7% of all pregnancies
*For maternal vitals see [[Maternal Vitals and Labs in Pregnancy]]

==Diagnosis (Abruption)==
Symptoms
#Vag bleed 70%
#Cramps/contractions
#Uterine tenderness
#Hypovolemia
#Abnl fetal HR

US only 50% acurate

==Treatment & Disposition==
#Nonviable fetus (<23-24wks)
##Standard treatment for trauma
##Consider RhoGAM 50mcg in rh neg
#Viable fetus (>23-24wks)
##Consider RhoGAM 300mcg in rh neg
##Avoid pressors
##Monitor (fetal) all for 4-6hrs -->
##Extend Monitoring to 24hrs, if risk factor or abnormal 6hr monitoring

===Risk Factors (ATLS)===
#Maternal heart rate > 100
#Injury Severity Score > 9
#Evidence of placental abruption
#Fetal heart rate > 160 or <120
#Ejection during a motor vehicle crash
#Motorcycle or pedestrian collisions

===Abnormal Monitoring===
#>3 contractions/hr
#Persistent uterine TTP
#Worrisome strip
#Vag bleed
#PROM
#Serious maternal injury

Partial abruption w/ stable mom/fetus and <32wk may have expectant care (with easy access to emergent C-section)

Abruption = risk DIC

==See Also==
*[[Fetal Maternal Hemorrhage (RhoGAM)]]
*[[Perimortum C-Section]]
*[[Abruption]]
*[[Maternal Vitals and Labs in Pregnancy]]

==Source==
3/29/06 DONALDSON (adapted from Rosen)

[[Category:Trauma]]
[[Category:OB/GYN]]

Placental abruption

2014-01-09T22:57:11Z

Tdeboyes: added content

==Background==
*Premature separation of placenta from uterus
*Usually occurs spontaneously but also associated w/ trauma (even minor trauma)
*Usually occurs at >15 weeks gestation
*Must be considered in pts who p/w painful vaginal bleeding near term
*Abruption may be complete, partial, or concealed
**Amount of external bleeding may not correlate with severity

==Risk Factors==
#HTN
#Trauma
#Smoking
#Advanced maternal age
#Cocaine abuse
#History of C-section or other uterine sx

==Clinical Features==
*Painful vaginal bleeding (may be absent if retroplacental)
*Severe uterine pain
*Uterine contractions
*Hypotension
*N/V
*Back pain
*Premature labor
*Fetal distress
*Increasing fundal height

==Work-Up==
#Type + Cross
#CBC
#DIC panel
#US
##Sp, not Sn (as low as 24% sensitive)
##Cannot be used alone to r/o dx if negative
##Can r/o previa

==Treatment==
#Fluid resuscitation
#Transfuse blood products (as needed)
#Emergent OB/GYN consult
##If unavailable consider C-section in ED

==Complications==
#Maternal
##Hemorrhagic shock
##DIC
##Uterine rupture
##Multi-organ failure
#Neonatal
##Neurodevelopmental abnormalities
##Death - 67 to 75% rate of fetal mortality

==Source==
Tintinalli

==See Also==
[[Vaginal Bleeding (Main)]]

[[Category:OB/GYN]]

Placental abruption

2014-01-09T22:53:51Z

Tdeboyes: added content

==Background==
*Premature separation of placenta from uterus
*Usually occurs spontaneously but also associated w/ trauma (even minor trauma)
*Usually occurs at >15 weeks gestation
*Must be considered in pts who p/w painful vaginal bleeding near term
*Abruption may be complete, partial, or concealed
**Amount of external bleeding may not correlate with severity

==Risk Factors==
#HTN
#Trauma
#Smoking
#Advanced maternal age
#Cocaine abuse
#History of C-section or other uterine sx

==Clinical Features==
*Painful vaginal bleeding (may be absent if retroplacental)
*Severe uterine pain
*Uterine contractions
*Hypotension
*N/V
*Back pain
*Premature labor
*Fetal distress
*Increasing fundal height

==Work-Up==
#Type + Cross
#CBC
#DIC panel
#US
##Sp, not Sn (as low as 24% sensitive)
##Cannot be used alone to r/o dx if negative
##Can r/o previa

==Treatment==
#Fluid resuscitation
#Transfuse blood products (as needed)
#Emergent OB/GYN consult
##If unavailable consider C-section in ED

==Complications==
#Maternal
##Hemorrhagic shock
##DIC
##Uterine rupture
##Multi-organ failure
#Neonatal
##Neurodevelopmental abnormalities
##Death

==Source==
Tintinalli

==See Also==
[[Vaginal Bleeding (Main)]]

[[Category:OB/GYN]]

Placental abruption

2014-01-09T22:41:53Z

Tdeboyes: added content

==Background==
*Premature separation of placenta from uterus
*Usually occurs spontaneously but also associated w/ trauma (even minor trauma)
*Usually occurs at >15 weeks gestation
*Must be considered in pts who p/w painful vaginal bleeding near term
*Abruption may be complete, partial, or concealed
**Amount of external bleeding may not correlate with severity

==Risk Factors==
#HTN
#Trauma
#Smoking
#Advanced maternal age
#Cocaine abuse
#History of C-section or other uterine sx

==Clinical Features==
*Painful vaginal bleeding (may be absent if retroplacental)
*Severe uterine pain
*Uterine contractions
*Hypotension
*N/V
*Back pain
*Premature labor
*Fetal distress
*Increasing fundal height

==Work-Up==
#Type + Cross
#CBC
#DIC panel
#US
##Sp, not Sn
##Can r/o previa

==Treatment==
#Fluid resuscitation
#Transfuse blood products (as needed)
#Emergent OB/GYN consult
##If unavailable consider C-section in ED

==Complications==
#Maternal
##Hemorrhagic shock
##DIC
##Uterine rupture
##Multi-organ failure
#Neonatal
##Neurodevelopmental abnormalities
##Death

==Source==
Tintinalli

==See Also==
[[Vaginal Bleeding (Main)]]

[[Category:OB/GYN]]

Placental abruption

2014-01-09T22:39:56Z

Tdeboyes: added content

==Background==
*Premature separation of placenta from uterus
*Usually occurs spontaneously but also associated w/ trauma (even minor trauma)
*Must be considered in pts who p/w painful vaginal bleeding near term
*Abruption may be complete, partial, or concealed
**Amount of external bleeding may not correlate with severity

==Risk Factors==
#HTN
#Trauma
#Smoking
#Advanced maternal age
#Cocaine abuse
#History of C-section or other uterine sx

==Clinical Features==
*Painful vaginal bleeding (may be absent if retroplacental)
*Severe uterine pain
*Uterine contractions
*Hypotension
*N/V
*Back pain
*Premature labor
*Fetal distress
*Increasing fundal height

==Work-Up==
#Type + Cross
#CBC
#DIC panel
#US
##Sp, not Sn
##Can r/o previa

==Treatment==
#Fluid resuscitation
#Transfuse blood products (as needed)
#Emergent OB/GYN consult
##If unavailable consider C-section in ED

==Complications==
#Maternal
##Hemorrhagic shock
##DIC
##Uterine rupture
##Multi-organ failure
#Neonatal
##Neurodevelopmental abnormalities
##Death

==Source==
Tintinalli

==See Also==
[[Vaginal Bleeding (Main)]]

[[Category:OB/GYN]]

Trauma in pregnancy

2014-01-09T22:31:51Z

Tdeboyes: changed content

==Background==
*Concern for trauma, premature labor, and abruption
*Viable = >23-24wk (~fundus above umbilicus)
*nl FHR = 110-160 beats/min
*The leading cause of death in women during their reproductive years
*The leading non-obstetric cause of death and disability in pregnant women
*Trauma or accidental injury complicates up to 7% of all pregnancies
*For maternal vitals see [[Maternal Vitals and Labs in Pregnancy]]

==Diagnosis (Abruption)==
Symptoms
#Vag bleed 70%
#Cramps/contractions
#Uterine tenderness
#Hypovolemia
#Abnl fetal HR

US only 50% acurate

==Treatment & Disposition==
#Nonviable fetus (<23-24wks)
##Standard treatment for trauma
##Consider RhoGAM 50mcg in rh neg
#Viable fetus (>23-24wks)
##Consider RhoGAM 300mcg in rh neg
##Avoid pressors
##Monitor (fetal) all for 4-6hrs -->
##Extend Monitoring to 24hrs, if risk factor or abnormal 6hr monitoring

===Risk Factors (ATLS)===
#Maternal heart rate > 100
#Injury Severity Score > 9
#Evidence of placental abruption
#Fetal heart rate > 160 or <120
#Ejection during a motor vehicle crash
#Motorcycle or pedestrian collisions

===Abnormal Monitoring===
#>3 contractions/hr
#Persistant uterine TTP
#Worisome strip
#Vag bleed
#PROM
#Serious maternal injury

Partial abrution w/ stable mom/fetus and <32wk may have expectant care (with easy access to emergent C-section)

Abrupion = risk DIC

==See Also==
*[[Fetal Maternal Hemorrhage (RhoGAM)]]
*[[Perimortum C-Section]]
*[[Abruption]]
*[[Maternal Vitals and Labs in Pregnancy]]

==Source==
3/29/06 DONALDSON (adapted from Rosen)

[[Category:Trauma]]
[[Category:OB/GYN]]

Trauma in pregnancy

2014-01-09T22:28:11Z

Tdeboyes: added info

==Background==
*Concern for trauma and abruption
*Viable = >23-24wk (~fundus above umbilicus)
*nl FHR = 110-160 beats/min
*The leading cause of death in women during their reproductive years
*The leading non-obstetric cause of death and disability in pregnant women
*Trauma or accidental injury complicates up to 7% of all pregnancies
*For maternal vitals see [[Maternal Vitals and Labs in Pregnancy]]

==Diagnosis (Abruption)==
Symptoms
#Vag bleed 70%
#Cramps/contractions
#Uterine tenderness
#Hypovolemia
#Abnl fetal HR

US only 50% acurate

==Treatment & Disposition==
#Nonviable fetus (<23-24wks)
##Standard treatment for trauma
##Consider RhoGAM 50mcg in rh neg
#Viable fetus (>23-24wks)
##Consider RhoGAM 300mcg in rh neg
##Avoid pressors
##Monitor (fetal) all for 4-6hrs -->
##Extend Monitoring to 24hrs, if risk factor or abnormal 6hr monitoring

===Risk Factors (ATLS)===
#Maternal heart rate > 100
#Injury Severity Score > 9
#Evidence of placental abruption
#Fetal heart rate > 160 or <120
#Ejection during a motor vehicle crash
#Motorcycle or pedestrian collisions

===Abnormal Monitoring===
#>3 contractions/hr
#Persistant uterine TTP
#Worisome strip
#Vag bleed
#PROM
#Serious maternal injury

Partial abrution w/ stable mom/fetus and <32wk may have expectant care (with easy access to emergent C-section)

Abrupion = risk DIC

==See Also==
*[[Fetal Maternal Hemorrhage (RhoGAM)]]
*[[Perimortum C-Section]]
*[[Abruption]]
*[[Maternal Vitals and Labs in Pregnancy]]

==Source==
3/29/06 DONALDSON (adapted from Rosen)

[[Category:Trauma]]
[[Category:OB/GYN]]

EBQ:HINTS Exam

2014-01-05T07:14:37Z

Tdeboyes: created primary outcomes

{{JC info
| title= HINTS to Diagnose Stroke in the Acute Vestibular Syndrome: Three-Step Bedside Oculomotor Examination More Sensitive Than Early MRI Diffusion-Weighted Imaging
| abbreviation= HINTS
| expansion=
| published= 2009
| author= Kattah, J. et al
| journal= Stroke
| year= 2009
| volume= 40
| issue=11
| pages= 3504–3510
| pmid= 19762709
| fulltexturl= http://stroke.ahajournals.org/content/40/11/3504.long
| pdfurl=http://stroke.ahajournals.org/content/40/11/3504.full.pdf
| status = Under Review
}}

==Clinical Question==
Is the HINTS exam (Head-Impulse—Nystagmus—Test-of-Skew) more sensitive for diagnosing stroke than early MRI diffusion-weighted imaging in Acute Vestibular Syndrome?

==Conclusion==
A negative HINTS examination can rule out a stroke better than a negative MRI with DWI in the first 24 to 48 hours after symptom onset with a specificity of 96%.

==Major Points==
*The 3 components of the HINTS exam include: head impulse test of vestibulo-ocular reflex function; observation for nystagmus in primary, right, and left gaze; alternate cover test for skew deviation.

*Skew deviation is a fairly specific predictor of brainstem involvement in patients with acute vestibular syndrome. The presence of skew may help identify stroke when a positive head impulse test falsely suggests a peripheral lesion.

*Initial MRIs are falsely negative in 12% and can prove misleading out to 48 hours after symptom onset.

==Inclusion Criteria==
At least one stroke risk factor: smoking, hypertension, diabetes, hyperlipidemia, atrial fibrillation, eclampsia, hypercoagulable state, recent cervical trauma, prior stroke or myocardial infarction.

==Exclusion Criteria==
A history of recurrent vertigo with or without auditory symptoms

==Interventions==
Patients presenting with symptoms of acute vestibular syndrome underwent neurological and vestibular examination according to a standard protocol:
*head impulse test
*prism cross-cover test for ocular alignment
*observation of nystagmus in different gaze positions

All patients underwent neuroimaging, generally after bedside evaluation, otherwise the examiner was masked to these results at the time of clinical assessment.

All patients were admitted for observation and underwent serial daily examinations for evolution of clinical findings.

==Outcome==

===Primary Outcomes===
*A positive HINTS exam: 100% sensitive and 96% specific for the presence of a central lesion.
*The HINTS exam was more sensitive than general neurological signs: 100% versus 51%.
*The sensitivity of early MRI with DWI for lateral medullary or pontine stroke was lower than that of the HINTS examination (72% versus 100%, P=0.004) with comparable specificity (100% versus 96%, P=1.0).

===Secondary Outcomes===

===Subgroup analysis===

==Criticisms==

==Funding==
the National Institutes of Health and the Agency for Healthcare Research and Quality

==Sources==

<references/>

[[Category:EBQ]]

EBQ:HINTS Exam

2014-01-05T06:33:41Z

Tdeboyes: created interventions

{{JC info
| title= HINTS to Diagnose Stroke in the Acute Vestibular Syndrome: Three-Step Bedside Oculomotor Examination More Sensitive Than Early MRI Diffusion-Weighted Imaging
| abbreviation= HINTS
| expansion=
| published= 2009
| author= Kattah, J. et al
| journal= Stroke
| year= 2009
| volume= 40
| issue=11
| pages= 3504–3510
| pmid= 19762709
| fulltexturl= http://stroke.ahajournals.org/content/40/11/3504.long
| pdfurl=http://stroke.ahajournals.org/content/40/11/3504.full.pdf
| status = Under Review
}}

==Clinical Question==
Is the HINTS exam (Head-Impulse—Nystagmus—Test-of-Skew) more sensitive for diagnosing stroke than early MRI diffusion-weighted imaging in Acute Vestibular Syndrome?

==Conclusion==
A negative HINTS examination can rule out a stroke better than a negative MRI with DWI in the first 24 to 48 hours after symptom onset with a specificity of 96%.

==Major Points==
*The 3 components of the HINTS exam include: head impulse test of vestibulo-ocular reflex function; observation for nystagmus in primary, right, and left gaze; alternate cover test for skew deviation.

*Skew deviation is a fairly specific predictor of brainstem involvement in patients with acute vestibular syndrome. The presence of skew may help identify stroke when a positive head impulse test falsely suggests a peripheral lesion.

*Initial MRIs are falsely negative in 12% and can prove misleading out to 48 hours after symptom onset.

==Inclusion Criteria==
At least one stroke risk factor: smoking, hypertension, diabetes, hyperlipidemia, atrial fibrillation, eclampsia, hypercoagulable state, recent cervical trauma, prior stroke or myocardial infarction.

==Exclusion Criteria==
A history of recurrent vertigo with or without auditory symptoms

==Interventions==
Patients presenting with symptoms of acute vestibular syndrome underwent neurological and vestibular examination according to a standard protocol:
*head impulse test
*prism cross-cover test for ocular alignment
*observation of nystagmus in different gaze positions

All patients underwent neuroimaging, generally after bedside evaluation, otherwise the examiner was masked to these results at the time of clinical assessment.

All patients were admitted for observation and underwent serial daily examinations for evolution of clinical findings.

==Outcome==

===Primary Outcomes===

===Secondary Outcomes===

===Subgroup analysis===

==Criticisms==

==Funding==
the National Institutes of Health and the Agency for Healthcare Research and Quality

==Sources==

<references/>

[[Category:EBQ]]

EBQ:HINTS Exam

2014-01-05T05:49:27Z

Tdeboyes: added funding

EBQ:HINTS Exam

2014-01-05T05:45:25Z

Tdeboyes: created inclusion criteria

EBQ:HINTS Exam

2014-01-05T05:35:47Z

Tdeboyes: created exclusion criteria

EBQ:HINTS Exam

2014-01-05T05:23:50Z

Tdeboyes: created major points

EBQ:HINTS Exam

2014-01-05T03:16:07Z

Tdeboyes: Created conclusion

EBQ:HINTS Exam

2014-01-05T02:58:58Z

Tdeboyes: Created clinical question