Precipitous Labor and Emergency Department Delivery.

A precipitous delivery can be among the most stressful events an emergency physician encounters. The physician must assess 2 patients (mother and fetus) and be prepared to manage a variety of complications that may arise during delivery. A majority of precipitous deliveries result in good outcomes for both mother and baby, but emergency physicians must be prepared to manage feared complications, such as tight nuchal cords, shoulder dystocia, and breech presentation. An understanding of the labor process as well as advanced planning can help decrease the stress and chaos inherent to any precipitous delivery.

Cardiovascular Emergencies in Pregnancy.

Cardiovascular disease has overtaken all other causes of maternal death in the United States. The physiologic changes of pregnancy place a significant amount of stress on the cardiovascular system and put pregnant women at risk for potentially catastrophic complications, such as pulmonary embolism, aortic or coronary artery dissection, myocardial infarction, and peripartum cardiomyopathy. The diagnosis of these conditions is challenging because the symptoms can mimic those experienced in normal pregnancies. There are subtle differences in the diagnosis and treatment of cardiovascular emergencies in pregnant patients that clinicians must be aware of; however, the overall management goals are similar.

Exaggerated Arthropod Bite: A Case Report and Review of the Mimics.

Exaggerated arthropod bite reactions causing hemorrhagic or necrotic bullous lesions can mimic other serious conditions such as cutaneous anthrax, brown recluse spider bite, and tularemia. A 55- year-old, healthy woman presented to the emergency department with a 3.5-centimeter painless, collapsed hemorrhagic bulla at the left costal margin. She was afebrile and had no systemic symptoms. Laboratory evaluation was unremarkable. She was prescribed silver sulfadiazine cream and mupirocin ointment. The area denuded two days later and the lesion completely healed. This case illustrates the broad differential to be considered when evaluating patients with hemorrhagic bullous lesions.

Emergency department management of vaginal bleeding in the nonpregnant patient.

Abnormal uterine bleeding is the most common reason women seek gynecologic care, and many of these women present to an emergency department for evaluation. It is essential that emergency clinicians have a thorough understanding of the underlying physiology of the menstrual cycle to appropriately manage a nonpregnant woman with abnormal bleeding. Evidence to guide the management of nonpregnant patients with abnormal bleeding is limited, and recommendations are based mostly on expert opinion. This issue reviews common causes of abnormal bleeding, including anovulatory, ovulatory, and structural causes in both stable and unstable patients. The approach to abnormal bleeding in the prepubertal girl is also discussed. Emergency clinicians are encouraged to initiate treatment to temporize an acute bleeding episode until timely follow-up with a gynecologist can be obtained.

Medical students benefit from the use of ultrasound when learning peripheral IV techniques.

BACKGROUND: Recent studies support high success rates after a short learning period of ultrasound IV technique, and increased patient and provider satisfaction when using ultrasound as an adjunct to peripheral IV placement. No study to date has addressed the efficacy for instructing ultrasound-naive providers. We studied the introduction of ultrasound to the teaching technique of peripheral IV insertion on first- and second-year medical students. METHODS: This was a prospective, randomized, and controlled trial. A total of 69 medical students were randomly assigned to the control group with a classic, landmark-based approach (n = 36) or the real-time ultrasound-guided group (n = 33). Both groups observed a 20-min tutorial on IV placement using both techniques and then attempted vein cannulation. Students were given a survey to report their results and observations by a 10-cm visual analog scale. The survey response rate was 100%. RESULTS: In the two groups, 73.9% stated that they attempted an IV previously, and 63.7% of students had used an ultrasound machine prior to the study. None had used ultrasound for IV access prior to our session. The average number of attempts at cannulation was 1.42 in either group. There was no difference between the control and ultrasound groups in terms of number of attempts (p = 0.31). In both groups, 66.7% of learners were able to cannulate in one attempt, 21.7% in two attempts, and 11.6% in three attempts. The study group commented that they felt they gained more knowledge from the experience (p < 0.005) and that it was easier with ultrasound guidance (p < 0.005). CONCLUSION: Medical students feel they learn more when using ultrasound after a 20-min tutorial to place IVs and cannulation of the vein feels easier. Success rates are comparable between the traditional and ultrasound teaching approaches.

Emergency department management of sexually transmitted infections.

Patients seeking treatment for sexually transmitted infections (STIs) account for a large number of emergency department (ED) visits per year. Despite the large volume of patients, STIs are often missed or treated inappropriately. Due to the high prevalence and incidence of STIs in the United States, it is important that emergency practitioners recognize symptoms consistent with STIs, and treat presumptively. This practice leads to overtreatment of STIs; however, when weighed against the public health risk and complications of untreated disease, empiric treatment is recommended. This article provides an overview of STIs encountered in the ED and recommendations for their treatment.