ER41 Emergency Medicine

Gynecologic/Urologic Emergencies

Toronto Notes 2016

2nd/3rd trimester pregnancy

placenta previa or placental abruption: obstetrics consult for possible admission
postpartum
manage ABCs: start 2 large bore IV rapid infusion, type and cross 4 units of blood, consult
OB/GYN immediately
non-pregnant
dysfunctional uterine bleeding (prolonged or heavy flow breakthrough bleeding and
without ovulation, a diagnosis of exclusion)
<35-40 yr of age: Provera 10 mg PO OD x 10 d, warn patient of a withdrawal bleed,
discharge if stable
if unstable, admit for IV hormonal therapy, possible D&C
>35-40 yr of age: uterine sampling necessary prior to initiation of hormonal treatment to
rule out endometrial cancer, U/S for any masses felt on exam
tranexamic acid (Cyklokapron) to stabilize clots
structural abnormalities: fibroids or uterine tumours may require excision for diagnosis/
treatment, U/S for workup of other pelvic masses, Pap smear/biopsy for cervical lesions
Disposition
decision to admit or discharge should be based on the stability of the patient, as well as the nature
of the underlying cause; consult gynecology for admitted patients
if patient can be safely discharged, ensure follo- up with family physician or gynecologist
instruct patient to return to ED for increased bleeding, presyncope

Pregnant Patient in the ED

Table 25. Complications of Pregnancy
Trimester

Fetal

Maternal

First
1-12 wk

Pregnancy failure
Spontaneous abortion
Fetal demise
Gestational trophoblastic disease

Ectopic pregnancy
Anemia
Hyperemesis gravidarum
UTI/pyelonephritis

Second
13-27 wk

Disorders of fetal growth

IUGR
Oligo/polyhydramnios

Gestational DM
Rh incompatibility
UTI/pyelonephritis

Third
28-41 wk

Vasa previa

Preterm labour/PPROM
Preeclampsia/eclampsia
Placenta previa
Placental abruption
Uterine rupture
DVT

Nephrolithiasis (Renal Colic)

see Urology, U17
Epidemiology and Risk Factors
10% of population (twice as common in males)
recurrence 50% at 5 yr
peak incidence 30-50 yr of age
75% of stones <5 mm pass spontaneously within 2 wk, larger stones may require consultation
Clinical Features
urinary obstruction upstream distention of ureter or collecting system severe colicky pain
may complain of pain at flank, groin, testes, or tip of penis
writhing, never comfortable, N/V, hematuria (90% microscopic), diaphoresis, tachycardia,
tachypnea
occasionally symptoms of trigonal irritation (frequency, urgency)
fever, chills, rigors in secondary pyelonephritis
peritoneal findings/anterior abdominal tenderness usually absent
Differential Diagnosis of Renal Colic
acute ureteric obstruction
acute abdomen: biliary, bowel, pancreas, AAA
gynecological: ectopic pregnancy, torsion/rupture of ovarian cyst
pyelonephritis (fever, chills, pyuria, vomiting)
radiculitis (L1): herpes zoster, nerve root compression

Kidney Stones
80% Calcium oxalate
10% Struvite
10% Uric acid

ER42 Emergency Medicine

Gynecologic/Urologic Emergencies/Ophthalmologic Emergencies

Toronto Notes 2016

Investigations
screening
CBC elevated WBC in presence of fever suggests infection
electrolytes, Cr, BUN to assess renal function
U/A: R&M (WBCs, RBCs, crystals), C&S
imaging
non-contrast spiral CT is the study of choice
abdominal U/S may demonstrate stone or hydronephrosis (consider in females of childbearing
age)
AXR will identify large radioopaque stones (calcium, struvite, and cystine stones) but may
miss smaller stones, uric acid stones, or stones overlying bony structures; consider as an initial
investigation in patients who have a history of radioopaque stones and similar episodes of acute
flank pain (CT necessary if film is negative)
strain all urine stone analysis
Management
analgesics: NSAIDs (usually ketorolac [Toradol], preferable over opioids), antiemetics, IV fluids
urology consult may be indicated, especially if stone >5 mm, or if patient has signs of obstruction
or infection
-blocker (e.g. tamsulosin) helpful to increase stone passage in select cases
Disposition
most patients can be discharged
ensure patient is stable, has adequate analgesia, and is able to tolerate oral medications
may advise hydration and limitation of protein, sodium, oxalate, and alcohol intake

Indications for Admission to Hospital

Intractable pain
Fever (suggests infection) or other
evidence of pyelonephritis
Single kidney with ureteral obstruction
Bilateral obstructing stones
Intractable vomiting
Compromised renal function

Ophthalmologic Emergencies
see Ophthalmology, OP5
History and Physical Exam
patient may complain of pain, tearing, itching, redness, photophobia, foreign body sensation,
trauma
mechanism of foreign body insertion if high velocity injury suspected (welding, metal grinding,
metal striking metal), must obtain orbital X-rays, U/S, or CT scan to exclude presence of
intraocular metallic foreign body
visual acuity in both eyes, pupils, extraocular structures, fundoscopy, tonometry, slit lamp exam
Management of Ophthalmologic Foreign Body
copious irrigation with saline for any foreign body
remove foreign body under slit lamp exam with cotton swab or sterile needle
antibiotic drops qid until healed
patching may not improve healing or comfort do not patch contact lens wearers
limit use of topical anesthetic to examination only
consider tetanus prophylaxis
ophthalmology consult if globe penetration suspected

Visual acuity is the vital sign of the

eyes and should ALWAYS be assessed
in both eyes when a patient presents
to the ER with an ophthalmologic
complaint

Table 26. Differential Diagnosis of Red Eye in the Emergency Department

Symptom

Possible Serious Etiology

Light sensitivity

Iritis, keratitis, abrasion, ulcer

Unilateral

Above + herpes simplex, acute angle closure glaucoma

Significant pain

Above + scleritis

White spot on cornea

Corneal ulcer

Blurred vision

All of the above

Non-reactive pupil

Acute glaucoma, iritis

Copious discharge

Gonococcal conjunctivitis

Blurred vision

All of the above

Contraindications to Pupil Dilation

Shallow anterior chamber
Iris-supported lens implant
Potential neurological abnormality
requiring pupillary evaluation
Caution with CV disease mydriatics
can cause tachycardia