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​Contraceptive emergencies and emergency contraception - Dr. Simonis

5/11/2017

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ASK, INFORM, and OFFER
  • Ask – reproductive aged females about unprotected intercourse and desire for pregnancy
  • Inform – about risk of pregnancy w/o contraception, and that emergency contraception is effective w/in 3-5 days after unprotected intercourse
  • Offer – discharge resources on contraception and family planning follow up 
 
Emergency Contraception
  • 2 FDA approved medications  + Copper IUD insertion: Progesterone receptor modulator (Ulipristal acetate “Ella”), progestin only (Levonorgestrel “Plan B”)
  • Plan B is available OTC, Ulipristal acetate requires Rx
  • Plan B effective up to 72 hours, Ulipristal up to 5 days
  • Some studies suggest Ella is more effective than planB
  • Recent survey shows ED infrequently prescribes ella
  • Copper IUD insertion, up to 5 days after unprotected intercourse
  • Side effects = nausea/vomiting, worse with ulipristal, irregular bleeding. No reported deaths or serious adverse effects. 
  • Very few (if any) contraindications to planB or Ella administration
  • EC has many barriers to use: insufficient knowledge, providers reluctant to discuss w/patients – especially teens. 
  • ED providers are good at offering EC to sexual assault victims, but not to patients who reports consensual, unprotected sex. 
 
Contraceptive emergencies
IUD related:
  • if expulsion suspected but not noted by user, need X-ray to eval for perforation
  • tx perforation with antimicrobials for PID, and consultation for laparoscopic removal 
  • IUD + STI (BV, trich, GC/CL) – do not need to remove IUD
  • IUD + PID: no immediate indication for IUD removal if improving on antimicrobial treatment, needs close f/u
  • Pelvic actinomyces: IUD users can be colonized, can cause PID/abscess requiring prolonged antimicrobials (w/ID involved) and IUD removal. Future IUD contraindicated. 
  • TSS: rare, but reported 

IUD  + ectopic:
  • IUD + first trimester gestation = IUD removal indicated
  • IUD + miscarriage = IUD removal and antibiotics

OCPs:
  • contraindications to combined OCPs (WHO/CDC) 

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May 04th, 2017

5/4/2017

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When managing patients with AG Metabolic Acidosis:
  • Same general resuscitation principles apply
  • Watch your patient’s respiratory rate
  • Broaden your differential for unknown source of acidosis
  • Don’t just get sucked into thinking this is sepsis
  • Realize you may have to start multiple antidotes initially while you rule things out

A CAT PILES MUD can help broaden your differential
A - Acetaminophen
C - CO, CN
A - AKA, Starvation ketoacidosis
T - Toluene
P - Paraldehyde, phenformin, propylene glycol
I - Isoniazid, Iron, Ibuprofen, Ischemia
L - Lactate elevation
E - Ethanol, Ethylene glycol
S - Salicylates
M - Methanol, Metformin
U - Uremia
D - DKA

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Rabies - Dr. M. Zeller

5/4/2017

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​​Why is rabies important?  Rabies has the highest case fatality rate of any infectious disease, and it is entirely preventable.  Although it is rare in the United States, it is very common in the developing world and is the cause of over 20,000 deaths per year in India alone.

What is an infectious exposure?  The direct exposure of saliva, CSF fluid, or CNS material to exposed wound or mucosa places an individual at risk of infection

What is not an infectious exposure?  The direct exposure to urine, feces, or blood or exposure of saliva to intact skin does not place an individual at risk of infection.

How do we treat an exposure?  Post exposure prophylaxis (PEP) includes a combination of local wound care, a one-time dose of human rabies immunoglobulin, and a total of four doses of rabies vaccine (on day 0, 3, 7, 14).

When do we treat an animal bite?  PEP is indicated in bites caused by bats, raccoons, foxes, skunks, possums, and large rodents (beaver and woodchuck) when the animal cannot be tested within 72 hours after the exposure.  PEP is also indicated in bites caused by dogs, cats, or ferrets that cannot be observed for a 10 day period by the local health department.

When do we not treat an animal bite?  PEP is not indicated in bites caused by dogs, cats, or ferrets that can be observed for a 10 day period by the local health department, herbivores, or small rodents (rats, squirrels, etc.)

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Carolinas Case Conference - Dr. Lounsbury

5/4/2017

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• Avoid diagnostic momentum from the prehospital setting and always perform your own cervical spine evaluation.
• Patients at risk for cervical spine injuries have a high-impact mechanism (diving, motorized vehicles, surfing, etc.) and/or those who present to the ED with an abnormal physical exam (altered mental status, neurologic deficits).

• The risk of delayed ICH in patients on anticoagulants is exceedingly low.
• Decision to observe or repeat head CT should be individualized per patient presentation.

• Always discuss risks of delayed ICH with patients and their families prior to discharge.

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  • RESIDENCY
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      • CMC ECG Masters
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