Bartholin Abscess
General

• Bartholin’s Gland is a pea sized glands located at the 4 and 8 o’clock positions of the vaginal vestibule, tasked with maintaining moisture of the vestibular surface.
• Can develop into cysts or abscesses (3x more common) with no overwhelming predisposing factors. Majority are polymicrobial but could be gonorrhea/chlamydia in origin.

Management

• Conservative MGMT = Sitz baths if <2cm and pt not immunocompromised
• Gold standard for management is I&D plus drainage device placement (Word catheter vs Loop)
• Word catheter highlights: Keep the cut small! 5mm, instill with approx. 3cc saline, tuck stalk into vagina for comfort
• Loop Drain highlights: Vessel loops or wrist loop of a sterile glove in resource poor environment, 2 incisions made at opposite ends of abscess, 2nd incision made with clamp tip as a marker internally, clamp exits 2nd incision and grasps loop material, pull through and tie ends together. Avoid excess tension that would cause pressure necrosis.
• Aftercare: Guard Word catheter from excess manipulation. Slide loop drain back and forth 2x per day. Sitz baths encouraged.
• Antibiotics IF: -Recurrent Bartholin abscess, Extensive surrounding cellulitis, pregnancy, immunocompromised, Culture-positive MRSA, Signs of systemic infection (eg, fever, chills).
• Antibiotic regimen - 1st line = trimethoprim-sulfamethoxazole DS tablet BID x 7days. Second line = Augmentin + clindamycin, 2nd or 3rd gen cephalosporin or fluoroquinolone, PLUS clinda or doxy.

Follow up

• Goal is to allow for tract formation, Word catheter recommendation is 4-6 weeks and Loop Drain has same time course or wound recheck at 3 weeks.

Vaginal Foreign Bodies

• If you don’t keep it on your differential, you will miss it! Keep in mind in both adult and pediatric populations, can be common in mentally handicapped children.
• Suspect when in cases of foul smelling vaginal discharge +/- vaginal bleeding, recurrent UTIs or vaginitis presentations, premenarchal vaginal bleeding
• More common objects: Adults – tampons, condoms; Pediatrics – toilet paper, toys, safety pins, pencil, crayons, erasers, coins.  
• Diagnosis via direct visualization, plain film, transvaginal vs. transperineal US, vaginography, MRI.
• Treatment is removal
• In pediatrics you can try:

- Examine external genitalia (knees to chest) and remove any obvious partially inserted objects
- Instill saline, irrigate
- Pediatric speculum or nasal speculum
- May require general anesthesia

**Do not forget potential sexual abuse in either population**

• Know when to consult GYN. Complications such as rectovaginal, rectovesicular fistulas CAN occur.

I. Bifascicular Block and Second Degree AV Block

1. In asymptomatic individuals, chronic bifascicular block in itself does not usually require cardiac work-up; the prognosis is generally benign
2. The following high-risk features, however, warrant urgent evaluation:
   

• Bifascicular block and syncope
  
• Bifascicular block and intermittent second degree AV block
  
• 1:1 AV conduction at slower sinus rates but higher grade block (i.e., 2:1 AV block) at faster sinus rates (“acceleration-dependent AV block”)
  

     3. Your role in the evaluation and management of patients with bifascicular block:

• Actively search for nonconducted P waves in the 12-lead ECG
  
• Also search for nonconducted P waves (second-degree AV block) in telemetry strips
  
• In patients with bifascicular block who develop acceleration-dependent AV block with a very slow ventricular rate, carotid massage or IV beta blocker, by decreasing the sinus rate, can paradoxically restore 1:1 AV conduction; IV atropine, on the other hand, can increase the degree of block
  
• Patients with bifascicular block and syncope require admission and cardiology consultation for possible pacemaker implantation
  
• Patients with bifascicular block with intermittent second degree AV block require admission and cardiology consultation for possible pacemaker implantation
  

II. Second Degree AV Block with Narrow QRS complexes
           · The block is located within the AV node or the His bundle
           · The vast majority is in the AV node and is usually benign
           · Type I AV block (Wenckebach periodicity) confirms AV nodal block
           · Even if the AV block appears to be type II, it is most likely localized within the AV node and is usually benign (“pseudo-type II AV block”)

• Confirm pseudo-type II block by demonstrating that the block occurred simultaneously with an abrupt deceleration of the sinus rate
• Pseudo-type II AV block occurs in autonomic dysfunction, sleep apnea, obesity-hypoventilation, coughing spells, suctioning, vomiting etc.
  

          · 1:1 conduction at slower sinus rates but 2:1 block at faster atrial rates (i.e., acceleration-dependent block) strongly suggests the block to be at the level of the His bundle rather than the AV node

• Implantation of a permanent pacemaker is usually indicated
  

 

Bleeding AV Fistulas

• AV Fistula vs. AV Graft
  • Fistula
    • Surgically connect artery to vein
    • Goal is to increase flow and pressure into the vein for access
    • About 2-3 months to mature for use
  • Graft
    • Foreign body
    • Tubing connects artery to vein
    • Only 2-3 weeks before able to access
    • Higher complication rate: thrombosis, infection
• Pink or white skin exposed in a Graft patient? Skin breakdown is a huge concern. Requires urgent evaluation.
• Uncontrolled bleeding? Hold pressure but with intention! Plug the source of bleeding directly. Wrapping with miles of Coban just diffuses the pressure elsewhere.
  • If you place a tourniquet, there may still be bleeding--likely venous ooze
  • Be wary of sutures--the dilated AV fistula gradually starts to fuse with skin. When you throw a suture, you may actually be insulting the VEIN itself
• Pseudoaneurysm vs. Aneurysm
  • Pseudoaneurysm: fibrous collection of blood that does not include all 3 vessel layers. Seen more commonly with grafts, likely from repeated cannulation
    • Can be diagnosed with ultrasound, also usually seen on physical exam
  • Aneurysm: Includes all 3 vessel layers. Unclear etiology. Likely from pressure.
• Hemorrhagic shock? Put the triple lumen down. Fluids are more quickly administered using LARGE diameter SHORT catheters. Peripheral IVs are just as fast, if not faster, than a large Cordis when administered with high pressure. (Poiseuille's law)

 
Agitated Delirium

• IM Ketamine works for agitated delirium and there is now evidence to suggest this. This can be administered IV and IM. IV dosing is 1-2mg/kg and IM dosing 4-6 mg/kg. Remember, you can’t “over-dissociate” someone, be confident in dosing.
• Concerns for respiratory depression with over sedation? Watch your end tidal CO2 and don’t hesitate to use nasopharyngeal airway.
• Do not talk yourself out of a lumbar puncture. If this is unattainable, at least give the patient the antibiotics necessary to cover for meningitis / encephalitis.
• Agitated patient? Unlikely to be traumatic brain or central nervous process (outside of infection). You will need the head CT but understand that these pathologies more likely to cause somnolence and depressed mental status.
• Watch out for your staff. Demanding IV access in the restrained patients with 5 security guards in the room is a safety risk. Use your IM medications instead and then place IV later.

 
Drugs and Considerations

• Lorazepam -- GABA agonist, slow onset, longer peak action, poor onset IM. Be wary of stacking Lorazepam doses because the peak action of about 20 minutes can seem like an eternity.
• Midazolam -- GABA agonist, fast onset, short peak of action, works well IM. You can generally bag a patient through midazolam over sedation with the anticipation it will wear off quickly. Be wary of synergism in EtOH intoxicated patient.
• Haloperidol/Ziprasidone -- dopamine receptor antagonist, rarely an immediate effect. QT prolongation, NMS and dystonic reactions to be considered. Hot patient with clonus or dystonia?--probably want to avoid.
• Dexmedetomidine -- alpha2 agonist, respiratory depression is rare, great for alcohol withdrawal. Be wary of hypotension/bradycardia--this is essentially IV clonidine