Rosen & Barkin's 5-Minute Emergency Medicine Consult (21 page)

• RHO immunoglobulin in Rh-negative women:
  
  • 50
    μ
    g for women with threatened or complete abortion at <12 wk
    
  • 300
    μ
    g for women with threatened or complete abortion at ≥12 wk
    
• Patients need RhoGAM administration within 72 hr to prevent future isoimmunization
  
• Misoprostol 800 μg vaginally if medical management is chosen in consultation with OB/GYN
  
• Repeat dose required in 48 hr
  

Usually given in consultation with OB/GYN:

• Oxytocin: 20 IU in 1,000 mL of NS at a rate of 20 mIU/min titrated to decrease bleeding; may repeat for a max. dose of 40 mIU/min
  
• Methylergonovine: 0.2 mg IM/PO QID for bleeding
  

FOLLOW-UP

• Suspected unstable ectopic pregnancy (see “Ectopic Pregnancy”)
  
• Hemodynamically unstable patients with hypovolemia or anemia
  
• DIC
  
• Septic abortions
  
• Suspected gestational trophoblastic disease
  

• D&Cs can be done in the ED for incomplete and inevitable abortions, and patients may be discharged home if stable after 2–3 hr
  
• Some early inevitable miscarriages can be discharged to complete their miscarriages at home without a D&C
  
• Discharge with pain medications and close OB/GYN follow-up
  
• Patients with threatened abortions should be told to avoid strenuous activity
  
• Pelvic rest (i.e., “nothing in the vagina” during active bleeding; may increase risk of infection)
  
• Patients should be instructed to return to the ED for any increase in bleeding, dizziness, or temperature >100.4°F
  
• Patients and their partners should be counseled that early pregnancy loss is common and that it is not anyone’s fault
  

Patients with positive pregnancy tests and vaginal bleeding with or without abdominal pain should be followed by OB/GYN.

• Recognize the possibility of ectopic pregnancy
  
• Patients with spontaneous abortion may have clinically significant blood loss
  

• Huancahuari N. Emergencies in early pregnancy.
  Emerg Med Clin North Am
  . 2012;30:837–847.
  
• Martonffy AI, Rindfleisch K, Lozeau AM, et al. First trimester complications.
  Prim Care
  . 2012;39:71–82.
  
• Marx JA, Hockberger RS, Walls RM, et al.
  Rosen’s Emergency Medicine: Concepts and Clinical Practice
  . 7th ed. St. Louis, MO: Mosby; 2009.
  
• Prine LW, MacNaughton H. Office management of early pregnancy loss.
  Am Fam Physician
  . 2011;84:75–82.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Ectopic Pregnancy
  
• Vaginal Bleeding
  

CODES

• 634.90 Spontaneous abortion, without mention of complication, unspecified
  
• 634.91 Spontaneous abortion, without mention of complication, incomplete
  
• 634.92 Spontaneous abortion, without mention of complication, complete
  

BASICS

• A localized collection of pus surrounded and walled off by inflamed tissue. Abscesses can occur on any part of the body
  
• Furuncle:
  
  • Arises from infected hair follicle
    
  • Most common on back, axilla, and lower extremities
    
• Carbuncle:
  
  • Larger and more extensive than furuncle
    
• Dog/cat bite:
  
  • Usually polymicrobial
    
• Breast:
  
  • Puerperal:
    
    • Usually during lactation
      
    • Located in peripheral wedge
      
    • Usually staphylococci
      
  • Duct ectasia:
    
    • Caused by ecstatic ducts
      
    • Periareolar location
      
    • Usually polymicrobial
      
• Hidradenitis suppurativa:
  
  • Chronic abscess of apocrine sweat glands
    
  • Groin and scalp
    
  • Staphylococcus aureus
    and
    staphylococcus viridans
    are common
    
  • Escherichia coli
    and
    Proteus
    may be present in chronic disease
    
• Pilonidal abscess:
  
  • Epithelial disruption of gluteal fold over coccyx
    
  • Staphylococcal species are most common
    
  • May be polymicrobial
    
• Bartholin abscess:
  
  • Obstruction of Bartholin duct
    
• Perirectal abscess:
  
  • Originates in anal crypts and extends through ischiorectal space
    
  • Inflammatory bowel disease and diabetes are predisposing factors
    
  • Bacteroides fragilis
    and
    E. coli
    are most common
    
  • Requires operative drainage
    
• Muscle (pyomyositis):
  
  • Typically in the tropics
    
  • S. aureus
    is most common
    
• IV drug abuse:
  
  • Staphylococcal species are most common
    
  • MRSA is common
    
  • May be sterile
    
• Paronychia:
  
  • Infection around nail fold
    
  • Usually
    S. aureus
    
• Felon:
  
  • Closed space abscess in distal pulp of finger
    
  • Usually
    S. aureus
    

• Abscess formation typically occurs due to a break in the skin, obstruction of sebaceous or sweats glands, or inflammation of hair follicles. The collection may be classified as bacterial or sterile:
  
• Bacterial: Most abscesses are bacterial with the microbiology reflective of the microflora of the involved body part:
  
  • S. aureus
    is the most common causative organism
    
  • Community-acquired MRSA (CA-MRSA) common
    
• Sterile: More associated with IV drug abuse and injection of chemical irritants
  
• Risk factors for abscess formation:
  
  • Immunosuppression
    
  • Soft tissue trauma
    
  • Mammalian/human bites
    
  • Tissue ischemia
    
  • IV drug use
    
  • Chron's disease (perirectal)
    

DIAGNOSIS

• Local:
  
  • Erythema
    
  • Tenderness
    
  • Heat
    
  • Swelling
    
  • Fluctuance
    
  • May have surrounding cellulitis
    
  • Regional lymphadenopathy and lymphangitis may occur
    
• Systemic:
  
  • Often absent
    
  • Patients with extensive soft tissue involvement, necrotizing fasciitis, or underlying bacteremia may present with signs of sepsis including:
    
    • Fever
      
    • Rigors
      
    • Hypotension
      
    • Altered mentation
      

• Previous episodes: Raise concern for CA-MRSA
  
• Immunosuppression
  
• Medications:
  
  • Chronic steroids, chemotherapy
    
• IVDU
  
• History of mammalian bite
  

• Location and extent of infection
  
• Presence of:
  
  • Associated cellulitis
    
  • Subcutaneous air
    
  • Deep structure involvement
    
• Involvement of specialty area:
  
  • Perirectal
    
  • Hand
    
  • Face/neck
    

• History and physical exam
  
• Gram stain unnecessary for simple abscesses in healthy patients
  
• Wound cultures:
  
  • Not indicated in simple abscesses
    
  • May help guide therapy if systemic treatment is planned
    
  • May be useful in confirming CA-MRSA in patients with recurrent abscesses
    
  • May guide specific therapy in a compromised host, abscesses of the central face or hand, and treatment failures