Rosen & Barkin's 5-Minute Emergency Medicine Consult (518 page)

• Hemodynamic instability, and pelvic hemorrhage to the ICU
  
• Type B or C pelvic fracture
  
• Acetabular fracture
  
• Other related injuries (e.g., genitourinary, intra-abdominal, neurologic)
  
• Intractable pain
  

Type A pelvic fracture; hemodynamically stable with no evidence of other injuries

Close follow-up should be ensured for discharged patients.

Discharged patients should be referred to an orthopedist for follow-up.

• Pelvic fractures can be a marker for high-energy traumatic mechanism and injury:
  
  • Assess for underlying abdominal/pelvic injuries including GI, genitourinary, vascular, and neurologic injuries
    
• In addition to initial resuscitation, immobilization and stabilization of the pelvis should be considered for unstable or open fractures or where hemorrhage is suspected
  
• Determination of diagnostic/therapeutic pathways including CT with or without angiography, selective IR angiography, and surgery are dictated by the patient’s hemodynamic status, suspected underlying injuries, and type of pelvic fractures
  
• All patients with Malgaigne fractures should be admitted with consultation by trauma and orthopedic services
  

• American College of Surgeons, Committee on Trauma.
  Advanced Trauma Life Support for Doctors
  , 9th ed. Chicago, IL: American College of Surgeons; 2012.
  
• Flint T, Cryer H. Pelvic Fracture: The Last 50 Years.
  J Trauma
  . 2010;69:483–488.
  
• Geeraerts T, Chhor V, Cheisson G, et al. Clinical review: Initial management of blunt pelvic trauma in patients with haemodynamic instability.
  Crit Care
  . 2007;11:204.
  
• Hak DJ, Smith WR, Suzuki T. Management of hemorrhage in life-threatening pelvic fracture.
  J Am Acad Orthop Surg.
  2009;17:447–457.
  
• Rice PL Jr, Rudolph M. Pelvic fractures.
  Emerg Med Clin North Am
  . 2007;25:795–802.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Hemorrhagic Shock
  
• Hip Injury
  

CODES

• 808.8 Closed unspecified fracture of pelvis
  
• 808.41 Closed fracture of ilium
  
• 808.42 Closed fracture of ischium
  

BASICS

• Pelvic inflammatory disease (PID) is an acute, community-acquired, sexually transmitted infection of the upper genital tract, including the uterus, fallopian tubes, ovaries, or adjacent structures
  
• Most frequent gynecologic cause for ED visits (350,000 per year)
  
• Represents a spectrum of infection:
  
  • No single diagnostic gold standard
    
  • Requires low clinical threshold for considering the diagnosis and starting empiric antibiotic therapy
    
• Progressive disease can lead to tubo-ovarian abscess (TOA)
  
• Fitz-Hugh–Curtis syndrome is a capsular inflammation of the liver associated with PID:
  
  • Sharp right upper quadrant abdominal pain
    
  • Worse with inspiration, movement, or coughing
    

• Risk factors:
  
  • Age <25 yr
    
  • Multiple or symptomatic sexual partners
    
  • Previous episode of PID
    
  • Nonbarrier contraception
    
  • Oral contraception
    
  • African American ethnicity
    
• Most common causes of PID are
  Chlamydia trachomatis
  and
  Neisseria gonorrhea
  
• Other organisms include groups A and B streptococci, staphylococci, gram-negative rods (commonly
  Klebsiella
  spp.,
  Escherichia coli
  , and
  Proteus
  spp.), and anaerobes
  

DIAGNOSIS

• Lower abdominal pain, usually bilateral
  
• Vaginal discharge
  
• Abnormal uterine bleeding
  
• Dysmenorrhea
  
• Dysuria
  
• Dyspareunia
  
• Nausea and vomiting
  
• Fever and chills
  
• Proctitis
  
• Lower abdominal tenderness
  
• Decreased bowel sounds
  
• Bilateral adnexal tenderness
  
• Cervical motion tenderness
  
• Purulent endocervical discharge
  
• Adnexal mass or fullness
  
• Right upper quadrant tenderness
  

• Lower abdominal pain is the most common symptom in PID, ranging from subtle to severe pain
  
• Abdominal pain that worsens during intercourse or onset of pain shortly after or during menses is suggestive of PID
  
• Abdominal pain is usually bilateral and usually present for ≤2 wk
  
• New vaginal discharge, urethritis, fever, and chills are common symptoms but are neither sensitive nor specific for the diagnosis
  

PID is rare during pregnancy, but if present usually occurs during the 1st trimester before hormonal changes such as mucus plug formation can protect the uterus from ascending bacteria.

• Only 50% of patients with PID have fever
  
• Abdominal exam reveals diffuse tenderness worse in the lower quadrants, usually but not always symmetric
  
• Rebound tenderness and decreased bowel sounds are commonly found
  
• Right upper quadrant tenderness is suggestive of perihepatitis (Fitz-Hugh–Curtis syndrome) in the setting of PID
  
• Pelvic exam can reveal a purulent endocervical discharge, cervical motion tenderness, or adnexal tenderness
  
• If uterine or adnexal tenderness is not prominent, one must consider other diagnoses
  

• History and physical exam including pelvic exam
  
• Pregnancy test to rule out ectopic pregnancy or complications of an intrauterine pregnancy
  
• Cervical culture for
  N. gonorrhea
  and
  C. trachomatis
  
• Minimum criteria for clinical diagnosis:
  
  • Lower abdominal tenderness
    or
    
  • Uterine/adnexal tenderness
    or
    
  • Cervical motion tenderness
    
• Supportive criteria for diagnosis:
  
  • Fever >38.3°C (101°F)
    
  • Abnormal cervical/vaginal discharge
    
  • Intracellular gram-negative diplococci on endocervical Gram stain
    
  • Leukocytosis >10,000/mm
    ³
    
  • Elevated erythrocyte sedimentation rate (ESR) or C-reactive protein
    
  • WBCs or bacteria in peritoneal fluid obtained by culdocentesis or laparoscopy
    

• CBC
  
• Gram stain of endocervix
  
• Urine polymerase chain reaction tests for
  Chlamydia
  and
  Gonococcus
  
• Microscopic exam of vaginal discharge in saline
  
• Liver enzymes may be elevated in Fitz-Hugh–Curtis syndrome
  
• Positive urinalysis or occult blood in stool decreases the probability of PID
  
• ESR or C-reactive protein may be elevated, but not routinely recommended
  

• Patients with adnexal fullness or an adnexal mass on exam should have a transvaginal US to exclude TOA
  
• Consider obtaining a pelvic US in patients who use an intrauterine device, fail outpatient antibiotic therapy for PID, or who have inadequate pelvic exams due to pain or obesity
  

Laparoscopy may be useful in confirming PID in a patient with a high suspicion of competing diagnosis or who failed outpatient treatment for PID

• Ectopic pregnancy (must be excluded with a pregnancy test in any woman suspected of having PID)
  
• Acute appendicitis
  
• Adnexal torsion
  
• Endometriosis
  
• Cystitis
  
• Urolithiasis
  
• Ovarian tumor
  
• Adenomyosis uteri
  
• Chronic pelvic pain
  
• Benign ovarian cyst
  
• Diverticulitis
  
• Inflammatory bowel disease
  
• Mesenteric vascular disease
  
• Irritable bowel syndrome
  

TREATMENT