552 CHAPTER 12 Ear, nose and throat Epistaxis Nasal bleeding may be idiopathic or follow minor trauma (eg nose picking). When i t occurs in patients with hypertension and coagulation disorders hemorrhage can be severe w ith signi \201 cant mortality. Epistaxis may follow isolated nasal fracture and more major facial injury. Site of bleeding Most nasal bleeding is from the anterior nasal septum in o r close to Little \200\231s area. A few patients have posterior nasal bleeding, which may b e brisk. Equipment Direct visualization of the anterior nasal cavity is aided by a headlamp (eg battery-operated head torch), \201 ne soft suction catheter, and nasal speculum. Wea r goggles to avoid blood splashes in the eyes. Initial approach Associated facial injury As sess ABC (especially pulse and BP) and resuscitate as necessary. Treat hypovolaemia vigorou sly. No associated injury Check airway patency, pulse, and BP. Treat hypovolaemia aggressiv ely. Check coagulation status of patients on anticoagulants and treat appropriately ( b p.1 70). Sit the patient up and instruct them to compress the \202 eshy part of their nose be tween \201 nger and thumb for 10min. If this stops the bleeding, the patient may be disch arged after 30min observation. Continuing bleeding after pressure Adults Apply a cotton wool pledget soaked in 4 % lidocai ne with 1 in 1000 adrenaline. Then, with a headlamp and nasal speculum, try to identify the bleeding point. Treat small anterior bleeding points with cautious cautery by applying a s ilver nitrate stick for 10 \200\22315sec. Avoid excessive cautery and never cauterize both sides of the septum \200\224 this may cause septal necrosis. If cautery stops the bleeding , observe for 15min, and discharge with GP follow- up. Advise avoidance of snif \201 ng, p icking or blowing the nose meantime. Children Applying nasal antiseptic cream (eg Naseptin ) is as effective as cautery in stopping bleeding. The cream is relatively easy to apply . Continuing bleeding despite cautery Insert a nasal pack. A specialized compressed surgical sponge nasal tampon (eg Merocel or Rapid Rhino) is ideal: gently insert a lubricated tam pon (horizontally) and \200\230in \202 ate \200\231 with a 10mL syringe of saline. Altern atively, pack the nose in a traditional way with 1.25cm wide ribbon gauze soaked in oily pa ste (eg bismuth iodoform paraf \201 n paste). Once packing has stopped the bleeding, refer to ENT for admission: observation is advisable (especially in the elderly). The pack may d islodge and obstruct the airway. Continuing bleeding despite packing Refer to the ENT surge on. The bleeding site is likely to be posterior and can cause hypovolaemic shock. In this s ituation, insert 2 large bore venous cannulae, send blood for FBC, coagulation screen, cros s-matching, and commence an IVI. Posterior nasal bleeding usually responds to tamponade wit h a Foley catheter. Remove the nasal tampon and insert a lubricated, unin \202 ated Foley catheter through the bleeding nostril into the nasopharynx. In \202 ate the balloon with a ir and gently withdraw the catheter, thus tamponading the bleeding site. Secure the cathete r to the cheek with tape, and then re-insert the anterior nasal tampon. 553 NASAL FRACTURE Nasal fracture The prominent exposed position of the nose, combined with the delicacy of it s bones, render it relatively prone to injury. Remember that the nose is part of the head, so nose injury = head injury (and potentially c ervical spine injury also). History The nose is commonly broken by a direct blow (eg from a punch) or following a fall onto the face. Nasal fracture is usually accompanied by bleeding. Search for a history of a ssociated facial/head injury (diplopia, loss of consciousness, etc.). Examination This is a clinical diagnosis based upon a history of injury with nasal swelling and tenderness. Having made the diagnosis, assess whether there is nasal deviation: it is useful to ask the patient to look in a mirror. Check and record whether the patient can bre athe through each nostril. Look for an associated septal haematoma \200\224 this will appe ar as a smooth bulging swelling, which may obstruct the nasal passage. Children are at part icular risk of septal haematoma, which predisposes to secondary infection and septal necros is. Assess for additional injuries to the head or face (eg tender mandible, diplopia, tender ma xilla). Injury to the bridge of the nose may result in persistent epistaxis and/or cerebros pinal \202 uid rhinorrhoea. Investigation Do not X-ray to diagnose a nasal fracture \200\224 the diagnosis is a clinic al one. Obtain appropriate X-rays (eg orthopantomogram (OPG) or facial views) if there is c linical suspicion of other bony injuries. Nasal fractures are often apparent on facial X-ra ys or CT scans. Treatment \200 Resuscitate and treat for associated head injury. \200 Continuing nasal hemorrhage is uncommon \200\224 refer to an ENT surgeon to consider urgent manipulation un der anesthetic (MUA) to stop the bleeding: meanwhile, insert a nasal tampon. Refer urgently to an ENT surgeon if there is a septal haematoma \200\224 this will require incision and drainage in order to prevent septal necrosis. \200 Clean and close overlyin g skin wounds: steristrips often allow good skin apposition. If there is signi \201 cant c ontamination of the wound, start a course of prophylactic oral antibiotics (eg co-amoxiclav : one tablet PO tds for 5 days). Provide oral analgesia (eg ibuprofen 400mg PO tds). \200 If the nose is deviated/distorte d, or if there is too much swelling to judge, arrange for ENT follow-up at 5 \200\2237 days , so that MUA may be performed within 10 days. It is particularly important to ensure accur ate reduction of fractures in children. Discharge with head injury instructions to the care of a relative. 554 CHAPTER 12 Ear, nose and throat Sore throat Tonsillitis Causes Acute pharyngo-tonsillitis may result from infection with a variety of viruses or bacteria: \200 Viral: Epstein \200\223Barr virus (EBV), herpes simp lex virus, adenoviruses. \200 Bacterial: group A B-haemolytic streptococcus (most common bacterial cause), mycoplasma , Corynebacterium diphtheriae . Features Sore throat is frequently accompanied by fever, headache, and mild dysphagia. Insp ection of the tonsils reveals in \202 ammation \200\224 the presence of pus on the tonsil s suggests bacterial infection. Enlarged cervical lymph nodes are found in a variety of inf ections, but generalized lymphadenopathy (sometimes also with splenomegaly) is indicative o f glandular fever (infectious mononucleosis \200\224 see b p.241). Diagnosis Despite the clinical pointers described above, it is usually impossible to distin guish clinically bacterial from viral causes. Investigation Consider throat swabs and anti-streptolysin titre in severe cases. If glandul ar fever is suspected, send blood for FBC and Paul \200\223Bunnell (or Monospot) test. Treatment Unless contraindicated, give paracetamol (1g PO qds PRN) or ibuprofen (400mg PO t ds PRN) and discharge to GP. Although frequently prescribed, oral antibiotics are rarely of bene \201 t: a sensible approach is to limit their use for patients with any of the follo wing: a history of valvular heart disease, immunosupression, diabetes, marked systemic upse t, peritonsillar cellulitis, known B \200\223haemolytic streptococci. In this case, prescr ibe penicillin 500mg PO qds for 5 days (or clarithromycin 500mg PO bd for 5 days if allergi c). Avoid ampicillin, amoxicillin, and co-amoxiclav, which cause a rash in patients infecte d with EBV. Occasionally, patients with acute tonsillitis may be unable to swallow \202 uids (this is more commonly a feature of peritonsillar or retropharyngeal abscess). In this case, refer for IV antibiotics and IV \202 uids. Complications Otitis media, sinusitis, retropharyngeal abscess, peritonsillar abscess. Peritonsillar abscess (quinsy) Typically, preceded by a sore throat for several days, the d evelopment of a peritonsillar abscess is heralded by high fever, pain localized to one side of the throat, and pain on swallowing. Dif \201 culty swallowing can result in drooling. Trismus may make inspection dif \201 cult, but if visualized there is tense bulging tonsil , pushing the uvula away from the affected side. Group A B -haemolytic streptococci are fre quently implicated. Treatment Insert an IV cannula and give IV benzyl penicillin 1.2g (clar ithromycin 500mg if allergic to penicillin), and refer immediately to an ENT surgeon for as piration or formal drainage. 555 SORE THROAT Retropharyngeal abscess Spread of infection from adjacent lymph nodes may occasionally caus e a retropharyngeal abscess, particularly in children aged <3 years. It is characterized by a sore throat, dif \201 culty swallowing, fever, and dehydration. I n children, cough is typically absent from the history (unlike in croup and other viral cau ses of upper airway obstruction). There may be evidence of airway compromise (stridor, neck hyperextension, signs of hypoxia). The differential diagnosis includes acute epiglottitis ( b p.677). Lateral X-rays of the neck show soft tissue swelling (obtain these in the resus citation room, rather than moving the patient to the X-ray department). Treatment Get senior ED, ENT, and anesthetic help. If the patient is a child with evidence of respiratory distress, do not upset them further. Airway obstruction may be precipitated by examination of the throat, so avoid this until appropriate staff and equipment are ready to cope with airway problems. The child can sit on mum \200\231s knee in the resuscitation room. On suspicion of a retropharyngeal abscess in an adult, insert an IV cannula, take bl oods and blood cultures, give IV \202 uids and IV co-amoxiclav 1.2g, and refer immediatel y to an ENT surgeon. Pharyngeal burns after cocaine use Smoking cocaine can result in dangerous burns of the thr oat, since the drug acts as a local anesthetic. Swelling of the epiglottis may result in ai rway obstruction. Paranasal sinusitis Bacterial infection may result from direct spread from infected tooth r oots or (more usually) be secondary to viral upper respiratory tract infection (URTI). Clinical features \200 Clear nasal discharge becoming purulent. \200 Pain in (and often also tenderness over) the affected sinus. \200 Fever. \200 Headache and/or toothache. Management Provide analgesia. Despite a lack of convincing evidence, oral antibiotics (eg a moxicillin, doxycycline or erythromycin) and nasal decongestant (eg 1 % ephedrine) are comm only given. Advise GP follow-up. In severe cases, refer to ENT. 556 CHAPTER 12 Ear, nose and throat Facial nerve palsy The facial (VII) nerve supplies the muscles of facial expression. Clinic al examination reveals whether facial nerve palsy is of upper motor neuron or lower motor n euron type. Upper motor neuron paralysis is usually due to a stroke ( b p.144), resulting i n unilateral facial muscle weakness, but with sparing of the muscles of the forehead. If st roke is the cause, there may be additional evidence elsewhere (eg hemiparesis affecting the limbs). Lower motor neuron paralysis of the facial nerve results in weakness of the muscle s of one side of the face. The facial nerve arises from its nucleus in the pons, emerges fr om the pons to travel past the cerebello- pontine angle, through the petrous part of the te mporal bone, to emerge from the stylomastoid foramen and thence into the parotid gland, whe re it divides into branches. During its passage through the petrous temporal bone, the faci al nerve is accompanied by the chorda tympani (carrying taste \201 bres from the anterior 2/3 of one half of the tongue) and gives off the nerve to stapedius . Lesions of the facia l nerve in the temporal bone therefore produce loss of taste and hyperacusis (noise is dist orted and sounds loud) on the affected side. Causes of lower motor neuron facial palsy \200 Bell \200\231s palsy: the commonest cause (see below). \200 Pontine tumors and vascular events: usually associated with other signs . \200 Acoustic neuroma: usually with evidence of other nerve involvement (V, VI, VIII nerves) at the cerebello-pontine angle. Ramsay \200\223Hunt syndrome (herpes zoster infection \200\224 see below). \200 Trauma. \200 Middle ear infection and cholesteatoma (see b Earache, p.550). \200 Sarcoidosis. \200 Parotid gland tumors, trauma and infection. \200 Human immunode \201 ciency virus (HIV). Bell \200\231s palsy Bell \200\231s palsy is the commonest cause of sudden onset isolated l ower motor neuron facial nerve palsy. It is believed to result from viral infection, pro- d ucing swelling of the facial nerve within the temporal bone: there may be associated hypera cusis and loss of taste of the anterior two-thirds of one half of the tongue. The absence o f involvement of other cranial nerves is a reassuring feature, helping to secure this clini cal diagnosis. Treatment Most patients recover completely over several months without treat ment \200\224 a small percentage are left with permanent weakness. Recovery is quicker if prednisolone is started within 72hr of the onset of symptoms (prednisolone 60mg daily for 5 days, then 10mg less each day; total of 10 days of treatment). Antiviral drugs do not seem to be helpful. Advise the use of arti \201 cial tears and an eye patch at night, to preve nt corneal drying, and refer for ENT follow up. Ramsay \200\223Hunt syndrome This is due to herpes zoster infection of the geniculate gangl ion. Clinical features of Bell \200\231s palsy are present, together with (painful) herpeti c vesi- cles present in the external auditory meatus and occasionally also, the soft palate . Refer to an ENT specialist for aciclovir and follow up. 557 SALIVARY GLAND PROBLEMS Salivary gland problems Saliva is a mixture containing water, various ions, mucin, and amyl ase, pro- duced by the parotid, submandibular, and sublingual salivary glands. The problems most commonly affecting the salivary glands are infection and calculous disease. Acute bilateral parotitis Painful swelling of both parotid glands in children is most frequ ently due to mumps infection ( b p.222). In adults, painless bilateral parotid swelling may be due to Sj gren \200\231s syndrome, sarcoidosis, hypothyroidism, lymphoma, drugs (eg or al contraceptive). In each of these cases, there are often other features, which will help in diagnosis. Acute unilateral parotitis Painful unilateral parotid swelling may occur as part of mumps i nfection, but also in other circumstances (eg poor oral hygiene, post-operatively). Refer t o an ENT surgeon for admission and IV antibiotics. Chronic pain- less unilateral parotitis is often neoplastic (mostly benign) in origin. Calculous disease Mechanical obstruction of the \202 ow of saliva is most commonly due to salivary gland stones, affecting the submandibular gland. Obstruction may also occur from neoplasms or strictures. Features Blockage of a salivary duct causes pain and swelling of the affected gland on eati ng. Bimanual palpation of the \202 oor of the mouth may reveal a stone \200\224 occasion ally this may be visible intra-orally at the duct ori \201 ce. If there is superimposed in fection, it may be possible to express pus from the duct. Investigation Obtain X-rays of the \202 oor of the mouth. If the patient presses down wit h the tongue when the X-ray is taken the stone may be seen more easily below the mandible o n a lateral view or OPG. Treatment Refer to an oral or ENT surgeon. If an immediate consultation is not available, d iscuss the use of antibiotics in the meantime (these are often reserved for situations wher e there is evidence of salivary gland infection). 558 CHAPTER 12 Ear, nose and throat Dental emergencies: 1 Dental anatomy (Figs. 12.1 & 12.2) The primary teeth erupt between 6 months and 2 years \200\224 they are replaced by permanent teeth which \201 rst start to appear at (cid:124) 6 years (Table 12.1 ). There are 20 primary and 32 permanent teeth. Th e permanent teeth are made up of 4 quadrants of 8 teeth: right upper, left upper, right low er, left lower. Each quadrant comprises (from medial to lateral): central incisor, lateral incisor, canine, \201 rst premolar, second premolar, \201 rst molar, second molar, and third molar ( \200\230wisdom tooth \200\231). Permanent molars Second premolar (biscuspid) Wisdom tooth First premolar (biscuspid) Canine (cuspid) Lateral incisor Central incisor 3rd 2nd 1st Fig. 12.1 Dental anatomy: lower jaw lateral view. Central incisor Lateral incisor Canine (cuspid) First premolar (bicuspid) Second premolar ( bicuspid) Permanent molars Wisdom tooth Fig. 12.2 Dental anatomy: upper jaw \200\224 view from below. 559 DENTAL EMERGENCIES: 1 Table 12.1 Tooth eruption Deciduous Permanent Incisors 6 \200\22310 months 7 \200\2238 years Canine 16 \200\22320 months 11 years Premolars 11 \200\22313 years Molars 10 \200\22324 months 6 \200\22325 years 560 CHAPTER 12 Ear, nose and throat Dental emergencies: 2 Damaged teeth Chipped teeth and crowns which have become dislodged do not require immediate attention: redirect the patient instead to their dentist. Specialist \200\230sensitive teeth \200\231 toothpaste rubbed over the broken area of tooth may d pa in. Tooth fractures which involve the pulp present with a small area of bleeding and are exquis itely tender to the touch. Refer to the on-call dentist. Mobile teeth after trauma need to be stabilized as soon as possible \200\224 advise the pa tient to avoid manipulating the tooth and to refer to the dentist. Simple classi \201 cation of tooth fractures (a) (b) (c) (d) Fig. 12.3 Simple classi \201 cation of tooth fractures (a) enamel only; (b) enamel and den tine; (c) enamel, dentine, and pulp; and (d) root fracture. Avulsed teeth Missing teeth need to be accounted for (especially in the unconscious patient ) in order to exclude the possibility of aspiration. Obtain a postero-anterior (PA) and lat eral CXR to search for both the tooth and secondary problems, such as pulmonary collapse an d air trapping distal to the obstruction. Ensure that there is adequate tetanus prophylaxis . Avulsed permanent teeth brought to the ED may be suitable for re-implantation. Avulsed prim ary teeth are usually not suitable. A history of rheumatic fever, valvular heart disease, o r immunosuppressive treatment are contraindications to re-implantation. Milk is the best ea sily available transportation medium to advise a patient to bring a tooth in. The best chan ce of success lies with early re-implantation (within the \201 rst few hours). Handle the tooth as little as possible. Hold it by the crown to clean it gently with 0.9 % saline. Or ientate the tooth, and then replace it within the socket using \201 rm pressure (this may be easiest after LA \200\224 see Dental anesthesia b p.302). Refer immediately to the on- call dentist for stabilization and prophylactic antibiotics (eg clarithromycin). Ensure tet anus prophylaxis. 561 DENTAL EMERGENCIES: 2 Post-extraction problems Hemorrhage after tooth extraction may respond to simple measures. Ask the patient to bite on a rolled up piece of gauze placed over the socket for 10min. If this is unsuccessful, consider stopping the bleeding by inserting a horizontal mattress sut ure (eg using \200\230Vicryl \200\231), placed under LA using lidocaine with adrenaline (F ig. 12.4 ). If bleeding continues despite these measures, apply direct pressure, send a coa gulation screen and refer to the on-call dentist. Dry socket pain may follow tooth extraction (typically 3 \200\2238 days later) when bone is exposed in the empty socket. Gently irrigate the socket with warm saline. Prescribe oral a ntibiotics (eg penicillin or erythromycin) and analgesia and refer to the dentist. Fig. 12.4 Horizontal mattress suture in tooth socket. Dental infection Toothache without associated local or systemic symptoms/signs usually resp onds to analgesia (eg ibuprofen 400mg PO tds with food). Add antibi- otics (eg penicillin o r clarithromycin) if there is a suspicion of local infection. Advise follow-up with a denti st. Toothache with associated swelling, trismus, dysphagia, or systemic evidence of infection r equires immediate referral to a maxillofacial surgeon for IV antibiotics and surgical drain age. This page intentionally left blank 563 Chapter 13 Obstetrics and gynecology Gynecological problems Vaginal discharge Contraceptive problems Genital injury and assault Gynecological pain Vaginal bleeding The pregnant patient Emergency normal delivery Dif \201 culties in normal delivery Vaginal bleeding in pregnancy Spontaneous abortion Ectopic pregnancy Vaginal bleeding in later pregnancy Abdominal pain in pregnancy Medical complicat ions of pregnancy Trauma in pregnancy Cardiac arrest in pregnancy Post-partum problems 564 566 568 570 572 574 576 578 580 582 584 586 588 590 592 594 596 598 564 CHAPTER 13 Obstetrics and gynecology Gynecological problems The history For gynecological problems, always take a proper gynecol ogical history. This involves asking personal and sometimes sensitive questions so privacy and con \201 dentiality are of utmost importance. Interview the patient without other fami ly members being present: \200 Ask about the presenting problem. Always ask about abdomin al pain, dyspareunia, and vaginal discharge. Take a detailed menstrual history including the date of the last menstrual period, length of cycle, and description of the bleeding. Obtain a full obstetric history asking about children, pregnancies, miscarriages, terminations, and infertility treatment. Do not forget to ask about sexual activity, type and number of partners in past year. Also establish what form of contraception has been used. Has she ever been treated for a sexually transmitted disease (STD)? \200 When was the las t smear test and what was the result? Examination procedure Prior to performing a vaginal examination, explain the procedure to t he patient and ensure you are in a private room. Allow the patient privacy to undress. Wear ing gloves, examine the patient in an unhurried manner, in the presence of a chaperone, who might usefully \200\230guard \200\231 the door to prevent sudden inadvertent interruption . Use a chaperone even when the patient is being examined by female member of staff. Docume nt the name of the chaperone in the medical record. Full examination includes digital and s peculum vaginal examination to inspect the vagina and cervix, and taking swabs. This is fol lowed by digital bimanual palpation. In certain circumstances (eg patients with painful vul val ulcers), this may not be appropriate in the ED. Vaginal examination in young children m ay require GA and should be undertaken by an expert. Adopt a low threshold for referring su ch patients. 565 gynecological PROBLEMS Vulvovaginal pain Distinguish between dysuria, dyspareunia (pain on vaginal penetration), a nd constant vulvovaginal pain/irritation. The latter is often associated with infection or ulceration. Enquire about other symptoms (abdominal pain, vaginal discharge and bleeding). Vulval ulcers \200 Herpes simplex virus is sexually transmitted and usually due to type I I, but is increasingly due to type I virus (responsible for cold sores). Primary infection is extremely painful, lasting up to 3 weeks and sometimes causing urinary retention. Look f or shallow yellow vulvovaginal or perineal ulcers with red edges. Cervical ulcers may also be present, although pain may prevent speculum examination. Refer primary infections immedi ately for aciclovir, analgesia and to exclude co-existing infection. Recurrent infections a re less severe, but may last up to a week. Treat with topical and oral aciclovir (200mg \201 ve times a day for 1 week) and arrange genitourinary (GU) follow-up, with advice to av oid sexual contact meantime. Do not prescribe aciclovir in pregnancy, but arrange for an ob stetric opinion. Other sexually transmitted diseases may cause ulceration: syphilis (non-tender indurated ul cers ( \200\230chancres \200\231) and lymphadenopathy), chancroid, lymphogranuloma venereum , and granuloma inguinale ( b p.238). Refer to GU clinic and advise to abstain from sexual contact until treated. Squamous carcinoma causes indurated ulcers with everted edges especially in the elderly. Refer. Consider also : Beh et \200\231s syndrome (arthritis, iritis, genital/oral ulceration), tuberculosis (TB), Crohn \200\231s disease. Painful lumps \200 Bartholin \200\231s abscess : infection of vestibular (Bartholin \200 \231s) cyst/gland at the posterior part of the labium majus is usually due to Staph. , Stre p ., or E. coli , but may be due to N. gonorrhea . Refer for incision and drainage (under G A) and a full GU screen. Infected sebaceous cysts may also require incision and drainage. \200 Urethral carbuncle : this small, red, painful swelling at the external urethral meatus is due to urethral muco sal prolapse. It may cause dysuria. Refer to an appropriate clinic to consider excision or diathermy. Pruritis vulvae Vulval irritation may be caused by a generalized pruritic skin disorder (eg eczema), infection (particularly candidiasis) and other causes of vaginal discharge ( b p. 566), urinary incontinence, threadworms, and vulval warts. Genital warts (including condylo mata accuminata) are usually sexually transmitted and caused by human papillomavirus 6. Oth er STDs may coexist. Refer to GU clinic. 566 CHAPTER 13 Obstetrics and gynecology Vaginal discharge May be physiological or due to atrophic vaginitis, infections including S TDs, cervical and endometrial carcinoma, a variety of \201 stulae, and FBs. Physiological A creamy/white discharge is normal. Variation in its consistency and amount o ccurs with puberty, pregnancy, oral contraceptive pill (OCP) use, ovulation, and immediatel y prior to menstruation. Atrophic vaginitis A profuse, sometimes bloody, yellow discharge may result from vaginal ep ithelial thinning due to d estrogen levels associated with the meno- pause. This responds w ell to local topical or oral oestrogens, most appro- priately prescribed by the patient \200\231s GP. \200\230Thrush \200\231 Candida albicans is the commonest vaginal infection. A white disch arge accompanies a red painful vulvovaginitis. Occurs in pregnancy, after oral antibiotics, and with HIV and diabetes: check for glycosuria. Treatment options include clotrimazole pe ssaries, oral \202 uconazole, and topical application of live yogurt. Advise GP for follo w-up of any continuing symptoms. Other infections Refer patients suspected of the following STDs to GU clinic and advise abs tinence from sexual contact in the meantime: \200 Neisseria gonorrhea may be asymptomatic , cause urethritis (dysuria), cervicitis (vaginal discharge), or pelvic in \202 ammatory d isease (PID; b Gynecological pain, p.573). Trichomonas vaginalis infection results in a smelly profuse yellow discharge. Chlamydia trachomatis causes chronic cervicitis, Reiter \200\231s syndrome, and PID. It may be present asymptomatically. Gardnerella vaginalis produces a brown offensive discharge. Cervical and endometrial carcinoma Classically presenting with bleeding between periods, th ese may cause discharge. Refer to a gynecologist. Fistulae Colovaginal \201 stulae may follow diverticulitis or locally invasive colorectal carcinoma. Other \201 stulae (including vesicovaginal and ureterovaginal) may occur afte r pelvic surgery. Refer for admission and investigation. 567 VAGINAL DISCHARGE Foreign bodies Tampons, condoms, and various other items may be \200\230lost \200\231 or f orgotten about in the vagina. Removal with forceps under direct vision should cure the offe nsive vaginal discharge. If a condom has been removed, ascertain whether or not post-coital contraception is required ( b Contraceptive problems, p.568). Consider hepatitis B/HIV pro phylaxis and GU referral for STD screen, depending upon the circumstances. Vaginal tampons (particularly highly-absorbent ones which have been left in situ for many hours) are associ ated with \200\230toxic shock syndrome \200\231. Toxic shock syndrome Tampons used during menstruation have been implicated in many cases of the \200\230toxic shock syndrome \200\231. First described in 1978, it is caused by exo- toxin produced by Staph. aureus (usually TSS toxin 1), or occasionally, Strep . Multi-organ failure may follow. Features High fever, headache, vomiting, diarrhea, myalgia, altered conscious level, hypote nsion, and a widespread erythematous macular rash (with subsequent desquamation one week la ter, especially of palms and soles). Diagnosis Based upon clinical \201 ndings. Recent menstruation and the above features sho uld prompt suspicion. Investigation Includes vaginal examination. U&E, LFTs, clotting screen, FBC, blood lactate, blood and vaginal cultures, ECG, CXR. Treatment Manage the patient in the resuscitation room. If due to a tampon: remove it. Foll ow guidelines for severe sepsis ( b p.59). Obtain venous access, give intravenous antibioti cs and start crystalloid. If hypotension is refractory, consider measuring central venous p ressure, placing an arterial line, and starting inotropic support. The patient may require intensive care treatment. 568 CHAPTER 13 Obstetrics and gynecology Contraceptive problems Missed pill Advice will depend on the type of OCP the patient takes (combined, com- bined low dose estrogen, or progesterone only). However, as a general rule, if the combined pill is delayed for more than 12hr, the patient should be advised to take the forgotten pill and use barrier contraception for 7 days. If there are less than 7 days of pills left in the pack, she should run two packs together. The same applies if they have diarrhea. If the patient has had unprotected sexual intercourse and may require emergency con- traception, it is worth referring to the NHS website ( http://www.nhs.uk ), which give s speci \201 c advice for each type of pill. This provides comprehensive patient advice th at could also be printed and given to the patient. Post-coital contraception Women may attend the ED requesting post-coital contraception afte r: \200 Isolated unprotected sexual intercourse. \200 Burst or lost condom. \200 Miss ed OCP. \200 Complete or partial expulsion of intrauterine contraceptive device (IUCD). Rape. The risk of pregnancy following unprotected intercourse is greatest during 5 days aro und ovulation, but exists at other times also. Patients given post-coital contraception req uire assessment and treatment including counseling and follow-up: usually this will be with the GP and/or family planning clinic. Options include levonorgestrel and insertion of IUCD . Levonorgestrel must be given within 72hr of intercourse (95 % effective if taken <24hr, 5 8 % effective at 72hr). An IUCD must be inserted within 5 days of intercourse. Both levonor gestrel and IUCD act principally to render the endometrium hostile to implantation. Levonorgestrel (previously called \200\230the morning after pill \200\231) In the UK, phar macists can sell this without prescription to women aged over 16 years. It is usually the p referred option if patient presents within 72hr of unprotected intercourse. Exclude contrai ndications (acute porphyria, pregnancy, focal migraine), then give levonorgestrel 1.5mg (Le vonelle 1500) as soon as possible. Advise the patient to return if she vomits shortly af ter taking the medication: give a replacement dose if vomiting occurs within 3hr of taking it. Explain that there is a chance of failure. Arrange follow-up (usually with the GP) in 3 weeks to con \201 rm that menstruation has occurred. Advise alternative contraception (eg condoms) meantime and discuss future contraception plans. Advise also about the theoretica l risk of ectopic pregnancy: instruct her to return if she develops abdominal pain. Documen t that this advice has been given. Note: hormonal emergency contraception is less effective if the patient is already taking e nzyme-inducing drugs: take specialist advice. Options include an IUCD or i dose of levonorg estrel to 3mg (see BNF) . 569 CONTRACEPTIVE PROBLEMS IUCD This may be useful for patients unable to take the OCP (eg previous pul- monary embolu s), patients who wish to use IUCD long-term and for those presenting between 3 and 5 days a fter unprotected intercourse. Failure is very rare. Insertion is uncomfortable and requires appropriate training: refer to the gynecology team. Note that IUCD should not be used with a history of recent PID. Prescribing to patients on OCP Both progestogen-only oral contraceptives and (combined) OCP may fail if enzyme inducing drugs are prescribed. These include: rifampicin, rifab- utin, carbamazepine, phenytoin, topiramate, griseofulvin, phenobarbital, and primidone. Patients need alternative or additional contraception if these drugs are started. Rifampicin and rif abutin are such potent enzyme- inducing drugs that contraceptive precautions should continu e for at least 4 weeks, even after a short course of rifabutin or rifampicin (as used for p rophylaxis of meningococcal infection). Antibiotics and the OCP (refer to BNF) Broad spectrum antibiotics commonly prescribed in th e ED may inter- fere with estrogen absorption and cause contraceptive failure. Before presc ribing antibiotics to a female of childbearing age, ask whether she is taking the OCP. Advi se additional contraceptive precautions (eg condoms), whilst taking the antibiotics and for 7 days after. If these 7 days run beyond the end of a packet, start the next packet immedi ately without a break. Document in the notes that this advice has been given. 570 CHAPTER 13 Obstetrics and gynecology Genital injury and assault The history may be misleading. Combine a high index of suspicion with a full examination to exclude signi \201 cant injury. Blunt genital injury may result from falls astride. Most resultant vulval haematomas settle with rest and ice packs. Refer very large haematomas for evacuation in theater. Penetrating injury may follow assault, FB insertion, or migration/ perforation of an IUCD ( particularly during insertion). Abdominal pain associated with a vaginal wound may be due t o peritonitis. Obtain venous access, erect chest X-ray (for free gas), abdominal X-ray (for FB), group and save, give antibiotics, and refer. Refer other vaginal tears without perito nitis for exploration and repair. Rape and sexual assault Rape is de \201 ned in the UK as vulval penetration by the penis w ithout consent. Rape and other forms of sexual assault are believed to be grossly under-rep orted. Those who do report it have special requirements. Privacy is essential: ideally, a s pecially equipped room will be devoted to assess- ment of women who have been sexually assa ulted. Ensure that a female member of staff is present throughout. Documentation must be le gible and meticulous. An established protocol will allow prompt and thorough investigation and treatment. Usually, ED staff provide emergency treat- ment and resuscitation, but most of the other aspects, including collection of forensic evidence are dealed with by a forens ic physician (police surgeon), ideally in a specialized Sexual Assault Referral Center. Som etimes, women initially decline police involvement: full assessment and documentation may p rove useful if there is a change of mind. First exclude life-threatening or serious injuries. History Establish the type, date, time, and place of the assault. Ask what occurred (vagina l/anal penetration, oral sexual activity, other injuries). Ask about contraception use and enquire about LMP. Find out what is known about the assailant(s), and their risk of HIV and hepatitis B. In particular are they injecting drug users, do they originate from sub-Sahar an Africa, are they homosexual? Examination Look for evidence of vaginal, oral or anal injury (the forensic physician will take swabs). Record any other injuries, such as bites, bruising, or skin wounds (photograph s of non-genital injuries may be useful \200\224 taken by the police with the patient \200 \231s consent). Investigation Obtain written informed consent. The police will be keen to retain clothing, loose hairs, \201 ngernail clippings, and tampons for evidence. Similarly, the forensic p hysician will take appropriate swabs (vaginal, oral, anal). Perform a pregnancy test. Take and store blood for future DNA and viral testing. 571 GENITAL INJURY AND ASSAULT Treatment \200 Resuscitate as necessary. Refer urgently the 1 % of patients who have sig ni \201 cant genital injuries (eg vaginal tears) requiring surgical intervention. Consider the need for post-coital contraception (see b p.568). \200 If the patient is not immunized, give hepatitis B immunoglobulin and start an active immunization course. Assess the risk of HIV. If the assailant is known to have HIV or is from an at risk group, discuss the risk of disease transmission with the patient. Involve a local expert such as a virologist or infectious disease specialist prior to offering HIV prophylaxis ( b Needlest ick injury, p.418). Assess tetanus vaccine requirements. \200 Arrange follow-up to exclude STD. Consider anti biotic prophylaxis against STD if the patient is unlikely to attend follow-up: liaise with the GU team. Provide initial counseling and ensure a safe place to stay (a social worker may arrange this). Arrange future counseling. Inform the patient about independent local advice available (eg Rape Crisis Center). Ascertain from the patient if she wishes her GP to be informed. Telephone advice Women may telephone the ED for advice after being raped. Advise them to in form the police immediately, and then attend the police station or the ED. Discourage them from washing, changing clothes, using a toilet or brushing teeth before being examined. 572 CHAPTER 13 Obstetrics and gynecology Gynecological pain Gynecological disorders presenting to the ED with abdominal pain may be dif \201 cult to distinguish from other disorders. Obtain a full history of the pain: sudd en onset of severe colicky pain follows ovarian torsion and acute vascular events; more ins idious onset and continuous pain occur in infection and in \202 ammation. Radiation of the pain into the back or legs sug- gests gynecological origin. Other clues in the history inc lude co-existing symptoms of vaginal discharge, vaginal bleeding, or missed last menstrual period (LMP). Abdominal and pelvic pain in early pregnancy may be due to ectopic pregnancy or threatened abortion ( b p.584): both occur in patients who do not realize that they are pregnant or wh o deny the possibility of pregnancy due to embarrassment. Pain related to the menstrual cycle Consider \201 rst: could any associated vaginal bleed ing be from ectopic pregnancy or threatened abortion? Physiological dysmenorrhoea Pain regularly preceding menstruation and peaking on the \201 rst day of a period may be physiological. Suggest NSAID and refer to the GP.