Contraccezione di emergenza: levonorgestrel vs ulipristal

  L’Organizzazione Mondiale della Sanità così definisce la contraccezione di emergenza:  “Metodi di supporto per emergenze contraccettive che le donne possono usare entro i primi giorni dopo un rapporto non protetto, per prevenire una gravidanza indesiderata. I contraccettivi di emergenza non sono adatti ad un uso regolare” [1]. Per la definizione stessa di emergenza il […]

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Boring Question: How useful are bowel sounds?

This month we launch the first post in a new series entitled “Boring Questions”.  This column will focus on reviewing key literature around common questions that might be asked during a shift.  – Teresa Chan (Managing Editor)

Clinical Scenario:

A 60-year-old female presented to the emergency department with a 24 hour history of lower abdominal pain. The pain had increased in intensity over the past day and was 7/10 on presentation. She has been nauseated for the past 12 hours with no episodes of emesis. She was not sure when her last bowel movement was and she also described feeling bloated. Her only previous surgery was an appendectomy (1980).  She had no urinary complaints and had not been sexually active in the past year. She denied eating any food out of the ordinary for her.

On physical examination her vitals were:

Temp: 37.5, HR: of 80,  RR: 16,  BP: 132/82, O2: 98% on room air.

She was moving in bed with the seeming discomfort. Her abdomen appeared distended with no surgical scars. She did not have any rebound tenderness or guarding to palpation. She was in mild discomfort with pain to palpation of both the left and right lower quadrant. Her digital rectal examination did not reveal any occult blood per rectum (usefulness of this test to be reviewed at a later date).

The Boring Question:

How useful are bowel sounds for a patient with abdominal pain and potential small bowel obstruction?

Background:

Auscultation of the abdomen  to evaluate motility and mechanical properties of the bowels is a well-established part of the physical examination but its clinical value has been understudied (1). Historically it has been taught that decreased bowel sounds may suggest ileus, mesenteric infarct or narcotic use while hyperactive bowel sounds, might suggest small bowel obstruction (SBO) (2).

Search Strategy:   

Using PubMed, two separate searches were performed. These were:

  1.  ‘Bowel Auscultation’ AND ‘Abdominal Pain’
  2. ‘Bowel Sounds’ AND ‘Abdominal Pain’.

The resulting abstracts were screened with relevant articles reviewed. In addition to the literature, the textbooks ‘Tintinalli’s Emergency Medicine’ and ‘Evidence-Based Physical Diagnosis’ were also reviewed.

The Evidence:

  • Evidence-Based Physical Examination reviews data that suggests that 40% of SBO patients have hyperactive bowel sounds, while 25% have diminished/absent bowel sounds (4). From this, the author surmises that  35% of patients with SBO have normal bowel sounds which gives a -LR of SBO of 0.4.  This is a moderate likelihood ratio that could be helpful as a diagnostic test but the author also admits that determining whether bowel sounds are hyperactive, normal or hypoactive is not objective and there are many associated variables including quadrants, time since last meal, normal bowel function etc.
  • A more recent investigation by Felder et al. in 2014 prospectively recorded bowel sounds from patients with normal gastrointestinal motility and small bowel obstruction, diagnosed by CT scan and confirmed in the operating room (1). The positive predictive value for auscultation in normal versus cases of small bowel obstruction was found to be 23% (CT diagnosed) and 28% (OR diagnosed) (1).
  • Similarly, a study by Bohner et al. in Germany assessed 1254 patients (3). This study found that increased bowel sounds had a  sensitivity of 39.6% and specificity of 88.6% (+LR 3.5) for the detection of bowel obstruction. (3). But the same group of patients, decreased bowel sounds also had a positive predictive value was 11.2% (3). It is important to note issues with this investigation which include a broad age group from 9 to 97 years with no demographic analysis (3).

Bottom Line:

There is little literature on this physical exam technique the available evidence suggests that bowel sounds are not an objective or reliable method to assess patients for small bowel obstruction.

References

1. Felder S, Margel D, Murrell Z, Fleshner P. (2014) Usefulness of Bowel Sound Auscultation: A Prospective Evaluation. Journal of Surgical Education In Press . Link

2. Tintinalli’s Emergency Medicine-A Comprehensive Study Guide (2011). New York. McGraw Hill Companies Inc. Link

3. Lamont C. (2011). Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 4. How useful are bowel sounds. Emerg Med J. 28 (4): 336. Link

4. McGee S. (2007). Auscultation of the Abdomen. In Evidence-Based Physical Diagnosis (588-593). Philadelphia: Saunders Elsevier. Link

Reviewed by Eve Purdy (Student Editor), and Teresa Chan MD FRCPC (Managing Editor)

Author information

Jatin Kaicker
Jatin Kaicker
Jatin Kaicker is a Family Medicine resident at McMaster University.

The post Boring Question: How useful are bowel sounds? appeared first on BoringEM and was written by Jatin Kaicker.

What are these devices? Answer…

Question earlier this week:  “There are two devices entering the mediastinal structures from below…what are they?”

IABP 2

iabp-2

There are a bunch of devices on this radiograph.  Here they are by color:

1.  Orange arrow:  A Swan-Ganz catheter coming up from the femoral vein

2.  Red arrow:  Intra-aortic balloon pump coming up from the femoral artery

3.  Green arrow:  External monitor cables extending to the various monitor points on the patient externally

4.  Blue arrow: Dialysis catheter coming from the right internal jugular vein

Admittedly, this is not your usual ED-based radiograph.  This patient was presented with a STEMI and in cardiogenic shock.  This was a radiograph obtained later in the cardiac ICU after coronary intervention.  The Swan-Ganz catheter is unclear if it is in proper position (pulmonary artery).  Usually Swan-Ganz catheters (AKA pulmonary artery catheters) are placed from the superior circulation and loop into the pulmonary artery.  This was placed under fluoroscopy while performing a coronary artery intervention in the cath lab; I’m not sure where the tip is located based on this radiograph.

Author:  Russell Jones, MD


Filed under: Chest XR, Devices, Non-Trauma, XR Tagged: Swan-Ganz

Flexor Tenosynovitis

Tenosynovitis = inflammation of a tendon and its sheath.  Most acute cases of flexor tenosynovitis (FT) are infectious but may also be secondary to inflammation from noninfectious cause (e.g. diabetes, overuse, arthritis)

Infectious tenosynovitis

May be result of trauma with direct inoculation (eg, laceration, puncture or bite), contiguous spread from infected adjacent soft tissues, or hematogenous spread. The most common pathogens in the setting of trauma are skin flora (eg, Staphylococcus aureus and streptococci). Pathogens associated with hematogenous spread include N. gonorrhoeae and mycobacteria.

Physical examination reveals Kanavel signs of flexor tendon sheath infection:

  • Finger held in slight flexion
  • Fusiform swelling
  • Tenderness along the flexor tendon sheath
  • Pain with passive extension of the digit

Clinical features of gonococcal tenosynovitis include:

  • Erythema, tenderness to palpation, and painful range of motion (ROM) of the involved tendon(s)
  • Fever – A common sign
  • Dermatitis – Also a common sign; it occurs in approximately two thirds of disseminated gonococcal infections; it is characterized by hemorrhagic macules or papules on the distal extremities or trunk

Inflammatory flexor tenosynovitis

  • Usually the result of an underlying disease process
  • Presentation is indolent but progressive if therapy is not initiated
  • Similar findings to those found in infectious FT eventually present
  • Swelling is the most common initial finding
  • Hallmark is a difference in active, versus passive, flexion
  • As the tissue expands and impingement occurs, pain and restricted motion ensue

Diagnosis

Diagnosis of tenosynovitis is confirmed by microbiological and histopathological evaluation: culture of the suppurative synovial fluid, diagnostic arthrocentesis is indicated if joint effusion is present (may have septic arthritis also, especially with gonococcal infection).

Management

Surgical intervention and antibiotic therapy.  Generally, early infection should be managed with tendon sheath irrigation and drainage, with or without debridement. Advanced infection should be managed with debridement of the tendon sheaths and surrounding necrotic tissue.

In certain circumstances, an acute presentation within the first 24 hours of infection development may initially be medically managed.  Prompt improvement of symptoms and physical findings must follow within 12 hours; otherwise, surgical intervention is necessary.