Rosen & Barkin's 5-Minute Emergency Medicine Consult (47 page)

No need for admission unless concern for ectopic pregnancy

Discharge with appropriate referral.

Referral to gynecology

Gynecology follow-up is recommended.

• Pregnancy is the most relevant etiology of amenorrhea in the emergency department.
  
  • Urine pregnancy test (UPT) may give false negative with low urine specific gravity.
    
  • UPT sensitivity for β-HCG level may vary depending on type/manufacturer. High concern for amenorrhea due to pregnancy, specifically an ectopic, may warrant a qualitative serum pregnancy test
    
• Anorexia nervosa is an important consideration in patients with amenorrhea, particularly in adolescents.
  

• Heiman DL. Amenorrhea.
  Prim Care Clin Office Pract
  . 2009;36:1–17.
  
• Lentz G, Lobo R, Gershenson D, et al.
  Comprehensive Gynecology
  , 6th ed. Philadelphia, PA: Mosby; 2012.
  
• Rosenberg HK. Sonography of the pelvis in patients with primary amenorrhea.
  Endocrinol Metab Clin N Am
  . 2009;38:739–760.
  
• Santoro N. Update in hyper- and hypogonadotropic amenorrhea.
  J Clin Endocrinol Metab.
  2011;96:3281–3288.
  

CODES

• 256.8 Other ovarian dysfunction
  
• 626.0 Absence of menstruation
  

BASICS

• Increased release of norepinephrine, dopamine, and serotonin
  
• Decreased catecholamine reuptake
  
• Direct effect on α- and β-adrenergic receptors
  

• Prescription drugs:
  
  • Amphetamine (Benzedrine)
    
  • Dextroamphetamine (Dexedrine)
    
  • Diethylpropion (Tenuate)
    
  • Fenfluramine (Pondimin)
    
  • Methamphetamine
    
  • Methylphenidate (Ritalin)
    
  • Phenmetrazine (Preludin)
    
  • Phentermine
    
• “Designer drugs”:
  
  • Variants of illegal parent drugs
    
  • Often synthesized in underground labs
    
  • “Crystal,” “Ice”:
    
    • Crystalline methamphetamine hydrochloride
      
    • Smoked, insufflated, or injected
      
    • Rapid onset; duration several hours
      
  • “Crank”
    
  • “Ecstasy” (3,4-methylenedioxymethamphetamine, MDMA, XTC, E):
    
    • Often used at dances and “rave” parties
      
    • Dehydration can lead to hyperthermia, hyponatremia, fatality
      
  • MDA (3,4,-methylenedioxyamphetamine)
    
  • Methcathinone (“cat,” “Jeff,” “mulka”):
    
    • Derivative of cathinone, found in the evergreen tree
      Catha edulis
      
    • Frequently synthesized in home labs
      
    • Does not show up on urine toxicology screens
      
  • Mephedrone
    
    • May be contained in “bath salts”
      

DIAGNOSIS

• CNS:
  
  • Agitation
    
  • Delirium
    
  • Hyperactivity
    
  • Tremors
    
  • Dizziness
    
  • Mydriasis
    
  • Headache
    
  • Choreoathetoid movements
    
  • Hyperreflexia
    
  • Cerebrovascular accident
    
  • Seizures and status epilepticus
    
  • Coma
    
• Psychiatric:
  
  • Euphoria
    
  • Increased aggressiveness
    
  • Anxiety
    
  • Hallucinations (visual, tactile)
    
  • Compulsive repetitive actions
    
• Cardiovascular:
  
  • Palpitations
    
  • Hypertensive crisis
    
  • Tachycardia or (reflex) bradycardia
    
  • Dysrhythmias (usually tachydysrhythmias)
    
  • Cardiovascular collapse
    
• Other:
  
  • Rhabdomyolysis
    
  • Myoglobinuria
    
  • Acute renal failure
    
  • Anorexia
    
  • Diaphoresis
    
  • Disseminated intravascular coagulation (DIC)
    

• Determine the type, amount, timing, and route of amphetamine exposure
  
• Assess for possible coingestions
  
• Evaluate for symptoms of end organ injury:
  
  • Chest pain
    
  • Shortness of breath
    
  • Headache, confusion, and vomiting
    

• Common findings include:
  
  • Agitation
    
  • Tachycardia
    
  • Diaphoresis
    
  • Mydriasis
    
• Severe intoxication characterized by:
  
  • Tachycardia
    
  • HTN
    
  • Hyperthermia
    
  • Agitated delirium
    
  • Seizures
    
  • Diaphoresis
    
• Hypotension and respiratory distress may precede cardiovascular collapse
  
• Evaluate for associated conditions:
  
  • Cellulitis and soft tissue infections
    
  • Diastolic cardiac murmurs or unequal pulses
    
  • Examine carefully for trauma
    
  • Pneumothorax from inhalation injury
    
  • Focal neurological deficits
    

• Vital signs:
  
  • Temperature >40°C:
    
    • Core temperature recording essential
      
    • Peripheral temperature may be cool
      
    • Indication for urgent cooling
      
    • Ominous prognostic sign
      
  • BP:
    
    • Severe hypertension can lead to cardiac and neurologic abnormalities.
      
    • Late in course, hypotension may supervene due to catecholamine depletion
      
• ECG:
  
  • Signs of cardiac ischemia
    
  • Ventricular tachydysrhythmias
    
  • Reflex bradycardia
    

• Urinalysis:
  
  • Blood
    
  • Myoglobin
    
• Electrolytes, BUN/creatinine, glucose:
  
  • Hypoglycemia may contribute to altered mental status.
    
  • Acidosis may accompany severe toxicity.
    
  • Rhabdomyolysis may cause renal failure.
    
  • Hyperkalemia—life-threatening consequence of acute renal failure
    
• Coagulation profile to monitor for potential DIC:
  
  • INR, PT, PTT, platelets
    
• Creatine phosphokinase (CPK):
  
  • Markedly elevated in rhabdomyolysis
    
• Urine toxicology screen:
  
  • For other toxins with similar effects (e.g., cocaine)
    
  • Some amphetamine-like substances (e.g., methcathinone) may not be detected.
    
• Aspirin and acetaminophen levels if suicide attempt is a possibility
  
• Arterial blood gas (ABG)
  

• Chest radiograph:
  
  • Adult respiratory distress syndrome
    
  • Noncardiogenic pulmonary edema
    
• Head CT for:
  
  • Significant headache
    
  • Altered mental status
    
  • Focal neurologic signs
    
  • For subarachnoid hemorrhage, intracerebral bleed
    

Lumbar puncture for:

• Suspected meningitis (headache, altered mental status, hyperpyrexia)
  
• Suspected subarachnoid hemorrhage and CT normal
  

• Sepsis
  
• Thyroid storm
  
• Serotonin syndrome
  
• Neuroleptic malignant syndrome
  
• Pheochromocytoma
  
• Subarachnoid hemorrhage
  
• Drugs that cause delirium:
  
  • Anticholinergics:
    
    • Belladonna alkaloids
      
    • Antihistamines
      
  • Tricyclic antidepressants
    
  • Cocaine
    
  • Ethanol withdrawal
    
  • Sedative/hypnotic withdrawal
    
  • Hallucinogens
    
  • Phencyclidine
    
• Drugs that cause HTN and tachycardia:
  
  • Sympathomimetics
    
  • Anticholinergics
    
  • Ethanol withdrawal
    
  • Phencyclidine
    
  • Caffeine
    
  • Phenylpropanolamine
    
  • Ephedrine
    
  • Monoamine oxidase inhibitors
    
  • Theophylline
    
  • Nicotine
    
• Drugs that cause seizures:
  
  • Carbon monoxide
    
  • Carbamazepine
    
  • Cyanide
    
  • Cocaine
    
  • Cholinergics (organophosphate insecticides)
    
  • Camphor
    
  • Chlorinated hydrocarbons
    
  • Ethanol withdrawal
    
  • Sedative/hypnotic withdrawal
    
  • Isoniazid
    
  • Theophylline
    
  • Hypoglycemics
    
  • Lead
    
  • Lithium
    
  • Local anesthetics
    
  • Anticholinergics
    
  • Phencyclidine
    
  • Phenothiazines
    
  • Phenytoin
    
  • Propoxyphene
    
  • Salicylates
    
  • Strychnine
    

TREATMENT