Rosen & Barkin's 5-Minute Emergency Medicine Consult (730 page)

• Definitive treatment is often surgical.
  
• Prompt stabilization, early recognition of the need for operative intervention, and appropriate trauma surgical consultation are paramount.
  

Dictated by need for specific interventions

Intraosseous lines are an alternative to IV lines for fluids and medications. Lack of rib cervical spine fractures does not exclude spinal cord injury

FOLLOW-UP

• Most major trauma patients should be admitted for observation, monitoring, and further evaluation.
  
• Patients with significant injuries or hemodynamic instability should be admitted to an ICU.
  
• Patients requiring frequent assessments should be admitted to a monitored setting.
  

Patients with minor trauma and negative objective workup/imaging may be observed in the ED for several hours and then discharged.

The main indications for referral concern the availability of subspecialists, such as neurosurgeons, orthopedists/hand surgeons, otolaryngologists, plastic surgeons, or intensivists.

Follow-up should be driven by the types of injuries and subspecialty care required.

• The ABCs of trauma remain the standard approach to guide the initial assessment and treatment of trauma patients.
  
• A high level of suspicion for occult injuries should be maintained, with a low threshold for obtaining objective imaging.
  
• Trauma systems are defined by an organized approach to accessing quality trauma and subspecialty care.
  

• Committee on Trauma, American College of Surgeons.
  Resources for Optimal care of the Injured Patient
  . St. Louis, MO: Mosby; 2006.
  
• Gin Shaw SL, Jordan RC. Multiple traumas. In: Marx J, ed.
  Rosen’s Emergency Medicine: Concepts and Clinical Practice
  . 5th ed. St. Louis, MO: Mosby; 2002:242–255.
  
• Krantz BE. Initial assessment. In: Feliciano DV, ed.
  Trauma
  . Stamford, CT: Appleton & Lange; 1996:123.
  

See Also (Topic, Algorithm, Electronic Media Element)

Specific Anatomic Injuries, Shock, Airway Management.

CODES

• 952.9 Unspecified site of spinal cord injury without evidence of spinal bone injury
  
• 959.01 Head injury, unspecified
  
• 959.8 Other specified sites, including multiple injury
  

BASICS

• Sexually transmitted disease (STD)
  
• Associated with high prevalence of other STDs
  
• Causes urogenital infections
  
• Sequelae:
  
  • May cause premature rupture of membranes or preterm labor in pregnancy
    
  • May cause low-birth-weight newborns
    
  • May facilitate transmission of HIV
    
• Prevalence:
  
  • 3–5 million cases per year in US
    
  • 35% of women treated in STD clinics
    
  • Overall prevalence 3.1%:
    
    • Prevalence in black women 13.3%
      
• Incubation 4–28 days
  
• May be asymptomatic
  

Trichomonas vaginalis:

• Flagellated protozoan:
  
  • Commonly found in urethra, bladder, and Skene gland
    

DIAGNOSIS

• Vaginitis:
  
  • Vaginal discharge is seen in <30% of patients
    
    • Frothy yellow/green to gray/white
      
  • Vulvar itching and irritation
    
  • Vaginal odor
    
  • Symptoms same as with bacterial vaginosis (caused by Gardnerella vaginalis) and vulvovaginal candidiasis (caused by Candida albicans)
    
  • Dysuria and urinary urgency
    
  • Painful sexual intercourse
    
  • Often asymptomatic (50%)
    
• Cervix:
  
  • Diffuse erythema (10–33%)
    
  • Punctate hemorrhage—colpitis macularis or strawberry cervix (2%)
    
• Abdominal pain uncommon
  

• Often asymptomatic (75%) or self-limited
  
• Male to male transmission is uncommon
  
• Nongonococcal urethritis:
  
  • 20% of nonspecific urethritis
    
  • Scant discharge
    
  • Dysuria and urinary urgency
    
• Complications:
  
  • Prostatitis
    
  • Epididymitis
    
  • Reversible sterility
    

• Female:
  
  • Vaginal discharge:
    
    • Frothy yellow/green to gray/white
      
  • Odor
    
  • Red ulcerations—vaginal wall and cervix
    
• Male:
  
  • Scant discharge
    

• Treat empirically if high enough clinical suspicion
  
• Females: Wet mount (“Hanging-drop”):
  
  • 60–70% sensitive in symptomatic patients
    
  • Saline wet mount from cervical/vaginal vault smear:
    
    • Requires immediate evaluation of slide
      
    • Many polymorphonuclear leukocytes (PMNs)
      
    • Motile, pear-shaped, flagellated trichomonads (slightly larger than leukocytes; seen in 60%)
      
    • Specimen from spun urine less sensitive
      
  • Absence of trichomonads does not rule out T. vaginalis infection (only present in 60–70%)
    
  • Many EDs not equipped to perform wet mount
    
• Elevated vaginal pH (>4.5) common:
  
  • Not specific
    
• Males: Wet mount insensitive
  
  • PCR reliable but not widely available
    

• Culture:
  
  • 95% sensitivity:
    
    • Prostate massage before collection increases sensitivity in males.
      
  • Do culture when trichomonads suspected but not confirmed by wet-mount microscopy
    
• Point-of-care tests:
  
  • High specificity (>97%) but variable sensitivities
    
• Polymerase chain reaction (PCR):
  
  • Expensive
    

• UTI
  
• Gonorrhea
  
• Chlamydia
  
• Bacterial vaginosis
  
• Candidal vaginitis
  
• Nonspecific vaginitis
  

TREATMENT

• Female:
  
  • Metronidazole 2 g PO once:
    
    • 90–95% cure rate
      
  • Metronidazole 250 mg PO TID for 7 days (urethritis)
    
  • Tinidazole 2 g PO once:
    
    • 86–100% cure rate
      
  • Metronidazole gel, less effective:
    
    • Not recommended
      
• Pregnant:
  
  • Symptomatic:
    
    • Metronidazole (FDA category B)
      
  • Asymptomatic:
    
    • Treatment is controversial as it does not reduce incidence of premature rupture of membranes or preterm delivery
      
    • Metronidazole
      
• Males (urethritis):
  
  • Metronidazole 2 g PO once
    
  • Tinidazole 2 g PO once
    
  • Metronidazole 250 mg PO TID for 7 days
    
• HIV positive
  
  • Consider 7-day course of treatment because of evidence of increased single dose treatment failure
    
• Treat sex partners to prevent reinfection
  
  • No sexual intercourse until both partners are asymptomatic and until after at least 1 wk after treatment completed
    
• Advise using latex condoms
  
• Avoid concomitant alcohol use with metronidazole:
  
  • No alcohol for 24 hr after last metronidazole as it precipitates Antabuse reaction