February 2014 Regional Training Day – Author Cerys Griffiths
Summary of key points only. This is intended to supplement your own work on these curriculum items and not provide a complete evidence base on which to change your practice. All drug choices and dosing calculations should be checked with external resources.
SARC Sexual Assault Referral Centres
In short, these are available and are a valuable resource for patients we see who have been victims of sexual assault and rape. Local access and details vary, so please familiarise yourself with your local SARC referral process. The facilities are set up in such a way to make the experience of evidence gathering as tolerable as possible, so we can provide such assurances to our patients.
College guidance: Management-of-patients-who-attend-EDs-after-sexual-assault
Sexually Transmitted Infections and HIV
This was an excellent session with some interesting pictures, as this summary will hopefully be an aide memoir rather that any attempt to reproduce the presentation.
Genital herpes: Aciclovir 200mg 5 times daily for 5 days. Recommend Instillagel for topical use to minimise discomfort. Urinary retention is very rare but if it should occur then suprapubic rather than urethral catheter is the most appropriate intervention.
Young males with dysuria: think chlamydia unless proven otherwise. Treatment of choice is doxycycline 100mg bd for 7 days.
Syphilis: Classically painless chancre. More common in MSM. Treatment is with benzathine penicillin 2.4megaunits stat.
HIV: HIV testing is improving in speed and accuracy. There is a finger-prick test that gives a result in 60seconds, with 100% NPV but with a small false positive rate. Excellent treatment now for HIV, note BHIVA guidelines 2008. We talked about the missed HIV cases that must present to our ED’s and the need for a high index of suspicion and the importance of consent for testing. Note College of Emergency Medicine (CEM) document on this: HIV-Testing-in-the-ED
CD4 counts of <350 are treated, those with CD4 count <200 start to have opportunistic infections.
CD4 counts are only required 1-2 times each year, at £50 each test – not a routine ED investigation.
PCP (or Jiroveci): Treated with 21 days of co-trimoxazole. If patients are hypoxic (PaO2 < 9.3) give prednisolone 40mg od or equivalent.
This was another excellent presentation, some of the key points I jotted down – but again is not intended to replace the learning experience on the day, or further SDL.
Paraphimosis: “Press and push” is what I have written down. This will sort it out I’m sure, or maybe “squeeze slowly, and push with both thumbs”. BMJ Best Practice link
Balanitis: Often due to irritant dermatitis or candida. Treat with imidazole and hydrocortisone.
Priapism: Classified as high flow (non-ischaemic, painless, semi-rigid) or low flow (rigid and painful). Low flow cases require emergency treatment and drainage within 12 hours or erectile dysfunction will result. In the ED we should provide analgesia and hydration (especially in sickle-crisis, with oxygen), and try exercise (we were advised to try to get the patient to run up the stairs) and application of ice. Click on this Link for a the explanation of ischaemic versus non ischaemic priapism: A Most Discombobulating Gas
Penile fracture: “Aubergine penis”, flaccid and painful. Often give a history of hearing a “snap” and being then unable to maintain erection. Beware urethral injury. All go to theatre. The differential diagnosis is injury to the superficial dorsal vein, there will be no snap and less pain – but let the urologists decide this.
Scrotal haematoma: If they can void and if you can palpate the testicle then they can go home. If there is a haematocele or you are unsure then refer to urology as they will need USS to exclude testicular rupture.
Fournier’s gangrene: Treat as severe sepsis, very sick patients. Will require surgical debridement ASAP. Here is a review article from 2006
Torsion: Pain, hydrocele, oedema. Is rapid onset and causes rapid destruction of testicle. All <18years go to theatre, most <25 are explored. If in doubt, refer to urology. There is no reliable investigation in the opinion of our consultant today.
Torsion of testicular appendage: Boys aged 8-11years typically with unilateral testicular pain. In 20% you might see the “blue-dot” sign, a visible nodule at the upper pole of the testis. These mandate urology review because of the possibility of torsion.
Epididymitis: Should be able to feel a normal cord. Testes do not need imaging if palpably normal. Treat with 2 weeks of antibiotics. If there is a hydrocele then an USS is required to exclude abscess or tumour; discus with urology.
Idiopathic scrotal oedema: Boys aged 5-6 years old – if the testes feel normal then they are discharged home.
Emergency Medicine Updates have provided nice summaries on lots of the above conditions, these can be found here
Asthma, COPD, pneumothorax OSCE stations. Teach BIPAP use and CXR interpretation to a medical student.