Intimate Partner Violence

Every 6 days a woman is killed at the hands of her partner. Victims of intimate partner violence and domestic violence that we see in the ED typically involve an abuse story of repeated escalating violence over time that ends up in a crisis situation.

Universal Screening for Intimate Partner Violence

Start with a normalizing statement

“Because violence is so common in many women’s lives and because there’s help available for women being abused, I now ask every patient about domestic violence.”

The Partner Violence Screen

  1. Have you been hit, kicked, slapped, punched or otherwise hurt by someone in the past year?
  2. Do you feel safe in your current relationship?
  3. Is there a partner from a previous relationship who is making you feel unsafe now?

 

Renal colic mimics

 

  • Some mimics of renal colic that may arrive at the ED include: upper UTI’s, ectopic pregnancies, ovarian torsion, adnexal masses, testicular torsion, acute aortic syndromes, renal artery aneurysms, renal infarction, splenic infarction, bowel obstruction, diverticulitis, appendicitis, biliary colic, cholecystitis, acute intestinal ischemia, pneumonia, pulmonary embolism, retroperitoneal hematoma, iliopsoas abscess.
  • Focused history and physical exam are paramount due to the multitude of structures in the area and potentially dangerous conditions that may mimic renal colic.
  • Flank pain and hematuria are the hallmarks of renal colic, however, the presentation is variable.
  • Diagnosis can be confirmed with CT scan, which will show most other potential items in the differential if the scan is negative for a stone.

 

Non-Traumatic Monocular Vision Loss

There are multitude of causes of vision loss. This post focuses on the following pathologies:

  • Glaucoma – A group of diseases that have increased intraocular pressure (IOP), causing damage the optic nerve leading to decreased vision
  • Giant Cell Arteritis
  • Vitreous Detachment – Separation between the posterior vitreous cortex and the internal limiting membrane (ILM) of the retina (which is the most external portion of the retina).
  • Retinal Detachment
  • Central Retinal Vein Occlusion
  • Central Retinal Artery Occlusion
  • Amaurosis Fugax – Sudden and transient visual loss or transient blurring or obscuration of vision, with a normal recovery of vision after the episode.

 

Dermatological Emergencies

Key concepts

  • You have to be able to describe the lesion(s) to diagnosis and manage it
  • Key steps: accurate history, physical examination, including lesions and distribution, and appropriate diagnostic tests.
  • Incision and drainage may be adequate therapy for simple abscesses**.
  • Tinea capitis requires 4 to 8 weeks of systemic antifungal treatment.
  • Onychomycosis requires long-term systemic treatment.
  • Newer nonsedating antihistamines are a useful alternative to older sedating ones to control pruritus and histamine-mediated rashes while allowing the patient to remain active.
  • Scabies infestations should be diagnosed clinically and treated expeditiously even without definitive proof of the infestation.
  • Medication reactions are common and may results from any medication, typically within 4 to 21 days after taking the medication.
  • Rashes that are associated with mucosal lesions, blisters, or desquamating skin are often caused by significant soft tissue infections, drug eruptions, or immune disorders.
  • Patients with Stevens-Johnson syndrome (<10% TBSA) and toxic epidermal necrolysis require inpatient treatment, preferably in a burn unit.
  • Cutaneous signs of systemic disease may include pruritus, urticaria, erythema multiforme, erythema nodosum, pyoderma gangrenosum, and others.
  • Physicians should be familiar with one or two topical steroid preparations of low, medium, and high potency and their appropriate therapeutic use.
    • Hydrocortisone 0.1% lotion – low/mid
    • Hydrocortisone valerate 0.2% ointment – mid
    • Betamethasone dipropionate 0.05% cream – high (more potent than beta.val)
  • Life-threatening conditions at risk for dehydration and infection require inpatient treatment – the rest should be managed as outpatients!

 

Hyperglycemic Hyperosmolar Syndrome

  • HHS is defined by hyperglycemia and hyperosmolarity due to volume depletion with resultant altered mental status
  • Profound hypokalemia is common as a result of osmotic diuresis. Replete aggressively
  • Hypokalemia = hypomagnesemia. Replete both of these electrolytes simultaneously
  • Fluid repletion is the key point in management but careful repletion is vital as patients may not tolerate aggressive administration
  • All patients should have an exhaustive investigation of the cause of their decompensation. Look for signs of infection, ischemia, trauma etc.

 

What does the law say about emergency medical treatment in Kenya?

  • Medical institutions that fail to provide health care services necessary to prevent and manage the damaging health effects due to an emergency situation are culpable.
  • Facilities that have systems that are inappropriately designed and invariably cause a patient deserving of emergency medical treatment not to receive such treatment, are also culpable.
  • Hospitals that prioritize monetary security prior to admission can also be held in violation of the Constitution as well as the Kenya National Patients’ Rights Charter.
  • The liability of the government arises from its duties as stipulated in the Constitution as well as sections 15 and 112 of the Health Act. Where the government thus fails to enact policies; mobilize financial resources, regulate, train and accredit emergency care providers or ensure compliance with already existing guidelines by medical institutions, then it is liable in law. This, must, of course, be done in consultation with county governments and other stakeholders in the health sector acknowledging that health is now a devolved function.

 

Slipped Capital Femoral Epiphysis (SCFE)

  • Image bilaterally as SCFE is often bilateral even in the absence of bilateral symptoms 
  • Patients may present with isolated knee or thigh pain without any hip pain, which can lead to delayed diagnosis and worse outcomes
  • More than 50% of SCFEs can be missed when the chief complaint is knee pain. Always range the hip and note the presence or absence of pain in patients presenting with knee pain
  • SCFE is usually seen in adolescent, obese patients. However, it can also be seen in tall, thin patients who have recently undergone a recent growth spurt