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Volume 27 • Number 2
In This Issue
Lesson 3
The AHA Guidelines Including Pediatric Resuscitation . . . . . . Page 2
Lesson 4
Vaginal Bleeding in the Nonpregnant Patient . . . . . . . . . . Page 13
Cardiopulmonary resuscitation (CPR) is indicated for patients who are in pulmonary or cardiac
arrest. Key recommendations for provision of CPR have changed as more research elucidates
optimal interventions. This lesson summarizes changes in the American Heart Association’s
recommendations for CPR and advanced cardiovascular life support in pediatric patients.
Vaginal bleeding in nonpregnant patients has multiple causes and can result in significant
morbidity and mortality. Emergency physicians must be able to identify common and concerning
etiologies, determine appropriate dispositions and followup for most patients who do not require
admission, and perform emergent interventions in patients at risk for hemodynamic compromise.
Contributors
2 013
February
■Also in This Issue
∙∙ The LLSA Literature
Review / Page 11
∙∙ The Critical ECG
/ Page 23
∙∙ The Critical Image
/ Page 24
∙∙ CME Questions
/ Page 26
∙∙ The Drug Box / Page 28
■ Next Month
∙∙ HIV-Positive Patients
with Headache
∙∙ Rib Fractures and
Contusions
Sharon E. Mace, MD, FACEP, wrote “The American Heart Association Guidelines Including Pediatric
Resuscitation.” Dr. Mace is professor of medicine at the Cleveland Clinic Lerner College of Medicine, Case
Western Reserve University, director of the Observation Unit and director of Pediatric Education and Quality
Improvement at the Cleveland Clinic Foundation, and faculty for the MetroHealth Medical Center Emergency
Medicine Residency Program in Cleveland, Ohio.
George L. Sternbach, MD, FACEP, reviewed “The American Heart Association Guidelines Including Pediatric
Resuscitation.” Dr. Sternbach is a clinical professor of surgery at Stanford University Medical Center in Stanford,
California, and an emergency physician at Seton Medical Center in Daly City, California.
Lisa Freeman Grossheim, MD, FACEP, and Rachel Metz, MD, wrote “Vaginal Bleeding in Nonpregnant
Patients.” Dr. Grossheim is assistant professor of emergency medicine at the University of Texas Medical
School at Houston, in Houston, Texas. Dr. Metz is a resident in the Department of Emergency Medicine at the
University of Texas Medical School at Houston.
Lynn P. Roppolo, MD, FACEP, reviewed “Vaginal Bleeding in Nonpregnant Patients.” Dr. Roppolo is an
associate professor of emergency medicine and Associate Emergency Medicine Residency director at the
University of Texas Southwestern Medical Center at Dallas, in Dallas, Texas.
Frank LoVecchio, DO, MPH, FACEP, reviewed the questions for these lessons. Dr. LoVecchio is research
director at the Maricopa Medical Center Emergency Medicine Program and medical director of the Banner
Poison Control Center, Phoenix, Arizona, and a professor at Midwestern University/Arizona College of
Osteopathic Medicine in Glendale, Arizona.
Louis G. Graff IV, MD, FACEP, is Editor-in-Chief of Critical Decisions. Dr. Graff is professor of traumatology
and emergency medicine at the University of Connecticut School of Medicine in Farmington, Connecticut.
Contributor Disclosures. In accordance with the ACCME Standards for Commercial Support and policy of the American College of Emergency
Physicians, all individuals with control over CME content (including but not limited to staff, planners, reviewers, and authors) must disclose
whether or not they have any relevant financial relationship(s) to learners prior to the start of the activity. These individuals have indicated that
they have a relationship which, in the context of their involvement in the CME activity, could be perceived by some as a real or apparent conflict of
interest (eg, ownership of stock, grants, honoraria, or consulting fees), but these individuals do not consider that it will influence the CME activity.
Sharon E. Mace, MD, FACEP; Masimo, consulting fees; Gebauer, contracted research, non-CME services; Baxter, contracted research; Luitpold,
contracted research. Joshua S. Broder, MD, FACEP; GlaxoSmithKline; his wife is employed by GlaxoSmithKline as a research organic chemist. All
remaining individuals with control over CME content have no significant financial interests or relationships to disclose.
Method of Participation. This educational activity consists of two lessons with a posttest, evaluation questions, and a pretest; it should take
approximately 5 hours to complete. To complete this educational activity as designed, the participant should, in order, take the pretest (posted
online following the previous month’s posttest), review the learning objectives, read the lessons as published in the print or online version, and
then complete the online posttest and evaluation questions. Release date February 1, 2013. Expiration date January 31, 2016.
Accreditation Statement. The American College of Emergency Physicians is accredited by the Accreditation Council for Continuing Medical
Education to provide continuing medical education for physicians.
The American College of Emergency Physicians designates this enduring material for a maximum of 5 AMA PRA Category 1 Credits™. Physicians
should claim only the credit commensurate with the extent of their participation in the activity.
Each issue of Critical Decisions in Emergency Medicine is approved by ACEP for a maximum of 5 ACEP Category I credits. Approved by the AOA
for 5 Category 2-B credits. A minimum score of 75% is required.
Commercial Support. There was no commercial support for this CME activity.
Target Audience. This educational activity has been developed for emergency physicians.
Critical Decisions in Emergency Medicine
Lesson 3
The American Heart
Association Guidelines
Including Pediatric
Resuscitation
Sharon E. Mace, MD, FACEP, FAAP
■ Objectives
On completion of this lesson, you
should be able to:
1. List the correct sequence of steps
and explain the rationale for the
performance of cardiopulmonary
resuscitation according to the new
basic life support guidelines.
2. Describe the 2010 guidelines for
chest compressions and discuss how
they differ from the 2005 guidelines.
3. Explain the differences in airway and
breathing assessment in the 2010
guidelines compared to the previous
guidelines and the physiology and
research behind the changes.
4. Discuss the recommendations for
automated external defibrillator
use in infants and children and
explain the science behind the
recommendations.
5. State the recommended defibrillation
doses for infants and children and
why these dosages are suggested.
6. Describe the specific
recommendations (including
capnography, therapeutic
hyperthermia, avoiding hyperoxia) for
post-arrest care.
7. Explain the pharmacology
recommendations in the 2010
guidelines and how they differ from
the 2005 guidelines.
■From the EM Model
3.0 Cardiovascular Disorders
3.1Cardiopulmonary Arrest
2
There have been many changes in
the basic and advanced cardiovascular
life support recommendations with
the publication of the American
Heart Association guidelines in
November 2010. This lesson will deal
with pediatric basic and advanced
cardiovascular life support.
The “2010 American Heart
Association (AHA) Guidelines for
Cardiopulmonary Resuscitation
(CPR) and Emergency Cardiovascular
Care (ECC)”1,2 were published in
November 2010. They are the result of
a 5-year-long process that included an
exhaustive review of the resuscitation
literature conducted by international
experts in the science of resuscitation
and by members of the AHA ECC
Committee and Subcommittees.
This work culminated in the 2010
International Consensus Conference
on CPR and ECC Science with
Treatment Recommendations that
was held in Dallas, Texas, in February
2010. There were 356 resuscitation
experts from 29 countries who
evaluated, discussed, and debated
the resuscitation science research
and produced 411 scientific evidence
reviews of 277 topics in resuscitation
and ECC. The process also included a
rigorous disclosure and management
of potential conflicts of interest
process.
Case Presentations
■ Case One
EMS first responders arrive at the
home of a 2-month-old female infant
who is found unresponsive in her
crib. She was born at full term, had
no neonatal problems, has no known
medical illnesses, is on no medicines,
and has no allergies. There are no
signs of trauma. Her weight is 4 kg.
The EMT checks the infant
for responsiveness and breathing
and then asks the parent to go get
both of his partners (who are in
the ambulance) and to bring the
automated external defibrillator
(AED). The infant is not responsive
and is not breathing, so the
EMT begins chest compressions
immediately at a rate of about 100/
min, and at a depth of approximately
1½ inches (4 mm).
The EMT does chest compressions
for 2 minutes, while his partners
set up and administer supplemental
oxygen and insert an intravenous
line without interrupting the
compressions. The EMTs do not
have a manual defibrillator and their
AED does not have a pediatric dose
attenuator system, so they use the
available AED. The AED advises a
shock, so a shock is given.
After another 2 minutes of chest
compressions, the rhythm is checked
and it is a shockable rhythm, so
another shock is given by the AED.
CPR with chest compressions
is continued for 2 minutes and
intravenous epinephrine (0.01 mg/
kg × 4 kg = 0.04 mg) is given every 3
to 5 minutes. The next rhythm check
recommends a shock so this is done,
chest compressions are restarted,
and amiodarone (5 mg/kg × 4 kg =
20 mg IV) is given. After another 2
minutes of chest compressions, the
AED does not advise a shock and
February 2013 • Volume 27 • Number 2
Critical Decisions
• What is the sequence of steps in CPR
recommended in the 2010 guidelines?
• What are the current recommendations
with regard to airway and breathing?
• What are the 2010 AHA recommendations for
chest compressions in pediatric patients (eg,
depth, rate, and time to initiate compressions)?
• What dosages are acceptable for the defibrillation of
infants and children, and what is the shock sequence?
• What are the new recommendations for AED use in
infants and children?
the monitor indicates asystole. CPR
with chest compressions is resumed,
epinephrine is given every 3 to 5
minutes, and reversible causes of the
patient’s condition are considered
as the patient is transported to the
emergency department.
■ Case Two
A 6-year-old boy arrives with a
chief complaint of trouble breathing.
His past medical history is negative.
He is on no medicine and has no
allergies. He has had a “cold” with
a fever and a cough for several days.
He is cyanotic and has bilateral
rales greater on the right than on
the left, with intercostal retractions.
His weight is 35 kg. Vital signs are
pulse rate 160, respiratory rate 52,
temperature 39.7°C (103.5°F), and
oxygen saturation 81% on room air.
Because the child is cyanotic and
in respiratory distress, a decision is
made to intubate the child. During
the intubation, the nurse asks if she
should apply cricoid pressure. The
physician responds that he will opt
to do the intubation without using
cricoid pressure since the Sellick
maneuver is no longer mandatory,
and he will use a cuffed endotracheal
tube. Successful intubation is verified
by capnography. The physician asks
the respiratory therapist to titrate
the oxygen, keeping the patient’s
oxyhemoglobin saturation between
94% and 99% in order to avoid
hyperoxemia.
While awaiting admission to the
• How have the pharmacology recommendations
changed in the 2010 guidelines?
• What are the key considerations for pediatric
post-arrest or postresuscitation care?
pediatric ICU, the boy becomes
tachycardic with a heart rate of 200.
An ECG shows supraventricular
tachycardia (SVT). He is maintaining
his blood pressure and oxygen
saturation. A vagal maneuver is done,
but the heart rate is unchanged, so
adenosine at 0.1 mg/kg × 35 kg
(0.35 mg) is given intravenously.
There is no change in the heart rate,
so a second dose of adenosine at 0.2
mg/kg × 35 kg (0.7 mg) is given
intravenously. There is no change
in the heart rate; his blood pressure
drops to 50 systolic, and his pulse
is now thready, so synchronized
cardioversion at 1 J/kg × 35 kg (35 J)
is administered. The blood pressure
is 45 systolic, and the heart rate still
200, so synchronized cardioversion at
2 J/kg × 35 kg (70 J) is administered.
The heart rate decreases to 130, the
repeat blood pressure is 100/60, and
the ECG now shows sinus tachycardia
(Figure 1).
■ Case Three
A 3-year-old boy is brought in
by his family because he has been
unusually lethargic; they think
he may have taken an unknown
medicine. His past medical history
is negative. He has no allergies
and is not taking any prescription
medications. His weight is 25 kg.
An intravenous line is placed, and
the child is put on a monitor. He
is lethargic but has spontaneous
respirations with a normal oxygen
saturation.
Vital signs are blood pressure
55/40, heart rate 30, respiratory rate
14, and oxygen saturation 94% on
room air. The ECG shows complete
heart block. Chest compressions are
started, and epinephrine, 0.01 mg/
kg IV (0.25 mg) is given. After 2
minutes, the child is still bradycardic
with poor perfusion despite adequate
oxygenation and ventilation, so
atropine, 0.02 mg/kg IV (0.50 mg), is
administered. At 3 minutes after the
first dose of epinephrine, a second
dose of epinephrine, 0.01 mg/kg IV
(0.5 mg), is administered. Repeat
vital signs are blood pressure 90/60,
heart rate 85, respiratory rate 20, and
oxygen saturation 96% on room air.
He is admitted to the pediatric ICU
(Figure 2).
CRITICAL DECISION
What is the sequence of steps in
CPR recommended in the 2010
guidelines?
The major change in the sequence
of steps for cardiopulmonary
resuscitation (CPR) is from airway,
breathing, chest compressions
(A-B-C) to chest compressions,
airway, breathing (C-A-B).3 This
is based on the fact that although
ventilations are important during
resuscitation, the key parameter
in adult resuscitation (and by
extrapolation, pediatric resuscitation,
as well) is chest compressions. The
downside of the A-B-C sequence is
that compressions are often delayed
while the airway is opened and
3
Critical Decisions in Emergency Medicine
breaths are delivered. In the new
guidelines, anything that delays chest
compressions is to be avoided
(Table 1).
According to the old and new
sequence for cardiopulmonary
resuscitation, the first step remains a
check for responsiveness, followed by
step 2, a call for help and for an AED.
However, the check for breathing is
now incorporated into step 1, where
the patient is checked not only for
responsiveness but also for breathing.4
Previously, the check for breathing
was separate from the check for
responsiveness and occurred after
the airway was opened and before
chest compressions or A-B-C. The
Figure 1.
Pediatric tachycardia algorithm. From: Kleinman ME, Chameides L, Schexnayder SM, et al. Part 14: Pediatric advanced life
support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
Circulation. 2010;122:S888. Used with permission from the American Heart Association.
4
February 2013 • Volume 27 • Number 2
“look, listen, and feel for breathing”
has been removed from the sequence
for assessment of breathing after
opening the airway. Now, breathing
should be briefly checked for by
health care providers when checking
for responsiveness. The check for
breathing is incorporated into the
check for cardiac arrest. Again, taking
some extra time to specifically “look,
listen, and feel” takes time away from
chest compressions.
Although most pediatric cardiac
arrests are not from a sudden primary
cardiac arrest but are asphyxial
and from respiratory failure and/or
shock, the literature still supports
the necessity of both ventilations
Figure 2.
Pediatric bradycardia algorithm. From: Kleinman ME, Chameides L, Schexnayder SM, et al. Part 14: Pediatric advanced life
support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
Circulation. 2010;122:S887. Used with permission from the American Heart Association.
5
Critical Decisions in Emergency Medicine
and chest compressions for pediatric
CPR. It is also true that many rescuers
fail to begin CPR because they are
confused or unsure about CPR and
that pediatric cardiac arrests are
much less frequent than adult sudden
(primary) cardiac arrest. Since most
pediatric cardiac arrest victims fail
to receive any bystander CPR, any
process that increases the probability
of bystander CPR is likely to save
lives. With this background, adoption
of the C-A-B sequence for all ages
is hoped to increase the initiation
of bystander CPR and save lives.
Moreover, since it takes less than 18
seconds to deliver 30 compressions
with two-rescuer CPR, the maximum
theoretical delay in rescue breaths
would only be 18 seconds.
CRITICAL DECISION
What are the 2010 AHA
recommendations for chest
compressions in pediatric patients
(eg, depth, rate, and time to initiate
compressions)?
The emphasis in the 2010
guidelines is on high-quality
CPR with high-quality chest
compressions.1-3 The new mantra is
“push hard, push fast” and push as
soon as possible. With the focus on
effective chest compressions, there
are multiple changes in how chest
compressions should be done. First,
begin chest compressions as soon
as possible. Chest compressions
should be started within 10 seconds
of recognition of the arrest. Next,
push hard, and push fast. The new
compression depths are greater than
those previously recommended. The
new recommendations for depth of
chest compressions for children are at
least one-third the anterior-posterior
chest diameter or about 2 inches (5
cm); previous recommendations were
one-third to one-half the diameter
of the chest. For infants, the new
recommendation is at least one-third
the chest diameter or about 1½ inches
(4 cm); the previous guidelines were
one-third to one-half the diameter of
the chest.
The literature indicates that
pushing hard is needed in order to
achieve effective chest compressions
and that the suggested depth of chest
compressions is approximately 2
inches (5 cm) in most children and
1½ inches (4 cm) in most infants.
These deeper compressions are
necessary in order to generate the
pressures required to perfuse the
cerebral and coronary arteries.
The “push fast” mandate is
to ensure that each set of chest
compressions should take 18
seconds or less versus the previous
recommendation for completion of
chest compressions within 23 seconds
or less (Table 2). Faster compressions
are needed to deliver the pressures
required in order to perfuse the
cerebral and coronary arteries.
CRITICAL DECISION
What are the new recommendations
for AED use in infants and children?
In the new guidelines, an AED may
be used in infants (<1 year of age).3 A
manual defibrillator is preferred for
use in infants. However, if a manual
defibrillator is not available, then an
AED with a pediatric dose attenuator
is the second choice, and if this is
not available, then an AED without a
dose attenuator may be used, but this
is the third choice. In the previous
guidelines, there was insufficient data
to recommend for or against the use
of an AED in infants so this is a new
recommendation for infants (<1 year
of age). The 2010 recommendation
for AED use in children is the same
as the 2005 recommendation. For
children (ages 1 to 8 years), an AED
with a pediatric dose attenuator
should be used if available. However,
if one with a pediatric dose attenuator
is not available, then a standard AED
may be used.
No documented adverse effects
have been reported when AEDs with
Table 1.
Comparison of the sequence of steps in cardiopulmonary resuscitation between the 2010 and the 2005 guidelines
CPR sequence
CPR step 1
CPR step 2
CPR step 3
CPR step 4
CPR step 5
CPR step 6
Check for breathing
“Look, listen, feel”
Rescue breaths
Rescue breaths (after advanced
airway placed)
6
2010 Guidelines
C-A-B
(chest compressions-airway-breathing)
Check responsiveness and breathing
Call for help, get AED
Check pulse
Give compressions
Open airway, give 2 rescue breaths
Resume compressions
Incorporated into step 1, check for
responsiveness and breathing
Omit “look, listen, feel”
Each breath takes 1 second
1 breath every 6-8 seconds (8-10 breaths/min)
2005 Guidelines
A-B-C
(airway-breathing-chest compressions)
Check responsiveness
Call for help, get AED
Open airway, “look, listen, feel”
Give 2 breaths, check pulse
Give compressions
After airway is opened, check for
breathing
“Look, listen, feel” after opening the
airway
Each breath takes 1 second
February 2013 • Volume 27 • Number 2
fairly high energy doses were used
to successfully resuscitate infants in
cardiac arrest.
CRITICAL DECISION
What are the current
recommendations with regard to
airway and breathing?
As mentioned previously, airway
now takes a back seat to chest
compressions, which are first and
foremost.4,5 Chest compressions
occur before airway and breathing
in the steps of CPR (C-A-B). “Look,
listen, and feel” as a distinct or
separate check for breathing has
been eliminated with incorporation
of breathing into the check for
responsiveness as part of the new
guidelines (Table 1).
Cricoid pressure, the Sellick
maneuver, is no longer routine or
mandatory but, instead, is an option.
Aspiration can occur even when
cricoid pressure is used. It is difficult
to teach rescuers how to perform
the Sellick maneuver, and it is often
applied incorrectly even by trained
health care providers. Furthermore,
in some cases, cricoid pressure can
impede passage of an endotracheal
tube.6
Cuffed endotracheal tubes may be
used in infants and children.
The use of capnography/
capnometry is suggested for
confirmation of endotracheal tube
position and can be used during CPR
to evaluate and improve the quality of
chest compressions.4
chest compressions.
Although the optimal defibrillation
dose for pediatric patients is
unknown, there have been case
reports and animal studies suggesting
that higher doses can be successful
without any adverse effects.
CRITICAL DECISION
What dosages are acceptable for
the defibrillation of infants and
children, and what is the shock
sequence?
CRITICAL DECISION
How have the pharmacology
recommendations changed in the
2010 guidelines?
The new recommendations
allow the use of higher doses for
defibrillation of infants and children
for both the initial and subsequent
defibrillation.7 Under the 2010
recommendations it is acceptable to
use 2 to 4 J/kg for the initial energy
dose, whereas the 2005 guidelines
called for 2 J/kg for the first attempt
and 4 J/kg for subsequent attempts.
Currently, providers may consider
subsequent energy levels of at least 4
J/kg and higher energy levels, up to
but not exceeding 10 J/kg or the adult
maximum dose (Table 3).
In the 2005 guidelines three
shocks were to be given in rapid
sequence. The new guidelines
recommend that a single shock be
followed by 2 minutes of high-quality
Atropine is no longer
recommended for routine use in the
management of pulseless electrical
activity (PEA)/asystole and has been
deleted from the ACLS cardiac arrest
algorithm. In the 2005 guidelines,
atropine was included in the ACLS
pulseless arrest algorithm and could
be considered for asystole or slow
PEA. The literature indicates that
routine use of atropine during PEA
or asystole is unlikely to have a
therapeutic benefit.
Adenosine is now suggested
for the initial treatment of
stable, undifferentiated, regular,
monomorphic, wide complex
tachycardia, although it should not
be used if the pattern is irregular.
Previously, in the tachycardia
algorithm, adenosine was
Table 2.
Comparison of chest compression recommendations between the 2010 and the 2005 AHA guidelines
Initiation of compressions
Compression rate
Time to complete cycle of 30
compressions
Compression depth
Infants
Children
Adults
Compression-to-ventilation ratio
Chest recoil
2010 Guidelines
Compressions begun before ventilations
Begin compressions within 10 seconds of
recognition of arrest
At least 100/min (>100/min)
≤18 seconds
2005 Guidelines
Compressions begun after assessment
of airway/breathing and after
ventilations given
About 100/min (≈100/min)
≤23 seconds
At least (>) one-third diameter of chest ≈ 1.5
inches = 4 mm
At least (>) one-third diameter of chest ≈ 2
inches = 5 mm
At least (>) 2 inches = 5 mm
30:2 single rescuer of adults, children, infants
(excludes newly born)
Allow complete chest recoil after each
compression
Minimize interruptions in chest compressions
Avoid excess ventilation
One-third to one-half chest diameter
One-third to one-half chest diameter
1.5-2 inches
Same (no change)
7
Critical Decisions in Emergency Medicine
recommended only for suspected
regular narrow complex reentry
supraventricular tachycardia. The
data suggest that adenosine is
safe and may be effective in the
treatment of undifferentiated regular
monomorphic, wide-complex
tachycardia when the rhythm is
regular.
In adults with symptomatic and
unstable bradycardia, chronotropic
drug infusions can now be used as
Pearls
• The critical element in resuscitation is chest compressions not
ventilations, so compressions are done before ventilations.
• The recommended CPR sequence is now chest
compressions, airway, breathing.
• Higher energy doses (>4 J/kg and as high as 9 J/kg) have
provided effective defibrillation in children and animal models
of pediatric arrest with no significant adverse effects.
• The new definition of wide complex tachycardia is a QRS width
greater than 0.09 seconds (previous definition was 0.08 seconds).
• Post-arrest, avoid hyperoxia by titrating oxygen administration to
maintain arterial oxyhemoglobin saturation between 94% and 100%.
• Postresuscitation, therapeutic hypothermia may be useful in adolescents.
Pitfalls
• Failing to recognize that the A-B-C sequence delays compressions;
the C-A-B sequence is the new recommendation.
• Using too low a dose for pediatric defibrillation (initial 2-4 J/kg,
subsequent at least 4 J/kg, up to 10 J/kg or adult maximum dose).
• Assuming that cricoid pressure will prevent aspiration.
• Failing to recognize that cricoid pressure may impede
passage of an endotracheal tube in some patients.
• Administering calcium routinely for cardiopulmonary arrest.
an alternative to pacing, while in
the previous bradycardia algorithm,
chronotropic drug infusions were to
be used after atropine while awaiting
a pacer or if pacing was ineffective.
Regarding the routine use of
calcium, the previous guidelines
commented that calcium does not
improve the outcome of cardiac
arrest. The new guidelines are more
emphatic and state that “it (calcium) is
not recommended,” except in specific
circumstances, such as documented
hypocalcemia, hyperkalemia,
hypermagnesemia, and calcium
channel blocker overdose.6,7
The new guidelines suggest
limiting the use of etomidate in
pediatric patients with septic shock.
This is because of concern over
adrenal suppression that has been
reported even with one dose of
etomidate8 (Table 4).
CRITICAL DECISION
What are the key recommendations
for pediatric post-arrest or
postresuscitation care?
Continuous waveform
capnography is recommended to
confirm endotracheal tube position in
all settings throughout the peri-arrest
period and in adults can also be used
to monitor CPR quality and detect
return of spontaneous circulation
based on end-tidal carbon dioxide
values. Previously, an exhaled carbon
dioxide detector or an esophageal
Table 3.
Comparison of electrical therapy recommendations between the 2010 and the 2005 AHA guidelines
AED
AED use in infants (<1 yr of age)
Defibrillation
Defibrillation dose
Defibrillation sequence
8
2010 Guidelines
May use manual defibrillator; if this is not
available, may use AED with pediatric dose
attenuator; if this is not available then may use
AED without a dose attenuator
2005 Guidelines
Insufficient data to recommend for or
against AED in infants
2-4 J/kg for initial attempt, consider ≥4 J/kg for
subsequent up to maximum of 10 J/kg or adult
dose
One-shock protocol for VF
There is no “sequence” of shocks. A single shock
is followed by 2 minutes of high-quality chest
compressions
2 J/kg for initial attempt, 4 J/kg for
subsequent attempts
3-shock sequence for VF
3 shocks are administered in rapid
sequence
February 2013 • Volume 27 • Number 2
detector device was recommended to
confirm endotracheal tube placement.
Continuous waveform capnography
is the most reliable method of
confirming and monitoring correct
endotracheal tube placement.
For postresuscitation care, there
is a new recommendation: once
spontaneous circulation has been
restored, the inspired oxygen should
be titrated to maintain an arterial
oxyhemoglobin saturation between
94% and 100% in order to minimize
the risks of hyperoxemia. There
were no specific recommendations
for the titration of inspired oxygen
in the previous guidelines, although
the risk for reperfusion injury was
mentioned. The literature suggests
that hyperoxemia (ie, a high Pao2)
increases the oxidative injury seen
after ischemia-reperfusion that can
occur after resuscitation from cardiac
arrest.
For adolescents who remain
comatose after resuscitation from
sudden witnessed out-of-hospital
ventricular fibrillation cardiac
arrest, therapeutic hypothermia
(32oC to 34oC) can be beneficial and
may be considered for infants and
children who remain comatose after
resuscitation from cardiac arrest.
Although extensive pediatric data are
lacking, adult studies document a
benefit from therapeutic hypothermia
for comatose patients after cardiac
arrest.
The Science Behind the
Recommendations
The International Liaison
Committee on Resuscitation
(ILCOR) Evidence-Based Medicine
Process
What is the evidence-based
medicine behind the new guidelines
or what is the resuscitation science
underlying the new guidelines? As
mentioned previously, there is an
extensive process, over several years,
which culminated in the production
of worksheets, an international
conference, and eventually the new
recommendations. These worksheets
can be accessed online (http://circ.
ahajournals.org/content/122/16_
suppl_2/S606.full.pdf+html), and
the recommendations are published
simultaneously in the journals
Circulation and Resuscitation:
The Importance of the High
Quality Chest Compressions
Sequence of CPR (C-A-B vs.
A-B-C)
The emphasis on chest
compressions in the new guidelines
is based on multiple studies that
document that the key parameters
of basic life support are chest
compressions and early defibrillation.
This is based on the facts that the
overwhelming number of cardiac
arrests in adults and the highest
survival rates from cardiac arrest in
patients of all ages occurs in those
who have witnessed arrest with
an initial rhythm of ventricular
fibrillation or pulseless ventricular
tachycardia.
Case Resolution
■ Case One
On arrival in the emergency
department, paramedics are
continuing CPR with chest
compressions on the 2-month-old
girl who was found unresponsive
in her crib. After 2 minutes of CPR,
the infant has return of spontaneous
circulation. An endotracheal
Table 4.
Comparison of the pharmacology recommendations between the 2010 and the 2005 AHA guidelines
Calcium
Etomidate
Atropine
Lidocaine
Magnesium
Chronotropic drug infusion
Adenosine
Amiodarone or procainamide
2010 Guidelines
Not recommended except for hypocalcemia,
hyperkalemia, hypermagnesemia, calcium
channel blocker overdose
Consider limiting etomidate use in pediatric
patients with septic shock
Not recommended for routine use in PEA/
asystole (is used in bradycardia algorithm)
Not recommended for routine use for VF/
pulseless VT
Not recommended for routine use for VF/
pulseless VT
Can be used as alternative to pacing (instead
of after pacing) in symptomatic unstable
bradycardia
Can be used for narrow complex SVT, and for
undifferentiated regular monomorphic wide
complex tachycardia
Do not routinely use both drugs simultaneously,
seek consult when using in stable patients
2005 Guidelines
Does not improve outcome of cardiac
arrest
No recommendation
Can be used in PEA/asystole
Can be used for VF/pulseless VT
Can be used for VF/pulseless VT
Can be used after atropine and if
transcutaneous pacing fails
Can be used for narrow complex
tachycardia (SVT)
Can be used for narrow complex
tachycardia (SVT)
9
Critical Decisions in Emergency Medicine
tube (cuffed) is inserted, and
continuous waveform capnography
is applied confirming the successful
endotracheal intubation. She is
admitted to the pediatric ICU where
postresuscitation care guidelines are
followed. Her oxygen is titrated to
maintain an arterial oxyhemoglobin
saturation between 94% and 100% to
minimize the risks of hyperoxemia.
The pediatric intensivists consider
therapeutic hypothermia; however,
retinal hemorrhages are seen on
ophthalmoscopic examination,
and a computed tomography scan
of the brain indicates multiple
severe intracerebral hemorrhages. A
diagnosis of shaken-baby syndrome
is made, and the infant dies the next
day.
■ Case Two
The 6-year-old boy who presented
with difficulty breathing and became
tachycardic is given antibiotics and
admitted to the pediatric ICU with
a diagnosis of pneumonia. He is
discharged home 4 days later on oral
antibiotics.
■ Case Three
In the case of the 3-year-old with
the suspected drug ingestion, the
family brings in an empty bottle of
the grandmother’s heart medicine.
It is discovered that the child took
an overdose of a β-blocker. As the
effects of the overdose wear off, the
child becomes more responsive, and
both his heart rate and blood pressure
return to the normal range. He does
well and is discharged home 2 days
later.
Summary
Although there are many
changes in the “2010 American
Heart Association Guidelines for
Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care,”
the new guidelines focus on the
importance of high-quality CPR with
high quality chest compressions
(“push hard, push fast”) and a new
C-A-B compressions-airway-breathing
sequence.
10
References
1. Field JM, Hazinski MF, Sayre MR, et al. Part 1:
executive summary 2010 American Heart Association
Guidelines for Cardiopulmonary Resuscitation
and Emergency Cardiovascular Care. Circulation.
2010;122(18 Suppl 3):S640-S656.
2. Tavers AH, Rea TD, Bobrow BJ, et al. Part 4: CPR
overview: 2010 American Heart Association
Guidelines for Cardiopulmonary Resuscitation
and Emergency Cardiovascular Care. Circulation.
2010;122(18 Suppl 3):S676-S684.
3. Berg MD, Schexnayder SM, Chameides L, et al.
Part 13: pediatric basic life support: 2010 American
Heart Association Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care.
Circulation. 2010;122(18 Suppl 3):S862-S875.
4. Science Update: Guidelines CPR/ECC 2010. American
Heart Association Guidelines CPR/ECC 2010 Instructor
Conference, Chicago, IL; 2010.
5. Mace SE. Essentials of pediatric basic and advanced
cardiac life support. 5th ed. In: Fuchs S, Yamamoto
L, eds. APLS: The Pediatric Emergency Medicine
Resource. Elk Grove Village, IL, and Dallas, TX.
American Academy of Pediatric (AAP) and American
College of Emergency Physicians (ACEP). 2011.
6. Mace SE. Challenges and advances in intubation:
airway evaluation and controversies with intubation.
Emerg Med Clin North Am. 2008;26(4):977-1000, ix.
7. Hazinski MF, Chameides L, Hemphill R, et al.
Highlights of the 2010 American Heart Association
Guidelines for CPR and ECC. Dallas, TX: American
Heart Association; 2010. Available online at: http://
www.heart.org/idc/groups/heart-public/@wcm/@ecc/
documents/downloadable/ucm_317350.pdf. Accessed
January 2, 2013.
8. Kleinman ME, Chameides L, Schexnayder SM,
et al. Part 14: pediatric advanced life support:
2010 American Heart Association Guidelines for
Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care. Circulation. 2010;122(18 Suppl
3):S876-S908.
February 2013 • Volume 27 • Number 2
The LLSA Literature Review
“The LLSA Literature Review” summarizes articles from ABEM’s “2013 Lifelong Learning and Self-Assessment Reading List.” These
articles are available online in the ACEP LLSA Resource Center (www.acep.org/llsa) and on the ABEM Web site.
Article 10
Does This Patient With Diabetes
Have Osteomyelitis of the Lower
Extremity?
Reviewed by J. Stephen Bohan, MS, MD, FACEP; Harvard
Affiliated Emergency Medicine Residency; Brigham and
Women’s Hospital
Butalia S, Palda VA, Sargeant RJ, et al. Does this patient with diabetes
have osteomyelitis of the lower extremity? JAMA.
2008:299(7):806-813.
Plain radiographs alone were only slightly helpful, with
a likelihood ratio substantially below the numbers for the
other tests above, and nuclear medicine studies were shown
to make no substantial contribution. MRI was very helpful,
especially when combined with ESR or ulcer size, increasing
the probability of osteomyelitis to 80%.
Highlights
∙∙ Ulcer size and ESR have respectable positive and negative
likelihood ratios.
∙∙ MRI is the only imaging test of any real value in
differentiating between isolated soft tissue infection and
the presence of bony infection. When combined with either
ulcer size or ESR, it is particularly valuable.
∙∙ No element from the history was useful, nor were any
imaging modalities other than MRI.
Foot and lower leg inflammation is common in
diabetics as are resulting ulcers that, in turn, often result
in amputation. Differentiating soft tissue infection from
bone infection is important because the treatments are
substantially different. This article, one of the “Rational
Clinical Exam” series, uses a comprehensive review of the
literature that addresses elements of the history and physical
examination as well as imaging and laboratory tests to
determine which are most useful in answering the clinical
question in the title. Of the 280 articles that dealt with the
subject, less than 10% met the authors’ standard for highquality information.
No element of the history was reliable in distinguishing
between soft tissue infection and osteomyelitis.
Total ulcer area (measuring the longest and widest
diameters) of more than 2 cm 2 yielded a likelihood ratio of
7.2, while an area of less than 2 cm 2 had a likelihood ratio
of 0.48.
The presence of inflammation did not aid in establishing
or eliminating the presence of osteomyelitis.
Physician gestalt was useful, with a likelihood ratio of
5.5 if the examiner thought osteomyelitis was present and a
likelihood ratio of 0.54 when osteomyelitis was thought to
be absent.
With respect to testing, none of the following were
useful: temperature, WBC count, swab culture. An
erythrocyte sedimentation rate (ESR) above 70 mm/hr
was definitely helpful, with a likelihood ratio of 11; the
likelihood ratio was 0.34 when the ESR was less than 70
mm/hr.
11
February 2013 • Volume 27 • Number 2
12
February 2013 • Volume 27 • Number 2
Vaginal Bleeding in
Nonpregnant Patients
Lesson 4
Lisa Freeman Grossheim, MD, FACEP, and Rachel Metz, MD
■ Objectives
On completion of this lesson, you
should be able to:
1. Describe the common and serious
causes of vaginal bleeding in
nonpregnant women.
2. Explain the initial approach to a
patient with vaginal bleeding with
emphasis on recognizing and treating
hemodynamic compromise.
3. Discuss the emergency department
diagnostic evaluation of vaginal
bleeding in nonpregnant patients.
4. Describe the management and
disposition of nonpregnant patients
with vaginal bleeding.
■From the EM Model
13.0 Obstetrics and Gynecology
13.1 Female Genital Tract
Vaginal bleeding is one of the most
common chief complaints of women
presenting to emergency departments.
Pregnancy status is the major branch
point influencing medical decision
making for these patients. The initial
approach to any pregnant patient
who presents with vaginal bleeding is
mostly influenced by the gestational
age of the fetus. For example, vaginal
bleeding in the first trimester may
be due to an ectopic pregnancy or
miscarriage. Placentia previa and
abruption placenta are well-known
causes of vaginal bleeding in the
second and third trimesters. There
are even more causes of abnormal
vaginal bleeding in the nonpregnant
patient. Examples include genital tract
pathology, systemic disease, and side
effects of medication. When compared
to the evaluation of a pregnant
patient with vaginal bleeding, the
evaluation of vaginal bleeding in the
nonpregnant patient can be rather
complex, is less familiar to the average
emergency physician, and may not
be completed in the emergency
department if the patient is otherwise
well appearing and the bleeding is
controlled.
This lesson will focus on the
nonpregnant patient who presents
with vaginal bleeding. There are
various ways to organize a discussion
on vaginal bleeding in nonpregnant
patients, but one common approach is
to stratify the etiologies and treatment
strategies by the appropriate stage
in the reproductive life cycle such as
premenarchal, reproductive age, and
postmenopausal.1
Case Presentations
■ Case One
A 15-year-old girl presents with a
history of excessive vaginal bleeding
that started yesterday but has been
increasing since early that morning.
She indicates that she had her first
period (menarche) when she was
13 years old, and since then her
periods have been irregular and
unpredictable. She denies any sexual
activity, and a pregnancy test is
negative. She states that she is soaking
one pad every 3 hours.
The physical examination reveals
a slightly pale but otherwise wellappearing girl with a normal body
habitus. Her vital signs are blood
pressure 105/58, pulse rate 110,
respiratory rate 16, temperature
37°C (98.6°F), and oxygen saturation
100%. Her mucous membranes are
pale, but she appears well hydrated.
Her abdomen is flat and nontender.
On pelvic examination, her uterus is
of normal size and is nontender. Her
adnexa are not tender and are without
masses. Her cervical os is closed and
there is a brisk amount of bleeding
from the os. Her physical examination
is otherwise unremarkable. Her CBC
is notable for a hemoglobin of 7.5 g/
dL, hematocrit of 24%, and mean
corpuscular volume (MCV) of 65
fL. A bolus of intravenous fluids
is ordered along with transvaginal
ultrasonography.
■ Case Two
A 40-year-old, gravida 2 para 2
woman presents because of severe
vaginal bleeding for the past nine
13
Critical Decisions in Emergency Medicine
Critical Decisions
• What are the most common causes of vaginal
bleeding in patients in the adolescent, reproductiveage, and postmenopausal age groups?
• What are the key components of the history and physical
examination in a patient with vaginal bleeding?
• Which patients should have an ultrasound
examination in the emergency department?
• What are the treatment options for nonpregnant
patients with vaginal bleeding?
• Which emergency department laboratory tests are useful
in the evaluation of patients with vaginal bleeding?
days. She complains of passing large
clots and going through a pad every 2
hours. She also notes that she is dizzy,
with shortness of breath, and has
mild abdominal cramping. She has a
history significant for irregular heavy
periods. She notes that she has been
placed on birth control pills in the
past for her heavy periods.
She states that she has daily
bleeding that varies in severity from
spotting to moderate bleeding with
small clots. Her cycles have been
irregular since her last pregnancy
5 years ago. Currently, she is using
10 pads per day. She adds that she
is chronically tired and has been
generally weak for the past several
days. Her past medical history is
significant for hypothyroidism for
which she takes thyroid hormone
replacement. She smokes one pack of
cigarettes per day and does not drink
alcohol or use illegal drugs. She has
not seen a physician for this problem
before today.
The physical examination reveals
a moderately obese woman in no
distress. Vital signs are blood pressure
165/78, pulse rate 85, respiratory
rate 14, temperature 37°C (98.6°F),
and oxygen saturation 100%. Her
mucous membranes are pale, but she
appears well hydrated. Her abdomen
is protuberant and nontender. On
pelvic examination, her uterus is
difficult to palpate secondary to
body habitus but is nontender. Her
adnexa are nontender. Her cervical
os is closed, and there is a small
amount of dark blood in the vaginal
vault. The remainder of her pelvic
14
examination is noncontributory. Her
physical examination is otherwise
unremarkable. Her pregnancy test
is negative. Her CBC is notable for a
hemoglobin of 9.2 g/dL, hematocrit of
26%, and MCV of 70 fL. Transvaginal
ultrasound is ordered.
■ Case Three
A 65-year-old, gravida 4 para 2
woman presents because she has
noted blood in her urine for the past
two weeks. She states that there is
blood on the toilet paper when she
urinates, but she also notices blood
in her underwear not associated with
urination. Her last menstrual period
was 13 years prior. Her past medical
history is significant only for two
miscarriages. She does not smoke, but
drinks “a couple of glasses of wine”
per day for “years.” The physical
examination reveals a well-appearing,
normal weight woman in no distress.
Vital signs are blood pressure 128/62,
pulse rate 68, respiratory rate 12,
temperature 36.5°C (97.7°F), and
oxygen saturation 97%. Results of
her nongynecologic examination
are normal. On pelvic examination,
her vulva is mildly atrophic with no
lesions. The speculum examination
reveals a small trickle of blood from
the cervical os. There are no lesions or
trauma of the vaginal walls. Bimanual
examination reveals a mildly enlarged
uterus that is tender to palpation. The
rectal examination is normal, and a
stool guaiac test is negative.
In order to differentiate hematuria
from vaginal bleeding, a catheterized
urinalysis is ordered, along with CBC,
electrolytes, BUN and creatinine,
coagulation profile, and transvaginal
ultrasound.
Knowledge of normal
menstrual function is important
in understanding the causes of
menorrhagia. Normal menstrual
bleeding is defined as regular vaginal
bleeding that occurs at intervals
ranging from 21 to 35 days. The
first day of bleeding is considered
the first day of the cycle. During the
first 14 days (follicular phase), the
ovarian follicle produces estrogen.
This stimulates the endometrium
to proliferate and thicken and helps
the oocyte mature for ovulation.
Approximately midcycle, luteinizing
hormones surge and cause release of
the mature oocyte (ovulation) from
the dominant follicle. The remaining
follicular capsule forms the corpus
luteum, which marks the beginning
of the luteal phase. The corpus luteum
secretes estrogen and progesterone
to maintain integrity of the
endometrium and make it receptive
to implantation if fertilization occurs.
If fertilization and implantation
occur, the embryo secretes human
chorionic gonadotrophin into the
bloodstream, which causes the corpus
luteum to continue the production
of progesterone and estrogen, which
enables the endometrium to support
early pregnancy. If implantation does
not occur within 14 days or so, the
corpus luteum will involute, causing
the estrogen and progesterone levels
to fall. This leads to vasoconstriction
in the arterioles of the endometrium.
February 2013 • Volume 27 • Number 2
Menses occurs when the endometrial
lining becomes necrotic and sloughs.
The typical amount of blood lost
during menses ranges from 25 to 60
mL.1,2
Abnormal vaginal bleeding can
be classified on the basis of the
duration, amount, and frequency
of bleeding (Table 1).3 Well-known
causes of abnormal vaginal bleeding
in nonpregnant women are listed in
Table 2.
CRITICAL DECISION
What are the most common causes
of vaginal bleeding in patients in
the premenarchal, reproductiveage, and postmenopausal age
groups?
Pregnancy-related complications
are the most common cause of
abnormal vaginal bleeding in
women of reproductive age. Thus,
a sensitive assay for beta human
chorionic gonadotropin (hCG) should
be performed during the initial
diagnostic evaluation of all patients
of reproductive age who present with
abnormal vaginal bleeding.1 The
pathophysiology of vaginal bleeding
in nonpregnant females varies with
age group.
Premenarchal
Normal newborn girls can
experience uterine bleeding in the
first 6 weeks of life secondary to
the withdrawal of estrogen from
placental transfer. Bleeding after this
time period is always abnormal and
requires further evaluation.
Vaginitis is the most common
cause of vaginal bleeding in
premenarchal children. This is related
to the immature anatomy and low
estrogen state. Contact vulvovaginitis
can occur from exposure of the
vulva to a chemical irritant or
allergen. Common offending agents
in children include soaps, bubble
baths, and scented toilet paper.
Bacterial vulvovaginitis from unusual
organisms such as Shigella and
Streptococcus pyogenes can occur as
well.6 Other dermatologic conditions
that can cause skin breakdown in the
genital area may also present with
vaginal bleeding.
Vaginal foreign bodies are another
cause of bleeding in premenarchal
children. Most vaginal foreign
bodies are found in girls between
the ages of 3 and 9 years.7 Symptoms
secondary to a vaginal foreign body
are responsible for approximately
4% of pediatric gynecologic
outpatient visits.8 Vaginal bleeding
with nonmalodorous discharge
is thought to be the most reliable
indicator of foreign body vaginitis
in pre-adolescent girls.8 The classic
symptoms include vaginal bleeding
or bloody vaginal discharge.8-11
Small wads of toilet paper are most
commonly identified.9-12
Genital trauma must alert the
physician to the possibility of
sexual abuse as well. Other causes
of external genital trauma include
bicycle accidents and straddle
injuries. Precocious puberty (sexual
Table 1.
Definitions3,4
Dysfunctional uterine bleeding
Menometrorrhagia
Menorrhagia
Metrorrhagia
Postcoital bleeding
Postmenopausal bleeding
Abnormal vaginal bleeding in the absence of
organic disease
Prolonged uterine bleeding that is irregular
and more frequent
Heavy or prolonged menstrual flow; more
than 7 days, more than 80 mL blood loss
daily; <21 day recurrence; regular
Intermenstrual bleeding; irregular
Bleeding after sexual intercourse
Any bleeding that occurs more than 6 months
after the cessation of menstruation
development before age 8) and
tumors, both benign and malignant,
can also cause abnormal vaginal
bleeding in this age group.
Reproductive Age
Dysfunctional uterine bleeding
(DUB) is the most common cause
of abnormal vaginal bleeding
in reproductive-age women and
Table 2.
Causes of vaginal bleeding in
nonpregnant women3,5
Dysfunctional uterine bleeding
(diagnosis of exclusion after
other causes have been ruled
out)
Anovulatory cycle (most
common)
Hypothalamic
Polycystic ovarian syndrome
Stress
Weight loss
Genital tract pathology
Cervicitis
Endometriosis and
adenomyosis
Endometritis
Fibroids (leiomyomata)
Neoplasm
Polyps
Vaginitis
Vascular malformations
Vulvitis
Iatrogenic
Intrauterine device
Medication induced
Anticoagulants
Antipsychotics
Oral contraceptives (initiation
or discontinuation)
Steroids
Thyroid hormone replacement
Systemic disease
Coagulopathies
Cushing disease
Liver dysfunction
Pituitary disease
Renal disease (low platelets
and hyperprolactinemia)
Thyroid disorders
Trauma
Foreign body
Trauma
15
Critical Decisions in Emergency Medicine
adolescents who are not pregnant. It
is most common at the extremes of
age during the reproductive years.
DUB is defined as abnormal vaginal
bleeding in the absence of structural
or organic pathology and is most
commonly caused by anovulation. It
is a diagnosis of exclusion and should
not be diagnosed in the emergency
department short of a patient that
has had the complete endocrine and
histologic workup. Menorrhagia
secondary to anovulation is seen in
10% to 15% of all gynecologic patients
and can result in significant anemia.3,13
Most anovulation is related to
hypothalamic abnormalities or
polycystic ovarian syndrome.5,14 It
can also be caused by physiologic
stress such as weight loss or excessive
exercise. It is normal for menstrual
cycles to be anovulatory for an average
of 18 months after menarche in
adolescents while the hypothalamicpituitary axis matures.4,14 The lack
of ovulation produces an unopposed
estrogen state. The lack of progesterone
production resulting from no ovulation
contributes to irregular endometrial
growth and nonuniform bleeding. In a
normal cycle, the entire endometrium
sloughs off during menstruation. In an
anovulatory cycle, different sections
of the endometrium outgrow their
blood supply at different times and
bleed erratically.5 There can be long
gaps between menses. When menses
occurs, it can vary from heavy to
light flow and continue for a number
of days; occasionally bleeding can
be profuse. Anovulatory cycles are
unpredictable and cannot be classified
by any one type of bleeding pattern.5
In contrast, ovulatory DUB presents
as menorrhagia or heavy bleeding at
regular intervals. Ovulatory DUB is
mostly caused by factors affecting the
hemostasis of the endometrium.
Abnormal vaginal bleeding can
also be caused by structural lesions
such as uterine leiomyomas (fibroids)
and presents as menorrhagia. Fibroids
are the most common lesions of the
uterus that cause abnormal bleeding
during the reproductive years and are
the most common pelvic tumor. They
16
are found in 25% to 50% of women
and are usually multiple. Fibroids are
usually nonmalignant neoplasms of
muscle cell origin; they can become
quite large. They cause hemorrhage by
disrupting the endometrial vascular
supply and the ability of the uterus to
contract to stop bleeding.3,4 Fibroids
can also degenerate, causing pain
and bleeding. Fibroids enlarge in
early pregnancy and decrease in
size during menopause. Fibroids
that are suspected on examination
are most commonly diagnosed by
ultrasound. Rapid growth of fibroids
at any age or growth after menopause
is highly suspicious for malignant
transformation.
Endometriosis can cause abnormal
vaginal bleeding and often causes
pelvic pain. Endometriosis is defined
as the presence of normal endometrial
mucosa abnormally implanted in
locations other than the uterine cavity.
This tissue has the same steroid
receptors as normal endometrium,
so it is capable of responding to the
normal cyclic hormonal changes.
Microscopic internal bleeding, with the
subsequent inflammatory response,
neovascularization, and fibrosis
formation, is responsible for the
clinical consequences of this disease.15
In the typical patient with
endometriosis, the ectopic implants are
located in the pelvis and manifest as
severe dysmenorrhea, chronic pelvic
pain, or infertility. The etiology and
pathophysiology of endometriosis
are not well understood. Patients
typically have regular, although short,
menstrual cycles with prolonged
flow of 8 or more days. Onset of
pain usually precedes flow by a few
days and begins to resolve 1 to 2
days into the menses. Symptoms also
usually improve during pregnancy
and after menopause; they can recur
post partum or with postmenopausal
hormone replacement therapy.
The hallmark finding on pelvic
examination is tender nodular masses
along a thickened uterosacral ligament,
the posterior uterus, or the posterior
cul-de-sac. However, the most
common finding is nonspecific pelvic
tenderness. Adenomyosis is similar
to endometriosis except that the
endometrial tissue invades the deeper
muscle layers of the uterus.
When the products of cyclic
sloughing of endometriotic implants
become entrapped by cyst formation,
the resulting mass is referred to as an
endometrioma, or “chocolate cyst.”
These can occur in any location but
are most commonly found involving
one or both ovaries. These masses can
become quite painful, and patients
with rupture present with an acute
surgical abdomen. Transvaginal
ultrasonography is a useful method of
identifying the classic chocolate cyst
of the ovary. The typical appearance
is that of a cyst containing low-level
homogenous internal echoes consistent
with old blood.2
Any genitourinary tract malignancy
can produce bleeding. The amount
of bleeding does not correlate with
the severity of disease. Endometrial
hyperplasia and endometrial cancer
must be considered in women 35
years old or older or in younger
women with other risk factors such as
obesity who present with abnormal
vaginal bleeding.1 Older patients may
not be able to describe the location
of the bleeding or determine if it is
from the vagina, bladder, or rectum.
Therefore the vagina and cervix must
be adequately visualized on pelvic
examination, and a rectal examination
must be performed. In addition, a
catheterized urine sample should be
obtained for analysis.
Inflammatory conditions such
as vaginitis or cervicitis can cause
intermenstrual vaginal bleeding
or spotting (metrorrhagia). Genital
trauma or vaginal foreign bodies can
cause vaginal bleeding.
Menorrhagia at menarche can be a
sign of a bleeding disorder. Up to 24%
of adolescents with menorrhagia have
an undiagnosed primary coagulation
disorder, most often von Willebrand
disease.5 von Willebrand disease is
the most commonly encountered
bleeding disorder in patients with
menorrhagia.3,16 A von Willebrand
screening test can be done as an
February 2013 • Volume 27 • Number 2
outpatient. Myeloproliferative disorders
and immune thrombocytopenia can be
diagnosed as well. In adults, bleeding
can result from taking anticoagulant
agents or be an acquired bleeding
disorder. Hypothyroidism can be
associated with menorrhagia as well
as intermenstrual bleeding. Cirrhosis
can lead to bleeding secondary to
a reduced capacity of the liver to
metabolize estrogens.1
Oral contraceptive use is the most
common cause of midcycle bleeding.
Eating disorders, excessive weight
loss, stress, and exercise can also
cause abnormal uterine bleeding.
Additionally, medications (eg,
antiseizure medications) that increase
the P450 system of the liver can
increase the metabolism of endogenous
hormonal glucocorticoids and can
cause withdrawal bleeding. The use of
warfarin, antiplatelet agents, or other
anticoagulants could be the culprit in
certain patients.2
Postmenopausal
Menopause is defined as 12
months without a menstrual cycle.
Menopause results from ovarian
“burnout” and occurs in the early
50s. During the perimenopausal
period, there is variation and
lengthening of the intermenstrual
intervals. Estrogen levels decline, then
eventually production becomes almost
undetectable.
Any bleeding that occurs after 6
months of menopause is abnormal.
The most common benign cause
of postmenopausal bleeding is
atrophic vaginitis.4 The main
concern regarding postmenopausal
bleeding is endometrial carcinoma.
Up to 40% of all postmenopausal
bleeding is caused by malignancy.3
Endometrial carcinoma is the most
common gynecologic malignancy
and most cases present as
postmenopausal bleeding. Women in
the perimenopausal period who are
undergoing some early evidence of
ovarian failure may also experience
dysfunctional uterine bleeding.
However, endometrial biopsy is
indicated in this age group to rule
out more serious conditions such as
malignancy.4 Fibroids rarely cause
vaginal bleeding in postmenopausal
women.
The differential diagnosis of
bleeding in postmenopausal women is
narrower due to the lack of the variable
influence of ovarian hormones.17
Abnormal vaginal bleeding in the
postmenopausal years is usually
attributed to an intrauterine source
but can also arise from the cervix,
vagina, vulva, fallopian tubes, or
ovaries. The origin of bleeding can
also involve nongynecologic sites such
as the urethra, bladder, and lower
gastrointestinal tract.1
Burbos et al followed a prospective
cohort of 3,047 women with
postmenopausal bleeding.8 All
patients underwent transvaginal
ultrasound and their endometrial
thickness was measured. When
endometrial thickness measured
less than 5 mm (44% of patients),
no further investigations were
performed as evidence suggests a
low probability of cancer below this
threshold.18,19 Women who had an
endometrial thickness equal to or
greater than 5 mm had endometrial
biopsy performed. Of those patients,
37% had benign histology, 10%
had benign endometrial polyps,
and 5% had endometrial cancer.
Endometritis, metaplasia, bladder
carcinoma, cervical carcinoma, and
ovarian carcinoma comprised the
remaining cases. The peak incidence
of endometrial cancer in this study was
in patients between 60 and 64 years of
age.17
CRITICAL DECISION
What are the key components of the
history and physical examination in
a patient with vaginal bleeding?
The most important components
of the history are pregnancy status,
the amount of vaginal bleeding, and
the presence of abdominal or pelvic
pain. If the bleeding is severe enough
to cause volume depletion, patients
may experience shortness of breath,
fatigue, palpitations, and other related
symptoms. Inquire about the volume,
duration, and timing of bleeding and
the last normal menstrual period. The
average tampon or pad absorbs 20 to
30 mL of vaginal effluent.3 Although
it is common practice to document
the number of pads or tampons used
per day in an attempt to quantify
bleeding, the number of pads or
tampons used is not reliable because
personal habits vary greatly among
women.3 If there is pain, determine
the duration, location, and whether
it is constant or intermittent. If a
patient’s bleeding normally occurs at
regular intervals and the irregularity
is new in onset, pathology must be
ruled out, regardless of age.
Pertinent past gynecologic history
includes previous history of abnormal
bleeding (and any associated testing,
including hormonal and biopsy),
other gynecological problems,
operations such as hysterectomy, and
previous pregnancy history. Inquire
about use of oral contraceptives or
other hormonal therapy. Did the
patient forget to take her prescribed
dose of oral contraceptive? Missed,
delayed, or discontinued dosing
can cause withdrawal bleeding. Is
the bleeding related to intercourse?
Bleeding during or after intercourse
could indicate a cervical lesion.3
Ask about a personal or family
history of bleeding disorders. An
underlying bleeding disorder should
be considered when a patient has had
menorrhagia since menarche; has a
family history of bleeding disorders;
or has a personal history of bruising
without known injury, bleeding of
oral cavity or gastrointestinal tract
without obvious lesion, or epistaxis
lasting longer than 10 minutes.
Consider hypothyroidism with
symptoms such as weight gain, cold
intolerance, and hair loss. Note use of
anticoagulants and presence of liver
or kidney disease. Inquire about a
history of trauma or possible foreign
bodies. Patients may not always be
willing to offer this history until a
genital injury is found.2
On physical examination, pay close
attention to vital signs and indications
of compensated shock, such as
17
Critical Decisions in Emergency Medicine
lethargy, tachycardia, tachypnea,
and peripheral vasoconstriction. If
any of these are present, aggressive
resuscitation should begin
immediately. Examine the abdomen
for tenderness, peritoneal signs,
and uterine enlargement. The nongynecologic examination should
focus on signs of liver or kidney
disease, hyper- or hypothyroidism,
galactorrhea (may indicate a pituitary
tumor), and obesity associated with
hirsutism (which is associated with
polycystic ovarian syndrome). Obesity
is an independent risk factor for
endometrial cancer. Adipose tissue
is a nidus for estrogen conversion.
Therefore, the larger the patient, the
greater the risk (and the higher the
unopposed estrogen level on the
endometrium).2
Prior to beginning the pelvic
examination, the procedure should
be explained in simple terms.
A chaperone should be present.
Decisions regarding the presence of
a parent during the examination of
a child or adolescent depend on the
patient’s age, level of maturity, and
desire for parental involvement.
The examination of nonvirginal
patients begins with a visual
inspection of the vulva and urethral
opening. Next insert a warmed,
lubricated speculum into the vagina.
The vagina should be inspected for
lacerations, lesions, signs of infection,
and foreign bodies. Examine the
cervix for inflammation, polyps,
ulceration, and potential malignancy.
The cervical os may reveal active
bleeding, clotted blood, tissue,
neoplasm, or an intrauterine device. If
cervical discharge is present, samples
should be taken for laboratory
testing.1
On bimanual examination, note
the consistency of the cervix and
the patency of the os. Document any
pain on movement of the cervix.
Palpate the uterus; estimate its size,
and note tenderness or masses.
Palpate the adnexa for tenderness
or masses. Adnexal fullness can be
difficult to appreciate, depending on
body habitus. Adnexal tenderness
18
or masses are especially concerning
in patients older than 40 years.
Ovarian cancer can present with
intermenstrual bleeding as its
only symptom. Rare but deadly
ovarian tumors also can present at
a younger age. Any suspicion of an
adnexal mass should prompt a pelvic
ultrasound. The last component of
the examination is the rectovaginal
examination. The posterior cul-desac should be palpated for masses,
and the stool should be examined for
blood.2
Virginal patients may not require
a speculum examination unless the
vaginal bleeding is associated with
trauma or possible sexual abuse or
there is concern for a foreign body.
An external vaginal examination
can be done with the child in a
“frog-leg position.” If a speculum
examination is needed, a pediatric
speculum should be used and
procedural sedation or even general
anesthesia may be needed, depending
on the circumstance. Gynecologic
consultation should be obtained.
CRITICAL DECISION
Which emergency department
laboratory tests are useful in the
evaluation of patients with vaginal
bleeding?
The urgency and extent of
the evaluation depends on the
patient’s presentation. Patients with
significant blood loss or who are
hemodynamically unstable need a
point-of-care hemoglobin level and a
CBC, coagulation profile, electrolytes,
and renal and liver function tests and
should be typed and cross-matched
for blood products. Use caution when
interpreting these tests, because in
acute bleeding, the hemoglobin may
not reflect the initial degree of blood
loss. Patients with prolonged vaginal
bleeding can be anemic despite
appearing well and having normal
vital signs because of compensation.
All patients with vaginal bleeding
should have a pregnancy test,
regardless of their insistence that
there is no possibility of pregnancy.
Bleeding in early pregnancy is one of
the most common causes of vaginal
bleeding. If a patient is found to be
pregnant, the evaluation will focus on
excluding an ectopic pregnancy.
hCG tests, available for both urine
and serum, are used for screening
purposes. A qualitative test answers
the question “pregnant or not
pregnant?” while a quantitative test
provides a numeric hCG value that
can be followed over time.20 hCG is
detectable after implantation of the
blastocyst (eight to nine days after
ovulation). The level will double
approximately every two days
during early pregnancy in normal
development.21
Current urine tests detect low
levels of hCG—approximately 25 to
50 IU/L.22 Urine qualitative testing
has been found to be 95% to 100%
sensitive and specific compared with
serum testing.3 Qualitative pregnancy
tests are typically reported as positive
when the hCG concentration is 20
mIU/mL or higher in the urine or
10 mIU/mL or higher in the serum.3
False negatives can occur when the
hCG level is extremely high.23,24
If a urine test is negative and
an ectopic pregnancy is still being
considered, quantitative serum
testing should be performed. The
sensitivity is virtually 100% when
an assay capable of detecting 5 mIU/
mL or more of hCG is used.22 There
is no hCG level that excludes ectopic
pregnancy.
Patients with vaginal bleeding who
are hemodynamically stable and have
a negative pregnancy test should have,
at minimum, a CBC. Patients who
lose more than 80 mL of blood per
day, especially repetitively, are at risk
for anemia. These women are likely to
develop iron-deficiency anemia as a
result of their blood loss. Menorrhagia
is the most common cause of anemia
in premenopausal women.
A urinalysis can be obtained if
there is clinical suspicion of a urinary
tract infection; this should be a
catheterized specimen in the presence
of vaginal bleeding. No further
laboratory testing is required unless
the history and physical examination
February 2013 • Volume 27 • Number 2
suggest potential liver or kidney
disease or a coagulopathy. These
patients should have electrolytes,
BUN and creatinine, liver function
tests, and a coagulation panel drawn.
A thyroid panel may be obtained
for women with unexplained
chronic bleeding and symptoms
of hypothyroidism such as fatigue,
weight gain, or cold intolerance.
CRITICAL DECISION
Which patients should have an
ultrasound examination in the
emergency department?
The most important indication for
pelvic ultrasonography in a patient
with vaginal bleeding is to reasonably
exclude an ectopic pregnancy.
The use of physician-performed
bedside ultrasound in the emergency
department is becoming more
commonplace. Studies of emergency
physician-performed ultrasonography
in this setting have demonstrated
sensitivity of 76% to 90% and
specificity of 88% to 92% for the
detection of ectopic pregnancy.25,26
Diagnostic performance improves as
the hCG level increases. Very early in
a pregnancy or ectopic pregnancy, the
pregnancy is unlikely to be identified
with ultrasonography. Once hCG
levels are above 2,000, the diagnostic
performance reaches high reliability.
A patient who is experiencing
vaginal bleeding with pelvic pain
who has a positive pregnancy test
and who does not have a gestational
sac within the uterus on ultrasound
should be considered to have an
ectopic pregnancy until it is proved
otherwise. Bedside ultrasonography
can reveal free intraperitoneal fluid,
which should lead to immediate
gynecologic evaluation for a possible
ruptured ectopic pregnancy.4
In nonpregnant patients,
sonography is used to determine
uterine size and the characteristics
of the endometrium as well as
the presence of fibroids, ovarian
cysts, abscesses, and masses.
Depending on the degree of pain and
findings on physical examination,
ultrasonography can be done on
an emergency basis or deferred for
outpatient evaluation.1
In the hemodynamically stable
patient in whom pregnancy has been
ruled out, the only diagnoses that
must absolutely be established in the
emergency department are trauma
(including sexual assault and abuse),
coagulopathy, infection, and retained
foreign bodies. If these diagnoses are
excluded, patients may be referred for
an outpatient evaluation, including
ultrasonography.
CRITICAL DECISION
What are the treatment options for
nonpregnant patients with vaginal
bleeding?
The likely causative disorder, as
well as the amount of bleeding, will
guide the emergency department
management. Patients presenting with
hemodynamic instability, regardless of
pregnancy status, require intravenous
access, volume resuscitation with
isotonic crystalloid solution or
blood products as indicated, and
consultation with obstetrics and
gynecology.3 After or concomitant
with immediate resuscitation and
stabilization, pregnancy status should
be determined; further treatment
depends on the result. Attempts
should be made to localize the source
of the bleeding. In women with
severe, persistent uterine bleeding, an
immediate dilatation and curettage
can be indicated, although other
options exist such as endometrial
ablation, interventional radiology
embolization, or even hysterectomy.
If obstetrics/gynecology consultation
is not quickly available, intravenous
estrogens or uterine packing may be
used as indicated.
Conjugated estrogens may be
used in the emergency department
treatment of life-threatening
hemorrhage that is not caused by
pregnancy, trauma, or a postsurgical
complication. The rationale for the
use of estrogens is that they cause
the rapid growth of the endometrial
tissue over the denuded epithelium.
High-dose estrogens, even for short
periods, are contraindicated in
some women such as those with a
history of thrombosis or estrogenresponsive cancers. Dilatation and
curettage should be considered for
these women. Obstetrics/gynecology
consultation should be obtained if the
use of intravenous estrogen is being
considered.1 The dose of conjugated
estrogen is 25 mg IV every 4 to 6
hours until the bleeding stops.3,27
If bleeding continues after
intravenous estrogen, one or more
urethral catheters can be inserted
into the cervical os and inflated to
tamponade the bleeding. The balloon
should be distended with saline until
the bleeding stops.3 If the bleeding is
coming from the vaginal wall, a rectal
tube can be inserted and inflated to
tamponade the bleeding. Alternatively,
the vagina may be packed with gauze.
Vaginal packing should be done with
caution because it increases the risk of
infection and may hide ongoing blood
loss. Patients who do not respond
to medical therapy can require
surgical intervention to control the
menorrhagia.2
Treatment of menorrhagia
with no identifiable cause in the
emergency department and that may
be ultimately diagnosed as DUB
usually involves nonsteroidal antiinflammatory medications (NSAIDs)
and oral contraception for hormonal
control as the first-line medical
therapies in ovulatory menorrhagia.
NSAIDs reduce prostaglandin levels
by inhibiting cyclooxygenase and lead
to average reductions of 20% to 46%
in menstrual blood flow.28 NSAIDs
should be taken for only 5 days of
the entire cycle, limiting their most
common adverse effect of gastritis.
Oral contraceptive pills provide
short-term hormonal manipulation
that allows the endometrium to
stabilize, which, in turn, will slow
or stop acute bleeding. Estrogen
may be used to stimulate growth
when ultrasonographic examination
has revealed a thin endometrium.
With the regimen outlined in
Table 3, subsequent bleeding
can be heavy but should not be
prolonged. Contraindications to oral
19
Critical Decisions in Emergency Medicine
contraceptive use are listed in Table 4.
The progesterone in oral
contraceptives decreases the number
of available estrogen receptors, and
as a result, bleeding may not stop
as quickly as when estrogen is used
alone. Two treatment regimens
described in Table 3 combine
a fixed-dosage pill with ethinyl
estradiol (estrogen), 35 micrograms,
and norethindrone (progestin), 1
microgram.1
Persistent light bleeding associated
with anovulation is treated with
progesterone alone to stabilize
the immature endometrium.
Bleeding recurs 3 to 10 days after
discontinuation and may be heavy as
a consequence of the large amount of
tissue being sloughed.1
Menorrhagia is the most common
cause of anemia in premenopausal
women. Patients who are anemic with
the likelihood of iron deficiency (low
MCV), should be started on a short
course of oral iron replacement.
Postmenopausal bleeding must
always be investigated because many
causes are premalignant or malignant.
Outpatient gynecologic referral is
appropriate given cardiovascular
stability.
Treatment options for fibroids
include medical management with
NSAIDS, hormone therapy, and
surgical options per gynecology.
Outpatient referral is indicated.
Tranexamic acid is the first
nonhormonal product approved by
the US Food and Drug Administration
(FDA) for the treatment of heavy
menstrual bleeding. It is a synthetic
derivative of lysine that uses
antifibrinolytic effects by inhibiting
the activation of plasminogen
to plasmin. Tranexamic acid’s
mechanism of action in treating heavy
menstrual bleeding is by prevention
of fibrinolysis and the breakdown
of clots via inhibiting endometrial
plasminogen activator.2
Patients with coagulopathies
require modification of their
management. Any disorder of blood
vessels, platelet abnormalities, and
coagulation disorders, including
von Willebrand disease, can result
in abnormal menstrual bleeding.
Treatment options include use
of antifibrinolytics and oral
Table 3.
Short-term medical management of hemodynamically stable uterine bleeding1,29
Estrogen therapy
Oral conjugated estrogen, 10 mg/day (2.5 mg 4 times a day) or 25 mg IV every
2 to 4 hours for 24 hours. Note: the efficacy of oral and intravenous estrogens
is similar. This should be taken for no more than 24 hours as this is high-dose
estrogen and three doses is usually enough.
When bleeding subsides, add medroxyprogesterone acetate, 10 mg/day, or
proceed with an oral contraceptive pill taper.
Continue both the conjugated estrogen and the medroxyprogesterone for 7
to 10 days.
Stop for synchronized withdrawal bleeding.
Oral contraceptive pill
Ethinyl estradiol, 35 mcg, and norethindrone, 1 mg (use a pill with at least 30
mcg of ethinyl estrogen):
1 tablet 4 times daily for 4 days, then
3 times daily for 3 days, followed by
2 times daily for 2 days, followed by
Once daily for 3 weeks, then
Skip one week (withdrawal bleed), then
Cycle on oral contraceptives for at least 3 months.
Progesterone:
Medroxyprogesterone acetate, 10 mg for 10 days
20
contraceptives. The former raises
factor VIII and von Willebrand
factor levels and is an effective form
of therapy. Antifibrinolytics such
as tranexamic acid reduce both
plasminogen activator activity and
plasmin activity. Desmopressin acetate
(DDAVP) stimulates endogenous
release of factor VIII and von
Willebrand factor and may be used
for the treatment of menorrhagia.5
NSAIDS are ineffective in decreasing
uterine bleeding and may increase
blood loss in these patients.1
Case Resolutions
■ Case One
The transvaginal ultrasound
examination of the 15-year-old
with irregular periods and heavy
bleeding was normal. She received
one unit of blood in the emergency
department, was given four pills of
ethinyl estradiol, 35 micrograms, and
norethindrone, 1 mg, and admitted to
the hospital overnight. Her bleeding
decreased and her heart rate and
blood pressure normalized. Her
diagnosis was anovulatory uterine
bleeding. She was discharged on an
oral contraceptive taper and iron
supplementation.
■ Case Two
In the case of the woman with
hypothyroidism with severe vaginal
bleeding and weakness, her sonogram
revealed multiple uterine fibroids
Table 4.
Contraindications to oral
contraceptive pills
Active liver disease
History of estrogen-dependent
tumor
Hypertriglyceridemia
Older than 35 years and smokes
more than 15 cigarettes per day
Older than 40 years is not a
contraindication but many
physicians favor progestin for
this age group
Pregnancy
Previous thromboembolic event
or stroke
February 2013 • Volume 27 • Number 2
and a thickened endometrial stripe.
After discussion with the patient’s
gynecologist, it was decided not to
start the patient on oral contraceptives
because of her age and smoking
history, as well as because of concern
for malignancy given the thickened
endometrial stripe. She was given a
prescription for ibuprofen 800 mg
and iron supplementation. Followup
was arranged for early the following
week with gynecology and with
Pearls
• Any postmenopausal woman
with vaginal bleeding
should be referred to
gynecology for evaluation
of possible reproductive
organ malignancy.
• Anemia from DUB is common
and can cause significant
blood loss over time. Strongly
consider menstrual blood loss
as the source of anemia in any
woman of reproductive age.
• All female patients of
reproductive age should
have a pregnancy test in the
emergency department.
• Vaginal packing should be
done with caution; it increases
the risk of infection and can
hide ongoing blood loss.
Pitfalls
• Failing to do a quantitative
hCG if there is any significant
suspicion of pregnancy;
false-negative quantitative
tests can be rarely falsely
negative in the case of an
extremely high hCG level, such
as with a molar pregnancy.
her internist to check her thyroid
function.
■ Case Three
A catheterized urine sample from
the postmenopausal woman who had
noticed blood in her underwear had
only 0 to 2 RBCs/hpf and no evidence
of infection. Hematuria was ruled
out by the result of the urinalysis
coupled with the visualization of
blood coming from the cervical os.
The patient’s hemoglobin was 9.2
g/dL, and her coagulation studies
were normal. Ultrasonography
demonstrated an irregularly
enlarged uterus. She was referred to
a gynecologist who later diagnosed
endometrial cancer.
Summary
Vaginal bleeding is a common
emergency department presentation.
Once pregnancy is excluded, the
evaluation and management depend
on the stability of the patient and
the acuity of the presentation. An
organized approach to the evaluation
and treatment is important. It is key
to recognize and treat hemodynamic
instability.
References
1. Tintinalli JE, Stapczynski JS, Ma OJ, et al, eds.
Tintinalli’s Emergency Medicine. 7th ed. New York,
NY: McGraw-Hill; 2011.
2. Shaw JA, Shaw HA. Menorrhagia. Updated: March
13, 2012. Online text. Available at: http://emedicine.
medscape.com/article/255540-overview. Accessed
December 11, 2012.
3. Cranmer H, Foran M. Vaginal bleeding. In: Marx
JA, Hockberger RS, Walls RM, et al, eds. Rosen’s
Emergency Medicine: Concepts and Clinical Practice.
7th ed. Philadelphia, PA: Mosby Elsevier;
2010:199-203.
4. Katz VL, Lentz GM, Lobo RA, et al, eds.
Comprehensive Gynecology. 5th ed. Philadelphia, PA:
Mosby Elsevier; 2007.
11. Emans SJ. Vulvovaginal problems in the prepubertal
child. In: Emans SJ, Laufer MR, Goldstein DP, eds.
Pediatric and Adolescent Gynecology. 5th ed.
Philadelphia, PA: Lippincott Williams & Wilkins;
2005:83-119.
12. Henderson PA, Scott RB. Foreign body vaginitis caused
by toilet tissue. Am J Dis Child. 1966;111:529.
13. Daniels R, McCuskey C. Abnormal vaginal bleeding in
the first twenty weeks of pregnancy. Emerg Med Clin
North Am. 2003;21:41.
14. Rimsza ME. Dysfunctional uterine bleeding. Pediatr
Rev. 2002;23(7):227-233.
15. Hallberg L, Nilsson L. Determination of menstrual
blood loss. Scand J Clin Lab Invest. 1964;16:244-248.
16. Marret H, Fauconnier A, Chabbert-Buffet N, et
al. Clinical practice guidelines on menorrhagia:
management of abnormal uterine bleeding before
menopause. Eur J Obstet Gynecol Reprod Biol.
2010;152(2):133-137.
17. Burbos N, Musonda P, Giarenis I, et al. Agerelated differential diagnosis of vaginal bleeding
in postmenopausal women: a series of 3,047
symptomatic postmenopausal women. Menopause
Int. 2010;16(1):5-8.
18. Karlsson B, Granberg S, Wikland M, et al. Transvaginal
ultrasonography of the endometrium in women with
postmenopausal bleeding – a Nordic multicenter
study. Am J Obstet Gynecol. 1995;172(5):1488-1494.
19. Smith-Bindman R, Kerlikowske K, Feldstein VA, et
al. Endovaginal ultrasound to exclude endometrial
cancer and other endometrial abnormalities. JAMA.
1998;280:1510-1517.
20. Promes SB, Nobay F. Pitfalls in first-trimester bleeding.
Emerg Med Clin North Am. 2010;28(1):219-234.
21. Snell BJ. Assessment and management of bleeding in
the first trimester of pregnancy. J Midwifery Womens
Health. 2009;54(6):483-491.
22. Alfthan H, Björses UM, Tiitinen A, Stenman UH.
Specificity and detection limit of ten pregnancy tests.
Scand J Clin Lab Invest Suppl. 1993;216:105-113.
23. Tabas JA, Strehlow M, Issacs E. A false negative
pregnancy test in a patient with a hydatidiform molar
pregnancy. N Engl J Med. 2003;349(22):2172-2173.
24. Hunter CL, Ladde J, Molar pregnancy with false
negative β-hCG urine in the emergency department.
West J Emerg Med. 2011;12(2):213-215.
25. Durham B, Lane B, Burbridge L, et al. Pelvic ultrasound
performed by emergency physicians for the detection
of ectopic pregnancy in complicated first-trimester
pregnancies. Ann Emerg Med. 1997;29(3):338-347.
26. Mandavia DP, Aragona J, Chan L, et al. Ultrasound
training for emergency physicians – a prospective
study. Acad Emerg Med. 2000;7(9):1008-1014.
27. DeVore GR, Owens O, Kase N. Use of intravenous
Premarin in the treatment of dysfunctional uterine
bleeding – a double-blind randomized controlled
study. Obstet Gynecol. 1982;59(3):285-291.
28. Jurema M, Zacur H. Menorrhagia. UptoDate. Available
at: http://bit.ly/fHJVtw. Accessed March 29, 2009.
29. Ely JW, Kennedy CM, Clark EC, Bowdler NC. Abnormal
uterine bleeding: a management algorithm. J Am
Board Fam Med. 2006;19(6):590-602.
5. Schrager SB, Paladine HL, Cadwallader K. Gynecology.
In: Rakel RE, Rakel DP, eds. Textbook of Family
Medicine. 8th ed. Philadelphia, PA: Elsevier;
2011:456-459.
6. Abdessamad HM, Greenfield M. Vaginal foreign body
presenting as bleeding with defecation in a child. J
Pediatr Adolesc Gynecol. 2009:22(2):e5-e7.
7. Stricker T, Navratil F, Sennhauser FH. Vaginal foreign
bodies. J Paediatr Child Health. 2004;40(4):205-207.
• Downplaying postmenopausal
bleeding—consider it
due to malignancy until
proved otherwise.
8. Paradise JE, Willis ED. Probability of vaginal foreign
body in girls with genital complaints. Am J Dis Child.
1985;139(5):472-476.
• Prescribing estrogen to a
patient with a contraindication
such as acute liver disease.
10. Pokorny SF. Long-term intravaginal presence of foreign
bodies in children. A preliminary study. J Reprod Med.
1994;39(12):931-935.
9. Sanfilippo JS. Gynecologic problems of childhood. In:
Behrman RE, Kleigman RM, Jenson HB, eds. Nelson
Textbook of Pediatrics. 16th ed. Philadelphia, PA: W.B.
Saunders; 2000:1659-1672.
21
Critical Decisions in Emergency Medicine
22
February 2013 • Volume 27 • Number 2
The Critical ECG
A 62-year-old man with epigastric burning, nausea, diaphoresis, and lightheadedness; blood pressure is 80/35.
Sinus rhythm with second-degree atrioventricular (AV) block and 2:1 AV conduction, rate 46, acute inferior MI. Regular
P waves at a rate of 92/minute are found easily in the inferior leads. There is a 2:1 ratio of P waves:QRS complexes, and
the PR interval remains constant, consistent with second-degree AV block. When second-degree AV block occurs with 2:1
AV conduction, the diagnosis of Mobitz I versus Mobitz II cannot be certain, although the narrow QRS complexes favors
Mobitz I. Q waves with ST-segment elevation are present in the inferior leads. Reciprocal ST-segment depression is found
in I, aVL, and V2-V4.
Feature Editor: Amal Mattu, MD, FACEP From: Mattu A, Brady W. ECGs for the Emergency Physician. London: BMJ
Publishing; 2003:122,149. Available at www.acep.org/bookstore. Reprinted with permission.
23
February 2013 • Volume 27 • Number 2
The Critical Image
An 18-year-old man with systemic scleroderma and pulmonary hypertension presenting with 4 to 5 days
of worsening dyspnea at rest, as well as chest pain. He was recently discharged from the hospital after a
syncopal episode. At discharge, he was dependent on a continuous epoprostenol infusion for his pulmonary
hypertension.
Vital signs are blood pressure 114/58, heart rate 102, respiratory rate 24, temperature 36.4°C, and oxygen
saturation 94% on 2 liters of oxygen via nasal canula. Examination revealed a thin young man with diffuse
skin changes of scleroderma. Neck examination revealed no jugular venous distention. The patient’s lungs
were clear to auscultation. His heart rate was regular but tachycardic without accessory heart sounds. He had
woody peripheral edema in all extremities.
A chest radiograph was performed, followed by bedside thoracic ultrasound by the emergency physician.
Central venous
catheter
Enlarged cardiac silhouette, occupying
more than 50% of the chest diameter
A
24
February 2013 • Volume 27 • Number 2
Right ventricle
Interventricular
septum
Left ventricular
outflow tract
with aortic valve
Left ventricle
Pericardial
effusion
Pericardium
Left atrium
Pleural effusion
Mitral valve
B
A: The patient’s upright chest radiograph reveals an enlarged cardiac silhouette, although it was unchanged from his
prior radiograph. The differential diagnosis includes cardiomegaly and pericardial effusion. Because the density of the
myocardium, blood within the heart, and pericardial fluid are nearly identical, they cannot be distinguished on chest
radiograph.
B: Parasternal long-axis echocardiogram reveals several key findings: a large pericardial effusion, a pleural effusion not
evident on the chest radiograph, and an enlarged right ventricle similar in size to the left ventricle—an indication of
significant pulmonary hypertension. Right ventricular enlargement can also be seen with acute pulmonary embolism,
which can cause an acute increase in pulmonary artery pressures and right ventricular volume overload.
A chest radiograph alone cannot reliably differentiate pericardial effusion from cardiomegaly. Bedside ultrasound should
be considered whenever an enlarged cardiac silhouette is present on chest radiograph because this could disguise pleural
effusions, which are readily detected with thoracic ultrasound. The right ventricular enlargement indicates elevated right
heart pressures, with a differential diagnosis including chronic pulmonary hypertension from a variety of causes and
acute pulmonary embolism.
The patient was admitted for further management of his pericardial effusion and pulmonary hypertension. Evaluation
was negative for pulmonary embolism, and the patient did not develop pericardial tamponade.
Thanks to Michael Boniface, MD, for ultrasound images and development of this case.
Feature Editor: Joshua S. Broder, MD, FACEP. See also Diagnostic Imaging for the Emergency Physician (winner of the 2011
Prose Award in Clinical Medicine, the American Publishers Award for Professional and Scholarly Excellence) by Dr. Broder,
available from the ACEP Bookstore, www.acep.org/bookstore.
25
Critical Decisions in Emergency Medicine
Questions
Qualified, paid subscribers to Critical Decisions in Emergency Medicine may receive CME certificates for up to 5
ACEP Category I credits, 5 AMA PRA Category 1 Credits™, and 5 AOA Category 2-B credits for answering the following
questions. To receive your certificate, go to www.acep.org/newcriticaldecisionstesting and submit your answers online.
On achieving a score of 75% or better, you will receive a printable CME certificate. You may submit the answers to
these questions at any time within 3 years of the publication date. You will be given appropriate credit for all tests you
complete and submit within this time. Answers to this month’s questions will be published in next month’s issue.
1. According to the American Heart Association (AHA), the
recommended sequence for cardiopulmonary resuscitation
(CPR) is:
A. call for help and get the automated external defibrillator (AED),
check responsiveness, open the airway and give 2 breaths,
check the pulse, give 30 compressions
B. call for help and get the AED, open the airway and give
2 breaths, check responsiveness, check the pulse, give 30
compressions (if no pulse)
C. check for responsiveness and breathing, call for help and get
the AED, check the pulse, give 30 compressions, open the
airway and give 2 breaths
D. check for responsiveness and breathing, call for help and get
the AED, open the airway and give 2 breaths, check the pulse,
give 30 compressions
2. Which of the following is correct regarding the
recommended sequence for CPR?
A. check for breathing and give 2 breaths, then check for pulse
and give compressions
B. open the airway and give 2 breaths, check the pulse and give
30 compressions
C. the sequence is chest compressions, airway, breathing (C-A-B)
D. the sequence is airway, breathing, chest compressions (A-B-C)
3. Which of the following is correct regarding the AHA
recommendations for chest compressions in CPR?
A. compressions should be given at a rate of about 100/min
B. compressions should be initiated within 20 seconds of
recognition of the arrest
C. compressions should be initiated within 10 seconds of
recognition of the arrest
D. each cycle of 30 compressions should be completed in ≤23
seconds
4. Which of the following is correct regarding recommended
compression depths in pediatric patients?
A. children: one-half the diameter of the chest
B. children: at least one-third the depth of the chest—
approximately 2 inches (5 mm)
C. infants: one-third the diameter of the chest
D. infants: less than one-third the diameter of the chest
5. Which of the following is correct regarding the use of
cricoid pressure?
A. cricoid pressure is no longer routinely recommended by the
AHA for ventilation
B. it is easy to train providers to perform the Sellick maneuver
C. use of cricoid pressure eliminates the possibility of aspiration
D. use of cricoid pressure is mandatory when there are an
adequate number of rescuers
26
6. Which of the following applies to pediatric defibrillation?
A. for refractory ventricular fibrillation (VF), subsequent energy
levels should never exceed 4 J/kg
B. for refractory VF, subsequent energy levels should be at least 4
J/kg
C. the initial dose for defibrillation should never be more than
2 J/kg
D. some data suggest that higher defibrillation doses may be
unsafe and potentially less effective
7. Which of the following is correct regarding the AHA’s 2010
recommendations for assessment of breathing during
CPR?
A. after delivery of 30 compressions, lone rescuers do not need to
open the victim’s airway and deliver 2 breaths
B. breathing is not part of the check for cardiac arrest but is a
separate, unique step in the CPR sequence
C. health care providers should not check for breathing when
checking responsiveness
D. “look, listen, and feel for breathing” has been removed from
the sequence for assessment of breathing after opening the
airway
8. Which of the following is the basis for the AHA’s 2010 CPR
recommendations of C-A-B?
A. compressions are the critical element in resuscitation
B. shallow compressions are sufficient to generate the pressures
necessary to perfuse the coronary and cerebral arteries
C. slower compressions are required to generate the pressures
necessary to perfuse the coronary and cerebral arteries
D. ventilations are the critical element in resuscitation
9. The rationale for the recommended use of higher
energy doses for defibrillation is based on which of the
following?
A. doses above 4 J/kg (as high as 9 J/kg) have provided effective
defibrillation in children and animal models of pediatric arrest,
with no significant adverse events
B. the upper limit for safe defibrillation is well established
C. the use of higher energy doses has not provided successful
resuscitation
D. the use of higher energy doses (up to 9 J/kg) has been
associated with significant adverse effects
10. Which of the following is correct regarding the use of
calcium in cardiac arrest patients?
A. it is recommended for all pediatric cardiopulmonary arrests
B. it may be used for patients with calcium channel blocker
overdose
C. it may be used for patients with hypercalcemia
D. it should be used for patients with hypomagnesemia
February 2013 • Volume 27 • Number 2
11. Which of the following is correct regarding abnormal
uterine bleeding?
A. it is the most common cause of iron deficiency anemia in
premenopausal women
B. it is never caused by an anovulatory cycle
C. it is not commonly caused by uterine leiomyomas
D. it is not concerning in a postmenopausal patient
12. A 27 year old woman presents with severe sudden onset
of vaginal bleeding; she is saturating more than 10 pads
per hour. Despite observation and intravenous fluids the
bleeding continues and obstetrics/gynecology consultation
is not quickly available. The best option at this point is:
A. administer intravenous estrogens and apply uterine packing
B. attempt emergency department dilatation and curettage
C. give oral nonsteroidal anti-inflammatory drugs
D. use an abdominal binder to apply pressure to abdomen
13. Which term refers to prolonged uterine bleeding that is
irregular and more frequent?
A.menarche
B.menometrorrhagia
C.menorrhagia
D.metrorrhagia
16. Which of the following is correct regarding
postmenopausal bleeding?
A. bleeding that occurs after nine months of menopause is
normal
B. fibroids are a rare cause of vaginal bleeding in postmenopausal
women
C. patients with postmenopausal bleeding and an endometrial
thickness of 5 mm or more have a very low risk of endometrial
cancer
D. the source of vaginal bleeding in postmenopausal patients is
confined to gynecologic sites
17. Which of the following drugs is the first nonhormonal
product approved by the FDA for the treatment of heavy
menstrual bleeding?
A.DDAVP
B.ibuprofen
C.norethindrone
D. tranexamic acid
18. What is the most common cause of vaginal bleeding in the
peripubertal age group?
A.anovulation
B. exogenous hormone use
C. thyroid dysfunction
D.vaginitis
14. A 16-year-old girl presents with a history of excessive
vaginal bleeding associated with irregular and
unpredictable menses. She denies any sexual activity,
and a pregnancy test is negative. She states that she
has been soaking one pad every 3 hours for 2 days. On
pelvic examination, her uterus is of normal size and is
nontender. Her adnexa are not tender and are without
masses. Her cervical os is closed, and there is a brisk
amount of bleeding from the os. The remainder of her
physical examination is unremarkable. Her CBC is notable
for a hemoglobin of 6.9 g/dL, hematocrit of 21%, and
mean corpuscular volume (MCV) of 61 fL. The most likely
diagnosis is:
A. anovulatory uterine bleeding
B. ectopic pregnancy
C. intrauterine pregnancy
D. ovarian malignancy
19. Which of the following statements regarding
endometriosis is correct?
A. the extrauterine endometrial tissue does not typically respond
to normal cyclic hormonal changes
B. nonspecific pelvic tenderness is a rare finding
C. the pathophysiology of endometriosis has been elucidated in
multiple studies
D. symptoms usually improve during pregnancy and after
menopause
15. During clinical evaluation of a patient with vaginal
bleeding, which of the following is the most important to
recognize?
A. age of the patient
B. presence of pelvic pain
C. previous pregnancy history
D. signs of circulatory shock
20. Which of the following statements is correct regarding
uterine fibroids?
A. fibroids are typically malignant
B. fibroids become smaller in early pregnancy
C. rapid growth of fibroids at any age or growth after menopause
is concerning for malignant transformation
D. they do not affect the uterine ability to contract
Answer key for January 2013, Volume 27, Number 1
1
D
2
D
3
C
4
A
5
A
6
B
7
D
8
C
9
A
10
D
11
C
12
C
13
A
14
D
15
B
16
C
17
B
18
B
19
A
20
C
27
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PERMIT NO.
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February 2013 • Volume 27 • Number 2
Critical Decisions in Emergency Medicine is the official CME
publication of the American College of Emergency Physicians.
Additional volumes are available to keep emergency medicine
professionals up-to-date on relevant clinical issues.
Editor-in-Chief
Louis G. Graff IV, MD, FACEP Professor of Traumatology and
Emergency Medicine, Professor of Clinical Medicine, University of
Connecticut School of Medicine; Farmington, Connecticut
Section Editor
J. Stephen Bohan, MS, MD, FACEP Executive Vice Chairman
and Clinical Director, Department of Emergency Medicine, Brigham
& Women’s Hospital; Instructor, Harvard Medical School, Boston,
Massachusetts
Feature Editors
Michael S. Beeson, MD, MBA, FACEP Program Director,
Department of Emergency Medicine, Akron General, Akron, Ohio;
Professor, Clinical Emergency Medicine, Northeastern Ohio Universities
College of Medicine, Rootstown, Ohio
Joshua S. Broder, MD, FACEP Associate Clinical Professor of
Surgery, Residency Program Director, Division of Emergency Medicine,
Duke University Medical Center, Durham, North Carolina
The Drug Box
Tranexamic Acid
Dale Robinson, DO, Akron General Medical Center
Tranexamic acid is an antifibrinolytic therapy currently approved in the United
States for use in dysfunctional uterine bleeding-related menorrhagia and for
perioperative use in patients with hemophilia undergoing dental procedures.
Emerging data are beginning to support its use for bleeding trauma patients early
in their care, although this is still considered an off-label use. Other off-label uses
include prevention of dental procedure bleeding in anticoagulated patients and
treatment of hereditary angioedema.
Mechanism of
Action
Indications
Dosing
Side Effects
Contraindications/
Precautions
Lysine analog: blocks lysine-binding sites on plasminogen and plasmin
and ultimately decreases plasmin available for fibrin degradation.
FDA-approved uses: menorrhagia; dental extractions in patients with
hemophilia
Off-label uses: trauma-associated hemorrhage; hereditary
angioedema; prevention of bleeding after dental surgery in nonhemophilia patient; traumatic hyphema; prophylactic bleeding
reduction in select perioperative settings
Menorrhagia: 1,300 mg orally 3 times/day during menstruation
(maximum 5 days)
Dental extraction in adult hemophilia patients: 10 mg/kg IV
immediately before surgery; may continue for 2-8 days postoperatively
Renal dosing adjustments needed.
Trauma-associated hemorrhage*: loading dose 1 gram IV over 10
minutes, then 1 gram IV over the next 8 hours
Prevention of dental procedure bleeding in patient on anticoagulant*:
oral rinse 10 mL for 2 minutes then spit, up to 4 times/day for 2 days
Common side effects: headache, backache, abdominal pain/
gastrointestinal upset
Serious side effects: hypersensitivity reaction, hypotension (with rapid
injection), thromboembolism
Contraindications: hypersensitivity, subarachnoid hemorrhage, current
thromboembolic disease, acquired color vision defect
Caution: renal impairment, upper urinary tract bleeding, disseminated
intravascular coagulation, history of thromboembolic disease,
concurrent use of oral contraceptives unless benefits outweigh risk
Avoid concurrent use of factor IX.
Pregnancy category B
*Off-label use.
Feature Editors: Michael S. Beeson, MD, MBA, FACEP; Steven Warrington, MD.
Amal Mattu, MD, FACEP Professor and Vice Chair, Department of
Emergency Medicine, Director, Faculty Development and Emergency
Cardiology Fellowships, University of Maryland School of Medicine,
Baltimore, Maryland
Robert C. Solomon, MD, FACEP Clinical Assistant Professor of
Emergency Medicine, West Virginia School of Osteopathic Medicine,
Lewisburg, West Virginia; attending physician, Trinity Health System,
Steubenville, Ohio
Associate Editors
Daniel A. Handel, MD, MPH, FACEP Vice Chair and Director of
Clinical Operations; Associate Professor, Department of Emergency
Medicine; Oregon Health & Science University, Portland, Oregon
Frank LoVecchio, DO, MPH, FACEP Research Director, Maricopa
Medical Center Emergency Medicine Program; Medical Director,
Banner Poison Control Center, Phoenix, Arizona; Professor, Midwestern
University/Arizona College of Osteopathic Medicine, Glendale, Arizona
Sharon E. Mace, MD, FACEP Associate Professor, Department of
Emergency Medicine, Ohio State University School of Medicine; Faculty,
MetroHealth Medical Center/Cleveland Clinic Foundation Emergency
Medicine Residency Program; Director, Pediatric Education/Quality
Improvement and Observation Unit, Cleveland Clinic Foundation,
Cleveland, Ohio
Lynn P. Roppolo, MD, FACEP Associate Emergency Medicine
Residency Director, Associate Professor of Emergency Medicine,
University of Texas Southwestern Medical Center, Dallas, Texas
Robert A. Rosen, MD, FACEP Medical Director, Culpeper Regional
Hospital, Culpeper, Virginia; Associate Professor, Emergency Medicine,
University of Virginia School of Medicine, Charlottesville, Virginia
George Sternbach, MD, FACEP Clinical Professor of Surgery
(Emergency Medicine), Stanford University Medical Center, Stanford,
California
Kathleen Wittels, MD Instructor, Harvard Medical School, Boston,
Massachusetts
Editorial Staff
Mary Anne Mitchell, ELS, Managing Editor
Mike Goodwin, Creative Services Manager
Jessica Hamilton, Educational Products Assistant
Lexi Schwartz, Subscriptions Coordinator
Marta Foster, Director, Educational Products
Critical Decisions in Emergency Medicine is a trademark owned
and published monthly by the American College of Emergency Physicians,
PO Box 619911, Dallas, TX 75261-9911. Send address changes and
comments to Critical Decisions in Emergency Medicine, PO Box 619911,
Dallas, TX 75261-9911, or to [email protected]; call toll free 800-7981822, or 972-550-0911.
Copyright 2013 © by the American College of Emergency Physicians. All
rights reserved. No part of this publication may be reproduced, stored,
or transmitted in any form or by any means, electronic or mechanical,
including storage and retrieval systems, without permission in writing
from the Publisher. Printed in the USA.
The American College of Emergency Physicians (ACEP) makes every
effort to ensure that contributors to its publications are knowledgeable
subject matter experts. Readers are nevertheless advised that the
statements and opinions expressed in this publication are provided
as the contributors’ recommendations at the time of publication and
should not be construed as official College policy. ACEP recognizes the
complexity of emergency medicine and makes no representation that
this publication serves as an authoritative resource for the prevention,
diagnosis, treatment, or intervention for any medical condition, nor
should it be the basis for the definition of, or standard of care that should
be practiced by all health care providers at any particular time or place.
Drugs are generally referred to by generic names. In some instances,
brand names are added for easier recognition. Device manufacturer
information is provided according to style conventions of the American
Medical Association. ACEP received no commercial support for this
publication. To the fullest extent permitted by law, and without
limitation, ACEP expressly disclaims all liability for errors or
omissions contained within this publication, and for damages
of any kind or nature, arising out of use, reference to, reliance
on, or performance of such information.
ISSN 2325-0186 (Print)
ISSN 2325-8365 (Online)