Volume 31 Number 1 January 2017

Pregnant Pause
Pregnant patients frequently present to the emergency
department with vaginal bleeding, but it can be
challenging to differentiate between benign presentations
and those that are life-threatening to both the mother
and developing fetus. The most common obstetrical
emergencies — ectopic pregnancy, placenta previa, and
placental abruption — must be evaluated and managed
with true clinical competency.

Pins and Needles

Pain management may be relatively straightforward when
a patient’s complaints are related to a specific disorder.
Chronic painful conditions, on the other hand, present
unique clinical challenges, especially in patients without
objective
Lumbar laboratory
puncture (LP)oris radiologic
used in theevidence of disease.
diagnostic
Emergency physicians must understand how to assess and
evaluation of central nervous system (CNS) processes,
most commonly in cases of suspected infection and and
treat more nebulous disorders such as fibromyalgia
complex regional
subarachnoid pain syndrome
hemorrhage. with boththe
Less commonly, medications
and non-pharmacological
procedure interventions.
is used for therapeutic purposes (eg, in cases
of idiopathic intracranial hypertension).

THE OFFICIAL CME PUBLICATION OF THE AMERICAN COLLEGE OF EMERGENCY PHYSICIANS

IN THIS ISSUE
Lesson 1 n Vaginal Bleeding in Pregnant Patients . . . . . . . . . . . . . . . . 3
Critical ECG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Critical Decisions in Emergency Medicine is the official
LLSA Literature Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 CME publication of the American College of Emergency
Physicians. Additional volumes are available to keep
Critical Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 emergency medicine professionals up to date on
Critical Image . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 relevant clinical issues.

Lesson 2 n Fibromyalgia and Complex Regional Pain Syndrome . . . 15

EDITOR-IN-CHIEF
CME Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Michael S. Beeson, MD, MBA, FACEP
Drug Box/Tox Box . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Northeastern Ohio Universities,
Rootstown, OH
NEXT MONTH SECTION EDITORS
n Pediatric Blunt Abdominal Trauma Andrew J. Eyre, MD
n Skiing and Snowboarding Injuries Brigham & Women’s Hospital/Harvard Medical School,
Boston, MA

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 Pregnant Pause
Vaginal Bleeding
in Pregnant Patients

LESSON 1

By Michelle D. Lall, MD, MHS, FACEP; and

Megan Cloutier Henn, MD
Drs. Lall and Henn are assistant professors in the Department of Emergency
Medicine at the Emory University School of Medicine in Atlanta, Georgia.
Reviewed by Kathleen A. Wittels, MD

OBJECTIVES
On completion of this lesson, you should be able to: CRITICAL DECISIONS
1. Identify the life-threatening causes of vaginal bleeding in n How should suspected ectopic pregnancy be
pregnant patients.
evaluated in the emergency department?
2. Describe the workup and management of both stable
and unstable pregnant patients with vaginal bleeding. n How should ectopic pregnancy be managed in

3. Explain the signs and symptoms of ectopic pregnancy. the acute setting?
4. Understand the role of bedside ultrasound in the evaluation n What features of third-trimester bleeding suggest
of a possible ectopic pregnancy. placenta previa?
5 Identify the clinical features that differentiate placenta n How should placenta previa be managed in the
previa from placental abruption.
acute setting?
6. Explain the risk factors for placental abruption.
n What signs should raise suspicion for placental
abruption?
FROM THE EM MODEL
n How should suspected placental abruption be
13.0 Obstetrics and Gynecology
treated in the emergency department?
13.3 Complications of Pregnancy

Pregnant patients frequently present to the emergency department with vaginal bleeding, but it can be
challenging to differentiate between benign presentations and those that are life-threatening to both the
mother and developing fetus. The most common obstetrical emergencies — ectopic pregnancy, placenta previa, and
placental abruption — must be handled with true competency. The clinician’s primary role is to identify the most likely
cause of bleeding based on estimated gestational age, and select the appropriate diagnostic tools for evaluation.

January 2017 n Volume 31 Number 1 3

 CASE PRESENTATIONS
■ CASE ONE
A 25-year-old woman arrives
via ambulance after experiencing
a syncopal episode at home. She
awoke in the middle of the night
and collapsed on her way to the
bathroom. Her initial vital signs
were blood pressure 84/40, heart rate
115, respiratory rate 18, temperature
36.5°C (97.7°F), and oxygen
saturation 98% on room air. EMS
obtained peripheral intravenous (IV)
access and administered a 1-liter
bolus of normal saline.
On arrival in the emergency
department, her blood pressure has
improved to 95/50 and her heart
rate to 110. The patient complains
of abdominal cramping and vaginal
bleeding for one day. The physical
examination confirms moderate
vaginal bleeding and significant
tenderness in the left lower quadrant.
Large-bore IV access is obtained
and a second 1-liter bolus of normal
saline is initiated. The patient
is placed on continuous cardiac
monitoring and laboratory tests
Ectopic Pregnancy
Pathophysiology
Ectopic pregnancy, which occurs
when a fertilized egg implants outside
of the main cavity of the uterus, can
be life-threatening if not diagnosed
and appropriately treated early in the
clinical course (Figure 1). Risk factors
for ectopic pregnancy include prior tubal
infections, pelvic inflammatory disease,
smoking, advanced age, prior medical
or spontaneous abortion, tubal surgery,
removal of a prior ectopic pregnancy, and
use of an intrauterine device (IUD).
The abnormal site of implantation
typically causes the pregnancy to grow
at a slower rate, which may result in low
or falling beta-hCG production.1 This
complication can trigger spontaneous
involution of the pregnancy, tubal
abortion into the vagina or peritoneal
cavity, or rupture of the pregnancy
causing internal or vaginal bleeding.
4 Critical Decisions in Emergency Medicine
are ordered, including a complete
blood count (CBC), type and
crossmatch, and a beta-human
choriogonadotropin (beta-hCG)
assay. An ultrasound machine is
brought to the bedside.
■ CASE TWO
A 26-year-old woman presents
with bright red vaginal bleeding
that began earlier that morning. She
denies abdominal pain, cramping,
or contractions. The patient is
currently 32 weeks pregnant, but
has received neither prenatal care
nor an ultrasound examination. Her
vital signs are blood pressure 110/70,
heart rate 94, respiratory rate 18,
temperature 37.2°C (98.9°F), and
oxygen saturation 98% on room air.
Intravenous access is obtained and
the patient is placed on continuous
cardiac monitoring. A formal
prenatal ultrasound is ordered,
along with a type and screen and
CBC. Fetal cardiotocodynamic
monitoring is initiated and the on-call
obstetrician is paged.
Clinical Presentation
Abdominal pain, vaginal bleeding,
and a missed menstrual cycle or
positive pregnancy test comprise the
classic triad of ectopic pregnancy. Pelvic
or abdominal pain is present in nearly
all such cases, and vaginal bleeding
occurs in nearly 75% of patients.1
Patients often present with symptoms
of normal pregnancy such as fatigue,
weight gain, breast tenderness, nausea
and vomiting, and lower abdominal
pain or cramps. Other presentations
that should prompt suspicion for the
diagnosis include but are not limited to
syncope, fever, dizziness or weakness,
and cardiac arrest. However, these
signs are highly variable; symptoms and
risk factors are unreliable when used
alone to diagnose ectopic pregnancy. 2
Clinically significant findings
may include abdominal tenderness
to palpation, abdominal rigidity,
■ CASE THREE
A 35-year-old woman who is 37
weeks pregnant arrives via ambulance.
She is experiencing nausea, abdominal
pain and cramping, and vaginal
bleeding. Her vital signs are blood
pressure 120/70, heart rate 88,
respiratory rate 16, temperature 37.2°C
(98.9°F), and oxygen saturation 99%
on room air. She has had an otherwise
normal and healthy pregnancy.
An examination confirms bright red
vaginal bleeding and increased uterine
tone; no other trauma is noted, and a
focused assessment with sonography in
trauma (FAST) examination is negative.
Laboratory tests are ordered, including
a comprehensive metabolic panel
(CMP), CBC, type and crossmatch,
coagulation studies (PT, INR, PTT), a
disseminated intravascular coagulation
(DIC) panel (D-dimer, fibrinogen,
fibrin degradation products), and a
transabdominal ultrasound. The patient
is placed on continuous cardiac and
fetal cardiotocodynamic monitoring.
involuntary guarding, positive
orthostatic vital signs, and signs of
shock (eg, hypotension and tachycardia).
Pelvic examination findings may include
an enlarged or tender uterus, cervical
motion tenderness, uterine tenderness
to palpation, debris in the vaginal vault,
and possibly an adnexal mass. 2
CRITICAL DECISION
How should suspected ectopic
pregnancy be evaluated in the
emergency department?
As with any other patient, an
assessment of the ABCs (airway,
breathing, and circulation) comes first.
The patient should be placed on a cardiac
monitor, IV access should be established,
and initial stabilization measures
should take priority. Initial diagnostic
testing should include a urine or serum
pregnancy test (whichever can be
performed faster), a quantitative serum
beta-hCG assay, and ultrasonography.
A single quantitative beta-hCG value
cannot be used to rule out the diagnosis.
These levels can be low, normal, or
higher than expected for gestational
age. In one series of ruptured ectopic
pregnancies, beta-hCG values were
as low as 10 mIU/mL and as high as
189,720 mIU/mL. 3 In another patient
series, women with pain or bleeding and
serum beta-hCG levels lower than 1,500
mIU/mL had a substantially increased
risk of ectopic pregnancy, along with a
low likelihood of normal intrauterine
pregnancy.4
An ultrasound evaluation should
be performed regardless of the
patient’s beta-hCG level. If a definitive
intrauterine pregnancy (IUP) is not
visualized on ultrasound when the beta-
hCG level is near the discriminatory
zone, the clinician must maintain a high
index of suspicion for ectopic pregnancy
and a very low threshold for further
diagnostic imaging. 5
In the event of a positive pregnancy
test and free fluid in the abdomen on
bedside ultrasound, a ruptured ectopic
pregnancy should be assumed until
definitively ruled out (Figure 2). In such
cases, a finding of free intraperitoneal
fluid in the Morison pouch (as
identified by bedside transabdominal
ultrasonography) rapidly identifies
and predicts the need for operative
intervention.6
Obstetrics and gynecology should be
consulted immediately; if these services
are unavailable, the patient should be
prepared for immediate transfer to a
facility that can provide a higher level
of care. Preoperative laboratory tests
should be obtained, including a CMP,
CBC, and type and crossmatch; and
aggressive fluid resuscitation (20-mL/kg
bolus) should be initiated with large-
bore intravenous access.
Additional resuscitation with packed
red blood cells and other blood products
should be performed as needed for
hemorrhagic shock. In the event that
crossmatched blood is unavailable,
type O Rh-negative blood should be
administered to minimize the risk of an
Rh incompatibility reaction.
If the patient is unstable, bedside
ultrasound should be used to evaluate
for the presence of free fluid. Free
fluid in the hepatorenal, splenorenal,
and suprapubic regions accompanied
by an empty uterus should increase
clinical suspicion for a ruptured ectopic
pregnancy.
Bedside or formal transvaginal
ultrasonography is the diagnostic study
of choice for detecting extrauterine
pregnancy in hemodynamically stable
patients. An empty uterus in a patient
with a beta-hCG level above the
institutional specific discriminatory
laboratory cut-off (1,000 to 2,000
mIU/mL) is an ectopic pregnancy until
proven otherwise.7 However, a single
measurement of beta-hCG is non-
diagnostic; the test is most reliable
when coupled with a transvaginal
ultrasound.8
An ultrasound that fails to
show an IUP but reveals adnexal
gestational tissue is suspicious for an
ectopic pregnancy (Figure 3).9 The
diagnostic sensitivity and specificity
of transvaginal ultrasound can be
improved with color-flow Doppler.
Laparoscopy remains the gold standard
for the diagnosis and treatment
of unstable patients with ectopic
pregnancy.9
FIGURE 1. Four Common Types of Ectopic Pregnancies
CRITICAL DECISION
How should ectopic pregnancy be
managed in the acute setting?
Patients with ectopic pregnancy
can be treated expectantly, medically,
or surgically. Women who are
hemodynamically unstable or exhibit
significant peritoneal signs should be
definitively managed in the operating
room with laparoscopy. Patients who
necessitate operative management include
those with hypovolemic/hemorrhagic
shock, a large amount of peritoneal fluid,
or an open cervical os.
Medical management most commonly
involves the use of methotrexate,
which is appropriate for patients who
are hemodynamically stable, show no
evidence of rupture or fetal cardiac
activity, and have a tubal mass smaller
than 3.5 cm.
Expectant management often is
chosen when the diagnosis remains
unclear even after a beta-hCG test and
transvaginal ultrasound have been
obtained. This diagnostic ambiguity
can occur in any early pregnancy of
unknown location. Regardless of the
treatment plan, any patient found to be
Rh-negative should receive intramuscular
Rho(D) immune globulin.7 This
January 2017 n Volume 31 Number 1 5
 should be suspected and a transvaginal
FIGURE 2. Ruptured Ectopic Sac ultrasound should be performed to
In this image, free fluid visualized in the right upper quadrant (Morison pouch) is confirm the diagnosis.11
consistent with a ruptured ectopic pregnancy in a woman with an empty uterus Placenta previa increases the
on ultrasound and a positive pregnancy test. risk of antepartum, intrapartum,
and postpartum hemorrhage, and
is associated with increased rates of
preterm delivery, neonatal intensive
care unit admission, and neonatal and
perinatal death. For women who have
not already undergone an ultrasound,
imaging should be initiated prior to a
digital vaginal examination because
manual palpation of the placenta may
cause hemorrhage.

CRITICAL DECISION
How should placenta previa be
managed in the acute setting?
Placenta previa with active bleeding
indicates a potential emergency.
IMAGE CREDIT: EMORY UNIVERSITY DEPARTMENT OF EMERGENCY MEDICINE DIVISION OF EMERGENCY Obstetrics should be consulted
ULTRASOUND immediately, and if unavailable,
preparations should made to transfer
blood product prevents the maternal (Figure 4) by the presence of placental the patient. The mother should be
production of Rh antibodies, thus tissue overlying the internal cervical os. evaluated continuously for signs
preventing the development of fetal A transabdominal ultrasound (either of shock and undergo cardiac
hemolytic anemia in future pregnancies. formal or at the bedside) should be monitoring, blood pressure checks
performed first to measure the distance every 5 minutes, Foley catheter
Placenta Previa between the lower edge of the placenta placement for accurate urine output
Pathophysiology and the internal os. If this distance is monitoring, and quantification of
Placenta previa, defined as an less than 2 to 3 cm, placenta previa vaginal blood loss.
abnormal implantation of the placenta
over the cervical os, is the leading cause
FIGURE 3. Classic Findings of Ectopic Pregnancy
of third-trimester bleeding, complicating
This ultrasound image shows a full bladder, empty uterus, and ectopic sac in
4 in 1,000 pregnancies more than
the adnexa.
20 weeks.10 Although these bleeding
episodes may be minor, if disrupted
— by pelvic examination or labor —
the separation of the placenta from
the os can tear the placental vessels,
resulting in significant hemorrhage.
Risk factors include advanced maternal
age, multiparity, prior cesarean section,
preterm labor, multiple gestation, and
smoking.10

CRITICAL DECISION
What features of third-trimester
bleeding suggest placenta
previa?
Placenta previa should be suspected
in any pregnant patient who presents
IMAGE CREDIT: EMORY UNIVERSITY DEPARTMENT OF EMERGENCY MEDICINE DIVISION OF EMERGENCY
with painless vaginal bleeding after 20
ULTRASOUND
weeks. The diagnosis can be confirmed

6 Critical Decisions in Emergency Medicine


FIGURE 4. Placenta Previa
Colored pelvic MRI scan of a 36-year-old
pregnant woman with placenta previa.
This disorder involves the placenta (lower
center) covering the cervix, the exit to the
uterus. The patient, who was unaware of
the pregnancy, had failed to have a period
for 33 weeks but had been suffering
irregular uterine bleeding due to the
placenta previa. The fetus (head down) is
seen in sagittal view, revealing its brain
(lower left).
If there are signs of maternal
shock, bolus intravenous fluids should
be administered to maintain urine
output at a rate of 20 to 30 mL/hour.
If shock persists after intravenous
fluid resuscitation with 2 liters of
0.9% normal saline, the mother
should be transfused with packed red
blood cells.
Laboratory studies should be
obtained, including a CBC; type and
screen; type and crossmatch (2 to 4
units); coagulation panel (PT, aPTT,
INR); fibrinogen measurement; and
a Kleihauer-Betke test, which can
diagnose fetal bleeding on a specimen
of vaginal blood.7 A normal fibrinogen
measurements level in pregnancy is
400 to 450 mg/dL; a value below
300 mg/dL shows consumption of
coagulation factors and is an indicator
of DIC.
Antenatal steroid treatment
with corticosteroids should be
administered to promote fetal lung
maturity in patients at 23 to 34 weeks’
gestation.12 Magnesium sulfate also is
recommended for the neuroprotective
effects it provides.13 Rh-negative
women should receive Rho(D) immune
globulin.7 An emergency delivery
necessitated by the maternal or fetal
status should not be delayed for the
administration of these medications.
Fetal cardiotocodynamic monitoring
also is required.
Indications for emergent delivery
include nonreassuring fetal tracing
despite adequate fluid resuscitation,
and life-threatening maternal
hemorrhage. Conservative management
is an option for any patient with
placenta previa who presents with an
acute symptomatic bleed responsive
to standard treatment. These patients
should receive continuous maternal and
fetal monitoring, and warrant referral
to an obstetrician for further evaluation
and management.
Placental Abruption
Pathophysiology
Any separation of the wall of the
uterus from the placenta constitutes
a placental abruption, a complication
responsible for 30% of bleeding
episodes in the second half of
pregnancy.7 Even small separations
can cause bleeding; however, these
complications often are self-limited and
not always diagnosed until delivery.
One-third of all antepartum bleeding
in the third trimester is due to placental
abruption.10
FIGURE 5. Post-Traumatic Placental Abruption
Placental abruption is most common
in women with hypertension and
preeclampsia. The risk further increases
with advanced maternal age, parity,
smoking, cocaine use, prior miscarriage
or abruption, and thrombophilia.14
Abdominal trauma also can trigger
abruption, as the uterus is elastic and
the placenta is not (Figure 5). This
complication occurs when there is
bleeding at the decidual-placental
interface, resulting in partial or total
placental detachment prior to delivery of
the fetus.
Premature placental separation
is caused by the rupture of maternal
vessels in the decidua basalis at their
interface with the anchoring villi of
the placenta. The accumulating blood
prompts the thin layer of the decidua to
separate from its placental attachment
to the uterus. The bleed may be small
or continue to accumulate, leading to
placental separation. The separated
portion of the placenta is nonfunctional;
when the remaining fetoplacental unit
is unable to compensate for this loss of
function, the fetus becomes distressed.
The etiology of most bleeds remains
unknown; only a small portion of
placental abruptions are related to
maternal trauma.
January 2017 n Volume 31 Number 1 7
 many as 50% of cases.16 The appearance
of an abruption on ultrasound depends
on its location, size, and the length of
time it has been present; it may appear
hyperechoic or isoechoic relative to the
placenta.17 Magnetic resonance imaging
n Any patient with a positive pregnancy test should be considered to have an
ectopic pregnancy until proven otherwise. (MRI) can be used to diagnose cases
n Patients with painless vaginal bleeding in the latter half of pregnancy should missed by ultrasound.16
be evaluated first with a transabdominal ultrasound to identify the location
Summary
of the placenta before receiving a vaginal examination, which can induce life-
threatening bleeding.
The pregnant patient with vaginal
n Placental abruption and placenta previa can be life-threatening to both the bleeding deserves an efficient and
mother and fetus; obstetrics should be consulted immediately upon diagnosis. thorough workup in the emergency
n Any bleeding in a patient with Rh-negative blood should be treated with department to evaluate for life-
Rho(D) immune globulin. threatening complications. In particular,
clinical suspicion should remain high
for ectopic pregnancy, placenta previa,
CRITICAL DECISION Intravenous fluid resuscitation and placental abruption. The clinician’s
should be initiated based on the primary role is to identify the most
What signs should raise suspicion
patient’s hemodynamic status; those likely cause of bleeding based on
for placental abruption?
who show persistent signs of shock estimated gestational age, and select
Acute abruption classically presents require transfused blood. Laboratory the appropriate diagnostic tools for
as abrupt-onset vaginal bleeding, studies should be obtained, including a evaluation. Hemodynamic stabilization
abdominal and back pain, and uterine CMP, CBC, type and screen, type and should always be the most critical first
contractions. These symptoms can crossmatch (2 to 4 units), coagulation step in the management of the unstable
be subtle in mild cases. On physical panel (PT, aPTT, and INR), DIC patient.
examination, the uterus is firm on panel (fibrinogen, fibrin degradation
palpation and may be tender and rigid. products, D-dimer), and a Kleihauer- REFERENCES
Vaginal bleeding ranges from mild Betke test.15 1. Surette A, Dunham SM. Chapter 13. Early Pregnancy
Risks. In: DeCherney AH, Nathan L, Laufer N, Roman
to life-threatening. Blood loss can be Magnesium sulfate should be AS. Eds. CURRENT Diagnosis & Treatment: Obstetrics
& Gynecology. 11th ed. New York, NY: McGraw-Hill;
underestimated when contained behind administered for fetal neuroprotection 2013; epub.
the placenta. in pregnancies less than 32 weeks’ 2. Ayim F, Tapp S, Guha S, et al. Can risk factors, clinical
history, and symptoms be used to predict the risk
In patients with significant gestation, and antenatal corticosteroids of ectopic pregnancy in women attending an early
pregnancy assessment unit? Ultrasound Obstet
separation, the maternal coagulation should be given for pregnancies less Gynecol. 2016; doi: 10.1002/uog.16007. epub ahead of
cascade may be triggered, causing than 34 weeks’ gestation. Group B
print.
3. Barnhart K, Mennuti MT, Benjamin I, et al.
DIC. Additional physical examination streptococcus prophylaxis may be Prompt diagnosis of ectopic pregnancy in an
emergency department setting. Obstet Gynecol.
findings include hypertonic uterine warranted according to local guidelines, 1994;84(6):1010–1015.
contractions, uterine tenderness, and and Rh-negative women should receive
4. Kohn MA, Kerr K, Malkevich D, et al. Beta-human
chorionic gonadotropin levels and the likelihood
nonreassuring fetal cardiac tracing. The Rho(D) immune globulin.12,13,15 of ectopic pregnancy in emergency department
patients with abdominal pain or vaginal bleeding.
differential diagnosis of vaginal bleeding Ultrasound is the diagnostic study Acad Emerg Med. 2003;10(2):119-126.
accompanied by pain and contractions of choice for placental abruption;
5. Layman K, Antonis M, Davis JE. Pitfalls in emergency
department focused bedside sonography
includes placental abruption, labor, however, the test can be negative in as of first trimester pregnancy. Emerg Med Int.
2013;2013:982318.
placenta previa, uterine rupture, and
subchorionic hemorrhage.15

CRITICAL DECISION
How should suspected placental
abruption be treated in the
emergency department?
Placental abruption is a significant n Using beta-hCG values alone to rule out ectopic pregnancy.
cause of maternal morbidity and fetal n Performing a pelvic examination in the latter half of pregnancy before
morbidity and mortality, with a rising confirming the location of the placenta.
incidence of 1%.14 If this diagnosis is n Relying on an ultrasound to diagnose placental abruption (this test accurate in
suspected, the patient should be placed only 50% of cases).
on continuous cardiac and fetal cardio- n Failing to consider a pregnancy-related emergency in a hemodynamically
tocodynamic monitoring, and obstetrics unstable woman.
should be consulted.

8 Critical Decisions in Emergency Medicine

 CASE RESOLUTIONS
■ CASE ONE
Positive free fluid in the right upper
quadrant and pelvis was visualized on
bedside ultrasound. The patient’s blood
pressure remained stable following
the administration of IV fluid (2 L).
Laboratory tests revealed a blood type
of A-positive, hemoglobin 9.3 g/dL,
and beta-hCG 3,587 mIU/mL. The
ultrasound confirmed a ruptured ectopic
pregnancy, and the patient was taken
immediately to the operating room.
■ CASE TWO
A formal ultrasound revealed
the lower edge of the placenta
overlying the cervical os, a finding
that confirmed the diagnosis
of placenta previa. The fetal
monitor showed good variability
with occasional decelerations.
Corticosteroids and magnesium
sulfate were administered, and
the patient underwent a successful
cesarean section the next day.
■ CASE THREE
Fetal cardiotocodynamic
monitoring indicated consistent
small contractions with late
decelerations. A computerized axial
tomography scan of the patient’s
abdomen and pelvis showed blood
between the uterine wall and
placenta; no other abdominal trauma
was noted. A cesarean section was
warranted due to fetal distress and
the full-term pregnancy.

6. Moore C, Todd WM, O’Brien E, Lin H. Free fluid in

Morison’s pouch on bedside ultrasound predicts
need for operative intervention in suspected ectopic
pregnancy. Acad Emerg Med. 2007;14(8):755-758.
7. Houry DE, Salhi BA. Chapter 178. Acute
Complications of Pregnancy. In: Marx JA,
Hockberger RS, Walls RM, eds. Rosen’s Emergency
Medicine Concepts and Clinical Practice. 8th ed.
Philadelphia, PA: Saunders; 2014; 2282-2299.
8. van Mello NM, Mol F, Opmeer BC, et al. Diagnostic
value of serum hCG on the outcome of pregnancy
of unknown location: a systematic review and meta-
analysis. Hum Reprod Update. 2012;18(6):603-617.
9. Taran AT, Kagan KO, Huber M, et al. The diagnosis
and treatment of ectopic pregnancy. Dtsch Arztebl
Int. 2015;112:693-704.
10. Wagner SA. Chapter 18. Third-trimester vaginal
bleeding. In: DeCherney AH, Nathan L, Laufer N,
Roman AS, eds. CURRENT Diagnosis & Treatment:
Obstetrics & Gynecology. 11th ed. New York, NY:
McGraw-Hill; 2013; epub.
11. Mehta SH, Sokol RJ. Chapter 12. Assessment of At-
Risk Pregnancy. In: DeCherney AH, Nathan L, Laufer
N, Roman AS. eds. CURRENT Diagnosis & Treatment:
Obstetrics & Gynecology. 11th ed. New York, NY:
McGraw-Hill; 2013; epub.
12. Gyamfi-Bannerman C, Thom EA, Blackwell SC, et al.
Antenatal betamethasone for women at risk for late
preterm delivery. N Engl J Med. 2016;374(14):1311-
1320.
13. Zeng X, Xue Y, Tian Q, et al. Effect and safety of
magnesium sulfate on neuroprotection. Medicine.
2016;95(1):1-12.
14. Echevarria MA, Kuhn GJ. Chapter 104. Emergencies
after 20 Weeks of Pregnancy and the Postpartum
Period. In: Tintinalli JE, Stapczynski J, Ma O, Cline
DM, Cydulka RK, Meckler GD, T. eds. Tintinalli’s
Emergency Medicine: A Comprehensive Study Guide.
7th ed. New York, NY: McGraw-Hill; 2011; epub.
15. Murray HG. Chapter 8. Obstetric Disorders. In:
Symonds I, Arulkumaran S. eds. Essential Obstetrics
and Gynaecology. 5th ed. Amsterdam, Netherlands:
Elsevier Ltd; 2013; 89-117.
16. Masselli G, Gualdi G. MR imaging of the placenta:
what a radiologist should know. Abdom Imaging.
2013;38(3):573-587.
17. Moore C, Promes SB. Ultrasound in pregnancy.
Emerg Med Clin N America. 2004;22(3):697-722.

January 2017 n Volume 31 Number 1 9

 A 56-year-old alcoholic man found unconscious.

The Critical ECG

Sinus rhythm, rate 70, J waves suggestive of hypothermia. By Amal Mattu, MD, FACEP
Dr. Mattu is a professor, vice chair, and
Baseline artifact is noted because the patient was shivering; his body director of the Emergency Cardiology
Fellowship in the Department of
temperature was 30°C (86°F). Osborne waves (also known as “J waves”) are
Emergency Medicine at the University
usually most notable in the precordial leads, although in this case they are of Maryland School of Medicine in
present in limb leads as well. In this case, they actually appear inverted in leads Baltimore.

V1-V2. Osborne waves are characteristic of hypothermia, although they are not
pathognomonic. Although not present in this case, other common ECG findings
in patients with hypothermia include prolongation of the intervals, bradycardias
and AV blocks, and ventricular arrhythmias.

As this patient was warmed, the Osborne waves became less prominent and
finally resolved by the time his body temperature reached 34°C (93.2°F).

From Mattu A, Brady W, ECGs for the Emergency Physician 2. London: BMJ Publishing; 2008:11,23. Reprinted with permission.

10 Critical Decisions in Emergency Medicine

 The LLSA
Literature Review
By Katrina Destree MD, LT(MC) and Daphne Morrison-Ponce, MD, LCDR,
Naval Medical Center, Portsmouth, Virginia
Reviewed by Andrew J. Eyre, MD

Recognition and Management of

Withdrawal Delirium (Delirium Tremens)
Schuckit MA. N Engl J Med. 2014;371(22):2109-2113.

Alcohol is classified as a central ner­
vous system depressant that increases
the release of gamma-aminobutyric
acid in the brain and inhibits post-
synaptic glutamate activity. Once the
body has developed a significant tolerance
to alcohol, a subsequent drop in the blood
alcohol level can trigger withdrawal
symptoms such as anxiety, insomnia,
hyperthermia, hypertension, tachycardia,
tachypnea, and tremors. These symptoms
can be seen within 8 hours after the initial
decrease in a patient’s blood alcohol level,
peak at 72 hours, and can linger for 5 to 7
days after the last drink.
The Clinical Institute Withdrawal
Assessment of Alcohol Scale (CIWA) is
a widely used tool for gauging the severity
of withdrawal symptoms and guiding
medication management. In brief, scores
lower than 8 indicate mild withdrawal
symptoms that typically do not require
medications; scores between 8 and 15
indicate moderate symptoms that usually
respond to benzodiazepines; and scores
greater than 15 may herald seizures and
delirium requiring close monitoring and
treatment with benzodiazepines.
Withdrawal delirium, also known
as delirium tremens, is evidenced by
fluctuating disturbances in attention
and cognition with or without
hallucinations. The typical onset of this
complication is 3 days after the start
of withdrawal symptoms; the typical
course runs from 1 to 8 days. The
mortality rate (1% to 4%) is secondary
Critical Decisions in Emergency Medicine’s series of LLSA reviews features articles articles from ABEM’s 2017 Lifelong Learning and
Self-Assessment Reading List. Available online at acep.org/llsa and on the ABEM website.
to cardiac arrhythmias, hyperthermia,
and complications caused by seizures
or other comorbidities. Withdrawal
delirium can be predicted by:
• A CIWA score greater than 15
• A recent seizure or prior history
of seizure or delirium
• Advanced age
• Additional misuse of depressants
• Comorbidities (eg, electrolyte
abnormalities, cardiac disease)
The management of withdrawal
delirium relies on the clinician’s ability
to identify and control symptoms in a
safe environment such as ICU or a locked
inpatient ward. Supportive treatment
includes patient reorientation; the
development of an appropriate sleep-
wake cycle; adequate hydration; and the
administration of glucose and thiamine
(to avoid Wernicke encephalopathy and
thiamine-related cardiomyopathies) and
benzodiazepines (to reduce agitation and
the risk of seizures).
A variety of benzodiazepine regimens
of have been used successfully, including
long-acting diazepam and short-acting
lorazepam; doses vary widely from patient
to patient. Alternative depressants such as
phenobarbital, midazolam, clomethiazole,
carbamazepine, and oxycarbazepine
can be considered; however, there is no
supportive data indicating that these
agents provide any benefit in patients
suffering from alcohol withdrawal.
Adjunct medications, including propofol,
dexmedetomidine and haldol, may be
used for patients with a minimal response
to high-dose benzodiazepines. These
alternative agents do, however, carry
specific contraindications for certain
populations.
***
The views expressed in this article are those of
the author(s) and do not necessarily reflect the
official policy or position of the Department of the
Navy, Department of Defense or the United States
Government.
***
I am (a military service member) (an employee of
the U.S. Government). This work was prepared
as part of my official duties. Title 17 U.S.C.
105 provides that ‘Copyright protection under
this title is not available for any work of the
United States Government.’ Title 17 U.S.C. 101
defines a United States Government work as a
work prepared by a military service member or
employee of the United States Government as part
of that person’s official duties.
KEY POINTS
n Alcohol withdrawal symptoms can be
seen within 8 hours of a patient’s last
drink, and as long as 7 days after.
n Signs of withdrawal range from agita­
tion, tachycardia, nausea/vomiting,
hypertension, and hyperthermia to
seizures and delirium.
n The management of withdrawal
delirium relies on the clinician’s
ability to identify and control
symptoms in a safe environment.
n Supportive treatment should
include the administration of IV
fluids, glucose, thiamine, and
benzodiazepines.
n Adjunct medications such as
pro­profol, haldol, and dexmedet­
omidine may be required for symp­
toms refractory to benzo­diazepines.

January 2017 n Volume 31 Number 1 11

 Intercostal nerves carry
impulses from the skin,
intercostal muscles,
and ribs; blocking this
pathway can provide
Branch 3
Dorsal rami significant — though
Innermost not complete — relief
intercostal muscle
Branch 4 from pain related to
Vein Lateral cutaneous “bruised” or fractured
Branches 1 & 2
Artery
Gray and white
Nerve
rami communicantes
ribs. Continuous
Intercostal muscle
External intercostal nerve blocks
Internal (ICNBs) have been shown
Innermost
to reduce pulmonary
Branch 5
Anterior cutaneous complications and
the need for narcotics
in patients with rib
fractures and chest wall
injuries.

The Critical
By Michael B. Pesce, MD, JD
Dr. Pesce is the chairman and medical
director of the Department of
Anesthesia at Kaweah Delta Health

Procedure
Care in Visalia, California.

Reviewed by Steven J. Warrington, MD, MEd

INTERCOSTAL NERVE BLOCK (RIB BLOCK)

CONTRAINDICATIONS Risks and Benefits
A single injection of liposomal
n Allergy to local anesthetic
bupivacaine suspension can provide
n Infection overlying the site of
relief for as many as 5 days without the
injection
need for catheter placement or repeat
injections. The primary complications
of ICNBs include pneumothorax (risk is
greatest on intubated patients receiving
positive-pressure ventilation), lung
injury (one study showed a rate of
0.1 %), absorption of toxic doses of
local anesthetic from the intercostal
space (which is rapid due high
vascularity), and a rare risk of spinal
anesthesia. Anesthetic toxicity also
can be a concern when administering
multiple intercostal injections.
Alternatives
The primary alternative to ICNB
for pain relief is oral medications.
Ultrasound guidance can be used
to supplement the Bonica method
detailed in this article. Another option
is the Omoigui Diffusion Technique,
which utilizes the spread and diffusion
characteristics of the injected local
anesthetic to block the peripheral
branches of the intercostal nerves.

12 Critical Decisions in Emergency Medicine

 The fingers are placed to stabilize
the superior and inferior borders of the
rib, respectively at a site proximal to
the area of pain. A short-bevel needle
(3 cm, 25-gauge) is inserted directly
into the midpoint of the rib, and
anesthetic is injected over the rib. There
is no need to “walk off” the lower
border of the rib or advance the needle
into the subcostal groove.
Reducing Side Effects
3 mL of 1.3% liposomal bupi­
vacaine suspension can be diluted with
10 mL of normal saline, enabling as
many as 10 injections (3 mL each) to
reduce the risk of anesthetic toxicity.
In addition, the procedure can be
performed at multiple sites/levels to
control pain and reduce the risk of
inadequate coverage.
Ultrasound guidance can be
beneficial in obese patients, and
might reduce side effects such as
pneumothorax or lung injury by
enabling direct visualization of the
needle tip.
Special Considerations
Since one primary complication
of ICNB is pneumothorax, emergency
clinicians may significantly reduce
this risk by initially considering the
procedure only in association with chest
tube placement.
The usual site for ICNB in adult
patients is at the angle of the rib, a
point at which the bone is relatively
superficial and easy to palpate and the
subcostal groove is at its widest, thus
reducing the risk of puncturing the
pleura. Injection at this site ensures
that the tissues innervated by the
lateral cutaneous nerve are properly
blocked, and eliminates the possibility
of a dural root sheath injection (and
an inadvertent spinal anesthetic). In
children, the block usually is initiated
just lateral to the paraspinous muscles.
Blocks above the 7th thoracic
vertebra may be hindered by the
scapulae, and ordinarily will require a
more medial injection entry point. A
second injection at the same level may
be required to achieve adequate anterior
coverage.
Advancing the needle much beyond
3 mm after contact with the inferior
border of the rib increases the risk of
pneumothorax, as the distance from the
posterior aspect of the rib to the pleura
averages 8 mm.
The visceral pleura is relatively
insensitive (except to stretch) and,
for the most part, impulses from the
lungs and mediastinum are carried by
the vagus nerve. The parietal pleura,
which is highly sensitive to noxious
stimuli, receives innervation from both
the intercostal and phrenic nerves.
Blocking the intercostal nerves may not
completely manage the patient’s pain.

TECHNIQUE
1. Obtain patient consent and notify staff.
2. Identify the insertion site(s):
a. Start counting from the 12th rib or from the
7th rib (the lowest rib covered by the inferior
tip of the scapula).
b. Blockade of two dermatomes above and two
below the level of injury usually is required.
3. Mark the inferior edges of the ribs to be blocked
just lateral to the lateral border of the paraspinous
muscles that correspond to the angles of the ribs.
The needle insertion site for the intercostal space is labeled 4 to
a. 4-7 cm from midline at upper ribs
7 cm lateral to the midline.
b. 6-8 cm from midline at lower ribs
4. Clean the insertion site.
5. Infiltrate with a small volume of 1% lidocaine.
6. Introduce a 25-gauge needle through the skin. It
should be beveled facing up at 20° cephalad so it
just scrapes underneath the inferior border of the
rib and reaches the subcostal groove.
7. Advance the needle up to 3 mm, still maintaining
the 20° cephalad tilt angle.
8. Aspirate to ensure you are not in the vessel.
The patient position for intercostal block. A pillow is used as an
9. Inject 3 mL of diluted long-acting anesthetic into abdominal/pelvic support, and the arms are hanging off the table.
the site, and repeat if necessary. PHOTOS COURTESY OF THE NEW YORK SCHOOL OF REGIONAL ANESTHESIA

January 2017 n Volume 31 Number 1 13

 The Critical Image
CASE By Joshua S. Broder, MD, FACEP
A 54-year-old man arrives via ambulance with abdominal pain, Dr. Broder is an associate professor and the
residency program director in the Division
vomiting, fever, and rectal bleeding. The patient is quadriplegic from of Emergency Medicine at Duke University
a remote cervical gunshot wound; he has a history of multiple prior Medical Center in Durham, North Carolina.
abdominal surgeries and bowel obstruction. His vital signs are blood Case contributor: Chanel Fischetti, MD
pressure 149/95, heart rate 150, respiratory rate 30, temperature 38.3°C
(100.9°F), and oxygen saturation 95%. The patient is
alert but diaphoretic and vomiting, with a distended A
and tender abdomen. He is tachycardic, with palpable
pulses in all extremities. His lung examination is clear.
A suprapubic catheter is in place.

A nasogastric tube is inserted, and x-rays are obtained

because of the high clinical suspicion for bowel
obstruction or perforation.

KEY POINTS
n A systematic approach to radiography should
include the identification of foreign bodies
and medical devices (eg, inserted tubes and
catheters). A single-view x-ray cannot prove the
location of an object. Visualized on a frontal
projection radiograph, for example, a tube
would have a similar appearance regardless of
its position anterior to, posterior to, or within A. An upright radiograph of the lower chest and upper
the body. A second orthogonal radiograph can abdomen. No free air is seen under the diaphragm. Notably, the
help triangulate the location; however, abnormal nasogastic tube is not seen in the stomach. Instead, it deviates
positioning may be strongly suggested by a laterally into the left chest, consistent with inadvertant left main
single x-ray. bronchus placement.
n In Figure A, the tube does not follow the expected
course through the esophagus toward the B
diaphragm (compare with Figure B) and is not Tube follows the
seen (as would be expected) within the stomach. expected course
On further review, the tube can be visualized over of the esophagus
the left lung field, suggesting it has entered the
trachea and continues into the left main bronchus.
Had the tube been used for gastric lavage, the
result could have been fatal. Recognition allowed
repositioning without ill effects.

CASE RESOLUTION
The patient was treated for sepsis and
admitted. An abdominal CT revealed ileus Tube now terminates
without obstruction or perforation. in stomach
B. A radiograph following replacement of the nasogastric tube,
which now terminates in the stomach.

14 Critical Decisions in Emergency Medicine

 Pins and Needles
Fibromyalgia and Complex
Regional Pain Syndrome

LESSON 2

By Sarah R. Money, MD; and Jonathan Glauser, MD, MBA, FACEP

Dr. Money is a clinical assistant professor in the Department of Physical Medicine &
Rehabilitation at the University of Michigan in Ann Arbor. Dr. Glauser is a professor
in the Department of Emergency Medicine at Case Western Reserve University in
Cleveland, Ohio.
Reviewed by Sharon E. Mace, MD, FACEP

OBJECTIVES
On completion of this lesson, you should be able to:
1. Apply appropriate diagnostic criteria when assessing a
patient with a chronic painful condition.
2. Describe the risk factors and clinical signs that point to
a diagnosis of fibromyalgia.
3. Explain the pharmacological and non-pharmacological
approaches to the treatment of fibromyalgia.
4. Outline the symptoms and risk factors that should raise
suspicion for complex regional pain syndrome (CRPS).
5. Describe effective strategies for managing CRPS-
related pain in the emergency department.
FROM THE EM MODEL
1.0 Signs, Symptoms, and Presentations
1.2 Pain
CRITICAL DECISIONS
n What clinical findings should raise suspicion for
fibromyalgia?
n What pharmacological agents are effective for the
treatment of fibromyalgia?
n How can ketamine be used to manage chronic
pain?
n What non-pharmacological interventions can
benefit patients with fibromyalgia?
n What symptoms should raise suspicion for complex
regional pain syndrome?
n How should acute CRPS symptoms be managed?

Pain management may be relatively straightforward when a patient’s complaints are related to a specific
disorder. Chronic painful conditions, on the other hand, present unique clinical challenges, especially in
patients without objective laboratory or radiologic evidence of disease. Emergency physicians must understand
how to assess and treat more nebulous disorders such as fibromyalgia and complex regional pain syndrome with both
medications and non-pharmacological interventions.

January 2017 n Volume 31 Number 1 15

 CASE PRESENTATIONS
■ CASE ONE
A 42-year-old woman presents
with three consecutive days of
“all-over” pain,” particularly in her
bilateral lower limbs. Her vital signs
are blood pressure 132/74, heart rate
84 and regular, respiratory rate 14,
and temperature 36.8°C (98.2°F).
She has a prescription for duloxetine
(60 mg 2x/day), but stopped taking
it “a couple of days ago” after a
breakup with her boyfriend.
The physical examination is
unremarkable, but a review of the
woman’s chart confirms a diagnosis
of fibromyalgia. A pain management
contract prohibits her from receiving
narcotics from any provider except
her pain management service;
CRITICAL DECISION
What clinical findings should
raise suspicion for fibromyalgia?
First identified in 1904 and termed
“fibrositis” until 1977, fibromyalgia is
marked by a constellation of symptoms,
including fatigue, stiffness, difficulty
moving, widespread and chronic pain,
cognitive dysfunction, tenderness
to palpation, dyscognition affecting
attention/forgetfulness (“fibro-fog”), sleep
disturbances, female urethral syndrome,
temporomandibular disorders, restless
legs, anxiety, and depression.
The most common cause of chronic
pain in women between the ages
of 20 and 55, fibromyalgia affects
between 2% and 3% of female patients.
Although the disorder can affect both
children and adults, its incidence
increases with age; it is significantly
more common in women than in
men (a ratio of 6:1).1,2 Even prior to
receiving a formal diagnosis, patients
with fibromyalgia visit the emergency
department more frequently, take more
prescription medications, and require
more testing than matched controls. 3
There is no “gold standard” for
diagnosing the disorder. The cause
16 Critical Decisions in Emergency Medicine
however, the emergency physician is
unable to reach the service after hours.
■ CASE TWO
A 22-year-old woman presents
with pain in her left lower limb. She
reports sustaining an ankle sprain while
playing soccer 5 weeks earlier, which
was treated with NSAIDs, ice, rest,
and elevation. She has been wearing
an ankle splint since the injury, but
recently has noticed skin changes in her
foot and ankle with worsening swelling
and pain. The patient reports that one
foot “feels warmer” than the other. Her
vital signs are heart rate 82 and regular,
blood pressure 122/68, and temperature
36.4°C (97.5°F). Her pedal pulses are
strong and symmetric, and she denies
is unknown, and patients show
no laboratory evidence of tissue
inflammation. Although not medically
life-threatening, the disease appears
to increase the risk of depression and
suicidal ideation.4
Since radiologic and laboratory
test results are unaffected by the
disease, the role of organic illness has
been questioned. The only physical
abnormality related to fibromyalgia is
the excessive tenderness of soft-tissue
sites on palpation — a highly subjective
barometer of disease (Figure 1). The
disorder does not cause joint swelling
except in cases of concurrent arthritis.
After osteoarthritis, it is the
second most common disorder treated
by rheumatologists. 5 In 1990 the
American College of Rheumatology
developed diagnostic criteria for
fibromyalgia: a history of widespread
pain (ie, above and below the waist in
both sides of the body), pain in 11 of
18 specific tender-point sites on digital
palpation, and the clinical symptoms
enumerated earlier. 6
These criteria were modified in
2010, largely because the designated
18-location tender point count seldom
was performed correctly.7 The new
recurrent injury. The patient’s
lungs are clear and she has no
proteinuria.
■ CASE THREE
A 58-year old woman with a
history of fibromyalgia presents
with fatigue, chest pain, and
diffuse aching in her joints. She
appears to be in mild distress, but
says her breathing “feels easier”
when she leans forward. She is
compliant with her prescribed
medications (milnacipran and
pregabalin). Her vital signs are
blood pressure 110/86, heart
rate 104, respiratory rate 24,
and temperature 99.8°C (100°F),
and her lungs are clear to
auscultation.
guidelines incorporated six self-
reported symptoms: impaired sleep,
fatigue, poor cognition, headaches,
depression, and abdominal pain.
Current criteria still include the
presence of symptoms for at least 3
months, widespread pain, and the
absence of a disorder that would
otherwise explain the pain (Table 1).8
Fibromyalgia shares symptoms with a
number of functional disorders, including
irritable bowel syndrome, tension and
migraine headache, temporomandibular
joint disorder, chronic fatigue syndrome,
and interstitial cystitis. These disorders all
are believed to be related to augmented
pain and sensory processing.9,10 For
purposes of this discussion, we will
assume that the diagnosis of fibromyalgia
has been established prior to the patient’s
emergency department visit.
CRITICAL DECISION
What pharmacological agents
are effective for the treatment
of fibromyalgia?
Although the pathophysiology
of fibromyalgia is, to a large extent,
outside of the scope of emergency
medicine, certain principles should be
considered. The widespread nature
of the discomfort coupled with a low
pain threshold suggests that the central
nervous system may be primarily
responsible for protean manifestations.
In other words, fibromyalgia appears to
be linked to a global problem in sensory
processing, justifying a central nervous
system approach to pain management
(Table 2). Brain imaging studies
suggest that the pain systems of these
patients are impaired by functional and
morphological changes in the forebrain.11
Three medications have been
approved by the Federal Drug
Admin­is­tration for the treatment
of fibromyalgia: duloxetine and
milnacipran (antidepressants), and
pregabalin (an anticonvulsant).
Duloxetine is a serotonin and
norepinephrine reuptake inhibitor
(SNRI) that first was studied because
of the role of 5-hydroxy tryptophan
and norepinephrine as the mediators of
descending pain pathways. The agent,
which lacks a specific affinity for opioid
receptors, can safely relieve the pain and
tenderness of fibromyalgia relative to
FIGURE 1. Trigger-Point Symptoms
Fibromyalgia
Anterior Trigger Points
placebo in doses of 60 to 120 mg/day.12
Milnacipran (12.5 mg/day up to
100 mg 2x/day) also selectively blocks
norepinephrine and serotonin reuptake,
and is considered a first-line medication
for the management of fibromyalgia.
It has been shown to effectively relieve
self-reported pain, improve physical
functioning, and reduce fatigue.13
Pregabalin, an antiepileptic drug that
binds to a subunit of a presynaptic
calcium channel, has been shown to
reduce pain and sleep disturbances
in patients with fibromyalgia.14 The
typical daily dosage ranges between
25 and 75 mg. Gabapentin, another
anticonvulsant that is structurally
related to pregabalin, also appears to
mitigate pain and improve sleep and
quality of life. The dose may range from
100 mg per day to as much as 2,400 mg
daily in divided doses.
Other drugs that show promise
include monoamine modulators such
as amitriptyline (25 to 50 mg) and
cyclobenzaprine (10 to 30 mg), which
appear to help sleep and wellbeing.15
Posterior Trigger Points
Quetiapine is the only antipsychotic
that appears to improve depression
and reduce pain in patients with
fibromyalgia.16
The management of acute and
chronic pain is evolving, as evidenced
by the promulgation of statewide
narcotic monitoring programs. With
the possible exception of tramadol,
opioids are ineffective for the treatment
of fibromyalgia and may lead to
poorer patient outcomes.17,18 Given the
skyrocketing rate of opioid addiction,
which led to the deaths of 5,500
Americans in 2014, it is incumbent
upon the emergency physician to
understand how to manage chronic
non-cancer pain without the use of
these lethal agents.19
CRITICAL DECISION
How can ketamine be used to
manage chronic pain?
The analgesic dose for ketamine
is between 0.15 and 0.6 mg/kg (most
commonly 0.3 mg/kg), infused over
approximately 10 minutes to minimize
adverse effects. It can be administered
intranasally (0.75 to 1 mg/kg), obviating
the need for injection, and also may be
continued for analgesia at an infusion rate
of 0.1 to 0.3 mg/kg/hour.20 In subdis­
sociative doses, the medication has been
shown to be as effective as morphine
(0.1 mg/kg) in relieving abdominal, flank,
and musculoskeletal pain.21
The drug’s most commonly reported
side effects are dizziness, disorientation,
mood changes, nausea, and a sense
of unreality. 21,22 However, these
complications can be ameliorated by
replacing bolus dosing with a 10-minute
infusion. 23 A glutamate receptor
antagonist, ketamine effectively blocks
the release of N-methyl-D aspartate
(NMDA), which has been implicated in
the etiology of chronic pain. The drug
also preserves airway reflexes and may
decrease the risk of developing chronic
pain following trauma.
Of note, ketamine depresses the
thalamus and limbic systems, a pitfall
that has been implicated in unpleasant
psychomometic effects and emergence
phenomena.22 It should also be
recognized that other clinicians outside
January 2017 n Volume 31 Number 1 17

TABLE 1. Differential Diagnoses
for Fibromyalgia 2,18
• Other central pain disorders
— Irritable bowel syndrome
— Chronic fatigue syndrome
— Migraine/tension headache
— Temporomandibular disorders
— Interstitial cystitis (ie, bladder pain,
urgency, frequency for >9 months)
— Localized/myofascial pain disorder
— Osteoarthritis, primary Sjogren
syndrome47
• Rheumatoid arthritis (joint deformities,
swelling, elevated erythrocyte
sedimentation rate [ESR] or creatine
phosphokinase [CRP])
• Chronic widespread pain associated
with Epstein-Barr, parvovirus, Q fever11
• Systemic lupus erythematosus (rash,
elevated ESR, ANA)
• Polymyalgia rheumatica (age >60,
stiffness when inactive, elevated ESR)
• Myositis, myopathies (weakness,
elevated aldolase or CRP)
• Ankylosing spondylitis (ie, back
or neck immobility, elevated ESR,
abnormal x-rays)
• Lyme disease (positive Lyme
serologies — ELISA, Western blot)
• Hypothyroidism (ie, abnormal thyroid
function tests)
• Hyperparathyroidism (increased
serum calcium, elevated parathyroid
hormone levels)
• Vitamin D deficiency
• Statin therapy6
• Neuropathies (weakness, loss of
sensation, abnormal electromyogram,
nerve conduction velocity)
• Metastatic malignancies
• Myotonic dystrophy
• Multiple sclerosis (CSF or
immunoglobulin, MRI of brain/spinal
cord, visual evoked potentials)
the scope of emergency medicine may be
unfamiliar the use of ketamine; once a
patient is admitted, narcotics may again
become the go-to solution for pain relief.
CRITICAL DECISION
What non-pharmacological
interventions can benefit
patients with fibromyalgia?
Although not of immediate
importance in the acute management
of fibromyalgia, there are several
non-pharmacological interventions
18 Critical Decisions in Emergency Medicine
with proven efficacy (Table 3). Exercise,
especially low-impact aerobic activities
such as biking, swimming, and fast
walking can help relieve symptoms.24,25
Alternative therapies (eg, tai chi and
yoga) and moderate-intensity aerobic
training also appear to improve overall
wellbeing and physical functioning.26,27
Notably, exercise is the only therapy
strongly endorsed by the European League
Against Rheumatism for the treatment of
fibromyalgia.28
These patients may require long-term
treatment programs that incorporate
multiple specialties, including psychiatry,
rheumatology, physical therapy,
psychology, and anesthesiology.
CRITICAL DECISION
What symptoms should raise
suspicion for complex regional
pain syndrome?
Previously called reflex sympathetic
dystrophy or causalgia, complex regional
pain syndrome (CRPS) entails severe and
chronic pain and disability involving a
part or whole of a limb. CRPS type 1
(reflex sympathetic dystrophy) differs
from CRPS type 2 (causalgia), which
can be attributed to an identifiable nerve
lesion. Symptoms typically begin 4 to 6
weeks following a minor or moderate
extremity injury such as a wrist fracture,
sprain, blunt injury, stab wound, animal
bite, or elective surgery.
CRPS is a major cause of disability;
only 20% of patients are able to resume
previous activities, and approximately
73% report that the pain has prevented
them from returning to work. 29 In a
minority of cases, no precipitating event
can be identified; however, the diagnosis
may follow a stroke or myocardial
infarction (“shoulder-hand syndrome”).
The incidence can be as high as 28%
following a Colles fracture (Figure 2),
although most of these cases resolve
after one year. Approximately 3% to 5%
of patients who sustain a distal radius
fracture develop CRPS characterized by
muscle weakness in the injured limb and
changes in sweating and hair and nail
growth patterns.30-33 Allodynia is defined
as pain induced by non-painful stimuli
(painful touch), whereas hyperalgesia
is marked by discomfort that is dispro­
portionate to the inciting event. One or
both of these signs should be present.
Pain, sensory, trophic, and motor
symptoms are not confined to single-
nerve innervation territories. 32 Vaso­
motor findings manifest as temperature
asymmetry, changes in skin color,
an increase or decrease in sweating,
or edema. 34 Unlike in fibromyalgia,
objective evidence may be available
for the diagnosis of CRPS, including
comparative differences in skin
temperature between limbs and
abnormal imaging (eg, CT, x-ray, MRI,
bone scan) or autonomic test results.
The diagnosis of CRPS is excluded by
the existence of another condition that
would better explain the degree of pain
and dysfunction (Table 4).35 As noted
earlier, CRPS type 2 entails a nerve
injury, although the continuing pain and
allodynia is not necessarily related to the
distribution of that nerve. The disease
TABLE 2. Drug Therapies for
Fibromyalgia
• Duloxetine (starting dose 60 mg/day,
up to 60 mg 2x/day)
• Milnacipran (12.5 mg each morning,
up to 50 mg 2x/day)
• Venlafaxine
• Fluoxetine
• Gabapentin (starting dose
300 mg/day, up to 2,400 mg/day)
• Pregabalin (starting dose 75 mg/day,
up to 450 to 600 mg/day)
• Amitriptyline (starting dose 10 to
25 mg/day)
• Cyclobenzaprine48
• Tramadol (200 to 300 mg/day3)
TABLE 3. Alternative Therapies
for Fibromyalgia
• Exercise (eg, strength training,
flexibility, walking, biking)
• Cognitive behavioral therapy
• Music therapy13
• Hyperbaric oxygen therapy
• Herbal medicine (Ganoderma
lucidium)17
• Trigger-point injections
• Chiropractic manipulation
• Acupuncture, electroacupuncture,
moxibustion
• Myofascial release therapy
• Tai chi, yoga27

FIGURE 2. Colles Fracture
may involve the disinhibition of spinal
and trigeminal nociceptive neurons.33
CRPS, which affects 26 out of
100,000 patients, is most common in
women between the ages of 61 and 70
years. 36 Approximately 60% of cases
affect the upper extremities, and 40%
affect the leg. It is not uncommon
for several family members to share
the diagnosis, suggesting a genetic
predisposition for the disease.
the affected extremity; in general, splints,
slings, and immobilizing devices should
be avoided. 32,37 A tricyclic antidepressant
can be prescribed to reduce sleep distur­
bances. Intravenous immunoglobulin
has been used to positive effect, with
the rationale that CRPS is related to
the presence of unidentified neural
antibodies. 39 There is some evidence that
gabapentin or carbamazepine therapy
also may reduce pain. 35
Low-dose ketamine (5 mg/hour),
which prevents or attenuates the
hyperalgesia and allodynia of CRPS,
may induce long-term pain relief when
administered over 4 to 14 days.40-43
Lidocaine
Topical lidocaine patches, creams,
and ointments — including an eutectic
mixture of local anesthetic cream
(EMLA) and a 5% lidocaine-impregnated
patch — can be used to treat CRPS, as
FIGURE 3. Mechanism of CRPS
well as cases of postherpetic neuralgia.44
Intravenous lidocaine (in doses
between 1.5 mg/kg and 100 mg IV)
has proven effective in reducing pain
in patients with renal colic and acute
low back pain; however, its use in
chronic and neuropathic pain has yet
to be elucidated. 23 The agent’s primary
side effects, nausea and dizziness, tend
to be mild and transient. It appears
to decrease the pain response to cold
stimuli in patients with CRPS, and
decrease the spontaneous pain level.45
Lidocaine infusions frequently are
used to manage severe or neuropathic
pain, as in cases of cancer or diabetic
neuropathy, often with dramatic
results.46 An initial challenge dose
between 1 and 3 mg/kg can be infused
over 20 to 30 minutes; if effective, an
infusion of 0.2 to 2 mg/kg per hour can
be administered.

CRITICAL DECISION
How should acute CRPS
symptoms be managed?
There is evidence to support the
existence of post-traumatic inflammation
in patients with CRPS, as indicated by
elevated pro-inflammatory cytokines
interleukin 6 and interleukin 12 and
tumor-necrosis factor-α receptors.
There is level 1 evidence to confirm the
efficacy of steroids in the treatment of
CRPS.35 Nonsteroidal anti-inflammatory
drug (NSAID) or steroid therapy in the
acute stage is reasonable; high-dose
prednisolone also may be considered
(Table 5).
Bisphosphonates inhibit the activity
of osteoclasts. A single dose of pami­
dro­nate (60 mg IV) also has been
recommended. 37,38 Topical dimethyl
sulfoxide cream (50%) may provide
significant pain relief when applied for
2 months, presumably because of its role
as a free-radical scavenger. 38
Patients should be encouraged to use

January 2017 n Volume 31 Number 1 19

 injuries (eg, Colles fracture) is uncertain.
TABLE 4. Differential Diagnosis More invasive therapies that are TABLE 5. Treatments for CRPS49
for CRPS34,36 Prevention
outside of the scope of emergency
• Musculoskeletal injury (eg, stress practice include spinal cord stimulation • Vitamin C (500 mg/day for 50
fracture, ligament damage) days) following fracture or surgery
and intrathecal baclofen pumps. Blocks
• Neuropathic pain (eg, spinal lesion, NSAIDs
of the stellate ganglion, brachial plexus, • Ibuprofen
peripheral nerve damage, diabetes)
and lumbar sympathetic system all have • Naproxen
• Infection (eg, bone, joint, soft tissue)
been used with some success. 35 Patients Oral corticosteroids
• Compartment syndrome
with CRPS may benefit from long-term Anticonvulsants
• Carpal tunnel syndrome • Gabapentin
treatment steered by an interdisciplinary
• Raynaud disease • Pregabalin
team of anesthesiologists, neurologists,
• Arthritis Bisphosphonates
physiotherapists, and pain specialists.
• Arterial insufficiency (eg, Buerger • Pamidronate IV
disease, atherosclerosis, trauma) Summary • Alendronate PO (70 mg/week)
• Nerve compression or vascular Topical
Fibromyalgia and complex regional
compression from thoracic outlet • Lidocaine cream (2% to 5%/EMLA)
pain syndrome are encountered • Capsaicin (.025% to .075%)
syndrome
frequently in emergency practice; both Free-radical scavengers
• Deep vein thrombosis
require timely access to pain specialists • Dimethyl sulfoxide cream (50%)
for optimal management. It is incumbent Ketamine
Alternatives upon the medical community to keep Intravenous immunoglobulin
Tricyclic antidepressants
The role of opioids as a second- or abreast of both pharmacological
• Amitriptyline
third-line therapy (“rescue dosing”) and non-pharmacological means for • Nortriptyline
has not been defined completely, and humanely relieving patient discomfort Alpha-adrenergic blockade
grave concerns persist regarding drug without exacerbating the nationwide • Clonidine (oral or patch)
tolerance, cognitive impairment, and scourge of opioid addiction. Clinicians • Prazocin
opioid-induced hyperalgesia. 35 These should understand how to recognize • Phenoxybenzamine
patients at risk for fibromyalgia, which • Sympathectomy
agents are not recommended for the
Trigger-point injections
treatment of CRPS, except when often is marked by impaired sleep,
Regional sympathetic nerve block
initiated on the specific advice of a pain fatigue, poor cognition, headaches, Spinal cord stimulation
management specialist. 37 depression, and abdominal pain; and Epidural clonidine
complex regional pain syndrome, which Intrathecal baclofen
Non-pharmacological treatment
options include isotonic strengthening, typically begins 4 to 6 weeks following
3. Hughes G, Martinez C, Myon E, et al. The impact of a
passive gentle range of motion, aerobic an extremity injury. diagnosis of fibromyalgia on health care resource use
by primary care patients in the UK: an observational
conditioning, aquatic therapy, and study based on clinical practice. Arthritis Rheum.
REFERENCES 2006;54(1):177-183.
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of fibromyalgia and chronic widespread pain. Scand J al. Mortality in a cohort of Danish patients with
suggests that high-dose vitamin C Prim Health Care. 2000;18(3):149-153. fibromyalgia: increased frequency of suicide. Arthritis
can help prevent CRPS, its viability 2. McNally JD, Matheson DA, Bakowsky VS. The Rheum. 2010;62(10):3101-3108.
epidemiology of self-reported fibromyalgia in Canada. 5. Goldenberg DL. Diagnosis and differential
as routine therapy following high-risk Chronic Dis Can. 2006;27(1):9-16. diagnosis of fibromyalgia. Am J Med. 2009;122(12
Suppl):S14-S21.
6. Wolfe F, Smythe HA, Yunus MB, et al. The
American College of Rheumatology 1990 Criteria
for the Classification of Fibromyalgia. Report
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7. Bennett RM, Friend R, Marcus D, et al. Criteria for the
diagnosis of fibromyalgia: validation of the modified
2010 preliminary American College of Rheumatology
criteria and the development of alternative criteria.
Arthritis Care Res (Hoboken). 2014;66(9):1364-1373.
n Three drugs are approved by the FDA for the specific treatment of 8. Wolfe F, Clauw DJ, Fitzcharles MA, et al. The American
fibromyalgia: duloxetine, pregabalin and milnacipran. College of Rheumatology preliminary diagnostic criteria
for fibromyalgia and measurement of symptom severity.
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of CRPS. NSAID or steroid therapy in the acute stage is reasonable; high- 9. Brill S, Ablin JN, Goor-Aryeh I, et al. Prevalence of
fibromyalgia syndrome in patients referred to a
dose prednisolone also may be considered. tertiary pain clinic. J Investig Med. 2012;60(4):685-688.
10. Ablin J, Neumann L, Buskila D. Pathogenesis
n Fibromyalgia causes no abnormalities on serum testing or imaging; the value of fibromyalgia- a review. Joint Bone Spine.
of routing testing has not been confirmed. 2008;75(3):273-279.
11. Schmidt-Wilcke T, Clauw DJ. Fibromyalgia: from
n The role of ketamine in the emergency department management of painful pathophysiology to therapy. Nat Rev Rheumatol.
conditions has become mainstream. The agent may induce long-term pain 2011;7(9):518-527.
12. Arnold LM, Lu Y, Crofford LJ, et al. A double-blind
relief in patients with CRPS when administered over a period of 4 to 14 days. multicenter trial comparing duloxetine with placebo
in the treatment of fibromyalgia patients with or
n Both fibromyalgia and CRPS are diagnoses of exclusion. Other disorders, without major depressive disorder. Arthritis Rheum.
including autoimmune diseases, eventually may be confirmed. 2004;50(9):2974-2984.
13. Goldenberg DL, Clauw DJ, Palmer RH, et al. Durability

20 Critical Decisions in Emergency Medicine

 CASE RESOLUTIONS
■ CASE ONE ■ CASE TWO emergency physician ordered a battery
of laboratory tests that revealed
The patient with a history of fibro­ The young woman with the healing
a sedimentation rate of 94, mild
myalgia who had ceased taking her dulo­ ankle sprain was diagnosed with CRPS
anemia with a hematocrit of 31.8,
xetine received an IV dose of ketamine and given prescriptions for prednisone
and a degree of renal insufficiency
(20 mg over 10 minutes). She continued to (60 mg/day) and topical dimethyl sulf- with mildly elevated blood urea
describe her discomfort as a 5 on a 10-point oxide cream (50%). She was instructed nitrogen and serum creatinine levels.
scale, so another infusion of ketamine to put weight on her extremity and The patient’s chest x-ray was clear
(10 mg) was administered over the next discontinue use of the splint. The of infiltrate, and a bedside cardiac
hour, which resolved her pain almost patient was referred to a rheumatology ultrasound showed a moderate-sized
completely. Following another hour of clinic, where she improved following cardiac effusion.
observation, the woman felt alert and steady. trials of IV immunoglobulin and one The patient was admitted to the
She was discharged with a prescription session of ketamine therapy. medical service, where a positive
for pregabalin (50 mg/day) and antinuclear antibody (ANA) test
instructions for follow up with a pain ■ CASE THREE raised suspicion for an autoimmune
management service. The clinician also Noting that the 58-year-old disease. She was discharged several
urged her to resume regular exercise (eg, woman’s abnormal vital signs could days later with a diagnosis of systemic
stationary bicycling or yoga). not be attributed to fibromyalgia, the lupus erythematosus.

of therapeutic response to milnacipran treatment for intravenous opioids for acute pain in the emergency 33. Marinus J, Moseley GL, Birklein F, et al. Clinical
fibromyalgia. Results of a randomized, double-blind, department: results of a randomized, double-blind features and pathophysiology of complex regional
monotherapy 6-month extension study. Pain Med. clinical trial. Acad Emerg Med. 2014;21(11):1193-1202. pain syndrome. Lancet Neurol. 2011;10(7):637-648.
2009;11(2):180-194. 23. Motov SM, Nelson LS. Advanced concepts and 34. Harden RN, Bruehl S, Perez RS, et al. Validation
14. Straube S, Derry S, Moore RA, McQuay HJ. controversies in emergency department pain of proposed diagnostic criteria (the “Budapest
Pregabalin in fibromyalgia: meta-analysis of efficacy management. Anesthesiol Clin. 2016;34(2):271-285. Criteria”) for complex regional pain syndrome. Pain.
and safety from company clinical trial reports. 24. Busch AJ, Schachter CL, Overend TJ, et al. Exercise 2010;150(2):268-274.
Rheumatology (Oxford). 2010;49(4):706-715. for fibromyalgia: a systematic review. J Rheumatol. 35. Harden RN, Oaklander AL, Burton AW, et al. Complex
15. Carette S, Bell MJ, Reynolds WJ, et al. Comparison 2008;35(6):1130-1144. regional pain syndrome: practical diagnostic
of amitryptiline, cyclobenzaprine, and placebo in the 25. Häuser W, Klose P, Langhorst J, et al. Efficacy of and treatment guidelines, 4th edition. Pain Med.
treatment of fibromyalgia. A randomized, double- different types of aerobic exercise in fibromyalgia 2013;14(2):180-229.
blind clinical trial. Arthritis Rheum. 1994;37(1):32-40. syndrome: a systematic review and meta-analysis 36. de Mos M, de Brujin AG, Huygen FJ, et al. The
16. Walitt B, Klos P, Üceyler N, et al. Antipsychotics for of randomized controlled trials. Arthritis Res Ther. incidence of complex regional pain syndrome: a
fibromyalgia in adults. Cochrane Database Syst Rev. 2010;12(3):R79. population-based study. Pain. 2007;129(1-2):12-20.
2016;(6):CD011804. 26. Busch AJ, Barber KA, Overend TJ, et al. Exercise for 37. Turner-Stokes L, Goebel A; Guideline Development
17. Bazzichi L, Giacomelli C, Consensi A, et al. One year treating fibromyalgia syndrome. Cochrane Database Group. Complex regional pain syndrome in adults:
in review 2016: fibromyalgia. Clin Exp Rheumatol. Syst Rev. 2007;(4):CD003786. concise guidance. Clin Med. 2011;11(6):596-600.
2016;34 (2 Suppl 96):S145-S149. 27. Wang C, Schmid CH, Rones R, et al. A randomized 38. Bussa M, Guttilla D, Lucia M, et al. Complex regional
18. Goldenberg DL, Clauw DJ, Palmer RE, Clair AG. trial of tai chi for fibromyalgia. N Engl J Med. pain syndrome type I: a comprehensive review. Acta
Opioid use in fibromyalgia: a cautionary tale. Mayo 2010;363(8):743-754. Anaesthesiol Scand. 2015;59(6):685-697.
Clin Proc. 2016;91(5):640-648. 28. Macfarlane GJ, Kronisch C, Dean LE, et al. EULAR 39. Goebel A, Baranowski A, Maurer K, et al. Intravenous
19. Drug overdose deaths hit record numbers in revised recommendations for the management of immunoglobulin treatment of the complex regional
2014. Available at: http://www.cdc.gov/media/ fibromyalgia. Ann Rheum Dis. 2016. doi: 10.1136. [Epub pain syndrome: a randomized trial. Ann Intern Med.
releases/2015/p1218-drug-overdose.html. Accessed ahead of print]. 2010;152:152-158.
July 25, 2016. 29. Schwartzman RJ, Erwin KL, Alexander GM. The natural 40. Schwartzman RJ, Alexander GM, Grothusen JR. The
20. Ducharme J. Non-opioid pain medications to history of complex regional pain syndrome. Clin J use of ketamine in complex regional pain syndrome:
consider for emergency department patients. ACEP Pain. 2009;25(4):273-280. possible mechanisms. Expert Rev Neurother.
Now. 2015;35(5). 30. Bickerstaff DR, Kania JA. Algodystrophy: an under- 2011;11(5):719-734.
21. Motov S, Rockoff B, Cohen V, et al. Intravenous recognized complication of minor trauma. Br J 41. Visser E, Schug SA. The role of ketamine in pain
subdissociative-dose ketamine versus morphine Rheumatol. 1994;33(3):240-248. management. Biomed Pharmacother. 2006;60(7):341-
for analgesia in the emergency department: a 31. Zyluk A. The natural history of post-traumatic reflex 348.
randomized controlled trial. Ann Emerg Med. sympathetic dystrophy. J Hand Surg. 1998;23(1):20-23. 42. Niesters M, Martini C, Dahan A. Ketamine for
2015;66(3):222-229. 32. Birklein F, O’Neill DO, Schlereth T. Complex regional chronic pain: risks and benefits. Br J Clin Pharmacol.
22. Beaudoin FL, Lin C, Guan W, Merchant RC. Low-dose pain syndrome: An optimistic perspective. Neurology. 2013;77(2):357-367.
ketamine improves pain relief in patients receiving 2015;84(1):89-96. 43. Sigtermans MJ, van Hilten JJ, Bauer MC, et al.
Ketamine produces effective and long-term pain relief
in patients with Complex Regional Pain Syndrome
Type I. Pain. 2009;145(3):304-311.
44. D’Arcy Y. Targeted topical analgesics for acute pain.
Pain Med News. 2014;12(12):56-63.
45. Wallace MS, Ridgeway BM, Leung AY, et al.
Concentration-effect relationship of intravenous
lidocaine on the allodynia of complex regional
pain syndrome types I and II. Anesthesiology.
2000;92(1):75-83.
46. Ferrini R, Paice JA. How to initiate and monitor
n Prescribing opioids for the treatment of diffuse widespread pain. infusional lidocaine for severe and/or neuropathic
pain. J Support Oncol. 2004;2(1):90-94.
n Failing to address non-pharmacological treatments when managing and 47. Iannuccelli C, Spinelli FR, Guzzo MP, et al. Fatigue and
discharging patients with fibromyalgia. Cardiovascular fitness training, widespread pain in systemic lupus erythematosus
and Sjogren’s syndrome: symptoms of inflammatory
including low-impact aerobic activities, provide significant benefits. disease or associated fibromyalgia? Clin Exp
Rheumatol. 2012;30 (6 Suppl 74):S117-S121.
n Discouraging patients with CRPS from using their affected extremity. 48. McCarthy J. Myalgias and myopathies: fibromyalgia.
n Dismissing the risk of depression and suicidal ideation in patients with chronic FP Essent. 2016;440: 11-15.
49. Freedman M, Greis AC, Marino L, et al. Complex
painful conditions. Mental health should be addressed. regional pain syndrome diagnosis and treatment. Phys
Med Rehabil Clin N Am. 2014;25(2):291-303.

January 2017 n Volume 31 Number 1 21

 CME
Reviewed by Lynn Roppolo, MD, FACEP

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

QUESTIONS
Credits™, and 5 AOA Category 2-B credits for completing this activity in its entirety.
Submit your answers online at acep.org/newcriticaldecisionstesting; a score of 75%
or better is required. You may receive credit for completing the CME activity any time
within three years of its publication date. Answers to this month’s questions will be
published in next month’s issue.

1 Which symptoms comprise the classic triad of

ectopic pregnancy?
A. Abdominal pain, hypotension, and a missed
5 Which of the following findings describes the classic
presentation of placenta previa?
A. Abdominal pain with vaginal bleeding
menstrual cycle B. Back pain with spotting
B. Abdominal pain, hypotension, and a positive C. Painful vaginal bleeding
pregnancy test D. Painless vaginal bleeding
C. Abdominal pain, vaginal bleeding, and a missed
menstrual cycle
D. Back pain, vaginal bleeding, and a missed 6 What initial diagnostic test is preferred for a patient
with vaginal bleeding at greater than 20 weeks’
gestation?
menstrual cycle
A. Bimanual pelvic examination

2 Which of the following ultrasound findings are

diagnostic for ectopic pregnancy?
A. Empty uterus and an adnexal mass
B. MRI of the abdomen
C. Transabdominal ultrasound
D. Transvaginal ultrasound
B. Empty uterus and no adnexal mass
C. Intrauterine gestational sac and yolk sac
D. Irregular gestational sac 7 What does the Kleihauer-Betke test diagnose?
A. Anemia
B. Coagulopathy

3 What solution is preferred for the initial

resuscitation of an unstable patient with suspected
ectopic pregnancy?
C. Fetal bleeding
D. Thrombocytopenia

A. 0.9% normal saline

B. 5% dextrose with 0.45% normal saline
C. 5% dextrose with 0.9% normal saline
D. Colloid-based intravenous fluid
8 Which of the following patients with placenta previa
can be managed conservatively?
A. 25-year-old G0 with vaginal bleeding and
hypotension unresponsive to intravenous crystalloid
fluids and blood products

4 Which of the following patients shows clear

indications for the surgical management of ectopic
pregnancy?
A. 24-year-old G1P0 with normal vital signs and a
2.5-cm adnexal mass
B. 28-year-old G2P1 with hypotension, tachycardia,
and an adnexal mass
C. 30-year-old with normal vital signs and a closed
cervical os
D. 35-year-old G4P3 with normal vital signs and an
absence of fetal cardiac activity on ultrasound
B. 27-year-old G2P1 with painless vaginal bleeding and
nonreassuring fetal tracing
C. 32-year-old G3P2 with painless vaginal bleeding,
hypotension, and a positive Kleihauer-Betke test
D. 34-year-old G4P2 with vaginal bleeding responsive to
standard treatment
9 Which of following signs is most likely to herald
placental abruption?
A. Gestational diabetes
B. History of pelvic inflammatory disease
C. Hypertension
D. Primigravida status

22 Critical Decisions in Emergency Medicine

10
Which of the following describes the classic
presentation of placental abruption?
A. Abdominal pain, uterine contractions, and

16 Which of the following is a drawback of
ketamine?
A. It can cause mood changes and unpleasant
ruptured membranes psychomometic effects
B. Back pain, uterine contractions, and ruptured B. It can increase the risk of long-term pain in
membranes trauma patients
C. Painless vaginal bleeding, tachycardia, and uterine C. It depresses airway reflexes
contractions D. It is an NMDA antagonist
D. Vaginal bleeding, abdominal pain, and uterine
contractions

17 Which antipsychotic agent shows promise in
alleviating depression and reducing pain in

11 Which agent is not approved by the FDA for the

treatment of fibromyalgia?
patients with fibromyalgia?
A. Clozapine
A. Duloxetine B. Olanzapine
B. Milnacipran C. Paliperidone
C. Oxycodone D. Quetiapine
D. Pregabalin

12 Which of the following symptoms are common in

patients with fibromyalgia?
18 Which finding is inconsistent with a diagnosis
of complex regional pain syndrome (CRPS)?
A. Continuing pain that is disproportionate to
A. Elevated parathyroid hormone levels any inciting event
B. Family history of the disorder B. Elevated erythrocyte sedimentation rate and
C. Impaired sleep, fatigue, and poor cognition C-reactive protein level
D. Sudden-onset pain in one limb C. Evidence of edema and/or sweating changes
D. Temperature asymmetry or skin color

13 Which disorder is least likely to be associated with

fibromyalgia?
changes

A. Acute renal insufficiency

B. Interstitial cystitis
C. Irritable bowel syndrome
19 Which class of drugs can most successfully
treat the symptoms of fibromyalgia?
A. Corticosteroids
D. Migraine headache B. Nonsteroidal anti-inflammatory agents
C. Opioid analgesics, with the exception of

14
Which of the following is most likely to be
efficacious in the management of fibromyalgia?
A. Acetaminophen
tramadol
D. SNRI antidepressants

B. Methadone therapy
C. Nonsteroidal anti-inflammatory medications
D. Regular aerobic physical activity

20 Which of the following accurately describes a
characteristic of CRPS?
A. Emergency management includes
intravenous immunoglobulin

15 Which of the following is an appropriate treatment
for CRPS-related symptoms?
A. Emergency surgical sympathectomy
B. Intravenous ketamine may provide
prolonged relief
C. Nonsteroidal anti-inflammatory agents are
B. High-dose vitamin C specifically contraindicated
C. Immobilization of the affected limb D. The incidence is equal in male and female
D. Oral corticosteroids patients

ANSWER KEY FOR DECEMBER 2016, VOLUME 30, NUMBER 12

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
A C A C D B A D B D B D C C B C C A B D

January 2017 n Volume 31 Number 1 23

 Drug Box
INTRAVENOUS ACETAMINOPHEN
By Daniel Rigdon, MD; and Frank Lovecchio, DO,
Maricopa Medical Center, Phoenix, Arizona
Intravenous (IV) acetaminophen is the only approved IV non-opioid
analgesic that is safe in children and does not require a boxed
warning label. Adding the drug (IV or oral) to morphine following
major surgery appears to decrease postoperative morphine use.
Combination therapy with acetaminophen and nonsteroidal anti-
inflammatory drugs (NSAIDs) appears to be more effective than
NSAIDs alone for the treatment of postoperative pain.
Pharmacokinetics
• Onset of effect: 5-10 min
• Time to peak concentration: 15 min
• Oral or rectal onset of effect: ≥10-60 min
Mechanism of Action
The exact mechanism is unknown; however, the reduction of
prostaglandins appears to play a role.
Indications
• Mild to moderate pain
• Moderate to severe pain with adjunctive opioid analgesics
• Fever reduction
• Patients in whom oral or rectal administration is not an option
Dosing
Adults >50 kg
• 650 mg q4 hrs OR 1,000 mg mg q6 hrs
• Max single dose: 1,000 mg
• Should not exceed 4 g/day
Children >2 yrs; adolescents and adults <50 kg
• 15 mg/kg q6 hrs OR 12.5 mg/kg q4 hrs
• Max single dose: 15 mg/kg (should not exceed 4 g/day)
• A reduced or modified dose should be used for hepatic insufficiency,
chronic alcoholism, malnutrition, or dehydration.
• For severe renal insufficiency (creatinine clearance ≤30 mL/min), give
usual dose <6 hrs.
Side Effects
IV acetaminophen vs placebo
• Nausea (34% vs 31%), vomiting (12% vs 11%)
• Headache (10% vs 9%), insomnia (7% vs 5%)
• Possible transient reduction in blood pressure in the critically ill
• Not linked to an increased risk of nausea, vomiting, and respiratory
depression (which can occur with opioids) or platelet dysfunction,
gastritis, and renal toxicity (associated with NSAIDs)
Precautions
Contraindicated in patients with severe hepatic insufficiency, severe
progressive liver disease, and known hypersensitivity to acetaminophen
Tox Box
VALPROIC ACID
By Christie Sun, MD, University of California, San Diego
Reviewed by Christian A. Tomaszewski, MD, MS, MBA, FACEP
Valproic acid (VPA) often is used to treat seizure disorders and
bipolar disorder, and prevent migraines. Given its many indications,
accidental and intentional overdoses are common. While mild
intoxications are well-tolerated, ingestions >200 mg/kg can require
acute intervention.
Pharmacokinetics
• Rapid absorption
— Delayed-release formulas can cause continued absorption.
• Highly protein-bound
— Decreases to 15% with VPA levels >1,000 mg/L
• Hepatic metabolism (glucoronidation, beta- and omega-oxidation)
Mechanism of Toxicity
VPA may increase levels of gamma-aminobutyric acid and alter fatty
acid metabolism and the urea cycle, resulting in hepatotoxicity and hy-
perammonemia. Deficiencies in carnitine also can contribute to toxicity.
Clinical Presentation
• CNS: Altered mental status (AMS), paradoxical seizures, coma
• Cardiovascular: Tachycardia, QT prolongation, hypotension
• Metabolic: Hypocalcemia, hypernatremia, anion gap metabolic
acidosis, hyperammonemia
• GI: Vomiting, hepatoxicity (with chronic use)
• Other (rarer): Myelosuppression, cerebral edema, hemorrhagic
pancreatitis
Diagnostic Evaluation
• Basic testing (eg, valproate level [therapeutic 50-100 mg/L]; CBC;
renal and liver panels; ammonia level)
• Some presentations warrant an ECG or brain CT.
Management
• Airway management and supportive measures for metabolic
derangements or cerebral edema
• Decontamination
— Activated charcoal within an hour (or later in sustained relief)
if airway protected
— In sustained-release preparations, charcoal + whole-bowel
irrigation can be considered later
• Hemodialysis (indications to consider)
— High serum concentrations (>900 mg/L)
— Severe toxicity (hemodynamic instability, altered mental
status, hyperammonemia, acidemia pH ≤7.10)
• Levocarnitine (100 mg/kg IV bolus)
— May be helpful in patients with coma, hyperammonemia, or
rising levels (>400 mg/dL)