Use (or lack thereof) of speculum exams in the ED

Today I want to talk about the use of speculum exams in the emergency department. A recent post on Life in the Fastlane discussed this topic and questioned whether there is much valuable information to be gained, and whether that warrants doing an invasive procedure. The post laid out a stringent set of presentations that definitively require a speculum exam in the ED. Those presentations are;

1. Cervical shock – vaginal bleeding with associated hypotension and bradycardia. This is due to products on conception stuck in the cervix, and causing a vagal response. Removing these products will reverse the shock.

2. Heavy PV Bleeding – similar idea as above, remove clots or products of conception, in this instance to encourage the uterus to contract and slow bleeding.

3. Suspected vaginal foreign body – this is obvious. These need to be removed to prevent infection and potential toxic shock syndrome.

The article goes on to argue against doing speculum exams in certain presentations. Here are the instances it argues against speculum exams;

1. Light bleeding in early pregnancy – speculum exam does not rule out ectopic and ultimately that is the priority over whether something is a threatened vs inevitable miscarriage. Imaging and likely follow up will be necessary in these patients regardless of speculum exam.

2. Suspected PID or torsion – suspicion of either of these diagnoses will require further testing, rendering the examination superfluous. Some combination of imaging, swabs, or empiric treatment will all be necessary regardless of pelvic examination.

A prospective cohort study in 2011 surveyed providers in the emergency department to ask whether pelvic examination changed management plans or not. 171 of the 187 patients (91%) in this study did not have a change in clinical plan before and after pelvic examination.

While neither of these articles are arguing against speculum examinations as an important tool for emergency providers, they are arguing against speculum examinations for all female patients with lower abdominal pain. The procedure is invasive, time intensive given space limitations, and some of the actual exam findings (adnexal tenderness) are nonspecific and will require imaging or other testing anyways. Should we as a practice reexamine the clinical use of this procedure? Should our threshold for doing speculum examinations be higher?

Brown J, Fleming R, Aristzabel J, Gishta R. Does pelvic exam in the emergency department add useful information? West J Emerg Med. 2011 May;12(2):208-12. PMID: 21691528; PMCID: PMC3099609.

Mackenzie, J., & Beech, A. (2024, January 11). Procedure: Speculum examination. Life in the Fast Lane • LITFL. https://litfl.com/procedure-speculum-examination/ 

Wide Complex Tachycardias and Dual Sequence Defibrillation

Wide complex tachyarrhythmias refer to abnormal rapid heart rhythms characterized by widened QRS complexes on an electrocardiogram (ECG). These arrhythmias can be life-threatening and require prompt evaluation and management. The etiology, clinical features, and management strategies for stable and unstable patients differ, and in some cases, an electrical storm may occur, necessitating advanced interventions like dual sequential defibrillation.

Etiology:

Wide complex tachyarrhythmias can have various causes, including:

1. Ventricular Tachycardia (VT): Most common cause, often associated with structural heart disease, myocardial infarction, or scar tissue. Appropriate medical care is to assume that any wide complex tachycardia is VT until proven otherwise.

2. Supraventricular Tachycardia (SVT) with Aberrancy: When a supraventricular origin rhythm encounters a conduction abnormality, it may result in a wide complex appearance on the ECG.

3. Pre-excited Atrial Fibrillation: In the presence of an accessory pathway (WPW), atrial fibrillation can conduct rapidly to the ventricles, leading to a wide QRS complex.

Management for Stable Patients:

1. Identification of Underlying Cause: Determine if the arrhythmia is ventricular or supraventricular in origin.

2. Antiarrhythmic Medications: Administer medications such as amiodarone, procainamide, or lidocaine depending on the underlying rhythm.

1. Amiodarone (preferred agent in setting of AMI or LV dysfunction) – dosing is 150mg over 10min, followed by 1mg/min drip over 6 hr.

2. Procainamide is a potential agent. Did better in the PROCAMIO trial over amiodarone. Initial dosing is 20-50mg/min until arrythmia breaks (max 17mg/kg or 1 gram) then maintenance of 1-4mg/min x 6hr.

3. Electrolyte Correction: Address any electrolyte imbalances, especially potassium and magnesium.

Management for Unstable Patients:

1. Immediate Cardioversion: Synchronized electrical cardioversion is the treatment of choice. The usual dosage for synchronized cardioversion is 100-200J. (Note if the patient loses a pulse, in conjunction with started ACLS, the treatment option becomes unsynchronized cardioversion, or defibrillation).

2. IV Antiarrhythmic Medications: Amiodarone or procainamide may be administered while preparing for cardioversion. Lidocaine is also a potential agent.

3. Advanced Cardiovascular Life Support (ACLS): Follow ACLS guidelines for managing cardiac arrest, including chest compressions and airway management.

Electrical Storm and Dual Sequential Defibrillation:

An electrical storm is a term used to describe the occurrence of multiple sustained ventricular arrhythmias within a short period. It is a life-threatening situation that may be refractory to standard treatments.

Dual Sequential Defibrillation (DSD):

• In cases of resistant ventricular arrhythmias, dual sequential defibrillation involves using two defibrillators almost simultaneously to deliver two shocks.

• The goal is to increase the energy delivered to the heart, potentially terminating the arrhythmia.

• This approach is considered in refractory cases where conventional defibrillation has failed.

Procedure for DSD:

1.       Apply both sets of pads, adjacent to one another, and not touching (see the diagram from RebelEM).

2.       Charge both monitors to max dosage (200J for biphasic, 360J for monophasic).

3.       Charge and simultaneously activate the defibrillation/shock button on each monitor.

4.       Continue with compressions and ACLS.

5.       Consider a beta-blocker (esmolol) bolus, and consider holding epinephrine dosing to limit cardiac excitation.

Sources:

 https://rebelem.com/dual-sequential-defibrillation-dsd/

https://pubmed.ncbi.nlm.nih.gov/27354046/

https://pubmed.ncbi.nlm.nih.gov/8144780/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4711501/#:~:text=A%20wide%20complex%20tachycardia%20(WCT,%3E120%20milliseconds%20(ms).

POTD: Sexual Assault Forensic Exam (SAFE)

This POTD will be regarding sexual assault forensic examiner (SAFE) exams. Keep in mind that these patients have obviously just undergone a traumatic event. However, also consider that the ED course and examination in itself can also add onto this trauma, and so there are several steps we should undertake to mitigate this as much as we can.

• Conduct interviews in a private setting. If available, please make use of a private room, such as an OBGYN room.

• In addition to placing a SAFE consult, also consult a social work. 

• Even if a patient does not want a forensic examination performed, SAFE consults are useful in providing resources to patients, including resources for safe shelters, resources for applying to the state victim’s compensation fund, and mental wellness helplines.

• When using translators, consider using audio-only translation or facing the video away from the patient, especially during the examination itself, to respect patient privacy.

General medical workup:

• If the patient has not changed clothes, do not change the patient into a hospital gown.

• All patients should be offered HIV PEP, STI prophylaxis, and pregnancy prophylaxis +/- pregnancy testing per patient preferences.

  • HIV PEP courses are 28 days. The Office of Victim Services funds the emergency department for a 7-day starter pack to take home. The patient will need to follow up with PMD or ID clinic for the rest.

  • STI testing may be considered if the patient asks for it, although will not have forensic value in the timeframe most patients show up after an assault. You should just treat empirically.

• On physical exams, extra attention should be placed on signs of physical trauma, with imaging as indicated by history and exam.

Pediatric patients

• All suspected sexual assaults or abuse of patients younger than 18 years are required to be reported to child protective services. All hospital staff are legally considered to be mandated reporters.

  • CPS reports may be made at 1-800-342-3720.

  • A written reports needs to be filed within 48 hours of calling. Forms are found at https://ocfs.ny.gov/programs/cps/

• Mature minors may choose to consent or not consent to a forensic exam without parental involvement.

Financial resources for patients

• Victims of sexual assault can apply to the Office of Victim Services for out-of-pocket expenses not covered by insurance.

• Examples of covered expenses are listed in the application form, but include lost wages, medical/ambulance costs, crime scene cleanup, purchasing a security system.

• An English form is included in the SAFE exam kit, part A. Other languages may be printed from https://ovs.ny.gov/victim-compensation

How to perform a SAFE examination and Sexual Offence Evidence Collection Kits (SOECK). Please allot up to 4 hours for this.

A powerpoint of these instructions, with pictures may be found at https://apps.criminaljustice.ny.gov/ofpa/pdfdocs/Sexual%20Offense%20Evidence%20Collection%20Kit%20Training%201-2023.pdf. 

• Two different kits.

  • Once the kit is opened, the chain of custody begins and you should not leave the kit until it has been sealed, signed, and handed off to the next custodian.

  • SOECK part A (larger kit)

    • Contains consent forms, victim compensation application form, STI/HIV prophylaxis educational forms, and an evidence seal.

    • Contains envelopes and swabs for specimen samples.

  • SOECK part B

    • Supplementary kit containing x2 blood tubes and x1 urine cup for suspected drug facilitated sexual assault.

    • Requires completion of part A in addition to part B. Should not be collected on its own.

    • Requires its own consent form.

• Items to obtain prior to exam, that are not included in kits.

  • x4 pages of patient labels with patient full name and DOB

  • Paper bags if collecting patient clothes.

  • Exam table paper (i.e. the paper found on the peds ED triage bed)

  • Clean bed sheets and blankets

  • Disposable cups

  • Consider bringing an extra kit in case you make a mistake and need to recollect a sample.

• Determine and obtain consent for the following:
  An English consent form is available in each kit. Consent forms in other languages may be printed from https://apps.criminaljustice.ny.gov/evidencekit.htm

  • Collection of evidence.

    1. Samples have the highest forensic value when collected within 120 hours after incident, but examiner discretion may be used for collections after this window.

  • Collection of photographs

    1. We do not regularly collect photographs as part of our exam, so this part is not relevant for us.

  • Release of evidence to the police.

    1. If the patient does not want to release evidence, it will be held for 20 years in either our hospital forensic storage room or a storage facility at the Office of Victim Services, which is not a law enforcement agency2. The patient may later elect to release the kit or destroy the kit.

• Supplemental information form

  • Information to obtain from the patient that is relevant for the forensic laboratory.

• Evidence collection

  • There should always be a chaperone in the room.

  • Part A contains 12 envelopes, each labelled with instructions for obtaining specimens (See example below). They are ordered from least invasive to most invasive samples.

• For each step:

  • The patient may consent or decline each step and skip to the next step.

  • Change gloves between each step.

  • Attached a patient label to each envelope, fill out any relevant fields. Date & timestamp & initial each envelope.

• Part A

  • Step 1 – Trace evidence and debris

  • Step 2 – Underwear

  • Step 3 – Clothing

    • If they release their clothes for collection. You can ask social work or mental health workers for replacement clothes.

    • This step requires a separate paper bag for each article of clothing (not included in kit)

  • Step 4 – Oral swabs

  • Step 5 – Buccal swabs

    1. This step serves as a reference sample for the patient’s own DNA and should be recommended to all patients.

  • Step 6 – Fingernail swabs

  • Step 7 – External dried secretions and bitemarks

  • Step 8 – Pubic Hair Combing

  • Step 9 – Perianal/Anal Sample

  • Step 10 – Vulvar or Penile Swab

  • Step 11 – Vaginal/Cervical Swab

  • Step 12 – Tampon/Pad/Liner Collection

• Part B (if applicable)

  1. Collect x2 blood samples, x1 urine sample. Label and seal each sample with the provided seal.

• Attach patient label to box. Seal all envelopes. Make copies of relevant forms (each form includes at bottom how many copies to make, where each copy goes)

• Seal and initial each kit with the provided seal.

• Storage or release of kit

  • If police are at bedside and patient consents to release evidence, you may release the completed kit to the police office and have them sign off on the chain of custody on the box.

  • Otherwise your hospital should have a secured and temperature controlled storage facility for storage pending transport to the storage facility at the Office of Victim Services.