Vaginal Bleeding in Early Pregnancy

(Great Britain—The Practitioner, February 1998, p. 84.) Approximately 20 percent of women have vaginal bleeding during the first trimester of pregnancy. Between 50 and 60 percent of these cases end in miscarriage, but if fetal heart activity can be demonstrated by ultrasound at presentation, the rate of miscarriage drops to 10 percent. Although most cases of bleeding in early pregnancy are caused by threatened miscarriage, other considerations include ectopic pregnancy, molar pregnancy and conditions of the cervix such as cervical ectopy, polyps and lacerations. Vaginal examination does not increase the risk of miscarriage, and the cervical examination may reveal products of conception that can cause torrential bleeding. Surgical evacuation is indicated for excessive bleeding if complete spontaneous expulsion is unlikely or if the patient is unable to tolerate expectant management of miscarriage of a nonviable fetus. Some experts recommend surgical evacuation except in asymptomatic patients with an empty uterus demonstrated by ultrasound examination. Rh_o(D) immune globulin should be given to all Rh-negative women who bleed in early pregnancy. If signs or symptoms of infection develop after miscarriage or evacuation, triple antibiotic therapy that includes coverage for anaerobes and Chlamydia should be administered.

Managing Injuries from Dog Attacks

(Australia—Australian Family Physician, December 1997, p. 1375.) Dog attacks are common and may result in trauma ranging in severity from trivial scratches to life-threatening injuries. Dog bites may cause incised, crushed, torn or punctured tissue with suffusion of saliva throughout the wound. The resulting wounds have a high potential for devascularization and for infection with organisms such as Pasteurella multocida, Staphylococcus aureus, Capnocytophaga canimorsus, Streptococcus species and anaerobes. Wounds should be surveyed carefully and the extent of damage documented, including assessment of the integrity of tendons, muscles, nerves, blood vessels and organs in the proximity of the wound. Large wounds should be surgically debrided under adequate anesthesia. Dog bite wounds should be copiously irrigated with normal saline, with special attention to wound edges. The choice of primary closure, delayed primary closure, referral to a surgeon or involvement of a plastic surgeon depends on the site and severity of the wound, its potential for infection and the general condition and wishes of the patient. The tetanus status of all patients should be confirmed, and immunization provided as indicated. The need for rabies prophylaxis must be considered. Studies have shown that antibiotics are most beneficial in selected patients and should not be used routinely. In patients with wounds with a high risk of infection, or in older or more vulnerable patients, a five- to 10-day course of amoxicillin-potassium clavulanate is recommended.

Topical Anesthesia for Laceration Repair

(Canada—Canadian Family Physician, March 1998, p. 505.) The repair of lacerations requires effective anesthesia, but traditional injected agents may contribute to discomfort and local swelling. A topical solution of 4 percent lidocaine, 1:1,000 epinephrine and 0.5 percent tetracaine (LET) can provide adequate anesthesia for laceration repair in 80 to 90 percent of patients and is especially useful in children. After preparation by a pharmacist, LET solution may be stored for up to six months if refrigerated and shielded from light. The solution may be used before repair of any laceration except those directly adjacent to mucous membranes. The solution is squirted on a gauze pad, and the pad is pressed against the laceration for approximately 20 minutes to ensure anesthesia. Edges of the wound should be tested before attempting repair. The LET solution is reported to have no side effects, including adverse effects on wound healing. The cost of LET solution is about 10 percent of the cost of conventional options for local anesthesia.

Common Sports Injuries of the Knee

(Australia—Australian Family Physician, December 1997, p. 1421.) In addition to pain, sports-related knee injuries may present as “locking,” instability or swelling. If the patient cannot squat fully, a mechanical condition is likely and is probably meniscal if squatting produces pain on the joint line. Anterior pain on squatting usually indicates a patellofemoral condition, and sensations of tightness are associated with effusions. Tears of the meniscus also may be indicated by difficulty in knee hyperextension (pushing the knee back into the table when the patient is supine). Effusions of the knee may be detected by palpation (the swipe test) or ballottement of the patella.