ED observation units (EDOUs) are designed for patients who require diagnostics or therapeutics beyond the initial ED visit to determine the need for hospital admission. Best evidence is that this care be delivered via ordersets or protocols. Occasionally, patients present with conditions that are amenable to EDOU care but fall outside the commonly used protocols. This article details a few of these conditions: abnormal uterine bleeding, allergic reaction, alcohol intoxication, acetaminophen overdose and sickle cell vaso-occlusive crisis. It is not meant to be exhaustive as patient care needs can vary hospital to hospital.
Key points
- •
There are many conditions that can be cared for in the EDOU that don’t fit into larger protocols.
- •
This list isn’t meant to be exhaustive.
- •
Any condition that complies with the definition of medical observation where the patient is 70–80% likely to be discharged in 15–18 hours is appropriate.
Victoria Woods is a 32-year-old woman who presents with complaints of heavy vaginal bleeding for 3 days. She is using four to five pads per day and is passing clots. This has been happening every month during her menses and she will occasionally have bleeding between her menses. She also endorses dizziness with standing and increased fatigue doing her daily tasks. Her physical examination is remarkable only for conjunctival pallor. Pelvic examination reveals no cervical lesions and a small amount of blood from the cervical os. Her uterus is slightly enlarged but nontender. Her urine pregnancy test is negative and hemoglobin (Hgb) concentration is 5.5 g/dL. She is placed in the emergency department observation unit (EDOU) for blood transfusion. While in the observation unit, the patient undergoes a transvaginal ultrasound that is unremarkable. She receives two units of packed red blood cells (PRBC) and her repeat Hgb is 7.5 g/dL. On reassessment, she states she is feeling better. In discussion with the on-call gynecologist, the decision is made to start her on progesterone hormone therapy. The patient is discharged with a diagnosis of abnormal uterine bleeding. She is started on iron supplementation in addition to her hormone therapy and instructions to follow-up with a gynecologist for further management of her condition.
Abnormal uterine bleeding
Abnormal uterine bleeding (AUB), formerly known as dysfunctional uterine bleeding, is a common reason for presentation to the emergency department (ED). It is estimated to affect 53 per 1000 women in the United States. AUB is defined as abnormal quantity, duration, or timing of menstrual bleeding in nonpregnant females. Patients can seek medical care for the bleeding itself or for sequelae of blood loss, such as anemia. Etiologies for AUB are beyond the scope of this article, but have been classified by the International Federation of Gynecology and Obstetrics ( Box 1 ).
Polyp
Adenomyosis
Leiomyoma
Malignancy and hyperplasia
Coagulopathy
Ovulatory dysfunction
Endometrial
Iatrogenic
Not yet classified
Emergency Department Evaluation
The primary priorities of ED evaluation should be to rule out pregnancy, confirm the source of bleeding, and resuscitate patients who are hemodynamically unstable. The history taken in the ED should attempt to quantify the bleeding (ie, number of pads/hour, presence of clots) and evidence of symptomatic anemia (ie, fatigue, dyspnea, or chest pain with exertion). In addition, there should be an attempt to screen for causes of the bleeding, such as a menstrual history (ie, age of menarche, usual frequency, and duration of menses), presence of bleeding/clotting disorders, and the use of any anticoagulant or antiplatelet medications.
The physical examination should be used to identify signs of anemia or hemorrhagic shock with special note taken of resting tachycardia or hypotension. The clinician can also assess for conjunctival pallor or the presence of a flow murmur. A pelvic examination should be performed in the ED to confirm the uterus as source of bleeding, and rule out vulvar/vaginal trauma or cervical lesions. This can be deferred if the patient is not currently bleeding and has a history of AUB with an established diagnosis.
Laboratory tests should include a pregnancy test, complete blood count (CBC) with differential. A coagulation profile can be considered in patients with new presentations of AUB to screen for bleeding disorders. A qualitative urine human chorionic gonadotropin test is sufficient for low to moderate suspicion of pregnancy, whereas a quantitative serum test should be sent in cases where pregnancy is highly suspected. The CBC should be examined for Hgb and hematocrit levels and to rule out thrombocytopenia as a cause for bleeding. A type and screen should be sent during the initial evaluation and if the level of anemia requires blood product administration a crossmatch should be ordered.
Imaging in the ED is left to the discretion of the provider. A pelvic ultrasound is helpful in establishing a diagnosis in patients with a new complaint of AUB but probably does not add much to the treatment of patients with established diagnosis and recurrent bleeding.
Observation Unit Care
Red cell transfusion
The inclusion and exclusions for EDOU placement are listed in Box 2 . In general, patients who are hemodynamically unstable, coagulopathic, have bleeding caused by a malignancy, or have heavy active bleeding are better served on an inpatient service because of suspected duration and intensity of treatment. The focus should be transfusion of patients who are hemodynamically stable and not having brisk active bleeding.
Inclusion
- •
CBC, type, and crossmatch sent
- •
Transfusion consent signed and in chart
Exclusion
- •
Pregnancy
- •
Malignancy found or suspected on pelvic examination or imaging
- •
Coagulopathy, including use of warfarin or direct oral anticoagulants
- •
Known presence of circulating antibodies making blood match difficult
- •
Contraindication or refusal of transfusion
- •
Anemia with symptoms or signs of cardiac ischemia
- •
Anticipated need for greater than two units PRBCs (Hgb <5 mg/dL)
Potential interventions
- •
Red cell transfusion
- •
Pain control
- •
Gynecology evaluation
- •
Initiation of hormone therapy
- •
Pelvic ultrasound/imaging to investigate cause of bleeding
Disposition
- •
Home
- ○
Stable vital signs
- ○
Posttransfusion Hgb in acceptable range (7–8 mg/dL)
- ○
No symptoms with exertion
- ○
- •
Hospital
- ○
Prolonged heavy bleeding
- ○
Unstable vital signs
- ○
Inpatient procedure required
- ○
The primary EDOU intervention is blood transfusion. Recommendations on transfusion thresholds vary among specialty societies. The decision to transfuse should be made using clinical judgment taking into account not only the absolute Hgb or hematocrit levels, but also the presence of active bleeding, symptomatic anemia, and patient wishes. The American Association of Blood Banks recommends that transfusion is rarely indicated for Hgb greater than 10 g/dL. Transfusion should be considered for patients with Hgb less than 10 g/dL if they have symptomatic anemia, ongoing bleeding, or evidence of myocardial ischemia. Transfusion is generally indicated with an Hgb of less than 7 g/dL in all populations. Hemodynamically stable patients should only be transfused to an Hgb of 7 to 8 g/dL, although symptomatic patients may require transfusion to a higher level.
Each unit of PRBCs is expected to take 4 hours to complete and raises the Hgb approximately 1 mg/dL. Therefore, patients who might require more than three or four units of PRBCs should be considered for admission. Repeat Hgb can be sent 15 minutes after completion of the transfusion.
Other treatments
Some patients may be candidates to start medical hormone therapy to decrease the frequency and severity of bleeding. This should be discussed with the gynecology consultants. Nonsteroidal anti-inflammatory medications are the first line of therapy for pain control in patients with pain related to menstrual cramping. Nonsteroidal anti-inflammatory medications have the additional benefit of reducing the amount of menstrual blood loss by up to 50% through alterations in the cyclooxygenase pathway. Low-dose opioids are used as needed for breakthrough pain.
Disposition
The indications for hospital admission or discharge are summarized in Box 2 . If a patient’s Hgb responds to transfusion and they are no longer symptomatic with walking or performing normal activities, they may be discharged home with gynecology follow-up. Patients with continued heavy bleeding, who are symptomatic because of blood loss, or who continue to be orthostatic should be admitted.
Abnormal uterine bleeding
Abnormal uterine bleeding (AUB), formerly known as dysfunctional uterine bleeding, is a common reason for presentation to the emergency department (ED). It is estimated to affect 53 per 1000 women in the United States. AUB is defined as abnormal quantity, duration, or timing of menstrual bleeding in nonpregnant females. Patients can seek medical care for the bleeding itself or for sequelae of blood loss, such as anemia. Etiologies for AUB are beyond the scope of this article, but have been classified by the International Federation of Gynecology and Obstetrics ( Box 1 ).
Polyp
Adenomyosis
Leiomyoma
Malignancy and hyperplasia
Coagulopathy
Ovulatory dysfunction
Endometrial
Iatrogenic
Not yet classified
Emergency Department Evaluation
The primary priorities of ED evaluation should be to rule out pregnancy, confirm the source of bleeding, and resuscitate patients who are hemodynamically unstable. The history taken in the ED should attempt to quantify the bleeding (ie, number of pads/hour, presence of clots) and evidence of symptomatic anemia (ie, fatigue, dyspnea, or chest pain with exertion). In addition, there should be an attempt to screen for causes of the bleeding, such as a menstrual history (ie, age of menarche, usual frequency, and duration of menses), presence of bleeding/clotting disorders, and the use of any anticoagulant or antiplatelet medications.
The physical examination should be used to identify signs of anemia or hemorrhagic shock with special note taken of resting tachycardia or hypotension. The clinician can also assess for conjunctival pallor or the presence of a flow murmur. A pelvic examination should be performed in the ED to confirm the uterus as source of bleeding, and rule out vulvar/vaginal trauma or cervical lesions. This can be deferred if the patient is not currently bleeding and has a history of AUB with an established diagnosis.
Laboratory tests should include a pregnancy test, complete blood count (CBC) with differential. A coagulation profile can be considered in patients with new presentations of AUB to screen for bleeding disorders. A qualitative urine human chorionic gonadotropin test is sufficient for low to moderate suspicion of pregnancy, whereas a quantitative serum test should be sent in cases where pregnancy is highly suspected. The CBC should be examined for Hgb and hematocrit levels and to rule out thrombocytopenia as a cause for bleeding. A type and screen should be sent during the initial evaluation and if the level of anemia requires blood product administration a crossmatch should be ordered.
Imaging in the ED is left to the discretion of the provider. A pelvic ultrasound is helpful in establishing a diagnosis in patients with a new complaint of AUB but probably does not add much to the treatment of patients with established diagnosis and recurrent bleeding.
Observation Unit Care
Red cell transfusion
The inclusion and exclusions for EDOU placement are listed in Box 2 . In general, patients who are hemodynamically unstable, coagulopathic, have bleeding caused by a malignancy, or have heavy active bleeding are better served on an inpatient service because of suspected duration and intensity of treatment. The focus should be transfusion of patients who are hemodynamically stable and not having brisk active bleeding.
Inclusion
- •
CBC, type, and crossmatch sent
- •
Transfusion consent signed and in chart
Exclusion
- •
Pregnancy
- •
Malignancy found or suspected on pelvic examination or imaging
- •
Coagulopathy, including use of warfarin or direct oral anticoagulants
- •
Known presence of circulating antibodies making blood match difficult
- •
Contraindication or refusal of transfusion
- •
Anemia with symptoms or signs of cardiac ischemia
- •
Anticipated need for greater than two units PRBCs (Hgb <5 mg/dL)
Potential interventions
- •
Red cell transfusion
- •
Pain control
- •
Gynecology evaluation
- •
Initiation of hormone therapy
- •
Pelvic ultrasound/imaging to investigate cause of bleeding
Disposition
- •
Home
- ○
Stable vital signs
- ○
Posttransfusion Hgb in acceptable range (7–8 mg/dL)
- ○
No symptoms with exertion
- ○
- •
Hospital
- ○
Prolonged heavy bleeding
- ○
Unstable vital signs
- ○
Inpatient procedure required
- ○
The primary EDOU intervention is blood transfusion. Recommendations on transfusion thresholds vary among specialty societies. The decision to transfuse should be made using clinical judgment taking into account not only the absolute Hgb or hematocrit levels, but also the presence of active bleeding, symptomatic anemia, and patient wishes. The American Association of Blood Banks recommends that transfusion is rarely indicated for Hgb greater than 10 g/dL. Transfusion should be considered for patients with Hgb less than 10 g/dL if they have symptomatic anemia, ongoing bleeding, or evidence of myocardial ischemia. Transfusion is generally indicated with an Hgb of less than 7 g/dL in all populations. Hemodynamically stable patients should only be transfused to an Hgb of 7 to 8 g/dL, although symptomatic patients may require transfusion to a higher level.
Each unit of PRBCs is expected to take 4 hours to complete and raises the Hgb approximately 1 mg/dL. Therefore, patients who might require more than three or four units of PRBCs should be considered for admission. Repeat Hgb can be sent 15 minutes after completion of the transfusion.
Other treatments
Some patients may be candidates to start medical hormone therapy to decrease the frequency and severity of bleeding. This should be discussed with the gynecology consultants. Nonsteroidal anti-inflammatory medications are the first line of therapy for pain control in patients with pain related to menstrual cramping. Nonsteroidal anti-inflammatory medications have the additional benefit of reducing the amount of menstrual blood loss by up to 50% through alterations in the cyclooxygenase pathway. Low-dose opioids are used as needed for breakthrough pain.
Disposition
The indications for hospital admission or discharge are summarized in Box 2 . If a patient’s Hgb responds to transfusion and they are no longer symptomatic with walking or performing normal activities, they may be discharged home with gynecology follow-up. Patients with continued heavy bleeding, who are symptomatic because of blood loss, or who continue to be orthostatic should be admitted.
Related posts:
Care of Metabolic and Endocrine Conditions in the Observation Unit
Care of Neurologic Conditions in an Observation Unit
Care of Respiratory Conditions in an Observation Unit
Care of Metabolic and Endocrine Conditions in the Observation Unit
Care of Neurologic Conditions in an Observation Unit
Care of Respiratory Conditions in an Observation Unit
Full access? Get Clinical Tree
