Just having an adolescent in the office constitutes an emergency for some practitioners. For those who are not lucky enough to deal with teens on a regular basis, there can be some discomfort when one presents with an emergent problem. This article provides a review of several of the more concerning adolescent emergencies, with recommendations for diagnosis and treatment.
A 15-year-old girl presents to the office after 2 weeks of heavy menses (saturating 10 to 12 tampons per day), complaining of pallor, lightheadedness, and fatigue. She has fallen once or twice but has had no abdominal or pelvic pain. On physical examination, heart rate is 105 and blood pressure is 110/76. The remainder of her vital signs are within normal limits.
Acute menorrhagia is a common problem in adolescent females. Anovulation is the cause approximately 80% of the time.1-3 Anovulation results in a lack of progesterone to stabilize the endometrium from unopposed estrogen stimulation, leaving a thick, fragile and very vascular endometrium. Progesterone also aids in vasospasm and clotting, so menstruation can be very heavy in anovulatory individuals when it finally occurs.
While menorrhagia caused by anovulation generally is mild, it can be severe and constitute an emergency.
In the management of acute menorrhagia, quantification of menstrual blood loss is paramount. Menorrhagia is defined as a menstrual blood loss of 80 mL or more during a particular menstrual cycle.4 Various procedures for quantifying blood loss during menses have been recommended; one requires collection of blood from each sanitary device during the period,4 while another relies on subjective determination of blood loss by a pictorial blood loss assessment chart.5
An indirect approach to measuring menstrual blood loss is the measurement of various hematological parameters. Studies have shown that most women who lose more than 80 mL of menstrual blood per cycle are anemic.6,7 In the case above, hemoglobin, hematocrit, and reticulocyte counts and perhaps a ferritin level would indirectly demonstrate the significance of the menstrual bleeding. The possibility of a spontaneous abortion always exists in a post-pubertal female with menorrhagia, and a pregnancy test is indicated as well.
Additional laboratory and imaging studies should be considered after the patient is stabilized. Irregular periods can be the only presenting symptom of cervicitis. While cervicitis would be unlikely to cause such significant menorrhagia, tests for chlamydia and gonorrhea should be performed on adolescents with abnormal periods by either a urine or cervical swab specimen. These tests are indicated even in those who deny sexual activity, because not all teenagers feel comfortable relaying their sexual history.
Evaluation for coagulopathy also should be considered. In one study of adolescent females hospitalized for menorrhagia, 19% were found to have a bleeding disorder.2 The prevalence increased to 25% if the hemoglobin was less than 10 gm/dL, to 33% if they required a transfusion, and to 50% if they presented at menarche. In another study of adolescents with menorrhagia and hemoglobin less than 11 gm/dL, the prevalence of a bleeding disorder was found to be 12%.3 To evaluate for a bleeding disorder, a coagulation panel, a platelet count, and a von Willebrand's disease work-up are indicated.
Other causes of adolescent menorrhagia include malignancy, polyps, congenital anomalies, endometritis, and fibroids.8 A pelvic ultrasound may be indicated to evaluate for these entities, although the likelihood of finding an abnormality in adolescence is rare. A retrospective chart review from 1975 to 1996 found only 10 cases of fibroids in females ages 13 to 21.9
Additional laboratory tests to consider in patients with irregular periods include a thyroid panel, prolactin level, testosterone panel, and 17-hydroxyprogesterone and dehydroepiandrosterone levels. Thyroid disorders, prolactinomas, and hyperandrogenism can all be a cause of anovulation.
Continued Case Description
Work-up of the patient reveals hemoglobin 8.3 gm/dL, hematocrit 25%, reticulocyte count 1.2%, normal platelet count, and negative pregnancy test. She is diagnosed with iron-deficiency anemia. The decision is made to admit her for close monitoring because of her severe symptomatic anemia.
Treatment of decompensated shock due to severe menorrhagia consists of isotonic crystalloid boluses, packed red blood cells, and conjugated estrogen at a dose of 25 mg intravenously every 4 to 6 hours for 24 hours until the bleeding stops.10 An anti-emetic also must be provided because such high doses of estrogen cause significant nausea. A high-dose progestin, such as that found in the oral contraceptive norgestrel, also may be added to help stabilize the fragile endometrium.11
If the patient is in compensated shock from blood loss, as in this case, therapy with oral contraceptives providing high doses of estrogen and progestin is indicated.8,11 The dose should be repeated every 6 hours until the bleeding has stopped. As with conjugated estrogen, an anti-emetic should be provided. If excessive bleeding continues after 2 pills, intravenous conjugated estrogen may be considered to control the bleeding.
Before adopting this regimen, it must be noted that the use of oral contraceptives to control heavy menstrual bleeding has never been established by a randomized, placebo-controlled study. Only one small study, not placebo-controlled, compared oral contraceptives to mefenamic acid, naproxen, and danazol and found them to be equally effective in effecting a 40% to 50% reduction in mean blood loss.12 Use of oral contraceptives is mostly anecdotal but is suggested in various review articles.8,11,13,14
In adolescents with severe menorrhagia, most authorities state that dilation and curettage is indicated only if acute hemorrhage continues after 24 hours of intravenous estrogen therapy.8,11,13,14 This recommendation is based on the fact that menorrhagia in adolescents is usually due to anovulation rather than a pathological abnormality.
After stabilization, the patient with severe menorrhagia should be maintained on a medication that continues to stabilize the endometrium, allowing the rebuilding of iron stores. While the optimal regimen has never been studied prospectively, various experts recommend continuing oral contraceptive use. After bleeding subsides, high-dose oral contraceptives can be tapered to one pill per day. This is usually achieved by day 5 to 7 of treatment and further tapered to an oral contraceptive dose of 30 to 35 meg by the end of the month. The patient may continue oral contraceptives for 2 to 3 months without withdrawal bleeding if there was a history of severe anemia. After 3 to 6 months of therapy, oral contraceptives may be stopped, with careful follow-up to ensure the problem does not recur.8,11,13,14 Iron therapy also should be added.
ACUTE SCROTAL PAIN
A 14-year-old boy presents to the clinic complaining of severe pain "down there." He reports that the pain started about 4 hours prior to the visit The pain is rated 10 out of 10 in severity and radiates to his abdomen and back. He denies any history of sexual activity, and there is no history of trauma. He had similar pain 2 days earlier and went to an emergency department, but the pain resolved by the time he was evaluated by a physician.
Acute scrotal pain in the adolescent can be a serious problem. Among the differential diagnoses (Sidebar 1), testicular torsion, or torsion of the spermatic cord, is the most conoerning. Testicular torsion presents with acute onset of severe pain, but the history often reveals intermittent prior pain due to twisting and untwisting of the spermatic cord. The pain of a complete torsion often radiates to the abdomen and back and is associated with nausea and vomiting. The affected testicle is swollen, tender, and elevated. The cremasteric reflex is characteristically absent, although there are case reports of surgically verified testicular torsion with a preserved cremasteric reflex.15 If the diagnosis is unclear, a Doppler ultrasound to evaluate for blood flow to the affected testicle should be done as quickly as possible.
Normally, the tunica vaginalis covers the testicle anteriorly. In some males, the tunica vaginalis covers the entire testicle, resulting in a "bell-clapper" defect that allows the testicle to twist on the spermatic cord, resulting in the torsion. Treatment is immediate surgical correction. Repair completed within 6 hours of onset has a good prognosis. The chance of saving the testicle drops to 70% after 6 hours and to 20% after 12 hours.16 At the time of surgery, a fixation orchidopexy is often done on the unaffected testicle to prevent it from developing a torsion in the future.
There are other structures that can twist in the scrotal area that may present similarly but are not surgical emergences. Torsion of the appendix testis can present with similar symptoms, but tenderness often is localized to the upper pole of the testis. Testicular ultrasound should be done if the diagnosis is unclear to rule out torsion of the spermatic cord. Treatment of torsion of the appendix testis consists of rest and analgesics. Surgical intervention usually is not needed.
Epididymitis is a frequent cause of pain and swelling in post-pubertal males. The clinical presentation is a more gradual onset of pain with associated urinary symptoms and sometimes fever. Pyuria can be seen and helps to differentiate from testicular torsion. On examination, the cremasteric reflex generally is present, and elevation of the scrotum may provide some relief (positive Prehn sign). The etiology usually is a sexually transmitted infection (STI) in adolescents, but it also can result from non-STI urinary tract infection (UTI), which is much less common in males than in females.17
Diagnosis using urine-based nucleic acid amplification tests can be done easily. It is important to note that the one-dose treatment regimens for urethritis are not sufficient to treat epididymitis, so a longer-course treatment with doxycycline and higher dose ceftriaxone (250 mg) or a fluoroquinolone where appropriate is needed.18
Orchitis can present with sudden-on-set testicular pain with associated nausea, vomiting, and fever. The testicle is enlarged and tender, sometimes with a reactive hydrocele. The etiology can be STI or UTI as in epididymitis but could also be viral (Sidebar 2, see page 897). If it is not possible to differentiate the condition from testicular torsion on examination, a Doppler ultrasound should be performed.
Urine testing for bacterial causes is indicated, and viral etiologies should be considered based on the rest of the clinical presentation. Treatment of viral orchitis includes bed rest, ice, and analgesics as needed.
Trauma with a developing hematoma can become a surgical emergency quickly if blood flow to the testicle is compromised by the expanding mass of blood. Early urologie consultation is needed in those circumstances. Henoch-Schoenlein Purpura can affect the vessels of the scrotal skin, testes, epididymis or spermatic cord and may initially present as scrotal pain.
Another common cause of scrotal pain in adolescent males that is well-known to practitioners caring for this population is "epididymal hypertension," known colloquially as "blue balls."19 The exact etiology is not known, but theories include venous congestion or epididymal distension from sexual stimulation without release of sperm by ejaculation. It must be remembered that all teenagers are sexual beings, even if they are not sexually active. Hormones have kicked in, and it is normal for them to have sexual thoughts and feelings or dreams which can result in sexual arousal. Kissing, touching, and sexual activities that do not result in ejaculation may also result in this syndrome.
One author reports that the pain can be relieved by straining to move a very heavy object, such lifting a car burn-per.20 Masturbation also remedies the pain but may not be an acceptable recommendation to all patients based on their beliefs. Being able to discuss this diagnosis with an adolescent may save an unnecessary work-up.
A 16-year-old girl presents to a clinic with her mother and requests a referral for counseling. Her mother reports her daughter has been acting sad since they moved to the area about 2 months earlier, and the day before she left a note saying she needed to talk to someone. After obtaining this history, a referral for counseling is made. Is there anything else that needs to be done?
Suicide is the third leading cause of death among the 10- to 24-year-old age group in the United States.21 Counseling and the selective serotonin reuptake inhibitor (SSRI) class of antidepressants are effective in treating adolescents,22 but new concerns about the safety and efficacy of SSRIs have called their use into question and may result in decreased use of SSRIs among teens.
It has been shown that fewer than one-third of suicidal adolescents access counseling services.23 Some adults feel that depression is a normal part of adolescence and do not fully understand the effects that some stressors can have on teenagers. In the above case, it is crucial that an assessment be completed to determine the patient's risk for suicide. If she is acutely suicidal, a referral to see a counselor in the future, even the next day, may be too late. A review of suicidal adolescents who were seen in an emergency department and then discharged with a referral to see a counselor showed that 42% to 77% were noncompliant with keeping the referral appointment.24
In addition to asking about suicidal intent and planning, several other factors should be assessed to determine risk of suicide. "Suicide is a deficiency disease - a deficiency of social connections" is a common dictum. Depressed individuals with no one with whom they are able or willing to talk are at greater risk of suicide. Having a safety plan that includes appropriate social connections for confidential sharing is essential.
Another risk factor is alcohol and substance use. A number of teens turn to these as an escape from their problems or as a solution to their depression. In addition, access to lethal means frequently is an overlooked risk factor. Removing or locking up firearms, prescription medications, and anything else that is part of the adolescent's suicide plan can decrease the chance that an attempt will be made impulsively. Other risk factors are listed in Sidebar 3 (see page 899).25,26
Most risk factors are related to social isolation or to a disruption in social connections. It is interesting that a paternal history of alcohol abuse or legal troubles increases suicide risk. Relationship problems are a trigger in males, as adolescent males are less likely than adolescent females to remain involved with a group of close friends and use those social connections to cope at the time of a break-up.25
Teens with sexual identity issues are at a significantly greater risk for depression and suicidal ideation than other adolescents. This risk is greatest during the time before the teen is comfortable discussing his or her identity issues with others and must be considered when evaluating suicidal youth, even if they do not admit to any same-sex attractions. Gay, lesbian, bisexual, and questioning youth who are open but experiencing harassment from others, including friends or family members, are at increased risk of suicide as well.
Even if a depressed teen is not suicidal at the time of assessment, the at-risk teen could become suicidal if a stressful life event (or "trigger") occurs. Reviewing the possible triggers with parents or caretakers and letting them know they need to increase their vigilance if a trigger occurs can strengthen the safety net
There are many approaches to the assessment of a suicidal teenager. Use of the HEADSSS (Home, Education, Activities, Drugs, Safety, Sexuality, Suicide/depression) assessment allows the provider to assess all of the pertinent areas of the adolescent's life.27 This format ensures the development of good patient rapport before asking about sensitive topics. Questionnaires and depression scales can be used to assess signs of depression. If there is insufficient time to employ one of these methods, straightforward questions often yield crucial information. "Do you ever get so sad you think about hurting yourself?" is a good way to open the discussion. Follow-up questions should include such things as, "What makes you feel that sad?" and "What do you do when you get that sad or down?" If the adolescent admits to having thought about self-harm, asking about a plan is important.
Not all depressed teens identify themselves as depressed. Asking about teenage "equivalents," such as boredom and irritability, increases the sensitivity of the screen.28 Formulating a signed safety contract, in which the patient promises to contact someone before doing anything harmful, and identifying the person they are going to contact, constitutes a reasonable approach for many teens. This gives the adolescent at least one social connection and allows an avenue for seeking help.
Any adolescent with suicidal ideation who refuses to sign a safety contract should be referred for immediate evaluation by a mental health professional. Most facilities with adolescent inpatient psychiatric faculties provide emergency assessments for admission Emergency departments can always be used as the back-up plan for acute evaluations as well.
Frequent follow-up with families not requiring immediate intervention but given referrals is important. This ensures that these families get involved with necessary services and that no deterioration of the original problem has occurred.
FEMORAL NECK STRESS FRACTURE
A 17-year-old girl presents to an office pediatrician complaining of left hip pain. She runs regularly and recently increased her activity to train for an upcoming marathon. Her pain was noticed approximately 10 miles into the run, and now she has pain with just walking. Physical examination reveals hip tenderness with range of motion maneuvers and deep palpation. Plain radiographs of the left hip are negative.
Diagnosis of stress fractures may be difficult, requiring a high index of suspicion. If missed, certain stress fractures (eg, femoral neck stress fractures, as in the above case) have potentially serious consequences. Osteopenia is a risk factor for stress fractures. Common locations for stress fractures in active adolescents include the metatarsals and the tibia.
Stress fractures have been classified according to etiology and include fatigue fractures and insufficiency fractures. Fatigue stress fractures occur in otherwise normal bone that is subjected to excessive repetitive mechanical forces. Bone is an active tissue that requires stress for normal growth and development. Bone remodeling through osteoclastic reabsorption and osteoblastic replacement occurs as a normal response to bone stress. With repetitive stressors, the reabsorption may be accelerated, resulting in an imbalance with replacement activity and resultant weakened bone. Continued stress on weakened bone can lead to bone fatigue and fracture.
Insufficiency fractures occur when already weakened bone is unable to handle the repetitive stress of daily activities, even without excessive or repetitive stressors.29,30 Groups at higher risk for insufficiency fractures include the elderly with osteoporosis but also younger patients with medications or disease states that result in osteopenia. These can include the female athlete triad (disordered eating, amenorrhea, and osteoporosis), anorexia, high dose corticosteroids, diabetes, hyperparathyroidism, and irradiation.29,31,32
Femoral neck stress fractures in the adolescent age group generally are seen in those who move either from relative inactivity to a high level of activity, or from regular activity to an even higher level of activity. Besides osteopenia, another risk factor for femoral neck stress fracture is weak hip abductors. In normal single-leg standing, there is a tension force on the superior aspect of the femoral neck. This is counteracted by contraction of the gluteus médius and minimus, which create a compensatory compressive strain. If these abductor muscles are weak or become fatigued, the tension force is heightened, increasing the risk for a tension stress fracture.29
Femoral neck stress fracture usually presents with insidious onset of an aching, deep hip pain during running that may radiate to the knee. As the injury worsens, the pain can occur with any weightbearing activity, including walking. On physical examination, range of motion is intact, but pain may be reproduced at the extremes. Heel percussion can cause pain in the hip but is not a reliable sign Hopping on the affected leg also can cause pain but is not recommended if the diagnosis is strongly suspected.
As with all stress fractures, femoral neck stress fractures initially can be inapparent on plain radiographs. Further evaluation requires bone scan or magnetic resonance imaging (MRI); the latter is the most sensitive and specific test for evaluating for femoral neck stress fractures. Patients who have pain with walking should be placed on crutches until the evaluation is complete or they are able to ambulate without pain.
Femoral neck stress fractures have several different classification schemes. Fullerton and Snowdy33 classify them into three categories: tension, compression, and displaced. Tension stress fractures occur on the superior lateral surface and are at risk for completed fracture and displacement. These require no weight-bearing movement and, if there is evidence of progression or if they are severe enough at presentation, require surgical pinning. Compression fractures occur on the inferior aspect of the femoral neck and show evidence of callous formation without cortical disruption. This type of fracture is more stable and can generally be managed conservatively. Displaced fractures require emergent repair.33 Long-term complications include nonunion, malunion, avascular necrosis of the femoral head, and posttraumatic arthrosis.34
Stress fractures account for a significant number of sports-related injuries, and femoral neck stress fractures account for approximately 5% of all cases.32 While most general pediatricians are aware that hip pain in younger children may represent serious pathology (eg, septic arthritis, osteomyelitis, slipped capital femoral epiphysis), femoral neck stress fracture can be missed if it is not considered in the adolescent, particularly because it may not be detected on initial plain radiographs. There are several case reports in the literature of this injury in pediatric patients, including a bilateral stress fracture in an 8-year-old girl.35
The cases presented in this article are representative of adolescent emergencies that may be encountered by the office practitioner. Many more examples in the area of adolescent gynecology could have been presented, including ectopic pregnancy and pelvic inflammatory disease. Substance abuse issues will be addressed in the second part of this topic, which will be published in the December 2005 issue of Pediatric Annals. Consultation with an adolescent medicine specialist is always recommended for challenging cases.
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