Special Considerations

THE LEGALITIES OF TREATING ADOLESCENTS WITHOUT PARENTAL CONSENT Consent is not required to evaluate and initiate treatment in an emergency. State consent statutes and case law vary, so emergency physicians should know and follow their state law and hospital policy with respect to consent. There should be a mechanism in place to obtain consent from the courts when necessary. The American College of Emergency Physicians policy on consent is summarized in Figure., 98:3. All states allow minors to consent to diagnosis and treatment of STDs and drug abuse without parental consent. Many states have similar statutes allowing minors independent direct access to prenatal care, termination of pregnancy, and medical care for crime-related injuries. Special considerations are included in some state legislation for emancipated and mature minors. Common sense and appropriate documentation should prevail above all with respect to issues of consent. An a priori awareness of the statutes and policies and established liaisons with local child protection services and the courts should assist emergency physicians in the ongoing provision of timely emergency care.

FIG. 98-3. Initial approach to consent for treatment. (From Tsai et al,31 with permission.)

HIV-INFECTED WOMEN In general, there is no need to change the approach to pelvic pain and bleeding in HIV-positive women. Physicians must look for associated infections and complications of chronic illness. The rate of vaginal and pelvic infections as well as cervical dysplasia is high in this cohort of patients. In a cross-sectional survey of 386 women younger than age 50, with and without HIV, neither infection nor immunosuppression affected menstruation or the rate of abnormal vaginal bleeding.21 This was also seen in a study of 85 seropositive women, although the power of the study was low.22

COMPLICATIONS OF IN VITRO FERTILIZATION Ovarian hyperstimulation syndrome complicates 5 to 10 percent of in vitro fertilization cycles, although only few cases become severe.23 Particular vigilance is needed with such patients presenting to the ED. The syndrome is characterized by ovarian enlargement and fluid loss from ovarian capillaries into the extravascular compartment. This leads to ascites, abdominal distention, hydrothorax, and localized or generalized tissue edema. Complications include hypovolemia, hemorrhage, and thromboembolism. The cause of the increased capillary permeability, fluid sequestration into the peritoneal cavity, and angiogenesis is not known. Presentation varies with severity. Patients with mild forms present with weight gain, increased thirst, and abdominal discomfort. More severe forms may include hypovolemia, acute respiratory distress due to the ascites and hydrothorax, pericardial effusions, hepatorenal failure, and/or thromboembolic phenomena. Factors associated with increased risk of developing ovarian hyperstimulation include age less than 35, the administration of hCG to trigger the ovulatory response, or endogenous hCG release in early pregnancy. 23

Elevated WBC level, hemoconcentration, hyponatremia, and hypoalbuminemia may be seen in moderate and severe cases. Ultrasound examination is usually indicated and should be helpful in demonstrating the extent of ovarian enlargement, size and number of corpora luteal cysts, and degree of pelvic and abdominal fluid. Pregnancy may have occurred in patients with ovarian hyperstimulation. Investigations and treatment should be adjusted accordingly. The treatment of mild to moderate cases includes increased fluid intake, close observation, and safe analgesia. Severe cases should be followed closely with serial hematocrits. A coagulation screen, liver function tests, renal function tests, and chest x-ray should also be obtained. Management includes intravenous fluids and, in some cases, the administration of heparin. The use of diuretics should be avoided, and paracentesis, using ultrasound guidance, may be indicated for relief of respiratory distress. Pleural effusions rarely need to be tapped. Pericardial effusion should be imaged and drained under echocardiographic guidance as indicated. Although aggressive resuscitation may be required in severe cases, death remains rare.

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