Paraphimosis and Phimosis

What is it?

Paraphimosis: the penile foreskin becomes retracted around the coronal sulcus (= the circumference at the base of the glans penis), leading to vascular congestion and glans edema

Phimosis: the foreskin is retracted over the glans

This is only an emergency if it is causing acute urinary retentionKeep in mind most uncircumcised infants have normal phimosis

Why do we care?

 If left untreated, paraphimosis can lead to some awful complications, such as necrosis or gangrene of the glans penis which can then necessitate a partial amputation of the penis 

For phimosis causing urinary retention, can cause infections and renal failure

When to suspect it?

The main risk factor is lack of circumcision.

Crying infants (the S=Strangulation in ITCRIES for those who love mnemonics)

Adolescents may present later due to embarassment - can be caused by genital piercings or sexual intercourse 

Another risk factor is prolonged erotic dancing, ie wining - a gyrating motion that alongside others causes prolonged erection and friction on the penis (multiple case reports)

How do we manage it? 

Don't miss other injuries - look at their scrotum for a concomitant torsion or Fournier's 

Paraphimosis

Call urology urgently if you note signs of ischemia or the patient has had symptoms for >12 hours.

If there are no signs of ischemia, consider non-manipulative methods, which entail a combination of compression and osmotic agents as well as patience:

1. "Iced Glove" - place ice and water in a glove and invaginate the thumb portion to place the penis into

2. Mannitol or glucose soaked gauze - soak gauze in 20% mannitol or D50 and wrap it around the glans of the penis while applying gentle pressure; this can take 1-2 hours for full effect

Next, attempt manual reduction. Don't forget pain control!

Methods of analgesia: topical EMLA, dorsal penile nerve block, fentanyl, ketamine, procedural sedation (though certain studies have shown topical anesthesia may work best) 

Manual reduction: Have both thumbs on the glans while applying countertraction with the index fingers to the foreskin

If it works, make sure the patient can freely urinate , instruct patients to not retract the foreskin for 2 weeks, and arrange urology followup in 2-3 weeks. 

If it fails, URGENT urology consultation. There are other options in case of a failed manual reduction (injecting hyaluronidase, aspirating the glans, poking the foreskin) that are especially useful if no one is immediately available to assist you 

Phimosis

If causing acute urinary retention, call urology for likely dorsal slit procedure.

If patient is able to freely urinate, educate patient on how to properly clean their foreskin and show them how to retract the foreskin (3 months of this exercise has been shown to lead to resolution of phimosis in 76% of patients).

Topical steroids (triamcinolone for 4-6 weeks) also improve or completely resolve phimosis.

Sources

http://www.emdocs.net/em3am-paraphimosis-and-phimosis/

https://pedemmorsels.com/pediatric-paraphimosis/

https://www.aliem.com/trick-trade-management-paraphimosis/

How to Check the pH of the Eye

Did your patient get a splash of bleach in his eye while doing laundry? 

If you called Poison Control they probably asked you what the pH of the eye is and after your failed search through the ED for eye pH paper, what can you use? 

Urine dipsticks! Gently tap the pH portion over a patient's eye and check the corresponding pH on the dipstick strip bottle. Just remember that a urine dipstick can only detect a pH range of 5-8.5, so you may end up needing the eye pH paper for the full range of 1-14. 

Sources:

https://www.aliem.com/trick-of-the-trade-eye-ph/

http://www.emdocs.net/toxcard-caustic-eye-injuries/

Euglycemic DKA

What is it? 

DKA without the elevated glucose that usually triggers us to think about DKA in the first place. Patients often have blood glucose levels less than 250 mg/dl. 

Why do we care? 

Because untreated DKA can lead to cerebral edema, ARDS, renal failure, shock and death.

Why does it happen?

Euglycemic DKA can occur in any diabetic, but there is a rising incidence in those taking SGLT2 inhibtors (-gliflozins) (listed below). The pathophysiology behind this isn't totally clear yet though there are some theories. 

US approved: Dapagliflozin (Farxiga), Canagliflozin (Invokana), Empagliflozin (Jardiance)

It can also occur in those who have underlying disease that depletes the liver's ability to make glucose (putting those who are pregnant or have long bouts of nausea and vomiting under increased risk).

And of course, think of the usual triggers for DKA (ie infection, alcohol use, etc)

When to suspect it?

In any patient with a history of diabetes, including but not limited to those taking SGLT2 inhibitors, who come in for vomiting, generalized weakness, or SOB. Also consider euglycemic DKA in those who have a metabolic acidosis without other clear cause. Draw serum ketones or obtain urine ketones in these patients. 

Sounds a lot like alcoholic ketoacidosis--how to tell the difference?

History: history of heavy alcohol use vs a diabetic on an SGLT2 inhibitor.

Signs: those with alcoholic ketoacidosis tend to have a very low glucose. 

And maintain a high level of suspicion. 

How do we treat it differently than hyperglycemic DKA?

Overall, we treat it pretty similarly. A key difference is that you will need to start fluids with dextrose initially or much earlier than you would with hyperglycemic DKA. 

Sources

https://rebelem.com/euglycemic-dka-not-myth/

https://emcrit.org/ibcc/dka/#euglycemic_DKA

https://emergencymedicinecases.com/euglycemic-dka/

http://www.emdocs.net/diabetic-ketoacidosis-sneaky-triggers-clinical-pearls/