CEN: Uterine Bleeding, Kidney Stones and Deep Neck Infections

In depth

The one-page summary above is what the PDF prints. These sections go further.

Abnormal uterine bleeding: definitions and causes

Merck defines normal menses as a cycle of 24 to 38 days with 8 days or less of bleeding, and heavy menstrual bleeding as loss over 80 mL or by the patient's report of volume. Causes follow PALM-COEIN: structural (polyp, adenomyosis, leiomyoma, malignancy or hyperplasia) and nonstructural (coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not yet classified). Ovulatory dysfunction is commonest in adolescents and in women over 45; in perimenopause it may be an early sign of ovarian insufficiency. Pregnancy is excluded first, even in young adolescents and perimenopausal women: urine hCG, then serum quantitative hCG if negative. CBC and ferritin look for iron deficiency.

Acute severe bleeding in the ED

The first job is hemodynamic stability: IV crystalloid and blood products as needed (Merck). Large-bore access and a type and crossmatch are usual hemorrhage practice; the Merck page does not list them. Once the patient is stable, hormones control the bleeding: conjugated estrogens 25 mg IV every 4 to 6 hours for a total of 4 doses, or an oral regimen such as a monophasic pill with 35 mcg ethinyl estradiol three times daily for 7 days or medroxyprogesterone 20 mg three times daily for 7 days. Tranexamic acid is 1.3 g orally or 10 mg/kg IV (maximum 600 mg) three times daily for 5 days. If bleeding persists, a bladder catheter placed in the uterus and inflated with 30 to 60 mL gives tamponade; D&C or uterine artery embolization follow, and hysterectomy is the option when bleeding cannot be controlled and the patient is unstable. After the acute regimen a daily estrogen-progestin pill usually continues until bleeding has been controlled for a few months.

Thrombosis: high-dose estrogen, progestin and tranexamic acid all raise clot risk, so selection, teaching and monitoring matter; estrogen is contraindicated in patients with cardiovascular risk factors or prior clots (Merck).

Adolescent heavy bleeding and VWD testing

CDC: von Willebrand disease is found in up to 1% of the US population; type 1 is the commonest and mildest, type 3 the rarest and most severe. Signs include nosebleeds lasting over 10 minutes or occurring 5 or more times a year, and heavy periods: soaking a pad or tampon every 1 to 2 hours on the heaviest days, bleeding over 7 days, clots larger than a grape, or anemia from menstrual loss. Perez Botero (ASH 2024) notes that heavy menstrual bleeding can be the first and only bleeding sign in adolescents, and that the diagnosis can be missed for over a decade.

Merck advises considering a coagulation disorder in adolescents with anemia or bleeding that needs hospitalization, starting with platelet count, PT and PTT, with VWD tests guided by the results. Perez Botero adds that physical stress (acute bleeding, anemia, illness, a traumatic draw), psychological stress and estrogen-containing drugs raise VWF and can mask the disease; blood group O, valproic acid, ciprofloxacin and hypothyroidism lower it. Pills with 30 mcg or less of estrogen have little effect and need not be stopped for testing, but drawing before therapy is quick and baseline samples read best. Per Perez Botero, a VWF activity above 50 IU/dL drawn during acute bleeding, severe anemia, illness or pregnancy should be retested when well.

The Merck page gives the pill and medroxyprogesterone regimens and the iron work-up but does not describe this adolescent scenario; the following is standard practice rather than a Merck statement. A stable adolescent with normal coagulation tests and mild anemia goes home on an estrogen-progestin pill or cyclic medroxyprogesterone, oral iron and prompt gynecology follow-up, with teaching to take the hormone exactly as prescribed and to return for heavier bleeding, dizziness or fainting.

Postmenopausal bleeding

Merck (Endometrial Cancer): over 90% of women with endometrial cancer present with abnormal bleeding, and 6 to 19% of women with postmenopausal bleeding have endometrial cancer, depending on age and risk. Risk factors are unopposed estrogen, age over 45, obesity, tamoxifen for over 2 years, Lynch syndrome and prior pelvic radiation. Outpatient endometrial biopsy has a sensitivity over 90%; transvaginal ultrasound is an alternative in average-risk women, with biopsy when the lining is over 4 mm. The AUB page adds that ultrasound alone is not enough with risk factors (obesity, current or recent tamoxifen), persistent or recurrent bleeding, or a lining over 4 to 5 mm. Atrophy is common, but it is a diagnosis reached after evaluation, not instead of it.

Stones: urinalysis and prevention by type

Merck: macroscopic or microscopic hematuria is common, but the urine may be normal despite multiple calculi, so a clear dipstick does not override a typical history of colicky flank-to-groin pain, restlessness and vomiting. Pyuria with fever or foul urine suggests infection. CT may also reveal other causes of the pain, such as an aortic aneurysm. Analgesia, imaging choices, passage rates and who stays are on CEN: Genitourinary, Gynecologic and Early-Pregnancy Emergencies.

Every stone former should make at least 2.5 L of urine a day. Prolonged alkalinization with potassium citrate 20 mEq orally two to three times a day can occasionally dissolve uric acid stones; calcium stones cannot be dissolved chemically.

Lemierre syndrome

Tiwari (2023): septic thrombophlebitis of the internal jugular vein that follows an oropharyngeal infection, usually pharyngitis, by several days, in healthy young adults (median age 21 in a 712-patient review). The usual organism is the anaerobe Fusobacterium necrophorum. Look for swelling along the sternocleidomastoid, although neck findings are absent in many, and septic emboli, mostly to the lungs (pleuritic pain, dyspnea, cough, hemoptysis), also joints, brain and liver. Merck notes that parapharyngeal abscess can cause the same jugular thrombophlebitis.

Contrast CT is the usual diagnostic standard; Doppler is less sensitive. Blood cultures may be negative if antibiotics come first, so draw them before. Treatment is a beta-lactam or carbapenem, usually with metronidazole, for about 3 to 5 weeks; the organism is less often sensitive to erythromycin and penicillin. Anticoagulation was used in about 23 to 56% of cases and remains without consensus. Mortality is now about 2 to 4%.

Descending necrotizing mediastinitis

Cobzeanu (2025): DNM complicates about 3% of deep neck infections, with mortality up to 50%, mostly from late diagnosis and inadequate drainage. Pharyngeal infections are the commonest source, then dental ones. Clues are crepitus from gas-forming anaerobes, chest pain, breathing difficulty and progression to septic shock. Contrast CT is the emergency study, and neck swelling that reaches the sternal notch suggests the mediastinum is involved, so the chest is scanned too. Treatment: secure the airway (the review favors tracheotomy under local anesthesia over oral or nasal intubation when the airway is acutely obstructed), broad aerobic and anaerobic antibiotics, wide cervical debridement and mediastinal drainage (transcervical for the upper mediastinum; sternotomy, thoracotomy or VATS lower). Delayed surgery raises morbidity and mortality.

The pulsatile neck mass and the pocket shot

A pocket shot is injection into the neck between the heads of the sternocleidomastoid, to reach central veins such as the subclavian or internal jugular (Kollia 2023). Complications include abscess, pneumothorax, hemothorax, mediastinitis, osteomyelitis and vascular complications; the reported case had cultures before antibiotics, echocardiography for endocarditis and counseling about drug use and withdrawal. Randhawa (2023) describes carotid mycotic aneurysms after neck injection: an expanding pulsatile mass with fever, bleeding or trouble speaking or swallowing, most often from Staphylococcus aureus, with rupture and septic emboli as the risks; repair is open or hybrid. Merck warns that posterior parapharyngeal abscesses can erode into the carotid. Kim and Kang (2025) report a carotid pseudoaneurysm mistaken for a peritonsillar abscess, cite massive hemorrhage after incision, and advise contrast CT or Doppler before any invasive step when a neck mass is uncertain. A pulsatile mass means the nurse holds the setup and reports it before any incision. The item also lists a bruit and ready pressure dressings, large-bore access and blood; none of the opened sources mention these, so treat them as usual practice, not sourced findings.

Drug-induced angle closure

Two mechanisms (Alarfaj and Qedair 2026). Pupillary block in a predisposed narrow angle follows drugs that half-dilate the pupil: anticholinergics, adrenergic decongestants, serotonergic and tricyclic antidepressants; it is treated with the standard regimen and iridotomy (see CEN: HEENT Emergencies). Sulfonamide-derived drugs, mainly topiramate and zonisamide, cause bilateral, non-pupillary-block closure from ciliochoroidal effusion, with an acute myopic shift and shallow chambers. Here pilocarpine and iridotomy are ineffective and may be harmful; stopping the drug, cycloplegia and topical steroids are the core.

The Topamax label: symptoms typically within 1 month of starting (reduced acuity, eye pain, myopia, mydriasis, raised pressure), and the primary treatment is stopping topiramate as rapidly as possible. EyeRounds: usually both eyes, mostly within 2 weeks of starting or a dose increase, distance vision worse than near; aqueous suppressants (with or without acetazolamide) are used, with topical cycloplegics and steroids; prostaglandins and miotics are avoided and iridotomy has no role; pressure often normalizes in 1 to 2 days. The nurse reports the recent drug start and questions an order for a miotic.

Waiting with a dislocated jaw

Yoshida (2025): a jaw that cannot close causes drooling, poor speech and impaired chewing and swallowing, and mouth breathing with poor swallowing raises the risk of aspiration pneumonia. Early dislocations usually reduce easily. Merck: sedation is usually unnecessary but may be needed for an uncooperative patient or a dislocation present for more than a few hours, and the reduction is done with the patient upright or slightly reclined and the head braced. Until then, common nursing practice (no opened source lists these steps) is to sit the patient upright with a Yankauer he can use himself and a basin, to ask the reducing clinician about nothing by mouth, to avoid packing the mouth, and to report stridor or falling saturation at once. Reduction technique and aftercare are on CEN: HEENT Emergencies.