Pediatric emergency medicine trisk 2169 2169

Patients with systemic signs of infection (fever, nausea, vomiting, abdominal
pain) following an IUD insertion should be treated with a similar regimen to PID,
which provides broad-spectrum coverage. IUD removal is not indicated unless
the patient fails to improve after 48 to 72 hours of empiric treatment.

SUBDERMAL HORMONAL IMPLANT
Clinical Manifestations
Like the IUD, serious complications due to a subdermal hormonal implant are
rare, with an overall complication rates estimated at 0.8%. Implants are generally
placed in the nondominant arm 8 to 10 cm above the median epicondyle and 3 to
5 cm below the biceps sulcus. Implant site infection and deep placement are the
primary complications that may present to the ED.

Management
Implant site infections should be treated similar to any other skin infections. In
the case of a nonpalpable device, imaging studies should be ordered to confirm
that the device is still in the arm. A linear probe ultrasound is the optimal strategy
for imaging the arm to assess the device location. Deep placements should be
referred to skilled provider for removal and generally do not warrant urgent or
emergent management. However, if the patient presents with significant persistent
pain and the device is noted to be within the biceps or triceps muscle, a surgical
consult from gynecologist or general surgeon should be obtained. If no skilled
provider is available, the manufacturer (Merck, Inc.) has a hotline that will
connect clinicians with the nearest provider trained to perform difficult removals.
If the device is not identified in the arm on imaging, the patient should have an xray of the chest and shoulder on the ipsilateral side to determine if it is
intravascular and has migrated. If the device cannot be identified on imaging, an
etonogestrel level can be ordered. This is a special request lab that can be
arranged through the device manufacturer.
Suggested Readings and Key References
Pregnancy
Chernick L, Kharbanda O, Santelli J, et al. Identifying adolescent females at high

risk of pregnancy in a pediatric emergency department. J Adolesc Health
2013;51:171–178.