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 to 10 cm above the median epicondyle and to 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 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