Transcript EMR - Palmetto Health

Emergencies in Obstetrics
Paul C. Browne, M.D.
Associate Professor
Department of Obstetrics and Gynecology
USC School of Medicine
Disclosures
Nature of Financial Relationship:
•Grant/Research Support–
•USC School of Medicine
•March of Dimes
Objectives
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1. Define “Emergency
2. Triage for Pregnancy Emergencies
3. Maternal versus Fetal Emergencies
4. Change in Mental Status
5. Hemorrhage
6. Cardiac/Pulmonary Insufficiency
8. Trauma
9. Cardiac Arrest
10. Appropriate Maternal Evaluation
11. Appropriate Fetal Evaluation
Definition of Emergency
• “An emergency is the sudden onset of
symptoms which, in the opinion of a
reasonable and prudent lay person,
require immediate medical attention
and where lack of treatment would
pose a significant health risk to the
mother or her unborn child”
Components of Emergency
• Sudden onset
• Symptoms which require immediate
attention
• Lack of treatment may cause harm
• Mother and/or fetus
Examples
• Chronic bleeding
• Acute bleeding
• Sudden-onset is
an emergency
Courtesy mybloodyourblood.org
Examples
• Symptoms which require immediate
attention
• Preterm labor
Courtesy activebodycare.co.uk
Examples
• Lack of Treatment may cause harm
Courtesy topnews.in and statejournal.com
Fetal Emergencies
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No Fetal Movement
Vaginal Bleeding
Preterm Labor
Abdominal Trauma
Viability
• World Health Organization/ACOG
– 20 weeks gestation
– 350 Grams
• State of South Carolina
– Completion of “Second Trimester”
• Your ER
– 20 weeks gestation
– Positive fetal heart rate
Statement of AAP
• Less than 23 weeks gestation
– No mandate to resuscitate secondary to
uniformly poor outcomes
• 23-25 weeks
– Resuscitation on a case by case basis in
consultation with the parents and NICU
professionals
• Greater than 25 weeks
– Ethical mandate for resuscitation in absence of
an anomaly incompatible with life
Maternal Emergencies
Altered mental status
Hemorrhage/DIC
Cardiopulmonary insufficiency
Trauma
Cardiopulmonary arrest
Change in Mental Status
• Disorientation
• Aphasia
• Slurred Speech
Causes of Altered Mental Status
• Recreational Drugs
• Hypotension
(internal bleeding)
• Diabetes
• Seizure (post-ictal
eclampsia)
Triage of Altered Mental Status
• Vital signs
– Pulse, Blood Pressure
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IV access
Fingerstick glucose
Urine drug screen
Fetal heart rate by doppler
Abbreviated EEG
J Clin Neurophysiol. 2007 Feb;24(1):16-21
Mental Status Score
Courtesy Scripps
Mercy Hospital
Triage of Altered Mental Status
• Majority of cases will be caused by
drug use or metabolic disturbance
• Easily corrected in ER setting
Altered Mental Status Triage
• Hypoglycemia
– Treat and release
• Hypotension
– Improved without bleeding
• Seizure
– Only with known seizure disorder
Treatment
• IV Hydration
– D5LR at 125 ml/hr
• Oxygen
– 2 liters/minute nasal cannula
• Serial Vital Signs
• Serial Mental Status Checks
• Monitor fetal status
Recreational Drug Use
• Observation
admission
– DHSS referral
– Arrange outpatient
drug rehab
– Schedule birth
defect screening
Courtesy pregnancy.about.com
Intracranial Hemorrhage
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Rare cause of altered mental status
Lateralizing signs
Often associated with seizures
Source of medical-legal action
Courtesy casereports.net and catscanman.net
Pearls in management of
altered mental status
• Global neurological dysfunction
– Drugs, metabolic disturbance, low BP
• Focal neurological dysfunction
– Seizure disorder, migraines, CVA
• Parallel workups
– Differential diagnosis evolves
Summary-Altered Mental
Status
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Usually corrected in ER
Secure patient
Start IVF with dextrose/give O2
Obtain labs/imaging
Serial neuro checks until resolution
Admit for substance abuse and
eclampsia
Hemorrhage
• 2nd leading cause of maternal death
• Unique physiology
– Pregnant women are prepared to bleed
• Increased blood volume
• Increased blood clotting
– Decompensate with rapid hemorrhage
• Abruptio placenta
• Severe trauma
• Difficult cesarean section
2007 SC DHEC Vital Statistics
Bleeding
Courtesy thepregnancyzone.com
Triage of Bleeding
• Blood from vagina
– Labor
– Rupture of membranes
– Abruption
• Blood from anywhere else
– Trauma
– Epistaxis (nosebleed)
– GI bleeding
Vaginal Bleeding
• First Thing
– Confirm fetal heart rate
• Important labs
– Baseline hematocrit
– Platelet Count
– Fibrinogen
– Drug screen
• Sterile Speculum Exam
– Locate source of bleeding
• Ask the big question
– Did you have sex within the past 24 hours?
Blood from Anywhere Else
• Stop the bleeding
• Need consultants
– Trauma surgeons, hematologists
• Important labs
– Baseline hematocrit
– Platelet count
– Work-up coagulopathy
• Von Willebrand disease
• Factor IX Deficiency
Bleeding-What’s the
Baseline?
Hct > 30%
Platelets >150,000
Fibinogen > 250 mg%
Courtesy robetech.com
Most likely incorrect
diagnosis in Obstetrics?
• DIC-Disseminated Intravascular
Coagulation
DIC versus Coagulopathy
• DIC is a primary diagnosis
• Coagulopathy occurs with
– Excessive surgical blood loss
– Amniotic fluid embolism
– Prophylactic anti-coagulation
– Pre-eclampsia
– Sepsis
Best Description
• Coagulopathy
– “any disorder of blood coagulation”
• DIC
– “a serious medical condition that
develops when the normal balance
between bleeding and clotting is
disturbed”
Thefreemedicaldictionary.com
Skin manifestations of DIC
Courtesy dermaamin.com
Consumption versus DIC
• Exhaustion of pro-coagulants from
hemorrhage versus inappropriate
depletion of pro-coagulants internally
• Macro clotting versus microvascular
clotting
• At 2000-3000 ml, recovery time to
replace lost pro-coagulants is
exceeded
Consumption-Abruption
Courtesy cbbsweb.org
DIC-Amniotic Fluid
Embolism
Courtesy brown.edu
Treatment of DIC
• Stop the inciting process
– Sepsis
– Surgical blood loss
• Anticoagulation with heparin
– Stop intravascular clotting
• Recombinant Factor VIIa
– Directly initiate thrombin formation at
sites of abnormal bleeding
Treatment of Coagulopathy
• Replacement of whole blood
– PRBC’s and Clotting factors
• Replacement of clotting factors
– FFP, dehydrated FFP (cryo)
• Recombinant Factor VII/Fibrin glue
– Rapid direct initiation of thrombin
Emergency Release Blood
• Whole Blood not available
• Make Whole Blood from Packed
RBC’s and Fresh Frozen Plasma
• Order 2 units of each stat
• Order 2 additional units of PRBC’s
and FFP cross-matched
Emergency Release Blood
• Men-Opos PRBC’s
• Women-Oneg PRBC’s
• Both-ABpos FFP
Palmetto Health Baptist Blood Bank
Bleeding-What’s the
Baseline?
Hct > 30%
Platelets >150,000
Fibinogen > 250 mg%
Courtesy robetech.com
Replacement
• Plain IVF work well
– Lactated Ringers
– 0.5 normal saline
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PRBC/FFP is OK for emergency
PRBC’s best for hemorrhage
FFP at 1:1 units PRBC’s
Platelets don’t usually help
Factor viia
• 80 patients with postpartum
hemorrhage
• 2.5% mortality
• 95% effective
• Majority of patients require 1 dose
Ceska Gynecol 2010;75:297
Clin Obstet
Gynecol
2010;53:219
Topical Hemostatics
• Lattice frame for coagulation
– Collagen
– Potato starch
• Fibrin glue
Lattice for fibrin deposition
Courtesy cardinal.com
Lattice for fibrin deposition
Courtesy policemag.com
Fibrin Glue
Courtesy laparoscopyhospital.com
Treatment of Coagulopathy
• Lattice material
– Must have circulating anticoagulants for
these to work
– Ineffective in DIC
• Replacement FFP and Factor VIIa
– Correct the deficiency of pro-coagulants
– Initiate thrombin formation at site of
abnormal bleeding
Summary-Coagulopathy
• Not all bleeding disorders are DIC
• Chicken versus the egg
– Bleeding then coagulopathy (not DIC)
– Coagulopathy then bleeding (DIC)
• Most common clinical situation
– Abruption
– Difficult cesarean section
• Treat with replacement and Factor VIIa
Cardio-Pulmonary Insufficiency
• Rare but serious emergency
• Tachypnea/tachycardia combination
• Presenting symptoms
– SOB
– Syncopal episode at home
• Best question to ask
– Orthopnea
Symptoms
Courtesy answerbag.com
Causes of Cardiopulmonary
Insufficiency
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Fluid overload
Pre-eclampsia
Tocolysis
Cardiomyopathy
Pulmonary Embolism
Triage of SOB/Syncope
• Vital signs
– Pulse, respiratory rate, BP
• Oxygen saturation
– Normal > 92%
• Oxygen treatment
– Cannula is usually sufficient
– Humidity
• IV access (Lactated Ringers)
What makes Pregnant Women
Unique?
• Respiratory rate higher
– Decrease TLC, FRC
– Normal less than 26/minute
• Pulse higher
– Compensates for increased cardiac
output
– Often greater than 100/minute
Helpful Laboratory Studies
• Echocardiogram
– Ejection fraction
• Renal function tests
• Not helpful
– CXR
• Typically shows cardiomegaly and poor
pleural demarcation in bases
– BNP
• Always elevated
– ABG
• Rarely shows CO2 retention
Cardiac Function
Pulmonary Function
Courtesy
glowm.com
Treatment for SOB
• Diuresis
– Lasix 10-20 mg IV
• Fluid restriction
• Oxygen
• Sedatives
– Morphine 5-10 mg IV
– Xanax 0.25 mg po
Cardio/Pulmonary
Insufficiency
• Automatic admission
• Critical care if available
• Lots of consults
– OB, Cardiology, Pulmonary, Renal
Remote Fetal Monitoring
• Only if Viable
• Protocol with
OB nursing
– Critical care
should not be
responsible
Courtesy delphine.latte.com
Summary-Cardio-Pulmonary
Insufficiency
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Elevate head
Tilt pelvis
Oxygen saturation monitoring
EKG
LISTEN!
– Rales-Pulmonary Fluid Overload
– Wheezes-Allergies or asthma
Trauma
• Usual causes
– MVA
– Fall
– Domestic Violence
• Unusual causes
– Gunshot/Shotgun injury
– Knife wound
Trauma
Courtesy centralnewyorkinjurylawyer.com
Courtesy Volvo
Courtesy howstuffworks.com
Courtesy coloribus.com
Trauma
• Categorize Trauma
– Blunt (most common)
• Injury to abdomen
• Injury to other areas (head, extremities)
– Sharp (less common)
• Injury to abdomen
• Injury to other areas
Doumentation
• When OB was first contacted
• When OB responded
• When fetal cardiac activity was
confirmed
Laceration Repair
• Verbal orders to ER physician
• Local anesthesia
– Lidocaine +/- epinephrine
• Oral/IM antibiotic therapy
• Acetominophen
• Narcotics
X-Rays
Courtesy thestir.cafemom.com
X-Rays
• Always when medically indicated
– Plain films have less exposure
– CT scans without contrast
– MRI may be best imaging
• Appropriate to have permission
– Disclaimers
– Can’t do when unconscious
– Establish next-of-kin
Imaging Studies
Courtesy University of Rochester
Priority List
• Head/Spine injury work-up
– X-Rays/MRI, neuro checks
– Poor anesthesia risk for delivery
• Work-up for occult abdominal
hemorrhage
– Ruptured liver/spleen
• Extremity injury
Summary-Trauma
• Fetus is rarely injured
• Placenta is often injured
• Litigation is frequent
– Document fetal events
– Document interactions with OB
• Team approach is best
• Have a plan for rapid transfer
Courtesy babble.com
Causes for arrest during
pregnancy
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Trauma
Pre-eclampsia
Magnesium toxicity
PE/Amniotic fluid embolism
Anesthesia
Cardiac disease
– Marfan Syndrome Aortic Dissection
– Acute coronary syndrome
Why are Pregnant ER Patients
Different?
• Less Risky Behavior
– Less Alcohol
– Less Drugs/Medication
• Less likely to be charged with an MVA
– Drive with their children
– Wear their seat belts
• Less likely to settle disputes with violence
– Suicide attempts are usually overdose
– Don’t frequent clubs
Survival from Cardiac Arrest
• Out of hospital
– 40% survival
• In-hospital
– 25% survival
Arrest in Women
• Arrest occurs 1/3 as often as in men
• Lower incidence of ventricular
fibrillation
• Lower resuscitation rates after arrest
(29 versus 32%)
• Lower survival rates following
resuscitation (11 versus 15%)
Circulation 2001;104:2699
Arrest secondary to
Anesthesia complications
• 1990-2003 malpractice cases
• 69 patient deaths or severe brain
injuries alleged secondary to OB
anesthesia
• 18% OB cases versus 7% of non-OB
cases related to airway problems
Anesthesiaology 2009;110:131
Courtesy digital02.com
What’s different doing CPR
on pregnant women?
• Left lateral decubitus position
• Hands-only bystander
• Airway and CPR for healthcare
providers
• Cesarean section in 5 minutes
Courtesy AHA
Year
2011
Citation
Number Outcom
of
e
Cases
J Matern
2
0%
Fetal
Neo Med
2011
Isreal
Med J
1
0%
2011
Anesthes
Intensive
Care
1
100%
2011
Transpla
nt Proc
1
0%
Courtesy medgadget.com
Survival
Survival
Therapeutic Normothermia
Hypothermia
Australia
77 patients
49%
26%
P<0.05
Europe
275 patients
55%
39%
P<0.05
N Engl J Med 2010;363:1262
Summary Cardiac Arrest
• Rare event during pregnancy
• CPR must be adapted
– LLD, rapid cesarean section
• Poor chance for survival
• Brain injury most significant sequela
• Brain cooling for adults improves
intact survival
Transfer
Questions?