Grand Rounds Recap - 11/5/14

R4 Sim w/Drs. Gozman, Redmond, & Stull - Peripartum Emergencies

Background of the simulation: eclamptic seizure leading to cardiac arrest

• Eclampsia should be high on the DDx of seizure for women of child bearing age without past history of seizures
  • Eclampsia typically follows the 1/3 rule: 1/3 occur after 20 weeks gestation, 1/3 occur antepartum, and 1/3 occur postpartum (up to 4 weeks)
  • Be aggressive about seizure management with benzodiazepines and use magnesium (4-6g MgSO4 IV over 10 minutes, followed by a drip for neuroprotection)
  • Follow magnesium levels clinical using reflexes and respiratory rate
• In a pregnant cardiac arrest manually displace the gravid uterus to the left to relieve pressure on the IVC and enhance preload, avoid rolling mom as compressions likely suffer
  • Peri-mortum C-section is indicated in any pregnant cardiac arrest over 20 weeks
  • Estimate gestational age by measuring the height of the uterine fundus (umbilicus = 20 weeks, each 1 cm above the umbilicus =~+1 week in gestational age)
  • If performing perimortum c-section on estimated gestation <24 weeks, the fetus is likely nonviable and the focus should be on ROSC for the mother
  • If performing perimortum c-section >24 week fetus than deliver the fetus and continue resuscitation of both mother and baby

Perimortum c-section is accomplished with a scalpel, scissors, and towels. 

• Make a vertical skin incision from xiphoid to pubic symphysis and use scissors to cut through subcutaneous tissues to expose the uterus. 
• Use the scalpel to make a punch incision through the anterior surface of the uterus and then us scissors to expose the fetus. 
• Deliver the fetus, clamp and cut the cord and continue resuscitation.
• CPR should continue during the procedure.  You can find a great simulated video of the procedure (by the Department of EM at Washington University) below

Oral Boards Case 1: Post-partum women with abdominal pain and fever

• In any post-partum female with fever assume endometritis until proven otherwise
• Most common organisms: GP and GN aerobes, anaerobes, GC and Neisseria
• Vaginal swabs and blood cultures are rarely positive
• Consider treating as outpatient if can guarantee follow up within 24 hours (use clinda or doxy if not breastfeeding) 
• Inpatient endometritis treatment: Vancomycin + Ampicillin + Gentamicin

Oral Boards Case 2: Post-partum women with breast pain

• Mastitis is a common cause of pain post-partum
• Most common organisms in mastitis: Staph Aureus (40%), E.Coli, Strep
• Mom should continue breast feeding and be encouraged to pump frequently in between feeds
• Treatment options:  Dicloxacillin 250 QID 10-14 days is first line, second line includes Keflex, Clinda, and Bactrim
• Be sure to provide analgesia as this can be a incredibly painful

Procedural Station: Difficult Delivery

• Suspect dystocia in gestational DM, late delivery, or when "Turtle's sign" (head is delivered but then moves back toward perineum) is present
• Shoulder dystocia can be scary but something as simple as the McRobert's Maneuver (flexing mom's knees to chest) and suprapubic pressure can relieve ~85% of these.
• If this doesn't work consider the Wood's Corkscrew Maneuver (place 2 fingers behind anterior shoulder and 2 fingers behind posterior shoulder and in screw like motion rotate the posterior shoulder anteriorly)
• Can consider delivery of the posterior arm by reaching in and pulling hand up over head, but should only grab the fetal hand to avoid brachial plexus injury
• In breech delivery consider attempting to abort labor via terbutaline and get OB involved
• If precipitous breech delivery allow mom to deliver to the shoulders, traction increases likelihood of head entrapment
• If head is entrapped, when delivering head, rest fetal body on the dominant arm and place index/middle finger on fetal maxilla (never mandible) and apply downward pressure to flex the head with gentle downward traction on fetal body (Mauriceau-Smellie-Viet Maneuver).

Air Care Grand Rounds w/Drs. Hinckley & Chinn

• Ways to enhance the likilhood of DASH-1A (Definitive Airway Sans Hypoxia on First Attempt) airways:
  
  • If you can optimize position, pre-oxygenate and use DSI (procedural sedation for pre oxygenation) if necessary
    
  • Always put apneic oxygenation on
    
  • Wait the full 45 seconds for sux or 60 secs for roc to work before your attempt
• There's a lot to think about on every flight, but don't forget the basics...glucose first in every altered mental status
• Impella is a temporary LVAD device that is inserted intravascularly that you may transport a patient in cardiogenic shock - keep it in place, continue to treat cardiogenic shock (consider drip triage), and document distal pulses
• While ketamine is a wonderful drug, our protocols are using it for RSI/post-intubation sedation.  If using for procedural sedation in the field call back to medical control for approval
• Know the expertise of your crew, specifically learn from your pilots on each shift
• Always approach the aircraft front the front after getting approval from the pilot
• Stay belted in your seat at all times but if you need to move, let the pilot know as it can impact flight controls
• Always be scanning your surroundings when not engaged in patient care and call out obstacles to the team using clock positions

ACEP 2014 Pearls

Pearls about the eye:

• Consider pterygium in patient with history of excessive sun exposure with injection extending beyond the margin of the iris
• Differentiate between scleritis (vision threatening) and episcleritis based on pain and lack of blanching with ocular phenylephrine (both indicators of scleritis)

First time peds seizure does not necessarily need a work-up, an effective H&P is adequate

In assessing an EKG for syncope, always consider Hypertrophic Obstructive Cardiomyopathy with tall narrow Q-waves (especially in III) and tall QRS complex in the precordial leads

Use the acronym "HPI" when using ultrasound to assess dyspnea: H: Heart (assess for squeeze, effusion and RV:LV), P: Pulmonary (assess pleural lines, parenchyma, and pleural space), and I: Inferior Veins (aka assess for DVT)

You can use a bougie one handed if you preload and wrap the top end back around through the tube's eyelet

5 Tips for a Long, Happy Career:

1. Establish core values and stick to them,
   
2. Continue to learn,
   
3. Put the patient first,
   
4. Take care of yourself,
   
5. Bring your A-game to every shift

Much of the risk of medical liability lies in your relationship with a patient, if you've not established a relationship you do not have a duty to act

The Good Samaritan Law applies only if you do not engaged in reckless behavior and that you are not being compensated for your care (i.e. being given a t-shirt for volunteering to provide medical coverage for a race can count as compensation)

Consider setting up a Sep IRA to help save long term when moonlighting (either in the community, on H2's, or even EMS lectures) as the money is not taxed until you remove it from the account

Ketamine is a wonderful analgesic in subdissociative doses (0.2-0.3 mg/kg) and don't forget about the utility of a ultrasound guided nerve block

Patients with low risk chest pain who've had continuous chest pain can almost assuredly by ruled out with a single troponin

When building a CV, make sure that the pertinent information (i.e. educational pedigree and clinical experience) is up front and easily reviewed in 10 seconds so that they want to go on to review it for 90 more seconds which is when they'll actually consider you

Pediatric transfusion dosing is 15 cc/kg, but there has not been shown to be a mortality benefit as most children die of TBI

When considering serious necrotizing soft tissue skin infection one of the most sensitive findings is a mild hyponatremia