Grand Rounds Summary 3/2/16

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OB-GYN Emergencies with Dr. McKinney

Case 1: 18 wk patient with vaginal spotting who is Rh- but antibody+

Bedside U/S shows fetal abnormality due to Rh alloimmunization with fetal hydrops. Positive antibody screening on gravid female should warrant obstetric consultation. Rhogam administration within 72 hours of bleeding is important.

Case 2: 40 wk female with gestational DM present with crowning fetus who fails to immediately deliver secondary to shoulder dystocia.

Treatment: stop pushing and avoid traction. Initially attempt hyperflexion of legs and suprapubic pressure to release (McRoberts maneuver). Then consider episiotomy because subsequent maneuvers involve twisting the baby to get shoulder into a different plane. 

Case 3: Post partum patient has GTC. Dx is eclampsia. Rapid administration of magnesium is critical and a loading dose is often sufficient to break seizures, but many providers will rapidly progress to administration of benzodiazepines as well.

Case 4: G1 8 wks pregnant female presents with nausea, vomiting, abdominal distension and pain. Numerous enlarged follicles and abdominal fluid visualized on ultrasound.

By Mikael Häggström. https://upload.wikimedia.org/wikipedia/commons/c/c1/Molar_pregnancy.jpg

By Mikael Häggström. https://upload.wikimedia.org/wikipedia/commons/c/c1/Molar_pregnancy.jpg

Dx: ovarian hyperstimulation syndrome (OHSS). This is an iatrogenic complication of IVF and exogenous gonodotropins. Patients will have increased capillary permeability, present with a broad spectrum of severity, and management is generally supportive as they physiologically have a lot in common with hypoalbuminemia of hepatic failure patients.

Case 5: G1 10 wk pregnant female presents with sinus tachycardia, has TSH 0.05, FT4 of 3, and BhCG > 400k. Dx: molar pregnancy. Molar pregnancy is spectrum of disease. Consider w/u for metastatic disease

Leadership Curriculum: Conflict Management

Commit to seek mutual purpose. Agree to disagree if you must, but commit to staying actively involved in the conversation until this happens.

Recognize purpose behind strategy. Why do we act a certain way or say certain things? When you unpack the motivations they may be related to fear or masking certain emotions.

Invent a mutual purpose. Discover common ground between yourself and the other party, search for outcomes that serve both your purposes.

Brainstorm new strategies. Resolution should seek to find the "and", and can avoid the "either/or". Again, establishing common ground is critical.

A number of small group breakout sessions worked through a few specific scenarios highlighting the above points.

CPC with Drs. Thompson & Wright

Elderly patient found with hemiplegia, stroke like symptoms, AMS. Contributory history reveals he was found in a greenhouse with a wood burning stove.

Diagnosis: carbon monoxide poisoning resulting in low oxygen delivery to watershed areas of cerebral perfusion.

CO poisoning learning points:

- CO has 240x greater affinity for Hb than Oxygen
- Non-specific symptoms: HA is most common
- CO can exacerbate cardiovascular disease, get an EKG on all patients
- Hyperbaric Oxygen (HBO) for severe CO poisoning: COHb >25%, Evidence of end organ ischemia, LOC, COHb >15-20% in pregnant females
- HBO reduces CO half life, and helps with prevention of DNS

Markedly atherosclerotic SMA with flow limitation, in the context of transient hypotension of bacteremia cause non-occlusive ischemic colitis

Markedly atherosclerotic SMA with flow limitation, in the context of transient hypotension of bacteremia cause non-occlusive ischemic colitis

Case Follow Up With Dr. LaFollette

Elderly male in her late 70s presents to the ED febrile, tachycardic with report of 'altered mental status' with no collateral and a patient that frankly denies but is not insulted by the implication

Physical exam significant for mild diffuse abdominal pain, normal lung exam and no skin changes and labs reveal a lactate of 5 and a SBP of 100 (baseline 150-160). Noncontrast CT shows significant atherosclerotic disease of the SMA, IMA and celiac axis and transverse colitis. Our patient ended up being bacteremic and her relative hypotension put her at risk of flow dependent ischemia. She stabilized with fluids, antibiotics and has been doing well.

Ischemic Colitis

While cognitively lumped with acute mesenteric ischemia, colonic ischemia is more insidious

  • More likely to have diffuse subtle pain than the traditional 'pain out of proportion to exam' 
  • 95% is non-occlusive and flow dependent
    • Common predilection is having any form of vasculopathy (calcifications, fibromuscular dysplasia, etc)
    • Any hypotensive stressor (sepsis, MI, bypass) can precipitate symptoms
  • Treatment is dependent on extent of colonic ischemia
    • Colitis with mild inflammatory markers can be treated with monitoring and hemodyanmic optimization
    • Gangrene, portal venous gas and peritonitis require immediate surgical evaluation