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#54 Not In My Box!


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#21 STPEMTP

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Posted 07 June 2011 - 07:43 PM

First off, thanks Sean for posting the case!

Oh boy, this has all shades of UGLY written all over it......

assessment:
What is estimated due date?
When was last pre-natal visit?
Have any previous children required Rhogam shots?
attempt to measure uterus (ballpark gestation? increased amino fluid probably will skew, ? able to tell if above/below 36wks if uterus over/under 36cm)
check mom's reflexes
amount of edema present and locations?
lung sounds?
any visual disturbances for mom?
headache?
does mom have desire to push?
any surgical scars on abdomen to suggest hx of c-sections?

Do we need a translator to interview mom/sister?
What capabilities does the rural ED have? (would like CBC, chemistry, LFT's, coag's, type/cross, UA, UTox)
Ultrasound (r/o multiple gestation, subxiphoid view of heart to see if there is any enlargement of R ventricle)
Any L/D staff available in house to assess dilation effacement of patient? Is a crewmember trained in assessing this? (I'm not trained in it, hoping partner is)

intial treatment:

o2 high flow
big bore IVx2
cardiac monitoring
12-lead (S1Q3T3? ST elevation? ST depression?
get some magnesium ready for mom (not at point yet for giving loading dose)
FIND THE BROSELOW TAPE!
start prepping neonatal meds/equipment (d10 for likely hypoglycemia of neonate 2nd to uncontrolled maternal hyperglycemia, epi doses x3, airway equipment, multiple tubes and meconium aspirator)
Have IO equipment available (if unable to obtain IV rapidly for neonate)

I think this is a good place to wait for additional info.

Thanks again Sean!
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#22 SerendepitySaki

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Posted 07 June 2011 - 09:20 PM

keep 'em coming, folks.... as usual, Sue and STP are rocking it....missed both of y'all! been waaaaaay too long! will reply tomorrow.... shooting for 48 hours max between my replies... Git R Done!
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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#23 pureadrenalin

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Posted 08 June 2011 - 04:00 AM

I'll echo the two previous statements and add

Was her previous abortion, spontaneous or "planned"?
Any drug usage, anything show up on tox screen? and I'll take a CHEM-8 and a CBC.
Any recent trauma history, planned or not?
Any potential exposure to organophosphates?
Any pre-natal care?
Is she actually having contractions, or is this a possible case of Braxton-Hicks?
Any of the other kids preterm?

Ground or Air...might make me think differently about the mag. Also talking with our doc during training today he said it's possible to give Decadron to mom during the preterm labor to help the kid develop surfactant.

The chest pain makes me think a few things fromt the start. PE is the first, MI second and then the mag sulfate as you can develop chest discomfort from that. If she's had prenatal care, and has had prior preterm labor, I would say it's possible she's getting IM Mag injections, or some other tocolytic, a stretch perhaps...Posted Image
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#24 SerendepitySaki

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Posted 08 June 2011 - 04:41 PM

you were called shortly after the patient presented...little has been done that you haven't done yourself...

sue, stp, pa... as always, you humble and amaze me... some quick comments....

sue....since i don't do HROB or have a lengthy clinical background in it....this was written as review for me too.... love loVE LOVE where you're going with the cardiomyopathy! SIMPLY BEAUTIFUL and high index of suspicion... if y'all don't know what she is referring to, IMHO, well worth adding to your knowlege base...will post some links during wrap-up...

stp... what an absolute tour de force! i want to come ride with you for the summer! reed and heed his wish list, folks.... GREAT STUFF! (also note...he is all over the potential for cardiomyopathy... anyone seeing a recurring theme here....?)

pa.... given her history....FREAKING awesome on the organophosphate exposure.... (and how would you r/o PE?)


Kudos aside, no sooner do you get your 12 lead (no drugs on board, yet) than dilation, etc becomes a moot point....

SHE'S CROWNING.....

(see y'all Friday....)
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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#25 TexRNmedic

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Posted 08 June 2011 - 10:20 PM

you were called shortly after the patient presented...little has been done that you haven't done yourself...

sue, stp, pa... as always, you humble and amaze me... some quick comments....

sue....since i don't do HROB or have a lengthy clinical background in it....this was written as review for me too.... love loVE LOVE where you're going with the cardiomyopathy! SIMPLY BEAUTIFUL and high index of suspicion... if y'all don't know what she is referring to, IMHO, well worth adding to your knowledge base...will post some links during wrap-up...

stp... what an absolute tour de force! i want to come ride with you for the summer! reed and heed his wish list, folks.... GREAT STUFF! (also note...he is all over the potential for cardiomyopathy... anyone seeing a recurring theme here....?)

pa.... given her history....FREAKING awesome on the organophosphate exposure.... (and how would you r/o PE?)


Kudos aside, no sooner do you get your 12 lead (no drugs on board, yet) than dilation, etc becomes a moot point....

SHE'S CROWNING.....

(see y'all Friday....)


I like what I've seen so far and agree. My first impression was that this pair (mom and kiddo and hopefully not twins) probably were too close to an immanent delivery for my comfort and I would have wanted to know how engaged and dilated we were (not within my expertise). Now that the patient's are delivering, I'm here to help the locals get this kiddo safely out. If this rural hospital is like any other around here, this isn't the first delivery they've handled. Let's get the local OB/Gyn folks on their way here. At some point in the near future we'll need to decide who is getting to ride with me and if we need any additional resources (like our neo team).

This may be a divide and conquer scenario where the crew splits up momma and kiddo while in the ED. So we need to turn on the Ohio warmer, open the ED's ob kit cause we are gonna have a baby (or two if I know Sean). Straight up NRP care. I'm worried about momma, but getting this kiddo out will hopefully lighten the burden on her heart. Gonna plan for the possibility of hemodynamic collapse and the potential for post-partum hemorrhage. Airway roll out for momma and neonate with blades and tubes for both. Broslow out next to the warmer. Pitocin loaded into a liter bag. D10 for the weeble (or if mom is capable, latch the kiddo on-good for both kiddo and PPH). Blood products if available (EDs or mine). Gonna ask my pilot to call back home to communications to let them know we are going to be on the ground for a bit (and that a neo crew may be needed). We are here to help as much as the locals want us to, but nobody is going anywhere at the moment by helicopter.

As a side note, I'd love to know this gal's CBC, chemistry and LFTs. Anemia, low platelets and elevated LFTS? Glucose level, lytes, anion gap? Serum CO2 or bicarb? All labs that they should be able to run. Once the delivery is done-foley and a look at her urine.

Alright! I get another stork certificate to put in my binder.
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Wes Seale
Houston , TX

#26 Sue

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Posted 08 June 2011 - 10:51 PM

[quote name='TexRNmedic' date='08 June 2011 - 06:20 PM' timestamp='1307571650' post='26296']
I like what I've seen so far and agree. My first impression was that this pair (mom and kiddo and hopefully not twins) probably were too close to an immanent delivery for my comfort and I would have wanted to know how engaged and dilated we were (not within my expertise). Now that the patient's are delivering, I'm here to help the locals get this kiddo safely out. If this rural hospital is like any other around here, this isn't the first delivery they've handled. Let's get the local OB/Gyn folks on their way here. At some point in the near future we'll need to decide who is getting to ride with me and if we need any additional resources (like our neo team).

This may be a divide and conquer scenario where the crew splits up momma and kiddo while in the ED. So we need to turn on the Ohio warmer, open the ED's ob kit cause we are gonna have a baby (or two if I know Sean). Straight up NRP care. I'm worried about momma, but getting this kiddo out will hopefully lighten the burden on her heart. Gonna plan for the possibility of hemodynamic collapse and the potential for post-partum hemorrhage. Airway roll out for momma and neonate with blades and tubes for both. Broslow out next to the warmer. Pitocin loaded into a liter bag. D10 for the weeble (or if mom is capable, latch the kiddo on-good for both kiddo and PPH). Blood products if available (EDs or mine). Gonna ask my pilot to call back home to communications to let them know we are going to be on the ground for a bit (and that a neo crew may be needed). We are here to help as much as the locals want us to, but nobody is going anywhere at the moment by helicopter.

As a side note, I'd love to know this gal's CBC, chemistry and LFTs. Anemia, low platelets and elevated LFTS? Glucose level, lytes, anion gap? Serum CO2 or bicarb? All labs that they should be able to run. Once the delivery is done-foley and a look at her urine.

Alright! I get another stork certificate to put in my binder.

Tex,

I like where you are going, and I am going to say divide and conquer with as much help as possible. If this was my flight program, I would be getting another A/C in the air with the neonate team on the way, too.

Now, I have seen a few of these mommies in the long ago past. They have not done very well...as I am sure Sean will show us. It is time for me to do some research. In the mean time, I hope Tex's team has the chaos controlled..NOT!!!LOL

Sue
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Sue Toberman, RN

#27 Sue

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Posted 08 June 2011 - 11:03 PM

Mom is going to be walking a fine line between fluid overload and hypovolemia should she be bleeding. This has fun written all over it. I want to say more, but have to wait for the next input of information so As to not jump the gun.

Bring it on!

Sue
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Sue Toberman, RN

#28 TexRNmedic

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Posted 08 June 2011 - 11:12 PM

Mom is going to be walking a fine line between fluid overload and hypovolemia should she be bleeding. This has fun written all over it. I want to say more, but have to wait for the next input of information so As to not jump the gun.

Bring it on!

Sue


You are reading my mind Sue. We can be pretty certain she will have the usual dilutional anemia associated with pregnancy. Throw in some PPH or hemolytic anemia and we will have some significant problems with 02 carrying capacity on top of a sick pump. I'm wanting a foley (as the poor man's swan ganz) to help me with RBC replacement and any diuresis. Lytes and AG may be pretty out of whack thanks to her overall condition and any complications of out of control DM. If I start giving lasix, I'd like to know what her lytes and renal function is. Don't forget the IV fluid bolus with pitocin she is about to get. Fine line is right!
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Wes Seale
Houston , TX

#29 FlyingScot

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Posted 09 June 2011 - 12:51 AM

Don't forget the polyhydramnios. This could be indicative of a big problem with the baby in addition to the probable prematurity. I think I remember a mention of possible VLBW as well. Remember the difference between IUGR and SGA babies? Also...forget the Broselow tape, it won't be all that helpful because you can't use it the same as you would for a straight-forward peds case. I imagine most of you have some sort of pocket guideline for neonatal care. If not, contact your local children's hospital...they probably have some. Speaking of the peds hospital. Probably a good idea to get on the horn and get the neonatal transport team en route. Otherwise it's straight up NRP with a whole lot fewer meds to remember than ACLS. Also remember that good bagging with a bag and mask is preferable to mangling up a tiny airway in an attempt to intubate.
I've got zero experience with HROB from the maternal side but one thing that came to mind was a possible amniotic fluid embolus. Nasty buggers. I've taken care of at least 5 infants whose mothers died from them leaving the babies motherless and usually encepahlopathic from oxygen deprivation.
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#30 SerendepitySaki

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Posted 09 June 2011 - 12:58 AM

just remembered i'm teaching all day friday...depending on the questions/actions, it might be saturday evening before comprehensive update...

in the meantime, sure! you can have another aircraft on the way.... approx 60 minute ETA...

Anyone ever heard the phrase "Gone in 60 seconds" with respect to NRP? yeppers.... TAG! you're it! and nope! anesthesia's NOT in the house... have fun....

Wes, you KNOW how i am... 6Ps.... tell me more about your airway mgt set up.... anyone want to discuss airway mgt concerns unique to pregnant patients?

trust me, aside from the theoretical question i asked PA, y'all are going to be waaaaay too busy to worry about labs.... if the scenario gets that far, we'll discuss them, but they will be incidental, not central...trying to make this informative, yet quick....

and other than current discussion, no comorbidities or zebras in momma....

however, just as your 12 lead is printing out, and you get a glimpse of elevation in your V leads...she screams "JESUS", and seems to faint....you see what appears to be VF on the monitor and the baby is being delivered...
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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#31 SerendepitySaki

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Posted 09 June 2011 - 01:24 AM

BTW...Flying Scot and I were typing at the same time.... i LIKE the way they're thinking...sort of.....Sláinte !!!!
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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#32 TexRNmedic

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Posted 09 June 2011 - 01:26 AM

Don't forget the polyhydramnios. This could be indicative of a big problem with the baby in addition to the probable prematurity. I think I remember a mention of possible VLBW as well. Remember the difference between IUGR and SGA babies? Also...forget the Broselow tape, it won't be all that helpful because you can't use it the same as you would for a straight-forward peds case. I imagine most of you have some sort of pocket guideline for neonatal care. If not, contact your local children's hospital...they probably have some. Speaking of the peds hospital. Probably a good idea to get on the horn and get the neonatal transport team en route. Otherwise it's straight up NRP with a whole lot fewer meds to remember than ACLS. Also remember that good bagging with a bag and mask is preferable to mangling up a tiny airway in an attempt to intubate.
I've got zero experience with HROB from the maternal side but one thing that came to mind was a possible amniotic fluid embolus. Nasty buggers. I've taken care of at least 5 infants whose mothers died from them leaving the babies motherless and usually encepahlopathic from oxygen deprivation.



I was afraid of placenta accreta. I've had a few of those post-op in SICU. Now that is some massive transfusion. Good point on the broslow. I know it doesn't go sub 3kg. I carry around my copy of the AHA ECC handbook with me. May just have to unzip that pocket. If this is a amniotic embolus, this resus isn't going to end well. I've only seen one survive, and she actually had no noticeable deficits. With the IUGR of DM or GD, this kiddo will probably be close to 1 kg, with a high probability of congenital defects. Glad others want the neo crew to help out too.
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Wes Seale
Houston , TX

#33 TexRNmedic

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Posted 09 June 2011 - 02:04 AM

just remembered i'm teaching all day friday...depending on the questions/actions, it might be saturday evening before comprehensive update...

in the meantime, sure! you can have another aircraft on the way.... approx 60 minute ETA...

Anyone ever heard the phrase "Gone in 60 seconds" with respect to NRP? yeppers.... TAG! you're it! and nope! anesthesia's NOT in the house... have fun....

Wes, you KNOW how i am... 6Ps.... tell me more about your airway mgt set up.... anyone want to discuss airway mgt concerns unique to pregnant patients?

trust me, aside from the theoretical question i asked PA, y'all are going to be waaaaay too busy to worry about labs.... if the scenario gets that far, we'll discuss them, but they will be incidental, not central...trying to make this informative, yet quick....

and other than current discussion, no comorbidities or zebras in momma....

however, just as your 12 lead is printing out, and you get a glimpse of elevation in your V leads...she screams "JESUS", and seems to faint....you see what appears to be VF on the monitor and the baby is being delivered...


Well now that we are working an arrest. Straight up ACLS. Compresion 30:2, pads ASAP and Defib ASAP. Epi 1mg. amio/lido of choice etc etc. Bag with an OPA/NPA and stick with it if good chest rise. ETCO2 ASAP. Will drop a tube after a couple/few rounds of ACLS.

Smaller airway secondary to pregger related edematous changes. Elevated diaphram reduces FRC and O2 reserve. Dilutional anemia reduces O2 carrying ability. Sean, I'm going to make my first shot my best. Proper positioning of patient, preoxygenate, drop my tube size down .5, backup airway handy, bougie not far away either, if video laryngoscopy available, I'll have that on and nearby. A calm, well planned DL with plan B, C and D ready to go.

Split the team up, one on mom with the locals helping, one on the kiddo with locals helping there too.

And because we rock, when the neo team gets here, they will find two hemodynamically stable patients with normal pH, paCO2 and paO2. Right Sean?
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Wes Seale
Houston , TX

#34 pureadrenalin

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Posted 09 June 2011 - 02:17 AM

Double post
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#35 pureadrenalin

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Posted 09 June 2011 - 02:18 AM

Wow this really escalated quick. I'm now outside my comfort range, but, I love these as it forces me to learn.

As for your question Sean. We obviously don't have time for a VQ scan or CT. So bedside echo, but seeing as this is a rural facility that's not happening. Left with D-Dimer and a CXR. Either I suppose works.
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#36 SerendepitySaki

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Posted 09 June 2011 - 02:25 AM

bingo PA... why "either"? i actually had BOTH in mind.... obviously, a gross cardiomegaly would show up on CXR, but what IS D-dimer, and how would you use that to rule PE in or out? what effect does Pregnancy have on D-dimer levels?
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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#37 onearmwonder

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Posted 09 June 2011 - 04:01 AM

bingo PA... why "either"? i actually had BOTH in mind.... obviously, a gross cardiomegaly would show up on CXR, but what IS D-dimer, and how would you use that to rule PE in or out? what effect does Pregnancy have on D-dimer levels?



Dude defibrillate 150J.... Chest compressions. Epi 1:10,000IVP... Very careful yet assertive/aggressive/appropriate airway management for mom to maximize oxygenation... Capnography... Is she on Mag? Think Calcium for differantials... Is this an arrest from Cardiac/Pregnancy/or Pulmonary? Or a combination? 300mg Amiodarone if pulseless V-Tach/V-Fib. Get another IV or IO. NRP for the babe and think IO quickly... Again as mentioned before BLS before ALS for the babe... We all know what to do in these situations. Just work as a team... Take a deep breath... Slow is smooth and smooth is fast... Just some thoughts...

Matt
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#38 SerendepitySaki

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Posted 09 June 2011 - 04:26 AM

speaking of BLS before ALS.... before you can begin compressions, one of the sending RNs points out that momma's VFIB has become a slow bradyarrythmia on the monitor....

more to follow on El Niño/La Niña...would like to hear more about how y'all are setting up for THAT patient, as well....
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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#39 onearmwonder

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Posted 09 June 2011 - 04:56 AM

Is she brady from hypoxia, or an injured heart, or a neuro injury? Sean has she ever been on mag?
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#40 ysumedic05

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Posted 09 June 2011 - 03:11 PM

D-dimer measures the level of fibrin degradation products. The problem with pregnancy is that fibrin is formed and broken down as a normal process. Therefore the D-Dimer level will be elevated but is not a reliable method of determining if there is a PE or not (but if it is >2000 you could start really considering DIC). At this point mom is not stable enough to even think about a CTA of the chest or a V/Q scan to r/o PE. Getting a PT, PTT, fibrinogen and platlet count would really help.
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Justin Koper FP-C, NREMT-P