Grand Rounds Recap 3.29.23

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R3 Taming the sru: resuscitative hysterotomy w/ Dr. stark

  • Indications: Maternal cardiac arrest > 20 weeks (at or above umbilicus) 

    • Ideally, perform within 4 minutes of arrest 

      • One study showed that this may be able to be extended to 10 minutes 

    • Increases maternal cardiac output by 30%

      • No studies have proven improved maternal survival 

  • Procedure:

    • Incision from umbilicus to pubic symphysis 

    • Expose the uterus and retract bladder

    • Make vertical incision through lower uterine segment 

    • Use scissors to extend incision 

    • Deliver infant and clamp/cut cord

    • Deliver placenta 

    • Pack abdomen 

    • Give oxytocin

    • Other considerations:

      • Do not delay the procedure for the arrival of an obstetrician or neonatologist.

      • Do not evaluate for fetal cardiac activity or tocometry.

      • Do not prepare a sterile field (but be as clean as possible).

      • Do not transport to an alternative location.

  • Cardiac Arrest in Pregnancy

    • 1 in 30,000 pregnancies 

    • 800 maternal deaths globally 

    • Rates have nearly doubled between 1989 and 2009 

    • Survival to hospital discharge after maternal in-hospital cardiac arrest 58.9%

  • Etiologies of arrest

    • Trauma is most common worldwide

    • Pulmonary embolism

      • Causes approximately 20% of maternal deaths

      • Risk factors: 

        • Prior thromboembolism 

        • Advanced maternal age 

        • Increased parity 

        • Obesity 

        • Immobility, trauma, or recent surgery  

        • Management 

          • Thrombolytics 

          • Pregnancy is relative contraindication to thrombolytics 

    • Hemorrhage

      • Hemorrhage accounts for 17-38% of maternal deaths 

      • Risk factors: 

        • Hypertension 

        • Preeclampsia or HELLP 

        • Trauma to abdomen 

        • Smoking 

        • Cocaine use 

        • Previous abruption 

      • Management 

        • Blood transfusion 

        • Uterotonics

    • Pregnancy induced hypertension

      • Estimated 14.5% of maternal deaths attributed to preeclampsia and its variants 

      • Can lead to arrest via

        • HTN → intracranial hemorrhage 

        • Eclampsia → hypoxia or stroke 

        • Pulmonary edema → hypoxia 

        • Hepatic failure or rupture → hemorrhage 

      • Management: 

        • Delivery 

        • Magnesium sulfate

          • AHA recommends magnesium in arrest thought to be secondary to eclampsia at the normal loading dose of 4-6g

    • Amniotic fluid embolism 

      • Most common immediately following delivery 

      • Anaphylactoid reaction → SIRS , DIC, and multi-organ failure 

      • 50% mortality within the first hour 

      • Risk factors: 

        • Difficult labor 

        • Advanced maternal age 

        • Multiparity 

        • PROM 

        • Amnioinfusion 

        • Trauma 

        • Abruption and rupture 

        • Fetal death 

    • Myocardial infarction

    • Infection/sepsis

    • Peripartum cardiomyopathy

    • Stroke

    • Anesthetic complications

R1 Clinical Knowledge: BRASH syndrome w/ Dr. wilson

  • Definition:

    • Bradycardia, Renal Failure, AV Nodal Blockade, Shock, Hyperkalemia

  • Etiology

    • AV nodal blockade (beta blockers, Ca channel blockers) + Renal injury

      • Renally-Cleared beta-blockers are: Atenolol, Nadolol, also bisoprolol, acebutolol​

      • Ca channel blockers implicated are often the non-dihydropyridines (verapamil, diltiazem)

      • Renally cleared ACEi/ARB: Enalapril, Lisinopril, Ramipril, Benazepril

    • Hyperkalemia synergizes with AV nodal blockade to worsen bradycardia

  • Clinical Presentation

    • Hyperkalemia may not always be significantly elevated

  • Management

    • Hyperkalemia

      • Calcium, insulin/D50, albuterol, potassium binders, RRT if needed

      • Diuretics can be considered to remove potassium following fluid repletion

    • Bradycardia

      • Calcium, epinephrine, isoproterenol

    • Fluid resuscitation

      • Consider isotonic bicarb for patients with uremic acidosis and hyperkalemia

R4 Capstone w/ Dr. gressick

Life Lessons from the Peace Corps and the People that Taught Them

  • You can always give to others, you don’t need wealth to give

  • Children are universal

  • People change and personal growth is inevitable

  • Sometimes you don’t know what you want, embrace unexpected experiences

  • Adaptability is crucial, expand your comfort zone

r4 case follow-up: HIV Screening in the emergency Department w/ Dr. Kimmel

  • Locally, from 2014-2018, UCMC diagnosed 142 new cases of HIV, which represented 18% of all new cases of HIV in Hamilton County during this period. ​

  • In the year 2022, our department diagnosed 18 new cases, and linked over 50 patients with known HIV who were referred to care​

  • Why this matters

    • ⅓ of all US transmissions of HIV occurs in undiagnosed individuals

  • Early Intervention Program (EIP)

    • Follows up all ED HIV test at UCMC

      • Will contact patient to establish follow up, and will contact the health department to arrange contact tracing

    • EIP staff are usually available from 8a-12a every day of the week

    • Rapid HIV testing

      • Oral swab - 20 minute turnaround

        • Tests only for HIV antibody, if positive, requires additional confirmatory testing

        • Positive at about 30 days after exposure

        • Sensitivity 92-99%

      • Finger prick confirmatory test- 1 minute turnaround

    • ED HIV Serum Screen

      • Tests for HIV antibody and p24 Antigen

      • Will be positive around 18 days after exposure

      • Sensitivity ~99-100%

  • Disclosure of HIV Diagnosis

    • If you discharge a patient with a pending HIV test, consider the ramifications of having to deliver a positive diagnosis over the phone

      • Is English your patient’s primary language?

      • Does your patient have access to a phone and do you have the right phone number for the patient?

      • Is the patient hard of hearing?

      • What is the next step for follow up?

    • EIP Linkage Coordinator will make this call for you, and is trained to discuss this diagnosis with patients

  • Expedited Partner Therapy

    • If a patient’s partner is unable or unwilling to present to a medical facility for treatment, a provider can provide an additional prescription to a patient to treat their partner at the time of an STI diagnosis

    • For Chlamydia, doxycycline 100mg BID x7d, and for gonorrhea, cefixime 800mg PO once

    • Write “EPT” in the name line on a prescription pad and give the prescription to the patient

      • In Ohio, can print a paper prescription with the patient's name, and physically write “For EPT” next to their name for the partner’s treatment

    • EPT is legal in most states in the US

  • Resources

    • In EPIC, there are pre-populated discharge resources for many special patient groups:

      • Local needle exchanges

      • LGBT resources

      • Shelter resources

      • Look at “ED DC” under attachments in the discharge instructions

    • Add the health department to discharge instructions for patients with frequent STI

    • Caracole, a greater Cincinnati non-profit organization, can help patients with access to medications in situations of financial difficulty

      • EIP can help navigate