Grand Rounds Recap 9.15.21
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OBGYN Consultant Corner: Delivery Complications WITH Dr. Boldt
Nuchal Cord
One loop occurs in 20-34% of deliveries, Two loops in 2.5-5%, and three loops in 0.2-0.5%
It is not associated with adverse perinatal outcomes
Management
Reduce it after delivery of the head, OR
Deliver through the cord loop, OR
If you think the cord is constricting, you can doubly clamp it and cut it and proceed with delivery.
Postpartum Hemorrhage
Cumulative blood loss of great than 1L or blood loss accompanied by signs and symptoms of hypovolemia within 24 hours of delivery
Causes include
Uterine atony
Uterine inversion
Injuries to the birth canal
Placental abruption
Placenta previa
Morbidly adherent placenta
Coagulopathies
Treatment
Uterine Massage - one hand internally applies pressure against the uterus, the other hand externally applies transabdominal pressure to the uterus.
Uterotonics such as methylergonovine, oxytocin (give all postpartum hemorrhage patients IM oxytocin, giving it IV can precipitate hypotension)
Uterine Tamponade - Ideally use a commercially available uterine tamponade balloon such as a Bakri Balloon. Can alternatively use a Foley catheter or uterine packing.
Shoulder Dystocia
When the anterior fetal shoulder becomes wedged behind the symphysis pubis and fails to deliver using normally exerted downward traction and maternal pushing. This compresses the cord in the birth canal and is therefore an emergency.
Treatment
Have the patient STOP PUSHING!! This helps minimize continued wedging
McRoberts Maneuver - Have the mother hyperflex and abduct her hips. This tilts the pelvis allowing for easier passage
Suprapubic pressure - apply suprapubic pressure transabdominally to apply downward pressure on the trapped shoulder
Delivery of the Posterior Shoulder - take 1-2 fingers and insert posteriorly into the birth canal. Follow the posterior arm toward the infants hand. Guide the hand across the infant's chest and up and out of the birth canal and then deliver the posterior shoulder first.
Woods Maneuver - A rotational maneuver in which you are attempting to rotate the baby. The goal is to rotate the posterior shoulder anteriorly (towards the 12 o’clock position), this can be a clockwise or counterclockwise maneuver depending on how the baby presents
Rubin Maneuver - Another rotational maneuver in which you attempt to dislodge the anterior shoulder by rotating it posteriorly (towards the 6 o’clock position).
Gaskin Maneuver- have the patient go on all fours, better in un-anesthetized patients
Umbilical Cord Prolapse
Overt prolapse – cord slips ahead of the presenting part
Occult prolapse – cord slips alongside of the presenting part
Comes with a risk for cord compression, vein occlusion, and arterial vasospasm
Occurs in 0.16 to 0.18% of live births
Treatment
Replace the cord into the vagina and protect it. Deliver as quickly and safely as possible, typically by C-section
Intrauterine Resuscitation
Elevate the presenting part
Trendelenburg the patient to assist with protection of the cord
Backfill the bladder (assists in elevating the presenting part of the infant)
Provide tocolytics
Manually replace the cord (controversial)
Prehospital Cord Prolapse
Can occur with premature rupture of membranes (PROM) outside of the hospital or during a planned home birth
Have the patient assume knee-chest face-down position or lie on the floor with pillows to elevate the hips above the level of the heart
The presenting part of the infant should be elevated manually or by bladder distension during transfer to a facility that provides obstetric care
There should be minimal handling of loops of cord in order to prevent cord vasospasm
Breech Delivery
At term, 3-5% of singletons will present breech
How to deliver a breech infant:
Allow the breech infant to deliver spontaneously to the umbilicus, encourage mom to push until the legs are accessible. Then, splint the femur with fingers parallel to the long axis and exert pressure upward and laterally to sweep the leg across the midline
To deliver the body, grasp the fetal bony pelvis with both hands with your fingers resting on the anterior superior iliac crests and your thumbs resting on the sacrum. Encourage maternal effort in conjunction with downward traction
To deliver the arms: Use steady, gentle, downward traction until the lower halves of the scapulas are delivered. •Do NOT attempt to deliver the shoulders/arms until one axilla is visible. Once visible, rotate 90 degrees to bring the anterior shoulder into view and then align your fingers and hand parallel to the humerus to splint and prevent a fracture. Then rotate 180 degrees in the reverse direction and repeat
To deliver the head: Note this is usually done with forceps or a series of special maneuvers in order to avoid hyperextension of the fetal neck
Mauriceau maneuver
The Index and middle finger should be applied over the maxilla, flex the head with the fetal body resting on the palm of the same hand and forearm with the fetal legs straddling the forearm. Two fingers of the other hand should hook over the neck and grasp the shoulders, applying downward traction until the subocciput appears under the symphysis. Then, slightly elevate the body until the head delivers
Placenta accreta spectrum
Mostly diagnosed prenatally, but now has an incidence of 1 in 700 live births.
ED Management
If the patient comes in delivering/delivered with a known accreta OR the placenta is not delivering with gentle downward traction – STOP!!!
Trim (and clamp) the cord
Transfuse mom if she is hemorrhaging
Call OB for help or transfer to a site with OBGYN
Perimortem C-Section
What Age do we consider peri-mortem c-section?
20 weeks, Fundal height at the umbilicus
What is the timeframe for perimortem C-section?
Within 4-5 minutes of maternal arrest
What Incision do we use
vertical midline (like an ex-lap)
How do we close?
With a running whip stitch
The neurologically intact neonatal survival rate and the cardiac arrest-to-delivery interval are inversely related
Within 5 minutes, 98% neurologically intact
6-15 minutes, 83% neurologically intact
16-25 minutes, 33% neurologically intact
26-35 minutes, 25% neurologically intact
EM Lit Blitz WITH Dr. zalesky
Therapeutics
Bijur et al - RCT comparing the Efficacy of Five Oral Analgesics for Treatment of Acute Musculoskeletal Extremity Pain in the Emergency. Regimens included 400 mg ibuprofen and 1,000 mg acetaminophen, 800 mg ibuprofen and 1,000 mg acetaminophen, 30 mg codeine and 300 mg acetaminophen, 5 mg hydrocodone and 300 mg acetaminophen, or 5 mg oxycodone and 325 mg acetaminophen. They found no difference in control of extremity musculoskeletal pain.
Reuben et al, NoPAC trial - RCT in the Annals of EM evaluating the use of 200mg TXA up to two times (vs placebo) in an attempt to reduce the need for anterior nasal packing for epistaxis in the ED - They found no difference between placebo and TXA.
Clement et al - RCT evaluating dorsal vs volar digital blocks in terms of discomfort with injection and extent of anesthesia. Utilized 3mL of 1% lidocaine per injection either at 2 dorsal points or 1 volar point. They found that after 10 minutes, the dorsal block had improved anesthesia on the dorsal side, on the volar side of the hand the dorsal block and volar block were equally effective except over the middle phalanx, in which the dorsal was more effective.
GI
CODA Collaborative - Compared antibiotics for appendicitis with abdominal pain vs appendectomy. They found no difference in quality of life at 30 days between surgery vs antibiotics. However there was a 29% appendectomy rate at 90 days in the antibiotic group and the antibiotics group had more ED visits, more complications, and a higher perforation rate.
Neurology
Perry et al - A Multicenter prospective cohort study validating the Canadian TIA score, also comparing it to the ABCD2 and ABCD2i score . The Canadian TIA score was able to successfully stratify people into low risk, medium risk, and high risk groups and do so more accurately than the ABCD2 and ABCD2i scores. Demonstrates that there is a population that is safe to manage as an outpatient with close follow up.
Kandil et al, MAGraine - An RCT which compared magnesium to conventional treatment (metoclopramide, prochlorperazine, magnesium) for relief of migraine symptoms. They evaluated patients at 30, 60, and 120 minutes. All studied medications showed similar pain reduction rates at each time point. However, the patients in the magnesium group typically required more rescue medications.
Cardiology
Ducrocq et al, REALITY - A Multicenter RCT evaluating the effect of a restrictive (Hgb 8) transfusion strategy vs liberal (Hgb 10) transfusion strategy on MACE among patients presenting with AMI and anemia. A more restrictive transfusion threshold was non-inferior for 30 day MACE. Study was underpowered.
Aslanger et al, DIFOCCULT - A single-center retrospective case controlled study out of Turkey comparing OMI/NOMI ECG criteria vs STEMI/NSTEMI criteria for identifying patients who would benefit from acute coronary reperfusion therapy. 28.2% of patients initially classified as NSTEMI were reclassified as having ACO by new criteria. .
Chen et al - Evaluated whether exposure to fluoroquinolones increased the risk of aortic-related adverse events in patients admitted for a new aortic dissection or aortic aneurysm. It was a retrospective cohort study. They found that patients who had been exposed to fluoroquinolones (vs amoxicillin) had higher incidence of all cause deaths and aortic deaths.
Critical Care
Pappal et al, ED-AWARENESS - A prospective observational cohort study assessing the incidence of awareness with paralysis in mechanically ventilated patients intubated in the ED. 10 of 383 patients indicated awareness of their paralysis - which was nearly double the rate which occurs in the operating room. They found no difference between induction medications utilized, but almost a 5 fold increase in awareness when rocuronium was used compared to succinylcholine.
Dankiewicz et al, TTM2 Trial - An open label RCT comparing hypothermia to normothermia after out of hospital cardiac arrest from any rhythm (excluding unwitnessed asystolic arrest). There was no significant difference in incidence of death at 6 months or a modified Rankin score. There were more arrhythmias in the hypothermia group.
Not a US study and so may not apply to our patient population as well (different rates of presenting rhythms and incidence of bystander CPR as well as different comorbidity rates in the studied patient population)
Fernando, et al - A retrospective analysis evaluating the effect of lung protective ventilation in the ED on patient outcomes and cost. Demonstrated that patients ventilated with lung protective strategies in the ED had decreased mortality, decreased LOS, and decreased cost.
Branch et al - Evaluated the diagnostic utility of early head to pelvis CT in patients who suffered out of hospital circulatory arrest without an obvious etiology. Patients underwent a CTH, coronary CTA, and a CT A/P. Of the 307 patients included in the study, 39% had a cause of cardiac arrest identified on imaging, and 16% were found to have a life threatening complication of their resuscitation (liver and spleen lacs, pneumothorax, pulmonary lac, mediastinal pericardial and vascular bleeding) on CT imaging.
Althoff et al - Evaluated the effect of non-invasive ventilation use in critically ill patients with acute asthma exacerbations on need for intubation later in their course -A retrospective cohort study which evaluated 53K patients admitted to the ICU with asthma exacerbations between 2010 and 2017. They found that patients who were managed with non-invasive ventilation had a lower mortality rate and lower odds of getting intubated.
Pediatrics
Pernica et al, SAFER - An RCT comparing short and long courses of high-dose amoxicillin for the treatment of pediatric community acquired pneumonia. They found that in patients 6 months to 10 years old the rate of cure following a short course of high-dose amoxicillin was non-inferior to a long course of high-dose amoxicillin.
Tieder et al - A retrospective cohort of infants, evaluating the ability of AAP risk factors and event characteristics to predict outcomes in patients presenting to the ED following a BRUE. Of 2036 patients that were included, 63% were hospitalized on initial presentation, 43% had a non serious cause identified (GERD, choking, viral), and 4% had a serious likely cause identified within 1 year of the original presentation (seizure, spasm, airway anomaly, NAT). Of the patients who had a serious cause identified, 50% discharged on their initial presentation
Pantell et al - Evaluation and management of well appearing febrile infants from 8 to 60 days.
If 8-21 days, get UA, Blood cultures, LP, consider labs and inflammatory markers. Treat with antibiotics +/- acyclovir and admit
If 22-28 get a UA and Blood culture, get inflammatory markers and +/- LP depending on inflammatory markers, admit
29-60 get a UA, blood culture and inflammatory markers +/- LP
Trauma
Guyette et al - A double-blind placebo-controlled RCT evaluating TXA during prehospital transport in patients at risk for hemorrhage after injury. All patients received either TXA or placebo within 2 hours of injury. There was no difference in 30-day mortality or incidence of VTE. However, TXA did improve mortality in patients with severe shock (as defined by SBP < 70).
Ultrasound
Nakao,et al - Evaluated the diagnostic accuracy of lung POCUS for acute heart failure compared to CXR among dyspneic older patients in terms of ability to differentiate between CHF and COPD. They found that POCUS had sensitivity of 92% and a specificity of 85% whereas CXR had sensitivity of 63% and a specificity of 92.9%.
Kropf - Evaluated the impact of POCUS on treatment time in patients presenting with ectopic pregnancy. ED LOS and Time to OR was shorter in POCUS group.
R4 Capstone WITH Dr. Hassani
What is a medical emergency
In a US based study, almost 50% of individuals surveyed agreed with the EMTALA definition of a medical emergency, “a condition that may result in death, permanent disability, or cause of severe pain”. However, 32% of individuals surveyed preferred the definition of “any condition at any time as determined by the patient”.
So what brings people in with ‘non-emergent’ problems
Knowledge Gaps - We have medical degrees, most of our patients don’t
We have vital signs as well as years of seeing patients that gives us basic information and a clinical gestalt that helps us decide if something is emergent or not. Think about how many clarifying questions you ask when a friend or family member asks you by phone if they should go to the ED.
Over the last year, especially during the peak of the COVID-19 pandemic in 2020, the ED was the only path into the healthcare system for many individuals as many clinics reduced hours and in person appointments.
The physical exam in modern emergency medicine
The Cardiac exam
A large study at Oxford evaluated the prevalence of cardiac disease in the population by screening asymptomatic patients with a TTE. 10% of the patients had undergone auscultation by a PCP prior to receiving a TTE. Cardiac auscultation was found to have limited accuracy in detecting valvular disease with a sensitivity of 0-37% and a specificity of 85-100%.
Another study had patients referred for a TTE undergo auscultation by a cardiologist prior to imaging. Out of 250 patients, 142 had abnormal findings on echo, only 42% of which were identified by auscultation by a cardiologist.
The Pulmonary Exam
LUST study – compared auscultation to ultrasound in high risk ESRD patients. Ultrasound and physical exam (lung auscultation, peripheral edema) were performed pre and post iHD. It was found that ultrasound much more accurately reflected interstitial pulmonary edema when compared to the clinical finding of rales, with or without peripheral edema.
A critical care study by Cox et al compared lung ultrasound and pulmonary auscultation for detecting pulmonary edema in critically ill patients. Out of 900+ patients, around 325 had evidence of pulmonary congestion on ultrasound. Of those, about 51% had a normal lung exam by auscultation.
Quarterly Peds Simulation and Cases WITH the CCHMC PEds EM TEAM
Neonatal Jaundice
Patient Weight
Neonates normally lose up to 10% of their birth weight in the first week of life but should regain the weight by 2 weeks of life.
Ask about breastfeeding vs bottle feeding, and how much the baby is taking, is mom having good let down and feeling like she is keeping up with baby’s feeding needs
Neonates would feed every 3 hours
Neonates should have about 5 wet diapers per day, infants should have at least 3 wet diapers a day.
Ask about the stool
Did they pass stool in the first 24 hours of life
What does it look like, is it pale (acholic), is it bloody, is its dark (might just be meconium if in the first 24 hours)
Tone, Posture, Reflex
Babies should be relatively flexed in their extremities and have good tone.
Check rooting reflex (touch their cheek and see if they turn), check the Morow refelx (lift them up slightly by their hands to create a startle reflex), grasp reflex (on hands and feet). We check reflexes for presence and asymmetry
Other things to check on exam of a pediatric patient with jaundice
HENT: Anterior fontanelle, cephalohematoma, mucous membranes
Skin: Jaundice, Rash (especially vesicular or petechial)
Cardiac: Murmurs
Pulm: Lung Sounds
Abdominal: Hepatosplenomegaly
Differential for Neonatal Jaundice
Breastfeeding/Physiologic Jaundice
Breast Milk Jaundice
ABO incompatibility
Biliary Structural Defects - Biliary Atresia
Metabolic Defects - Gilbert’s, Crigler-Najarr, Hypothyroidism, Rotor’s syndrome, Dubin-Johnson
Red Blood Cell Defects
Infection
Bacterial Tracheitis
Secondary bacterial tracheitis is most common. It occurs when a preceding virus has damaged the airway epithelium allowing for a secondary bacterial infection to set in.
Typically presents with a URI prodrome followed by fever, voice hoarseness, stridor, throat pain, difficulty breathing, ill appearance, a tender anterior neck, and lymphadenopathy
Primary bacterial tracheitis - is less common but more severe. Patients presenting with this can progress from symptom onset to florid respiratory failure within 24 hours. Patient will be ill appearing with fever and rapid progression of respiratory decline.
Blood work will likely show signs of infection (leukocytosis, elevated inflammatory markers)
A lateral neck XR may show subglottic narrowing, and a ragged airway lining (pseudomembrane)
Management
Antibiotics with coverage for MRSA, Group A Strep, Strep pneumo, Haemophilus, Moraxella
Ceftriaxone or cefotaxime or ampicillin-sulbactam PLUS vancomycin
Treat flu if they are flu positive and in the treatment window.
Influenza A, followed by influenza B, is the most common preceding viral illness to bacterial tracheitis.
Nebulized epinephrine may or may not help with airway edema
Steroids are not recommended in the initial management
72-75% of patients with bacterial tracheitis end up requiring intubation
Due to infectious secretions, these kids are at high risk for airway occlusion, so make sure to gently suction them regularly if your intubate them
Patients need to be admitted to the PICU as an airway watch if they aren’t already intubated.
Conscious Sedation in Pediatrics
Pre-sedation risk assessment
Pulmonary or cardiac history, airway anomalies, history of prematurity, recent lower respiratory illness
Counseling parents, beyond the informed consent
Remember the kids won’t be awake but the parents will. Guide them through what can be expected with the sedation, what they might see, what is normal and what the child will be experiencing. It's also helpful to explain to the parent a little bit of the room setup and everyone’s roles, it can help put the parents at ease when they see equipment moving around This will help avoid questions and parental stress during a sedation when your focus and attention needs to be on the patient, not on the parent.
Equipment:
Make sure you have all of your safety, monitoring, and rescue equipment. Make sure all of your equipment is the correct size for the patient you are treating.
Ketamine induced laryngospasm
Risk factors
Instrumentation or irritation of the vocal cords under light sedation
Current or recent URI
Young infants are at highest risk, and it is more common in pediatrics than adults (ranges from 1.7-25%)
Airway anomalies
Management
Step 1: Apply 100% FiO2 by facemask
Step 2: Obtain a tight mask seal and deliver continuous positive pressure with the assistance of a PEEP valve on a BVM.
Step 3: Use your fingertips to apply pressure to a Larson’s notch, which is located between the ramus of the mandible, the skull base, and the mastoid. It requires significant pressure.
Step 4: Deepen anesthesia with propofol
Step 5: Administer succinylcholine 0.25-0.5 mg/kg IV, if necessary proceed to RSI. Make sure to maintain adequate sedation. If administering medications IM, The dose of succinylcholine in 4 mg/kg
