Conference Lectures 1/2020

Obstetrics and Gynecology Emergencies – Dr. Marques

Normal Vaginal Delivery Key Steps

  • Support the perineum to prevent tearing with delivery of the anterior shoulder
  • Upon delivery of the anterior shoulder, provide upward pressure to deliver the newborn
  • Pull only gentle traction when delivering the placenta, to avoid uterine inversion

Post-Partum Hemorrhage

  • Palpate the uterus to feel for inversion or retained products
  • Provide tone by providing suprapubic pressure with an external hand and uterine pressure with an intravaginal hand
  • Oxytocin can be given IM or IV to treat uterine atony

Shoulder Dystocia

  • Leg hyperflexion and abduction at the hips along with suprapubic pressure (McRobert’s Maneuver) can be done if the anterior shoulder cannot be delivered

Breech Delivery

  • This happens in 3-4% of all deliveries
  • Do not pull traction at any time, as this can lead to entrapment in a cervix that is not dilated
  • A pressure against the popliteal fossa can help flex the leg and deliver each leg

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Oral Boards: Sepsis Due to Spontaneous Bacterial Peritonitis – Hugh, Shoff, MD

  • The CMS Core Measures (SEP-1) provide quality measures for providers to follow in sepsis
  • Severe Sepsis is defined as Lactate >2 or organ dysfunction
  • Septic Shock is defined as severe sepsis with hypoperfusion despite fluid resuscitation or lactate>4
  • Within 3 hours of presentation, obtain a lactate, blood cultures prior to broad spectrum antibiotics, and 30cc/kg fluid resuscitation
  • Within 6 hours, lactate must be repeated if >2

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CCU Follow-Up – Phil Giddings, MD

Myocardial bridging- coronary arteries travel deep into myocardium as opposed to laying upon the muscle

The vessels are occluded but when there is demand ischemia it can look like a STEMI

Myocardial bridging is fairly common in the general population, but usually isn’t symptomatic or pathologic.

If it is symptomatic- you could do Ca2+ channel blockers, beta blockers, and even myotomy or CABG if you’re feeling wild.

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Urology Review- Isaac Shaw, MD

Priapism-

  • Normal tumescence- veins constrict so the corpus cavernosum engorges because blood flows in
  • Ischemic= low flow, less venous outflow, rigid, painful
  • Nonsichemic= high flow, more arterial inflow, half rigid
  • (Distinguish w/ a blood gas)
  • Treatment
  • anesthetize by blocking the dorsal nerve of the penis (2 & 10 o’clock) w/o epi
  • then aspirate at 3 or 9 o’clock from the corpus cavernosum
  • Use a phenylephrine stick from Room 9, 100mcg-500mcg Q1-5min

Fournier’s Gangrene

  • polymicrobial
  • assoc w/ DM
  • 22-40% mortality
  • empiric + clindamycin (clinda first because it’s addressing the toxins)

consult surgery before imaging

Paraphimosis

  • foreskin trapped proximal to glans so the tip can get ischemic
  • Treatment: manually reduce, dextrose, lube, may have to incise the dorsal foreskin

Phimosis

  • foreskin can’t be retracted over the glans 2/2 inflammation
  • Treatment in ED: topical steroids with urology follow-up

Urinary Retention

  • often have hesitancy, nocturia, frequency, urgency
  • >200cc PVR
  • d/c w/ Foley à Uro will keep that in for 2 weeks prior to void trial

Renal Stones

  • remember that 10-15% don’t have hematuria
  • CT w/o contrast is still the standard for diagnosis, but some emergent literature exists that US alone is sufficient in young, healthy patients
  • if <5mm, 90% pass; but if >8mm, 5% pass
  • admit for intractable vomiting, pain, urinary extravasation, infection & obstruction

Balanitis

  • Candida on the glans
  • Associated with DM or uncircumcised

Torsion

  • twisted around the spermatic cord
  • if actively torsed, you will NOT have a cremasteric reflex
  • ultrasound 88-100% sensitive because they can torse and untorse
  • consult before imaging

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Breaking Bad NewsFrank Woggon, PhD

  • insensitive truth telling can have similar effects as lying
  • goals include gathering info, provide info, support patient, strategy for care
  • keep it simple, no jargon, talk slow, repeat PRN, use neutral language, be honest, allow emotions, consider cultural differences
  • “compassion is the willingness to let yourself be affected by the life and suffering of others”

SPIKES

  • Setting- privacy, sit down, eye contact, turn off pager
  • Perception- don’t combat denial at first, interpret first
  • Invitation- ask how much they want to know first
  • Knowledge- “what I’m about to say is not good,” be direct but not blunt, use their language
  • Empathize- ok to validate the emotions, silence is ok
  • Strategy & Summary- what comes next

GRIEV_ING Protocol

  • Gather the family
  • Resources- call for support
  • Identify yourself & staff, those in the room
  • Educate the family about what happened
  • Verify that the patient died by using that word
  • SPACE- silence is ok, let them have their gut reaction
  • Inquire whether they have questions
  • Nuts & bolts- organ donation, funeral arrangements, personal belongings, etc.
  • Give contact info for f/u questions

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STEMI Mimicks – Frank Shary, MD

OMI= occlusive MI

  • V2 & V3 2mm elev = STEMI; Everywhere else 1mm
  • Wellens: biphasic T wave, they recently had an OMI, symptoms may have gotten somewhat better by the time of the EKG, they need a cath
    • Deep T Wellens- deep and wide
  • LV aneurysm- deep Q wave w/ biphasic T wave, static
  • Sgarbossa criteria- OMI in the setting of LBBB and/or paced rhythm
    • look at vector of QRS and vector of ST segment
    • concordant elevation or depression greater than 1mm
    • discordant greater than 5mm
  • Hyperacute T waves- early into the ischemia, before ST elevation, cath soon because you have potential to save more myocardium, large area under the curve especially in proportion to the QRS complex
    • L circumflex is the vessel most likely to be silent
  • aVR- if it’s the only lead elevated and everywhere else is diffusely depressed, you might have diffuse subendocardial ischemia
    • could be bad triple vessel disease

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Managing the Bleeding Patient Without Blood Products – Chase, PharmD

There are 6 Jehovah’s Witness churches in Louisville

  • Plasma Derivatives are technically not Blood products… so whether or not a patient wants that is up to the individual
  • albumin, clotting factors, PCC, Immunoglobulins (including Rhogam and vaccines)
  • equine Ig and Crofab could also be iffy
  • ECMO, cardiopulmonary bypass, dialysis are allowed generally

Source Control

  • bone wax/putty- use in NES and long bone fx, high infection rate though
  • oxidized regenerated cellulose- ex. Surgicell, promotes rebuilding of proteins to heal & achieve hemostasis, like a mesh
  • gelatin matrix- ex. Floseal, more like a gel
  • there is a powder too but it’s $$$ and causes microemboli so don’t use
  • thombin- apply w/ 4×4’s
  • TXA- derivative of lysine THIS IS NOT A PLASMA DERIVATIVE SO THEY SHOULD BE OK WITH IT, 1g over 10min à another 1g over 8-10 hours
  • have a lower threshold to give TXA since there is a decrease in mortality, even if you wouldn’t have given TXA to a non-Jehovah’s witness

Usable Therapies:

  • Cell Saver
    • blood is collected, washed, centrifuged, returned to patient
    • example indications: AAA, TKA, THA, cardiac surgeries
  • Vitamin K
  • PCC- most efficacious
    • 4 factor is better than 3 factor, but if you try to give 3 factor and then just add Factor VII a la carte, more thromboembolic events
  • FFP- prep time is longer, tonzo volume
  • Adnexanet Alpha- new antidote for rivaroxaban and apixaban, we don’t have that
  • Novo7- directly activates Factor VIII, black box warning for thromboembolic events, no difference in mortality but there was a reduction in transfusions
  • Dabigatran reversal- idarucizumab, dialysis, charcoal
  • Antiplatelet reversal- ASA and Plavix are irreversible, but ticagrelor is reversible
    • DDAVP- indicated for DI, von Willebrand disease, uremic bleeding (renal failure), nocturnal enuresis
    • 0.4mcg/kg over 10min

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Pediatric Environmental Emergencies- Dr. Said

Drowning

  • fresh or salt water doesn’t matter, you’re ruining your surfactant
  • if you are anoxic you get brain damage in 4-6min, irreversible
  • cold temp is only helpful if it happens really quickly
  • outcomes depend on initial resuscitation, degree of pulmonary damage, time submerged
  • poor prognosis- coma, apnea, submersion >9min
  • can try vapotherm for positive pressure, albuterol can treat bronchospasm
  • steroids don’t help
  • goal warming 32C
  • if asymptomatic, obs for 8 hours! Oy vey
  • admit if prolonged submersion, respiratory or neuro symptoms, abnormal CXR

Electrical Injuries

  • lightning strikes carry 30% mortality risk, it causes asystole
  • doesn’t cause renal failure or burns/compartment syndrome
  • thicker tissue less damaged
  • tissue between entry and exit wounds could be more damaged interiorly than it appears
  • AC worse than DC because AC at low voltage causes tetany so you’re holding on longer
  • we use DC for defib, countershock, pacing but you get thrown off
  • oral electrical injury – monitor for progressive edema
  • could have delayed bleeding from labial artery

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EMTALA- Melissa Platt, MD

  • in court, all are case-by-case
  • we have to provide a medical screening exam and treat and stabilize an emergency medical condition
  • transferring physician assumes the risk if the patient crumps en route to accepting hospital

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