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 News– Frank 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