CCP Fall 2013 - Week 3

• 0.1 u/kg Bolus
• Followed by drip at 0.1 u/kg/hr

100 mg/dl

D5W

Too much sugar compared to their insulin production

• SEVERE dehydration
• Absence of ketosis – NO kussmaul breathing
• Relative hypernatremia
• Hyperglycemia [> 800 mg/dl common]Elevated BUN/Creatinine ratio

AGGRESSIVE fluid rehydrationInsulinAnticipate severe hypokalemia

• Head Injury
• Dilantin

• Extreme urine output w/very low urine osmolarity/specific gravity
• Hypernatremia

• Aggressive fluid replacement
• vasopressin (Pitressin©)dDAVP (DDAVP©, Stimate©, Minirin©)

A syndrome of increased ADH activity despite reduced plasma osmolarity

• Dilutional hyponatremia
• Cerebral edema
• Seizures
• Urine osmolarity/Specific gravity elevated

• Restrict fluids
• Diuresis
•     1° loop diuretics
• Democlocycline (tetracycline family)
•     ADH receptor antagonism

• Essentially treat as a trauma pt
• Also NGT/OGT & evacuate stomach
• octreotide (Sandostatin) 25-50 mcg IVP followed by 25-50 mcg/hr IVgtt - Reduces hepatic portal pressures, allows relief of venous congestion
• vasopressin (caution in CAD) - Decreases arterial pressure feeding to the hepatic portal system

• Dramatic weight loss
• CP, SOB & palpitations
• Fever
• Tremor, nervousness
• Marked tachycardia (AF common)
• ** Any new tach/AF in an otherwise healthy female **

• Antithyroid meds needed
• Antipyretics (Avoid ASA)
• Fluids
• Correct electrolytes: K⁺, Mg⁺
• Supplement O₂ delivery
• Consider IV glucocorticoids, dexamethasone specifically inhibits hormone production & conversion from T₄ to T₃
• Tachycardias not likely to respond to digitalis, will convert once antithyroid therapy initiated

• Primarily women
• Almost exclusively > 60 YOA
• > 90% of cases occur in winter
• Fatigue & weight gain
• Cold intolerance, deep voice, coarse hair
• Officially “myxedema coma” upon any change in LOC

• Supportive during comatose states
• IV levothyroxine (T4)
• Watch for adrenal insufficiency (Etomidate issues)

• Inadequate aldosterone, cortisol & androgens
• Fatigue, weakness, low BP 2°
•     ↓ Na⁺/H₂O retention
•     Hypoglycemia
•     Poor catecholamine production
• Failure to respond to exogenous pressor agents 

• Avoid abrupt discontinuation of chronic glucocorticoid  use
• May need to initiate steroids
• Caution w/Etomidate (overstated)

• Chronic glucocorticoid use w/abrupt cessation
• Pituitary disorders (too much ACTH released
• Oat Cell carcinoma (‘fake’ cortisol)
• Adrenal carcinoma (too much cortisol produced/secreted)

• Upper body obesity w/thin arms & legs (muscle wasting)
• Rounded face “buffalo hump”
• Fatigue, HTN, hyperglycemia
•     Incr. Norepinephrine/Epi
•     Fatty & amino acids convert to glucose
•       Type II DM (hyperglycemia wears out the pancreas)

• Initiation or reduction of glucocorticoids (Hydrocortisone)
• Supportive
• Need surgery

• EtOH abuse
• Biliary stone disease
• Steroids & antibiotics
• Infections (viral/bacterial)

• Low Ca+
• Elevation of the left diaphragm w/left base atelectasis
• Bilateral pleural effusions
• Concomitant sepsis & ARDS
• Renal failure
• Cullen’s sign

• Fluid resuscitation
• NPO & place NGT/OGT
• Meperidine vs. Morphine (Sphincter of Oddi spasticity)
• Alternate use of atropine, β-blockers, Narcan® & tetrodotoxin
• Anticipate progression
•     Sepsis
•     ARDS
•     MODS
•     DIC
•     DEAD
• Abx for sepsis (Rocephin, Ampicillin)

• Post operative adhesions
• Malignancy
• Crohn’s disease
• Hernias

• Large vs. Small
• Bowel ischemia results in sepsis
• Pancreatitis is common

• NPO & place OGT/NGT
• Aggressive fluid resuscitation
• Aggressive pain control
• Antiemetics
• Antibiotics
•     Ancef

• Ammonia toxicity
•   By-product of protein metabolism
•     TPN, blood, etc… Amine removal from amino acid
•     NH₃ converted to urea & glutamine for renal excretion
•   Hypokalemia
•     Diuretics
•     Diarrhea
•     Alkalotic states

• ⇧ AST & ALT (SGOT/SPGT)
• ⇧ BUN
• Stuperous ⇨ obtunded ⇨ coma
• “Coarse muscle flapping”

• Stop GI bleeding & evacuate bowel of blood w/OGT/NGT
• STOP protein intake (TPN, etc.)
• Correct K⁺ levels
•   Stop K⁺ retention

Trauma - most commonly affected organ in blunt force trauma

• Left shoulder pain (referred pain AKA Kehr’s sign)
• Shock

• Supportive
• Aggressive fluid resuscitation & PRBCs
• Get to surgeon

• Meningitis
• Flex the neck & pt will bring up hamstring

• Meningitis
• Bring up the pt's hamstring & the pt will flex their neck

• Pancreatitis
• Periumbilical bruising

• Pancreatitis
• Flank & groin bruising

• Splenic disease/rupture
• Left shoulder referred pain

• Gallbladder
• RUQ & push up, have pt take deep breath
• + sign = pain & inability to take a full breath

• Cardiac pain
• Clenched fist over chest

• Peripheral vasoconstriction
• Skeletal muscle vasodilation
• ⇧ Cardiac Output
• Shivering
•   Increases MRO₂ by up to 600%
•   Limited by available glycogen stores
•   Loss of shivering @ 32°C (89.6° F)

32° C (89.6° F)

• Initially metabolism⇧to produce heat
• Metabolism ⇩ by ½ for every drop in core temp of 10° C
• Pts BGL will ⇩ with mild chronic hypothermia
• BGL is ⇧ w/severe hypothermia as insulin stops working
• Respiratory minute volume (V_E) ⇩ 
• RR becomes inadequate to blow off CO₂ - respiratory acidosis follows
• ⇩ CO
• ⇧ SVR
•   Capillary leak decreases intravascular volume
• Metabolic acidosis related to anaerobic metabolism
• Enzyme function ⇩ dramatically
•   Coagulation deficits
•   Medication biometabolism deficits

• >32-34°C
• ⇧BMR, CO, HR begins to ⇩ @ 32° C

• 29 - < 32° C
• Body stops attempting to conserve or produce heat @ 32° C, shivering stops, LOC & SVR fall, acidosis, hyperglycemia, CO falls

• < - 28° C
• Hypotension
• ECG Δ: Prolonged QR, QRS, QT intervals, VF
• risk highest @ 22° C. Osborn waves clear @ 25° C.
• PT, PTT ⇧by 50%, Platelets ⇩ by 40%

Osborn wave

• Remove from cold & wet environment
• Manage airway, consider ETI, Risk of VF
• Handle gently
• Only start CPR if monitor shows VF or asystole
• Defer meds until core temp > 30° C
• < 33° C we see enzymatic retardation

Pt allowed to re-warm self w/blankets & transport vehicle heater

• Heat placed on external body surfaces (neck, groin, axilla)
• Watch for afterdrop

• Heat directly to core
• IVF, hemodialysis, gastric lavage, rectal lavage, ECMO

Cerebral edema & seizure activity 2° to hyponatremia

Hypokalemia, ATN

Hypoglycemia & ⇧ clotting times

Increased CK (CK-MM) & rhabdomyolosis

• ARDS
• DIC

• In heavily exercised muscles
• High heat

• Hyponatremia
• Associated w/only H₂O replacement

• Cool
• Rehydrate w/Salt containing solutions (0.9% saline)

Defined as an increase in core temp w/o neurologic impairment

• Temperature is lower & symptoms less severe than heat STROKE
• Pt retains ability to sweat

• Cooling
• Fluid replacement
• Electrolyte replacement

A life threatening emergency characterized by failure of the body to dissipate heat effectively

• LOC is altered
• Core temp ⇧ 42° C
• O₂ demand exceeds supply
• Respiratory alkalosis ⇨ Metabolic acidosis
• High output cardiac failure (use caution w/over-aggressive cooling)

• Aggressive cooling
•   Soak & air flow (Conduct/Convect)
• Aggressive airway management
•   Don’t under ventilate, use vent to reduce work load (use of AC mode ideal &/or pressure support)
• Expose
• IV fluids
• Prevent shivering
•   Phenothiazines & NMBAs
•   MRO₂ ⇧ x 600% w/shivering!
• Place OGT/NGT & consider H₂ blockers
•   cimetidine (Tagamet®) * consider drug interactions
• Foley & monitor
•   Volume output
•   Color/evidence of rhabdomyolosis
• Monitor labs
•   ABGs for acidosis
•   Watch clotting factors for early onset DIC
•   Monitor liver enzymes
•   Watch Na+ for hyponatremia

• ⇧ urine output to 2 mL/kg/hr
• Alkalinize urine w/NaHCO₃^-
• Assist diuresis w/Lasix &/or mannitol

Replace by correcting Na⁺: 3.3% saline SLOWLY (central pontine myelinolysis)

• Mimics Class I AAs (quinidine, lidocaine)
•   Blocks Na+ Channels
• Inhibits NE (norepinephrine) uptake [Like
• cocaine]
• Blocks PNS (Peripheral Nervous System) [Like jimson weed]
•   Early tachycardia
•   Widening of QRS
•   Aberrant SVT
•   Torsades de Pointes/VT/VF

• NaHCO₃^-
• Norepinephrine: 1st choice pressor
• Dialysis NOT helpful

• atenolol (Tenormin^®),
• metoprolol (Lopressor^®),
• esmolol (Brevibloc^®),
• betaxolol (Betoptic^®)

• propanolol (Inderal^®),
• sotalol (Betapace^®),
• nadolol (Corgard^®),
• timolol (Timoptic^®)

• Bradycardias w/resultant hypotension
• Look for escape rhythms

• May result in an “Inverse Epinephrine Response”
•   With β₁ blocked, Epi can only stimulate β₂ & α₁
•     β₂ will vasodilate
•       May attenuate α₁ effect
•       May override α₁ completely ⇨ hypotension
•       α₁ will vasoconstrict ⇨ ⇧ BP ⇨ baroreceptors triggered ⇨ ⇩ HR = BAD

• Respiratory distress, exacerbation of RAD
•   Beta₂ blocked @ same time as Beta₁
•   Inhibits bronchodilation

• Atropine rule out / Parasympathetic tone/prasympathetic tone prophylaxis (will pay off post TCP capture)
• TCP ASAP
• Glucagon 2-5 mg IVP (incr. cAMP via glucagon receptor)
• dopamine (Intropin) PRN for hypotension

• Severe bradycardias
• AV Dissociation w/comcomitant hypotension

Severe hypotension

• CaCl/Ca⁺ Gluconate
• TCP
• Maintain Insulin Euglycemia

• CaCl/Ca⁺ Gluconate
• TCP
• Maintain Insulin Euglycemia

• Visual disturbances {Yellow/Green Halos}
• Bradycardia, SVT, VT, AV Blocks

• Digoxin Immune Fab (Digibind)
• Assure normal electroclytes
•   K⁺ 1^st, then Ca⁺⁺ & Mg⁺⁺
• TCP
• lidocaine (Xylocaine), MagSulfate & phenytoin (Dilantin) for tachyarrhythmias
• Caution w/electricty

• Profound acidosis (DKA, vent mismanagement, etc)
• K⁺ supplement OD
• ECG: Flattening/slurring of P's w/peaked T's

• CaCl
•   Raises the action potential threshold to compensate for hyperkalemic elevated resting potential
•   CAUTION w/hyperkalemia secondary to malignant hyperthermia
• NaHCO₃^- [Do not mix w/CaCl]
• Insulin
• D₅₀
• Beta₂ agonists
• sodium polystyrene sulfonate (Kayexalate)
• furosemide (Lasix)

• Loop diuretic misuse/OD
• Serum K⁺ important as well as pH
• ECG: Peaked P's, flattened/slurred T's & apperance of U's

• KCl, KPhos
• Commonly 10-20 mEq/hr (10 mEq/hr peripheral, 20- central)
•   Never more than 0.5-1.0 mEq/kg/hr

• Tinnitus
• Headache
• Vertigo
• Mental confusion
• Thirst
• Sweating
• N/V
• Hyperventilation

• Agitation/restlessness
• Coma
• Seizures
• Non-cardiac pulmonary edema
• Electrolyte disturbances (TCO₂, HCO₃^-)

• Gastric emptying
• Charcoal
• Alkaline diuresis using NaHCO₃^-
•   Ion trapping mechanism
• Hemodialysis
• Management of Acid/Base & electrolyte disturbances

• "Flu like symptoms"
• Occurs w/in 30 min - 24 hrs
• N/V/Anorexia
• Malaise
• Pallor
• Diaphoresis

• "Ow my liver!"
• 24 - 48 hrs
• RUQ pain/tenderness
• Incr Liver enzymes
• Incr serum bilirubin
• Incr PT
• Oliguria as a result of ATN

• "Gonna die now"
• 72-96 hrs
• Peak for liver function abnormalities
• Return of anorexia, N/V, Malaise
• Jaundice becomes apparent
• Hepatic encephalopathy
• DIC
• Death d/t fulminant hepatic necrosis

• "I'm not dead yet"
• 4 days to 2 wks
• Resolution period
• Liver functions return to normal baseline values
• Patients are asymptomatic

7.5 GM or 150 mg/kg

4 hrs

• n-acetylcysteine (Mucomyst)
• Orally 140 mg/kg followed by 70 mg/kg Q 4 hrs for 17 dosings

• Profound anion gap
• Osmolar gap
• Nystagmus / blindness
• Depressed DTRs
• Stupor/Coma/Convulsions
• Myoclonic jerks
• Hypothermia/Low grade fever
• Profound hypocalcemia

• IV ethanol drip
• fomepizole (Antizol)
• Thiamine
• pyridoxine (Aminoxin)

• Avoid beta-blockers
• Utilize alpha-blockers for HTN
• Use benzodiazipines for anxiety

Beware of violent propensity

Dialysis

• 0.1 - 0.2 mg IVP, Max 3.0 - 5.0 mg
• Caution w/Seizure or chronic use history

• 0.4 - 2.0 mg IVP, Repeat PRN
• Reverses all beneficial effects of opioids as well as problematic
• Be alert for negative pressure induced pulmonary edema

• O₂
• Hyperbarics

• atropine
• 2-PAM

methylene blue

• Mad as a Hatter
• Red as a Beet
• Dry as a Bone
• Blind as a Bat

physostigmine (Eserine)

Inhibits acetylcholinesterase

• Vitamin K (IV, IM)
•   6 hr onset
•   High rate of anaphylaxis when given IVP
• FFP - for when 6 hrs is too long

• Protamine
• Derived from whale sperm so watch for allergies to seafood & fish
• Typical profile is to give a small test dose then give larger dose once risk of anaphylaxis is deemed low

• glucagon
• CaCl/gluconate

The Choroid Plexus

Arachnoid Villi

Pia Mater

Dura Mater

Subarachnoid space

Diagnostic for epidural bleed

Olfactory

Optic

Oculomotor

Trochlear

Trigeminal

Abducens

Facial

Vestibulocochlear

Glossopharyngeal

Vagus

Accessory

Hypoglossal

• Smell
• Sensory

• Sight
• Sensory

• Eye movement [Adduction]
• Motor

• Eye movement
• Motor

• Facial sensory, chewing
• Both

• Eye movement [Abduction]
• Motor

• Facial muscles, taste
• Both

• Balance / Position
• Sensory

• Taste, baroreceptors
• Both

• Parasympathetic Nervous System (PNS), Motor of Larynx/Pharynx
• Both

• Shoulder / Head movement
• Motor

• Moves tongue
• Motor

• or

0 - 10 mmHg

> 60 mmHg

• Change in LOC
• Change in pupil size & reaction
• Abnormal motor responses
•   Decorticate
•   Decerebrate

Adduction of upper extremities towards the "Core"

Indicates damage above the cerebellum & brainstem (supra-tentorial)

Extension & hyperpronation of upper extremities

Damage to brainstem or compression of the thalamus & brainstem

• HTN
• Bradycardia
• Respiratory changes

• Position patient
•   Eyes forward
•   15-30 degrees reverse trendelenburg
• Limit noxious stimuli
•   Suctioning/Invasive procedures
•   Noise
•   Atmospheric pressure changes
• Maintain euvolemia, normothermia & normal electrolytes
• Pharmacology:
•   Sedation - benzos, propofol
•   Analgesia - fentanyl
•   NMBAs
• Systematic Approach to Herniation

• Paralyze, ETI & slightly hyperventilate to a PaCO₂ of ~ 32-35 mmHg
•   If using ETCO₂ don’t forget gradient correction
•   What happens w/hypoventilation?
•     “Cerebral Steal or Luxury Perfusion”
•   What happens w/hyperventilation?
•     "Reverse Steal or Robin Hood Effect”
• Assure adequate O₂ delivery
•   100% for duration of transport
• Assure adequate fluid resuscitation 1^st, then consider
•   Mannitol
•   Hypertonic saline
• ⇩ O₂ demand by induction of barbiturate coma
•   thiopental (Pentothal^®) TOO SHORT ACTING
•   phenobarbital (Luminal^®) DRUG OF CHOICE

• Blood btn the Dura & Arachnoid membranes
• Usually venous in nature
• High morbidity/mortality
• 3 types
•   Acute: Symptomatic w/in 24°
•   Subacute: Symptomatic w/in 2-10 days
•   Chronic: Symptomatic after 2 weeks

Larger subdurals w/slowly developing symptoms d/t cerebral atrophy

• Rapid onset of symptoms w/marked ⇧ ICP
•   Peds subdurals typically occur
•     < 18 mos
•     Look for bulging fontanelle & retinal hemorrhages

• Bleeding btn the skull & the dura mater
• Usually arterial but can be venous
• Laceration of the middle meningeal artery in the temporal lobe area

• Classic symptomology – Transient loss of consciousness followed by a period of lucidity “Lucid Interval”
• Epidural bleeds cause uncal herniation
•   Will result in dilation of the ipsilateral pupil w/contralateral neuro deficits/posturing

• Bleeding btn the arachnoid membrane & the
• pia mater
• Trauma is the most common cause
•   Berri aneurysm 2^nd most common cause w/rupture 2° HTN

• “Worst Headache of My Life”
• N/V, stiff neck, visual disturbances, Δ LOC
•   Confused w/meningitis
•   No LP if Sub-A bleed possible

• Hemorrhage in the brain parenchyma
• Produced from shearing & tensile forces
• Frequently occurs in the white matter of the frontal & temporal regions
• May be single or multiple & is associated w/contusions, subdural hematoma & diffuse axonal injury (DAI)
• Less common injury w/delayed onset of symptoms (24° or more after injury)

• Bleeding into the ventricles as a result of severe brain trauma
• Result of shearing forces
• Greatly ⇧ mortality rate
• Usually found in frontal or temporal lobes

• Rotational Force
• Reversible w/no persistent sequelae
• Retrograde amnesia of short duration

• Rotational or direct force
• Reversible w/memory & info processing problems
• Brief LOC, retrograde & post traumatic amnesia

• Diffuse shearing injury – rotational acceleration
• Irreversible w/profound neuro, psych & personality deficits
• Usually coma

• Embolic – Most common
• Hemorrhagic – Bleeding into brain tissue
• Thrombotic – Least common

• Prevent additional insult
• Maximize Cerebral blood flow
• Control ⇧ ICP
• Manage associated conditions
• Thrombolytic therapy w/i 3 hrs of neurologic deterioration onset

A line that extends toward the base of the skull

Multiple Fx that radiate from the compressed area

Involves a separation of the bones at a suture line or a marked separation of bone fragments

May be open or closed

Fx of the base of the skull

• Battle’s sign: Bruising behind the ear on the mastoid bone
• Periorbital Ecchymosis (Raccoon Eyes): Ecchymosis around the eyes
• Otorrhea: Bleeding from ear w/CSF leak 
• Rhinorrhea: Bleeding from the nose w/a CSF leak

• Intracranial Infections
• Hematomas
• Meningeal & brain tissue damage
• Pneumocephalus
• Associated nerve damage & palsies

• LeFort I: Fx of the mandible
• LeFort II: Nose & maxilla separate from skull
• LeFort III: Through the zygomas; The face from the eyes down is free floating

• Areflexia w/flaccid paralysis immediately or shortly after injury
• Parasympathetic dominance below the lesion

• Hypotension
• Warm red skin below injury
• Absence of tachycardia

• HTN
• Hypervolemia
• Hemodilution

Pediatric patients

• HR ⇧ 15-20 bpm
• BP ⇩ in 2nd Trimester 5-15 torr & ⇧ in 3rd trimester 10 torr
• Cardiac Output ⇧ ~ 2 L/min
• Plasma volume ⇧ 40% ⇨ ⇧ clotting factors
• Placenta very high in tissue thromboplastin content
• RBC’s ⇧ but not @ same rate as plasma ⇨ dilutional anemia
• ⇧ volume ⇨ capillary engorgement ⇨ airway swelling
•   Mallampati ⇧ 2-3 classes
•   Failed airways 1:2230 vs 1:280 when Pg
• Heart elevates anteriorly & ↺ to left
• WBC ⇧ 
• Progesterone relaxes everything (sphincters,
• vasculature, etc)
• ⇩ Functional Residual Capacity [FRC] by ~ 20%

Refers to the extent of cervical dilation as judged by palpation

Relates to the thickness of the cervix & is expressed as a %. The cervix is normally about 2 cm thick & thins during labor. When thinned to 1 cm would be said to be 50% effaced.

Refers to the longitudinal orientation of the fetus in relation to the longitudinal orientation of the mother

Refers to the fetal head in relation to the mother’s pubic bone & is expressed as a + or a - number as measured in cm

What is attempting to emerge 1st? Cephalic, breech or shoulder? (Cephalic – Vertex, brow or face)

120-160/min

The single most important predictor of fetal well-being

• Fetal hypoxia
• Meds given to mom
• Smoking
• Extreme prematurity
• Fetal sleep

• Usually GOOD
• Usually associated w/fetal movement & CNS
• response to stimuli
• Hypoxic fetus w/metabolic acidosis cannot
• accelerate the heart

• OK sign
• Typical vagal response to squeezing of head caused by contractions

• BAD
• Indicate uteroplacental insufficiency causing the fetus to experience a hypoxic bradycardia
• Commonly associated with:
•   PIH
•   DM
•   Smoking
•   Late Deliveries

• Not good but correctable
• Common during contractions, typically V or W shaped
• Caused by cord compression
• Shouldering” is common
• Look for ‘cord’ problems
•   Prolapse
•   Short
•   Entanglement
•   Nuchal

• Typical of fetal hypovolemia OR anemia
• Accidental tap of the umbilical cord during amniocentesis
• Fetal maternal transfusion
• Placental abruption

FHR < 120 for 5-10 min

FHR > 160 for 10 min

• Assure fetal oxygenation: Give mom High flow O₂ by NRB
• Maternal hypotension
•   Initiate 250-500 cc IVF bolus
•   Correct supine hypotension
•   “Tank her up”
• Hypertonic or tetanic contractions: D/C oxytocin infusion
• R/O cord prolapse
• Assess for placental abruption
• Δ positions

• VB
• Contractions more frequent than q 10 min
• ⇧ intensity
• Urge to push
• Crowning

• ☑ 4 signs of Imminent Delivery
• Obtain status of amniotic membranes
• Determine cervical status
• L Lateral Recumbent
• Assess for infection
•   Prophylactic Abx for Group B Strep
• Tocolytics
•   MgSO₄^-: Watch 4 toxicity
•   Terbutaline
• Monitor FHT, movement

• DTRs
• BP
• LOC
• Resps

• CaCl 4 the acute OD
• Push fluids w/diuresis [Renal excretion is very good]

• terbutaline
• (Brethine^®, Breathaire^®)
• 0.25 mg sq q 15
• Pre-Term Labor

• magnesium sulfate
• (MgSO₄^-)
• 4-6 gm bolus / 15-30 min, 2 gm/hr maint
• Preeclampsia, Pre-Term Labor

• oxytocin
• (Pitocin^®)
• 20-40 units/1000 cc @ 125 cc/hr
• Post-Partum hemorrhage

• hydralazine
• (Apresoline^®)
• 2 mg IVP q 5 min to DBP 90-100 mmHg OR 5-10 mg q 20 min
• PIH, Preeclampsia

• ⇧ Volume - Autoregulation Mismatch
• Placental Toxins

A syndrome where pts experience a myriad of symptoms including Hemolysis, Elevated Liver enzymes & a Low Platelet count

• HTN
• Proteinuria
• Edema

• African-American Females
• Prima Gravida
• Multi Gravida
• Very young maternal
• Advanced maternal age

• Watch for late decels & ⇩ variability as well as fetal movement
• MgSO₄ 4-6 G bolus followed by 1-2 G/hr
• Steroids betamethasone (Celestone^®) ASAP
• Consider labetalol (Trandate^®) 20 mg SIVP
• Consider hydralazine (Apresoline^®) 2 mg SIVP
• Give diazepam (Valium^®) PRN 4 seizure activity w/MgSO₄ (MgSO₄ inhibits cerebral vasospasm primarily)

• Gravid uterus ⇧ clonic pressure on distal aorta & femoral arteries
• ⇧ circulating volume
• ⇧ aortic ejection pressures

• CP similar to AMI
•   May actually be complicated by an AMI

Aggressively treat mom like you treat other trauma pts

• Uterine scarring
• Multiparity w/short intervals
• Post D&C

Painless Bright red vaginal bleeding

Ripping or tearing pain w/dark or no evident blood loss

• Exsanguination
• Placental insufficiency

Blood is irritating to the uterus ∴ it will initiate contractions

• High flow O₂, VS, Fluids
• Assess for contractions, fetal movement, FHTs, hemorrhage
• Continually reassess fundal height
• Consider tocolytics & blood products
• Watch for signs of DIC

Serial fundal height measurements

Variable decelerations

• Gently loosen & draw down over head
• Clamp & cut before shoulders deliver if it is too tight to remove
• Focus is relieving cord tension before next contraction

• Elevate presenting part off the cord w/a hand in the vagina to prevent cord compression
• Trendelenburg or knee-chest position
• Tocolytics to reduce pressure on the cord during contractions

• Fetus should not be touched until cord has spontaneously delivered
• Palpate the cord for FHR
• After shoulders have delivered, rotate baby’s trunk so that the back is anterior & apply gentle downward traction
• Apply suprapubic pressure to facilitate delivery of the head
•   Mauriceau’s Maneuver
• Do not attempt to deliver a footling breech

• Suction mouth, posterior pharynx & nose after delivery of head, but before delivery of
• shoulders
• If baby is vigorous continue w/supportive care
• If baby is not vigorous suction mouth & trachea

• Strong respiratory efforts
• Good muscle tone
• HR > 100 bpm

• Vigorous fundal massage
• Rapid infusion of 20-40 units of oxytocin (Pitocin^®)
• methylergonovine (Methergine^®) 0.2 mg IM
• Assess blood loss
• Replace fluids, blood
• Bimanual uterine compression

• Manual replacement if the uterus has not yet contracted down & cervix has not constricted
• Tocolytics if the uterus has contracted to relax the uterus & allow replacement
• DO NOT REMOVE THE PLACENTA
• oxytocin use post replacement

• High flow O₂, ETI PRN
• PEEP may be required
• Fluid resuscitation
• Hemodynamic monitoring
• Blood product replacement as needed
•   FFP, Platelets, Cryo
• Anticipate severe fetal distress if syndrome presents prepartum
• Prepare for emergent post-mortum c-section

• Airway management
• Stop ongoing major hemorrhage
• Volume replacement
• Minimize needle sticks
• Blood products (FFP, platelets)

• ⇧ sensitivity to aminosteroids (VEC & ROC)
• Possible prolonged effects of SUX
• Difficult airway/Failed airway more common