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Maternity > 11, 12 & 13. Emergencies > Flashcards

11, 12 & 13. Emergencies Flashcards

1
Q

What is the minimum mouth opening, sternomental distance and thyromental distances we are looking for when pre-assessing?

A

MO over 3cm
SM over 12.5
TM over 6.5

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2
Q

What should we ask about in pregnant patients to allow us to evaluate what tube size they need and why?

A

Prone to airway oedema so ask about snoring and voice changes.

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3
Q

What preparation do we need to do for an obstetric GA prior to induction?

A

Bra off, arms out and hair bobble out.
Sodium citrate 30ml of 3m

Z bed, tilt, suction under pillow. Monitors and BP 1 minute.

IV access working and grey +/- more or lines etc. fast fluids.

3m preoxygenate and unobstructed trace

Quiet please and tell plan.

10n while awake, 30n when asleep.

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4
Q

What are the doses of sux and thio?

A

Sux = 1 - 1.5 mg/kg (actual body weight)

Thio = 5mg/kg

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5
Q

What is the rate of difficult airway in obstetrics vs. normal?

A

1:250 vs 1:2000

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6
Q

What are the steps in a difficult obstetric airway?

A

Cricoid off
Retract breasts

McCoy = flip blade

Make sure declare failed after 2nd attempt.
DAS - if using igel, remove cricoid for insertion and the pan replace.
Always use OPA I’d bagging.

Wake unless surgery would help mum e.g. resuscitation

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7
Q

What do we need to ensure during maintenance of obstetric anaesthesia?

A

1 MAC with 50% nitrous and 50% O2. Prior to KTS

Aim normocarbia (too high = baby lost concentration gradient).

Ensure twitches before give ROC

Give more analgesia once baby out

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8
Q

What are the rules with for obstetric extubations?

A

Don’t reduce volatiles until fully reversed.
Deflate cough to check for leak if difficult or oedema.
Wide awake

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9
Q

What so Mendelsons syndrome and what has a higher risk of damage?

A

Aspiration under GA

Higher risk of damage if over 25ml or pH under 2.5

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10
Q

What prophylaxis do we give for aspiration in obstetrics?

A

Elective H2/PPI oral x2, 6h apart
Emergency = IV plus sodium citrate

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11
Q

How long does sodium citrate work for?

A

Raises pH for 20m

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12
Q

What do we do if an obstetric patient aspirates?

A

Head down/ lateral and suction prior to ventilating to avoid pushing down food stuffs.

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13
Q

How does epidural haematoma present and how do we treat it?

A

Severe localised back pain usually 12-24h post insertion

Radicular pain: sensory/motor +/- cauda equina

Needs urgent MRI and decompression a.s.a.p. Under 12h but over 6h after dx has worse outcomes

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14
Q

What are the steps in dealing with anaphylaxis?

A
  1. Note time and ask for arrest trolley and help
  2. Turn O2 up to 100% and give fluid bolus
  3. Remove the causative agent
  4. IV adrenaline 50mcg = 0.5 ml of 1:10,000 (- if beta blocked give IM glucagon 1mg)
    - IM = 500mcg = 0.5ml of 1:1000
    - up to three doses, if no response = infusion of 5mg in 500ml dextrose, titrate to response.
  5. Treat other symptoms:
    - bronchospasm = 250mcg IV, dilute and give slowly
    - 2g mg over 20 mins (50mcg/kg)
    - 20mg IV ketamine
    - 4mg/kg hydrocortisone (adult 200mg)
    - alter I:E ratio to avoid breath stacking
  6. If still hypotension, think about other infusions e.g. norad.
  7. CTG
  8. Serum triptase, when stable, then at 1-2h, then over 24h.
  9. Critical care
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15
Q

In what groups of patient is latex allergy more common?

A

Fruit allergy e.g. avocado
Spina bifida

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16
Q

What is a high spinal?

A

Above the level for respiratory/ CVS stability (T4)

17
Q

What are the different spinal levels that we can test for a high spinal?

A

T1-4 = cardiac accelerators = bradycardia and hypotension
C6-8 = shortness of breath (intercostals), parasthesia and hand weakness
C3-5 = shoulder and diaphragm weakness/arrest
Brain stem = slurring and loss of consciousness

18
Q

Is shortness of breath normal during a spinal?

A

Can be as we can get some intercostal weakness, but they should be able to talk, not whisper.

19
Q

How can a subdural block result in a high spinal and how can we spot one?

When do they present?

A

The thin arrachnoid mater can burst

Two patterns:
- extensive sensory +/- horners and cranial nerves
- very restricted spread

Usually present over 20-40mins with mild hypotension and mild motor block

20
Q

How do high spinals present?

A

Hypotension
Brady
Respiratory weakness/apnoea
Inability to phonate
Arm changes

21
Q

What is a total spinal?

What is the treatment?

A

Come from LA brain stem depression.

O2 and airway (decreased doses if intubate), aggressive vasopressors. Need to ensure good arm movement prior to extubation.

22
Q

What is the risk of DPH?

When does it present?

How is it classified?

Treatments?

A

1% (80% of punctures get the headache)

Usually 24-48h later

Bilateral headache (anywhere), +/- shoulders, within 7 days of procedure, increases in under 15 mins of upright and decreases within 30m of lying. Gone in under 14 days. Caused by vasodilation and meningeal traction.

Rx: hydrate, analgesia and caffeine, blood patch 15-20ml (20% need repeat)

23
Q

When does LA toxicity present?

What are the early and late signs?

What is the treatment?

How does intralipid work?

A

20-40m post large intravascular LA

Early CVS: hypo and Brady (opposite with adrenaline)
Early CNS: tinnitus, visual changes, peri-oral tingling/numbness, metallic taste, drowsy, twitchy

Late CVS: heart block, asystole, ectopics, VF/VT
Late CNS: loc and resp depression

Supportive (+/- arrest trolley and +/- help)
Left lateral and CTG +/- delivery
Dysrhythmias as per ALS
Benzo for seizure
Intralipid for significant CVS
-1.5ml/kg over 1m and infusion of 15ml/kg/h
- another bolus at 5-10 mins if unstable and can double rate
Max dose = 12ml/kg, for 70kg = 840ml

Intralipid counteracts the inhibition of myocardial fatty acid oxidation in the mitochondria

24
Q

What is the mortality from an amniotic fluid embolism?

When does it occur?

What is the triad and pathophysiology?

How does we diagnose it?

What is the treatment?

A

25-60% are fatal

Triad = hypoxia, CVS collapse and coagulopathy
RV outflow obstruction leads to pulmonary vasoconstriction => ARDS => RV dysfunction
If survive = LVF, anaphylaxis/SIRS reaction and DIC

DX = high suspicion and TEG

Rx: oxygenate, aggressive fluid resus, pressors, invasive, monitoring and baby out

25
Q

What are the most common causes of major haemorrhage?

What is the definition? And normals?

A

Tone, trauma, tissue (retained) and thrombin

Normal vaginal = 300-500ml. Section = 750-1000
Definition = over 1500 or 25-30%, Hb drop of over 4 or more than three units required.

26
Q

What are the different types of PPH?

A

Primary = under 24h
Secondary 24h - 6w.

27
Q

What are the steps in obstetric major haemorrhage?

A

1000ml = ?TXA and document
- ?group specific release
- ? Increase fluids

1500 = controlled, if not = MH, dad out and O2 (plus help)
- extra IV access and bloods plus gas and TEG
- extra fluids/o neg
- ?more uterotonics
- if no call = document why.

2000 = start any type of blood
- Prep for GA

2500 = more blood products
- asleep by then

Remember rapid infuser and scribe.

After every 4 units give 30ml calcium gluconate

28
Q

What are the order and doses of uterotonics?

A
  1. 5iu IV of syntocinon and 15 over 30m
  2. 500 ergo IV IM
    - not in high BP or pre-eclampsia or raised ICP
    - can give IV, dilute and small increments.
    - give anti-emetics as definite vomiting
  3. Haemabate (carboprost)
    - 250mcg IM every 15 mins, max 2g
    - document times on board
    - no in asthma
  4. Misoprostol vaginal
29
Q

What are the different classes of haemorrhage and results?

A

Class: 1. 2. 3. 4
%. 15. 15-30. 30-40. >40
Ml. 1000. 1500. 2000. 250p
HR. <100 100. 120. 140
BP. N. N. Down
RR. 20. 30. 40. >40

30
Q

What are the goals in major haemorrhage transfusion?

How do we manage coagulopathy’s?

A

Volume
Normothermia
No coagulopathy

(Coag, cold, acid)

Platelets over 50 = platelets
Fibrinogen over 1 = cryo
PT under 18 and APPT under 45 = FFP (12-15ml/kg)

31
Q

What is in the MH packs?

A

Pack A = 6 XM and 4 FFP if requested for obs. +/- platelets.
Pack B = 4 XM, 4FFP, 1 platelets and 2 cryo

32
Q

How do we manage resus in arrest of pregnant people?

A

Manual displacement or 15 to 30deg from 20w.

30:2 or continuous.

Shockable: after 3 then every 2
1mg adrenaline (10mls 1:10,000)
300mg amiodarone after 3
Can give 150 after 5

Same pad position and voltage (150j)

Cannula above diaphragm due to ACC

ETT for normal CO2 4.5 - 5, may need increased minute volume

Perimortem c-section, start by 4min, out by 5.
- Vertical incision.
- over 20w

33
Q

How do we manage magnesium sulphate overdose?

What are the signs and symptoms?

A

10ml, 10% calcium gluconate and ALS

Can be caused by AKI as renally excreted

Causes: uterine relaxation, hypotension, reduced RR, reduced muscle power, reduced reflexes, prolonged PR and wide QRS

34
Q

How do we manage severe PET/seizure?

A

4g slow IV mg
- over 10m, use pump

Then 1g/h until delivered

(4.1mmol per gram)

35
Q

What are the most common organisms in obstetric sepsis?

When should we consider this?

A

GAS or ecoli

Consider in: unexplained pain, sob, multiple non-specific issues
Always check ENT

36
Q

What is the resus fluid volume in sepsis?

A

30ml/kg if hypotension or lactate over 4

Maternity (8 decks)

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