Book 2, Case 1-JW, PET, TRALI, TACO

Question 1

If pt is JW, and they ask if you are concerned, then say that you are-not only because they won’t accept blood, but because of the reasons that blood loss might occur!!! for example…

Answer 1

For ex…

• repeat c section (scar tissue)
• PET (probs with hemostasis)
• TOLAC-risk of uterine rupture.

Question 2

If pt had motor and sensory loss from a previous epidural and is now scared-what are you going to do? What are alternative non regional methods of pain control for laboring women?

Answer 2

review the chart and then ask the patient for details
concerning the motor and sensory loss such as how long the deficit persisted and the
specific area( s) of sensory and motor deficit. 

Alternatives: IV narcotics, Remeifenail PCA (metabolized by plasma esterases), and inhaled nitrous ,

Question 3

What are other regional methods for pain control in laboring women? What’s the problem with these?
Nerve distribution for pain in 1st vs 2nd stage of labor

Answer 3

paracervical block-local anesthetic injected alongside vaginal portion of cervix. for
the first stage of labor and a pudendal block with simultaneous infiltration of the
perineum for the second stage of labor.

1st stage of labor pain: T10-L1
Paracervical probs: high risk of fetal bradycardia. Pts with PET are already at risk for uteroplacental insufficiency which means its a no for this pt with pet.

Pudendal block: s2-s4Through the vaginal wall and into pudendal nerve in pelvis. possible intravascular injection, retroperitonieal hematoma

Question 4

pt wants epidural but you are now too tied up and she is in pain. RN asked if she can give nalbuphine-wyd?

Answer 4

Ideally consent for any obstetric procedure would be obtained before
the patient was in severe pain or under the influence of premedication (i.e. narcotics
and/or anxiolytics ). However, recognizing that the provision of some pain relief may
enhance her ability to provide adequate consent, I would not withhold medication to
ease her suffering. Instead, I would attempt to provide adequate pain control, while at
the same time, avoiding excessive medication that may render her unable to
understand the risks and benefits associated with the planned procedure.

Question 5

If you can’t get a peripheral IV-next steps:

Answer 5

Central or IO .

Question 6

How do you place an IO line?

Answer 6

Insert it into tibia at 10-15 caudal angle (avoiding epiphyseal plate) at 1-2 cm below and 1 cm medial to the tibial tuberosity. Advance until i feel a pop. Confirm with aspiration of bone marrow. Ensure that fluids flow without signs of extravasation

Question 7

Props with IO lines

Answer 7

compartment syndrome (extravasation), osteomyelitis, growth plate injury in kids

Question 8

RSI and hypotension:

Answer 8

RSI, which carries the risk of further hemodynamic instability (secondary
to the administration of a large bolus of induction drug to rapidly obtain optimum
intubating conditions). I would, instead, administer fluids and phenylephrine to treat
her hypotension, and perform a controlled induction using etomidate.

Obvi-make your own decision but keep this in mind

Question 9

What is DIC:

Answer 9

Disseminated intravascular coagulaion: pathological activation of coagulation cascade. Widespread clotting leads to a depletion of coagulation factors-thrombocytopenia, hemolytic anemia, diffuse bleeding

Question 10

What lab work confirms diagnosis of DIC?

Answer 10

elevated PT and PTT 
Fibrinogen <100 
Thrombocytopenia 
presence of d dimer 
decreased AT3 levels

Question 11

How to tx DIC?

Answer 11

Treat underlying cause. IN addition to treating hypovolemia, hypotension, hypoxemia and acidosis (which could contribute to and exacerabate DIC-give cryo, ffp, platelets, and PRBCcs. Cryo is not always indicated, but can be helpful when fibrinogen gets to be less than 50.

Question 12

You stick yourself-what do you do?

Answer 12

immediately wash with soap and water. report to EH. Obtain consent from pt to draw additional blood to be tested for presence of blood borne disease.

Question 13

Don’t forget that pulmonary edema DDX should include ARDS, TRALI, and TACO-depending on what happened (rb ARDS can happen with massive blood transfusion also.

Answer 13

Okay

Question 14

What is TRALI?

Answer 14

Non-cardiogenic pulmonary edema that may occur within 1-6 hours folliowing transfuison of any blood product, but especailly FFP and platelets.

fever, tachy, dyspnea
PaO2/Fio2 <300
SpO2 <90
and pulmonary edema (b/l chest infiltrates on CXR) within 6 hours of transfusion IN THE ABSENCE OF CARDIAC FAILURE

Question 15

Pathophys of TRALI

Answer 15

transmission of donor leukocyte antibodies during transfusion of blood products which can case capillary leakage

Question 16

TRALI vs TACO: How can you tell them apart?

Normal BNP

Answer 16

( 1) the patient’s presenting signs and symptoms
(TRALI: normal-to-low blood pressure, fever, and transient leukopenia; TACO:
hypertension, jugular venous distention, peripheral edema, and S3 heart sound); (2)
fluid status (TRALI: usually normovolemia or hypovolemia, but can be
hypervolemic; TACO: hypervolemia); (3) cardiac function (TRALI: usually normal;
TACO: impaired); (4) brain natriuretic peptide, a polypeptide secreted from the
cardiac ventricles in response to ventricular volume expansion and/or pressure
overload (TRALI: < 200 pg/ml - some sources say < 100 pg/ml; post/pre transfusion
ration< 1.5; TACO: higher levels of BNP)

BNP: <125

Question 17

Treatment of TRALI:

Answer 17

stop any ongoing transfusions, notify blood bank, provide O2 and ventilation (low tidal volumes in intubated pts)

Question 18

Tx of TACO:

Answer 18

Consider administering a diuretic (to correct fluid overload) Finally, in the presence of compromised ventricular function, I
would consider an inotrope and/or an afterload reducing agent.