Emergencies Flashcards
Massive gynaecology bleed in ED
State emergency
Get additional help
A, B, C
2x large bore IV cannulae
CBC, coags, G&H, BhCG
Cross match 2units, consider MTP
Replace clotting factors if known deficiency
IV fluids, fluid balance, IDUC
TXA, progesterone if applicable
Focused history and exam
Emergency management:
Packing (adrenaline or TXA on the tip)
Monsells and silver nitrate if focal lesion
Consent for EUA in MOT
Oversewing with suture
Foleys balloon
Embolisation
Laparotomy, internal iliac ligation
Hysterectomy
Outline the steps taken if external iliac artery is perforated at laparoscopic port insertion
Declare emergency - to OT, anaesthetist
Send for help - vascular surgeons, senior gynaecology staff
Ensure 2x large bore IVs, IVFs
2u blood to OT, consider activating MTP
Midline laparotomy - may need to re-prep and drape
Identify injury and compress until vascular present
Consider aortic compression above injury level
IV TXA
Utilise suction and calculate blood loss, consider cell saver if can arrange emergently
Vascular repair vs bypass, consider haemostatic agents e.g. Floseal
Discontinue planned surgery and plan to defer
Close - HDU/ICU care, VTE prophylaxis, Hb, coags check, UO monitoring
Document
Debrief
ACC/ treatment injury forms
Reschedule planned surgery
Neonatal resuscitation - flat baby at birth. How do you proceed?
DRSABCs
Declare emergency - help from MW staff, neonatal
Stimulate the baby with warm towel, ensure dry
Clamp cord and bring over to resuscitaire (pre-checked)
Neutral chin position
Assess tone, respiratory effort, HR
Attach pulse oximeter to R Hand (Pre ductal)
If no response to stimulation - Neopuff or ambibag and create seal on face, start on room air FiO2 21%, IPPV rate of 40-60 per minute, watch for chest movements
If no response check seal, increase FiO2
If HR <60 commence cardiac compressions at 3:1rate, FiO2 at 100%
Prepare for intubation or LMA
Prepare for UVC, administration of adrenaline
Ensure mother attended to - monitor for PPH
Double clamp cord and take cord gasses
Document
Debrief
What is the differential diagnosis for a maternal collapse?
Hypovolaemia
* Abruption
* Uterine rupture
* APH, PPH
* Aortic dissection
* Intra-abdominal event - e.g. splenic artery aneurysm
Cardiogenic
* IHD - MI
* Cardiomyopathy
* Arrhythmia
* Toxicity - MgSO4, LA
Obstructive
* PE
* Tension pnuemothorax
* Cardiac tamponade
Distributive
* Sepsis
* Anaphylaxis
* AFE
Neurogenic
* Eclampsia
* Epilepsy
* CVA - haemorrhagic
How do you manage a maternal collapse?
DRS ABCs - declare emergency
- MDT - early involvement of senior staff and ICU, cardiac arrest team, SMO obs, SMO anaesthetist, senior midwife, neonatal if delivery likely and >22weeks
- LEFT lateral tilt or manual displacement
- Airway - support, guedel, intubate when able, bag and mask
- Breathing - High flow O2, 10 breaths per minute if intubated
- Circulation - immediate chest compressions (30:2) if airway clear and not breathing
- IV access - 2x wide bore, consider central, arterial or intraossesous if unable. Send off FBC, renal, LFTs, extended electrolytes, coags, G&H
- Warmed IVFs - caution if eclampsia, PET suspected. Fluid balance.
- Apply AED pad, follow algorithm for shockable/non shockable rhythms
- Consider causes - 4Hs, 4Ts, obstetric
- Perimortem CS if not ROSC within 4minutes
- pack once baby out
- transfer to OT if ROSC for haemostasis, closure, anticipate PPH - activate MTP, correct coagulopathy, B lynch suture, uterine artery ligation, internal artery ligation, emergency hysterectomy - Post rescuscitative cares - ICU, cardiology
- VTE prophylaxis,
- IVABx
- Debrief - patient, family, staff
- Documentation, log adverse outcome, review in M&M
- Continue efforts until decision made by SMO obstetrician and SMO anaesthetist to stop
- If death, report to coroner, PMMRC (NZ), must leave all tubes and lines in
A primiparous woman at 37weeks has presented with a headache, RUQ tenderness and swollen feet. Her urine PCR is 200 and she is hypertensive. She feels jittery and starts having a seizure. How you manage?
Declare emergency - most likely eclamptic seizure
DRSABCs
Move on to bed or flat surface, away from objects that could be injured on
HELP from MDT - obstetric SMO, midwifery, anaesthetics, neonatal, OT
Support airway in left lateral position
Apply Oxygen
Assess HR, BP
Establish IV access, take FBC, U&E, LFTs, coags, G&H
4g loading dose MgSO4 IV
Treat HTN with IV labetalol or hydralazine
CTG for fetal monitoring - prioritiy is stabilising mother
Have benzodiazepine available if not terminating- rectal diazepam, IV midazolam
IDUC, fluid balance monitoring
Consider differential diagnosis - epilepsy, ICH, intracranial lesion, infection, SLE
Cerebral imaging - MRI or CT to exclude ICH and other cause
Once stabilised plan for urgent delivery via caesarean
Prepare for PPH, avoid ergometrine
Post op care in HDU/ICU
Document
Debrief - patient, family, staff
Discuss at M&M meeting
VTE prophylaxis
Psychological support
Future pregnancy - recurrence risk
You are repairing a vaginal tear and insert a generous amount of local anaesthetic and do not calculate based on her body weight. The patient becomes unresponsive and bradycardic, you suspect local anaesthetic toxicity, how do you proceed?
Declare emergency - local anaesthetic toxicity
DRSABCs
Move sharps away
HELP from MDT - obstetric SMO, midwifery, anaesthetics,
Support airway - chin lift, jawthrust, Guedel
Apply Oxygen
Assess HR, BP
Apply defibulator pads
Establish IV access, take FBC, U&E, LFTs, coags, G&H
IV fluid bolus
Administer intralipid 1.5mg/kg bolus then infusion to follow
Repair tear if bleeding, otherwise apply pressure and preferentially stabilise
Document
Debrief - patient, family, staff
Register as serious event, review at M&M
You are performing an ERPOC and the anaesthetist advises you the patient is extremely bradycardic. You suspect cervical shock. How do you proceed?
Declare emergency - cervical shock
DRSABCs
Send for help - extra staff
Airway and breathing (anaesthetics)
Ensure adequate IV access, check valid G&H
IV Fluids
Elevate legs
Remove stimuli from cervix - instruments, sution catheter, check no POC sitting in os
Attach defib pads
Administer IV atropine if HR not improving
Document - problem, how it was resolved, any anticipated complications
Debrief - patient, family, staff
Pre-empt if needs any further cervical instrumentation
You are called to ED to manage a 34week pregnant woman who has been involved in a high speed MVA. How do you proceed?
- ABCs
- Involve MDT - Obs, ED, anaesthetics, gen surg, ortho, neonates
- Be mindful of C spine
- Utilise a wedge under R side
- Airway adjuncts - jawthrust, guedel
- High flow O2
- 2x wide bore IV lines - CBC, Cr, coags, G&H, kleihauer
- Warmed IVFs
- Xmatch 2units RBCs
- Attach defib pads if needed
- USS - placenta, fetus, FAST
- Later a secondary survey - CT acceptable as need information about injuries
- Corticosteroids for fetal protection if needed
- If unstable - may need laparotomy +/- CS
- Check Rh status - anti-D if negative, may need to dose adjust if FMH
- If stable, CTG for 4hours after event
- DV screen
- Tetanus vaccine
- VTE prophylaxis
- Delayed follow up and delivery planning, consider safety of VB, consult with orthopaedics if boney trauma, consider complexity of CS,
How do you manage the deeply impacted head at CS?
- Prevention/preparation prior - VE for station, fetal position. Insert fetal pillow. High incision on uterus.
- Declare the emergency
- Call for help - senior obstetric member, ensure senior paediatric support
- Watch the clock, document timing
- Optimise my position - use a step, take tilt off
- Extend skin, rectus sheath, rectus muscle
- Tocolysis - GTN (prepare for bleeding)
- Trial with left hand to get under fetal occiput
- Take care not to overflex wrist, ensure fetal occiput cupped in hand - limit maternal and fetal injury
- Apply upwards pressure and flexion on the fetal head by an experienced operator
- Extend uterine incision to inverted T or J
- Reverse breech extraction, or delivery of the torso
- Afterwards - prepare for PPH
How do you manage a uterine rupture?
MDT
Recruit adequate assistance - 2nd SMO, GONC, urology if urinary tract involved
Grasp edges with Green Armytages or sponge forceps
Oppose edges with vicryl (or monocryl as tears through less)
Weigh blood loss
Administer ecbolics
Administer TXA
Next measures include uterine artery ligation (O’Leary Stitch), internal miliac ligation, hysterectomy
Document
Debrief
VTE prophylaxis
Future pregnancy - not for VBAC, communicate location for placental check as higher risk accreta
You review a woman post partum who is having a PPH, EBL 2000mL and ongoing. How do you manage?
Simultaneously assess, arrest, resuscitate and communicate
Declare emergency
Call for help
DRs ABCs
2x wide bore IV lines
FBC, Cr, coags, G&H
Request 2units blood (o-ve if none Xmatched), prepare for MTP if ongoing
Warmed IVFs
Assess - perineum, placenta, tone, VE to check no inversion
Arrest - fundal rub and bimanual compression, ecbolics - oxytocin bolus, infusion over 4hours, syntometrine, carboprost 250mcg every 15mins 2g max, misprostol 800mcg PR, TXA 1g IV, repeat in 30mins if need
IDUC, fluid balance
Avoid hypothermia - Bair hugger
If ongoing bleeding plan for EUA in OT
Options in OT - Bakiri balloon, laparotomy, B lynch suture, internal iliiac ligation, hysterectomy
IR for uterine artery embolisation if available
Ensure loss is weighed for accuracy
Care in HDU/ICU
Document
Debrief
VTE prophylaxis
Consider need for Fe
Breastfeeding support
Contraception
You are called to a delivery of a diabetic primip who has an LGA baby. The head is very slow to deliver and you anticipate a shoulder dystocia. How do you manage?
Declare emergency
Call for help
Watch to clock, state manouvres and times for accurate documentation
Flatten bed, legs into McRoberts
Ascertain side of fetal back and apply suprapubic pressure
Evaluate for episiotomy to facilitate internal manouvers
Take care to avoid excessive downwards traction
Internal manouvers
- Rubin II: Rotate anterior shoulder around
- Wood’s screw: rotation of both fetal shoulders, posterior to anterior shoulder and anterior to posterior shoulder
- Reverse wood’s screw: opposite way to above
- Axillary traction of posterior arm
- Delivery of posterior arm by grasping hand, bring infront of fetal face
Roll on to all fours
Other measures
- cleidotomy (break fetal clavicle)
- symphysiotomy
- Zavanelli manouvre (replace fetal head vaginally and perform CS)
Take note of which arm is anterior
Immediate cord clamping
Prepare for PPH
Careful inspection of perineum
Document
Debrief
Discuss future pregnancy complications
Uterine inversion
Declare emergency
Replace uterus
* Physical reduction
* Hydrostatic reduction with fluid in vagina,
* OT for EUA
* Laparotomy - grasp round ligaments sequentially (Huntington’s) or if constriction ring incise ring in posterior uterus (Haltain’s)
*
Tocolytics
Remove placenta via MROP
THEN ecbolics as risk of PPH
