Emergencies Flashcards
Cervical Shock
Danger – check legs not about to fall on you
Response – none
Send for help – This is a medical emergency, press the emergency bell and request immediate 777 call
Elevate legs
Airway – Jaw thrust, gudelle
Breathing - breathing
Circulation – bradycardic HR 40 100/60
Despite initial resuscitative measure of above remains profoundly bradycardic and does not regain consciousness 2min later. HR 30.
Request and apply AED
IV access
Atropine 300-600mcg IV
Eclampsia
Eclamptic seizure
Communication
Its an obstetric emergency
Call for help (Physicians, SMO, and charge midwife and other staff midvives, neonatologist)
Delegate the tasks
Communicate with the staff member to obtain a brief history
Vitals noted BP, PR, O2 SATURATION, and R/R
Evaluate A left lateral position
B Administer high flow oxygen (after the seizure)
C Ensure 2 large i/v canula take bloods FBC, Group and hold, Urates, Liver function test
Loading dose of MGSO4 4 MG I/V over 20 min
If unable to establish circulation then give MGSO4 intramuscular (2gm each buttock i.m)
Treat high blood pressure if blood pressure is elevated
Assess fetal wellbeing with CTG OR BED SIDE USS
IDC insertion with hourly bag take MSU and send for urea protein creatinine ratio
Then maintenance dose of MGSO4 1GM /HR for at least 24 HOURS or continue till 24 hours of delivery
Recurrent seizure Magnesium sulphate 2g bolus over 5 minutes
Transfer to HDU/ICU for close monitoring
Delivery within 24 hours (mode of delivery will depend on the favourability of cervix
Debrief, document
Postnatal F/U and discussion of future pregnancy and cardiovascular risks
Acute Asthma
Severe or life-threatening Asthma
Call for help – Medical emergency.
Assess severity:
HR, RR, Sp02, ability to talk, PEFR, signs of hypoxaemia
Severe = Sp02 90-94%, breathless, increased WOB, unable to talk in sentences
Life threatening = SpO2 < 90%, drowsy, cyanotic, silent chest, poor respiratory effort, collapsed
Commence treatment:
Administer oxygen to keep Sp02 92-95%
Administer salbutamol - 5mg neb for severe or salbutamol 12 puff via spacer q20min x 3
10mg neb for life-threatening, run back to back until improve
Remove known triggers where able ie foods, medications, cold
Obtain IV access
Reassess severity:
If ongoing poor response, add ipratropium bromide
500mcg neb or 8 puffs via spacer q20 min x 3
If ongoing poor response, add magnesium sulphate 10mmol IV over 20 minutes
If ongoing poor response, consider salbutamol IV infusion à in a ICU setting only
200mcg/1 minute loading then 5mcg/minute maintenance
Cardiac monitoring, regular lactates, potassium levels
Beware salbutamol toxicity!
Administer corticosteroids < 1 hour – 100mg IV hydrocortisone Q6H or 50mg prednisone if rapidly stabilises
If ongoing poor response, Non invasive PPV or intubate and venitilate
Can also consider adrenaline 0.5mg IM as some asthma is triggered by a food allergy
Observe at least 1 hour after resolution of acute attack prior to transfer home/ward etc
If stabilises, write asthma action plan, arrange GP follow up, review inhaler technique, consider commencing on regular corticosteroid inhaler, and send home with 5 days oral prednisone
Shoulder dystocia
Emergency – Shoulder Dystocia
Aim – deliver the fetus as fast as possible using set manouvers
This is an obstetric-neonatal emergency.
I am pushing the emergency bell to summon help
Senior anaesthetist
Senior obstetrician
Senior midwife
Senior neonatologist
I am placing the woman flat on her back with “Knees to nipples” McRoberts position to open the pelvis. I am encouraging the woman to bear down and attempt tot deliver the baby
I am then performing supra-pubic pressure (Rubin 1), applying pressure downwards and lareral, using a rocking motion, over the fetal back and just above the pubic bone to slip the anterior fetal shoulder under the pubic arch.
I am assessing for and performing an episiotomy to aid access for internal manouvers
I am performing internal manouvers to reduce the bisacromial diameter of the fetus. I am moving the woman to the edge of the bed to facilitate access. I am placing my whole hand into the vagina, via posterior access along the sacral hollow.
Rubin 2 maneuver
Applying pressure to posterior aspect of anterior shoulder, pushing shoulder to anterior chest
Woodscrew
Along with Rubin 2, Insert second hand into vagina, apply pressure to anterior aspect of posterior shoulder
Reverse Woodscrew
Hands switch position; pressure on anterior aspect of anterior arm and posterior aspect of posterior arm
Posterior arm
I am attempting to grasp the fetal wrist, gently easing the arm over the fetal face and reducing the diameter of the shoulders
I am rotating the woman onto all fours and repeating the internal manouvers
I am instructing the team to rotate through each performing the manouvers
I am breaking the fetal clavicle to aid delivery
I am moving the woman to caesarean theatre as a category one procedure, to perform a Zavanelli manouvere
With administration of uterine relaxants, I am flexing the fetal head and replacing it back into the vagina, pushing up as far as possible. I am then performing an emergency caesarean section to deliver the fetus abdominally
The woman should then be watched closely for signs of PPH
The baby should be carefully reviewed by a neonatologist, looking for signs if asphyxia, brachial plexus injury and fractured clavicle
The woman her family and involved medical staff should be offered full debrief at an appropriate time
neonatal resuscitation
Emergency – Neonatal resuscitation
I am pressing the emergency button and summoning
Senior neonatologist
Senior midwife
Neonatal nurses
I am wrapping the baby in a warmed towel, stimulating the baby and carrying to the resuscitaire, placing the baby on its back with head towards mysele.
I am removing the wet towel, keeping the baby under the heatlamps and will wrap a warm towel around as much of the baby as possible while resuscitation takes place.
I am assessing the babys tone, colour and breathing/airway in the “sniffing roses” position.
I am assessing the heart rate, either by auscultation/brachial pulse or sats probe.
If HR<100, gasping or apneic, I am rechecking airway and applying Positive Pressure ventilation (40-60/min) while the Sats probe is applied.
If the heart rate remains below 100, I am increasing the oxygen to 100% and checking for leaks
If the heart rate is below 60 after 30sec I am commencing chest compressions rate 3:1, encircling the chest with thumbs superimposed over lower third sternum.
I am ensuring 100% oxygen.
I am considering placing an LMA or intubating baby.
I am considering venous access, adrenaline 0.1-0.3mL/kg 1:10,000) (0.3mL to 0.9mL in 3kg infant)
PPH
PPH
It’s an obstetric emergency
Call for help (MDT including SMO, anaesthetist, senior and staff midwives, Alert haematology and transfusion specialist and orderly)
Consider ABC if unconscious
Administer O2 by mask
Vital BP, pulse rate, Respiratory rate, o2 saturation, temperature (every 5 min through automated machine)
2 i/v bore cannula start I/V fluids, withdraw bloods FBC, coagulation profile, Group and hold and cross match, urea and creatinine
In the delivery room
Determine the cause of bleeding 4 Ts (Tone, trauma, Tissue, coagulation disorder)
If atony then
Continue uterine compression, and uterine massage
Ensure Synto bolus (5 units I/V) given, Syntometrine (5u synto +500 mg ergometrine) if no contraindications
Start Synto infusion 40 units IN 500 mls 0.9 % saline I/V 125 mls over an hour
Consider carboprost 250ug intramuscular upto 8 doses
IDC with hourly urine bag (commence fluid balance chart)
Start preparing for theatre if bleeding continue(>1500 mls)
Inform anaesthetist Cross match 4 units of blood (or o neg blood)
Consent Bleeding, infection, risk of hysterectomy
Inform intervention radiologist if available on site
Operation EUA +management of PPH and proceed
Assess for perineal trauma vaginal laceration and cervical lacerations
Check the uterine cavity is empty
Review the coagulation profile
Activate the massive transfusion protocol if ongoing heavy bleeding
Consider Insertion of Bakri balloon
Laparotomy with B Lynch Suture
Internal artery ligation /embolization
Uterine artery ligation /embolization
Hysterectomy
Post op
Document
Debrief
APH
Massive APH
It’s an obstetric emergency
Call for help (SMO, Charge midwife, staff midwives, anaesthetist, paeds)
Inform haematologist in case of developing DIC
Communicate obtain a brief history regarding the circumstance, estimation of blood loss colour pain quantity, gestational age, prior USS to know about the placental location , Evaluate ABC assessment
Airway
Breathing high flow oxygen
Circulation Blood pressure, pulse rate, o2 saturation +/- CVP/arterial lines
2 i/v bore cannula, i/v fluids, bloods FBC, group and hold and antibody screening, coagulation profile, Keilhauer
Assessment vitals abdominal findings tense? Tender? SFH, presenting part, fetal heart, CTG
If painless bleeding consider Placenta previa and if tense tender abdomen with pain consider abruption
P/S assessment of blood loss, os open dilatation, any SROM
Betamethasone, MG SO4 if premature baby
Replace circulating volume /blood and blood products
Inform theatre (in case of needing a c section for maternal or fetal indication), cross match 4 units
Severe HTN in pregnancy
Severe HTN (PET) BP >/=170/110
Call for help: obstetrician, senior midwife, anaesthetics
ABC
2x IVL and take bloods (FBC, G&H, UEC, LFTs, urate, coags) + PCR
Treat HTN:
10mg po Nifedipine OR
20-80mg IV labetalol OR
Hydralazine 5-10mg with 250ml bolus
BPs Q15 mins and continuous sats
Continuous CTG
If persistent, admit to obstetric HDU, ART line and consider labetalol infusion
Consider MgSO4
Fluid balance + IDC
Once BP stable plan delivery
Postpartum antihypertensive, admission for 3-4 days, BP check at 6 weeks
Postpartum document, debrief, discuss breastfeeding and contraception, anti-D, postnatal depression
Uterine inversion
This is an obstetric emergency
Want: experienced midwives, experienced obstetrician, anaesthetist, theatre being prepared, orderly
Concurrently resuscitate and replace the prolapse: obs, IV access + bloods, 2L crystalloid, blood bank (MTP)
Stop syntocinon
Do not remove the placenta
Immediately attempt to manually replace the uterus:
Place the palm of the hand on the most dependent part and the fingers on the cervix
Push upwards with the palm and fingers and replace the prolapse into the vagina
Then make a fist to push up the fundus back to the correct position
If this is unsuccessful, then consider the use of a uterotonic (GTN or terbutaline) to aid in replacement
Attempt manual replacement again
If this is unsuccessful, then proceed to theatre
If delay to theatre: (O’Sullivan’s)
Reverse trendelenberg lithotomy
Hang a bag of warmed fluid above the patient
Let the water flow into the vagina with gravity or with light pressure by connecting the fluid to a silastic ventouse cup in the vagina
In theatre:
Attempt to manually replace whilst preparing for laparotomy
Huntington procedure: place two clamps on the round ligaments entering the cup and gently pull up (ideally with an assistant’s hand also in the vagina)
Haultain procedure: incise the posterior uterus to bisect the constriction ring and allow correction manually or with Huntington’s procedure
Once everted, manually remove the placenta
Give ecbolics and continue to manage PPH
Post-op: document, debrief, DVT prophylaxis, anti-D, postnatal depression
Transfusion reaction
Suspect when: fever, chills, pruritis, urticaria, resp distress, LOC, hypo/hyperTN, flank/back pain, jaundice, abnormal bleeding, oligo/anuria, bleeding from IV sites
Several things will happen simultaneously but for the purposes of this examination I will state them sequentially
Immediately stop the transfusion and set aside the blood and tubing
Given stat normal saline to maintain the IVL and hydrate aggressively
Review: the name band of the patient, the record on the blood bag and the type of blood of the patient and on the blood bag
Notify the blood bank
Assess: symptoms, signs of anaphylaxis, patient obs
Ix: CXR, FBC, repeat G&H, urine dipstick, haemolysis screen, UEC, LFTs, coags, tryptase, CRP, coombs test
Repeat ABO testing on the blood in the lab
If anaphylaxis is present, call a code and give 0.5mls of 1:1000 adrenaline IM, consider the use of bronchodilators, antihistamines and steroids
In a suspected septic reaction call ID and give broad spectrum antibiotics
Complete incident form
After incident: debrief, document, arrange follow-up
Pueperal sepsis
Call for help: code team, anaesthetics, ICU, med reg, orderly, midwives, ICU nurse
A: patent
B: give O2 if hypoxic, auscultate chest +/- ABG
C: check BP/pulse, IVL x2 and bloods (FBC, G&H, UEC, LFTs, coags, venous lactate, blood cultures x2)
IV fluid resuscitation
Top to toe assessment of patient for source
Prompt broad spectrum antibiotics that cover common causes of sepsis
Endometritis: clindamycin and gent gold standard
Pneumonia: cefuroxime
UTI: amoxiclav +/- gent
Mastitis: flucloxacillin
Chorioamnionitis: cefuroxime + metronidazole and deliver
Septic screen: MSU, CXR, high vaginal swabs, throat swab, NPA, USS (?RPOC)
Analgesia
Insert IDC and keep strict fluid balance
ICU review
Document, debrief, DVT prophylaxis
Entrapped head at CS
This is an emergency
Inform anaesthetist and theatre team
Pre-op
Fetal pillow
Manually elevate baby up vagina
Bed as low as possible, stand on stool
Intra-op
Ensure good access with reflection of bladder
High lower segment incision, consider T or J incision
Constant pressure to elevate head out of pelvis, keep wrist straight, don’t use uterus as fulcrum
Change from dominant to non-dominant hand to assist in flexing head
Manually elevate baby up vagina from assistant, use all 5 fingers of hand and flex baby’s head
Shoulder traction
Uterine relaxant (terbutaline or GTN)
Trendelenburg position
Reverse breech extraction
Forceps of aftercoming head
Hand baby to paeds for resus
Active mgmt. 3rd stage
Expect atonic PPH
Continue with Caesaean section closure
Cord bloods
Post-op: document, debrief (future CS if done T incision etc), DVT prophylaxis, discuss breastfeeding and contraception, anti-D, postnatal depression, follow-up 6/52
Transverse back down at CS
This is an emergency
Inform anaesthetist and theatre team
If membranes intact, intra-abdominal version before hysterotomy, doesn’t matter which pole presents but get it to longitudinal
If membranes ruptured, consider classical or vertical upper uterine incision, ensure long enough incision to reach feet which will be in upper uterus
Consider tocolytic
Find a foot and delivery by breech extraction
Hand baby to paeds for resus
Active mgmt. 3rd stage
Expect atonic PPH
Continue with Caesaean section closure
Cord bloods
Post-op: document, debrief (future CS if done classical incision), DVT prophylaxis, discuss breastfeeding and contraception, anti-D, postnatal depression, follow-up 6/52
Bakri balloon
Bakri balloon
After vaginal delivery
For transvaginal placement following vaginal delivery, the following steps should be considered:
Before insertion the balloon, ensure that the bladder is empty by placing a Foley catheter.
Inspection of the uterine cavity should be made to ascertain that the uterine cavity is clear of placental fragments.
The cervix and vagina should be cleansed with an antiseptic solution, such as povidone iodine.
Grasp the cervix with ring forceps. Insert the balloon into the cavity of the uterus under ultrasound guidance, making sure that the entire portion of the balloon passes the cervical canal above the internal cervical os. This can be also achieved by manual insertion of the catheter similar to insertion of an intrauterine pressure catheter.
Once the correct placement is confirmed, inflate the balloon with sterile saline using the enclosed syringe. The recommended maximum capacity of the balloon is 500 mL
In order to maximize the effect of tamponade most notable to the lower uterine segment, apply gentle traction to the shaft of the balloon. This can be achieved and maintained by securing the balloon shaft to the patient leg or attaching to a weight, not to exceed 500 grams.
Connect the drainage port to a fluid collecting bag to monitor hemostasis.
Monitor patient continuously for signs of increased bleeding and uterine cramping.
After cesarean section
At laparotomy following a cesarean section, the following specific steps should be considered:
Insert the end of the catheter through the open uterine incision to the cervix and then into the vagina.
Close the uterine incision while taking special care not to damage the balloon by the suturing needle.
Insufflate the balloon under direct visualization.
This may potentially result in balloon failure secondary to incidental puncture of the balloon by the needle. An alternative approach is to close the uterus first and then insert the balloon from the vagina and inflate it while the surgeon watches from above.
Post op Care
Admit HDU/ICU
Tamponade test positive continue with Bakri Balloon, if negative consider further measures to stop the bleeding
Consider broad spectrum antibiotic prophylaxis while the balloon is in place.
Continue use of oxytocin infusion for six to eight hours to prevent uterine atony
Analgesia
Thromboprophylaxis
Breast feeding /express feeding
Monitor for signs and symptoms of ongoing blood loss, such as pallor, dizziness, hypotension, tachycardia, confusion, uterine enlargement, abdominal pain, abdominal distension, and oliguria.
Blood transfusion(s) and/or blood products should be given, as needed, to correct prior deficits.
The balloon catheter can be removed can be removed as early as 2 hours.It can be left for as long as 24 hours.
To remove the balloon, it is deflated, either all at once or gradually over several hours, while monitoring the patient for recurrent bleeding.
The deflated balloon can be left in situ for 30 minutes to observe for any bleeding and withdrawn once the absence of bleeding is confirmed.
B lynch Suture
B lynch suture is applied in order to control the PPH due to atony following PPH.
It is a vertical compression brace suture.
Benefits Control pph prevents hysterectomy
Risks Injury to surrounding structures ,not able to control the bleeding ,infection ,DVT ,thromboembolism
This would be done as part of the management of pph in theatre
The following steps are involved in competent application of the B-Lynch suturing technique:
The patient is catheterized under general anaesthesia and placed in the dorsal lithotomy (Lloyd Davis) position for access to the vagina and to assess objectively the control of bleeding by swabbing.
The abdomen is opened by an appropriate sized Pfannenstiel incision or, if the patient has had a cesarean section after which she bled, the same incision is re-opened.
On entering the abdomen, either a lower segment incision is made after dissecting of the bladder or the sutures of the recent cesarean section are removed and the uterine cavity entered. The uterine cavity is evacuated, examined and swabbed out.(don’t forget as they have marks for it ).
The uterus is exteriorized and rechecked to identify any bleeding point, which might be controlled with a figure-eight suture. If no obvious bleeding point is observed, then bi-manual compression is first tried, to assess the potential chance of success of a B-Lynch suture. At the same time, the vagina is swabbed out by an assistant to confirm adequate control of bleeding.
If vaginal bleeding is controlled, for a left-handed surgeon or a surgeon electing to stand on the left side of the patient, the procedure is as follows:
A blunt, 70mm semicircular needle, mounted with a No. 1 Monocryl (is used to puncture the uterus 3 cm from the right lower edge of the uterine incision and 3 cm from the right lateral border
The suture is threaded through the uterine cavity to emerge at the upper incision margin 3 cm above and approximately 4 cm from the lateral border (because the uterus widens from below upwards).
The suture is now passed over to compress the uterine fundus approximately 3 to 4 cm from the right cornual border.
The suture is pulled under moderate tension, assisted by manual compression exerted by an assistant. The length of the suture is passed back posteriorly through the same surface, marking as for the right side, the suture lying horizontally
The suture is fed through posteriorly and vertically over the fundus to lie anteriorly and vertically compressing the fundus on the left side, as occurred on the right. The needle is passed in the same fashion on the left side through the uterine cavity and out approximately 3 cm anteriorly and below the lower incision margin on the left side (Figure 1).
The two lengths of suture are pulled tight, assisted by bi-manual compression to minimize trauma and to achieve or aid compression. During such compression the vagina is checked to confirm control of bleeding.
As good homeostasis is secured, and while the uterus is compressed by an assistant, the principal surgeon ties a knot (double throw) followed by two or three further knots to secure tension.
The lower transverse uterine incision is now closed in the normal fashion, in two layers, with or without closure of the lower uterine segment peritoneum.
For a major placenta praevia an independent figure-eight suture can be placed anteriorly or posteriorly – or both – prior to application of the B-Lynch suture as described above, if necessarily.
The suture should be more or less vertical and lying about 4 cm from the cornua. It does not tend to slip laterally toward the broad ligament, because the uterus has already been compressed and the suture milked through prior to tying, ensuring that proper placement is achieved and maintained. During the compression the vagina is checked to confirm that the bleeding is controlled.
Post op
Monitoring in HDU/ICU
Monitor P/V loss, urine output
Continue antibiotics
Breast feeding lactation support
Monitor fbc and start iron if necessary
Thromboprophyaxis
Follow up in GOPD at 6 weeks
Debreif and Document
Contraception
