Module 8: Part 3 (47-69) Flashcards
Two thirds of the primary headaches are ____ and ___
tension-type and migraines
___ ____ are often circumferential and constricting, a/w scalp tenderness and mild to moderate in severity
Tension type
usually pulsating in a unilateral location, nausea and photophobia, aura possible & often history of this type of headache
migraine headaches
type of HA where its musculoskeletal &worsened by maternal physical exertion during labor and lack of sleep
Secondary HA
Neck and shoulder pain without HX of dural puncture
Secondary HA
Headache is a serious premonitory sign in over 50% of women who develop ___
eclampsia (headache, visual disturbances, n/V, seizures, stupor and coma)
variable signs but can have evidence of increased ICP (headaches, somnolence, vomiting, confusion) and focal abnormalities
subdural hematoma
classic presentation with sudden onset of severe headache, decreased LOC
Subarachnoid hemorrhage
Pneumocephalus: (3)
INJECTION OF AIR INTO THE SUBDURAL OR SUBARACHNOID SPACE
ASSOCIATED WITH SUDDEN ONSET OF SEVERE HEADACHE, SOMETIMES NECK PAIN, BACK PAIN OR CHANGES IN MENTAL STATUS
CAN MIMIC PDPH BUT USUALLY RESOLVES IN 1 WEEK
Caffeine Withdrawal & Lactation headache
secondary HA
PDPH procedural risks (4)
Gauge of needle (25 vs 17 g tuohy)
Pencil point vs. cutting (Quincke)
Orientation of the bevel (parallel to long axis decreased PDPH by 70% compared to perpendicular orientation)
Loss of resistance technique (air or saline)
PDPH patient risks (6)
Young age
Female
Low BMI ?
Vaginal > cesarean delivery
Prior history of headache
Previous history of PDPH
ICHD-3 definition of PDPH
(6)
Headache occurring within 5 days of lumbar puncture caused by a CSF leak through the dural puncture
Can occur immediately or within minutes of moving to an upright position (sitting or standing)
Resolves within a minute of moving to the supine position
Has one of the following symptoms: headache, neck stiffness, tinnitus, photophobia or nausea
Hearing loss (can improve within an hours of epidural blood patch)
Usually remits spontaneously within 2 weeks or after an autologous blood patch
Pathophysiology of PDPH
Continued Leak of CSF from intracranial compartment d/t dural puncture (loss > production)
Loss of cushioning effect of CSF causes brain to sag &creates tension on pain sensitive meninges (most apparent in the upright position)
Loss of CSF causes intracranial hypotension which leads to Reflex cerebral vasodilation
Cerebral hyperemia
Headache symptoms
downsides of PDPH (5)
Inability to care for the newborn/Inability to get out of bed
Repeat hospitalization
Need to have a blood patch, Inconvenience, Cost
Diplopia or hearing loss an be permanent or take months to recover
Persistent headaches, backaches and cranial nerve symptoms
PDPH TX (7)
Main goal Should be the prevention of PDPH
Talk to the patient
Conservative: Bed rest, hydration, abdominal binder, caffeine (oral or parenteral)
Medications: muscle relaxants and pain meds, gabapentin
Leaving the intrathecal catheter in for 24 hours may dec. epidural patch use (catheter acts to block the hole and decrease of csf)
Saline, morphine
Prophylactic blood patch, early (within 24 hours) or late (after 24 hours)
Epidural blood patch
Treatment of choice especially if cranial symptoms
injected blood becomes a small epidural hematoma that decreases the pressure gradient and the rate of CSF leak from the intrathecal space
Blood increases lumbar CSF pressure, restores intracranial CSF pressure and possibly reflex cerebral vasoconstriction
percentage of pts that get good relief with epidural blood patch for PDPH
70%
epidural blood patch risks
Risks are the same as epidural plus low back pain/hip pain
epidural blood patch complications
Infection
Neurologic :Lumbovertebral syndrome, arachnoiditis, radicular back pain;
Compressive complications (lumbovertebral, subdural hematoma, cauda equina)
Patient should stay in the supine position after blood patch for how long?
for 1-2 hours, also avoiding Valsalva and heavy lifting
Most patients will get almost immediate relief, some delayed up to ___hours
May continue to have neck pressure, back pain/pressure or hours to days
Second blood patch after 24 hours if not relieved may need neuro consult
Second blood patch after ___ hours , if not relieved may need neuro consult
24 hrs
Trauma affects __-___% of pregnancies
5-7%
___-____% of all maternal deaths in US due to trauma
Leading cause of non-obstetric maternal and fetal mortality
45-50%
Most common causes of trauma in pregnancy
MVA (most common cause of injury-related death) 49-70%
Domestic violence 11-25%
Falls 9-23%
risk factors for trauma in pregnancy
: younger than 25 years old, low socioeconomic status, minority, drugs and alcohol, domestic violence
Hemorrhagic shock and brain injury are the most common mechanisms of ___ in pregnant trauma patients
death
Obstetric injuries
placental abruption, uterine rupture, preterm labor and direct fetal injury
Blunt trauma is ___ times more common than penetrating
10
Maternal and fetal mortality higher in this type of trauma
penetrating
ATLS in pregnancy
the best initial treatment for the fetus is the provision of optimum resuscitation of the mother and early assessment of the fetus
ATLS survey (8)
Maternal airway/cspine
Breathing/PaCO2 /oxygen
Circulation (LUD, physiologic anemia of pregnancy, hypotension and tachycardia are late signs of hemorrhage in pregnant women)
Focused abdominal sonography in trauma (FAST)
Brief exam for fractures
Fluid resuscitation
Damage control
Deadly triad
Lab tests for ATLS
Evaluation driven by type and severity of injury/trauma
Coagulation, type/screen/cross, electrolytes, blood glucose, lactate levels, toxicology screens
Kleihauer-Betke test
Fetal-maternal hemorrhage
Complication in up to 50% of maternal traumas
Fetal-maternal (trans-placental) hemorrhage can occur after trauma and result in maternal isoimmunization
Rh negative mom and Rh positive fetus
Rh incompatibility (later pregnancies)
The deadly Triad
hypothermia, metabolic acidosis, and coagulopathy
Cardiac Arrest in Pregnancy (6)
CPR
Large bore IVs in the upper extremities
Difficult airway, LUD
Stop Magnesium and give Calcium
Defib: remove fetal monitor
No circulation within 4 min of cardiac arrest, cesarean if >20 weeks within 5 min of arrest
Continue resuscitation after cesarean delivery
Mnemonic for Causes of Maternal Collapse - BEAU-CHOPS
Bleeding/DIC
Embolism (coronary, pulmonary, amniotic fluid)
Anesthetic complications
Uterine atony
Cardiac disease (MI, ischemia, aortic dissection, cardiomyopathy)
HTN/pre-e/eclampsia
Other: ACLS algorithms
Placental abruption/previa
Sepsis
Peri-Mortem Cesarean delivery
Delivery of fetus allows for more blood to be diverted to the mother
Decompress the IVC
Improve efficacy of chest compressions
Initiate cesarean section 4 min into resuscitation
