Pre-eclampsia

[FL_Medic]

I recently competed in a scenario-based ALS competition in Temple Terrace Florida. One of the patients in the finals presented with pre-eclampsia that developed into eclampsia. As my protocol dictates, I treated the patient with Mag Sulfate once she seized. All the other competitors treated the pre-eclampsia. This was foreign to me, but once explained, made sense.

I spoke with my medical director and he asked me to present the research. We practice evidence-based medicine, so I am going to write a paper with all the sources outlined. I have access to medical research databases so that isn't a problem.

If anyone has experience with this including the fallowing, I would appreciate it.

I need sources on the fallowing:

-Current prehospital protocols

-Morbidity caused by pre-eclampsia

-Risk factors of pre-eclampsia

-Benefits of Tx

-Anything else that would support my position.

All help would be appreciated, I am of coarse open to discussion on this topic.

[spenac]

I look forward to this information as well as I am trying to help update our protocols.

[akroeze]

I really wish they would let us carry Mag Sulfate at all...

[triemal04]

It's taking the easy way out, but hey, I'm lazy. http://emedicine.medscape.com/article/796690-overview Between the info there, the references to where the info there came from (it's only abstracts, but better than nothing), and links to further info, you should be able to gain enough to start things moving. This is probably one of the more relevant abstracts although it is 10+ years old; though with this problem that shouldn't be a huge issue. http://www.medscape.com/medline/abstract/9794688 Little more current: http://www.ncbi.nlm.nih.gov/pubmed/19202042

Far as local protocols, generally in this area it's 1gm IVP for eclampsia and preeclampsia, with some services continuing with either a mag drip (total of 4gm in 20 minutes) or giving repeat 1gm doses IVP every 5 to a total of 4gm's. I don't know of any that cannot treat the problem before the pt seizes.

[wrmedic82]

This is our protocol

Eclampsia

1. Magnesium Sulfate infusion 2 Grams no faster than 1Gram/min. Mix 4cc of 50% Magnesium

Sulfate and 100cc Normal Saline in a Volutrol (60 gtts set) and infuse wide open rate. May repeat once

if seizure is still present. Monitor patellar reflexes for Magnesium toxicity and discontinue if they

appear.

a. Bend the patient’s leg to a 90° angle and tap on the patellar reflex. If the patient’s reflex

causes the leg to continually bounce, discontinue the Magnesium Sulfate infusion.

Edited April 5, 2009 by wrmedic82

[croaker260]

http://www.adaweb.net/Portals/0/Paramedics...uments/ob04.pdf

[Niftymedi911]

Why not just get the order from d7 on the radio Adam??? If that type of call presents itself, I'll be touching base with the doc at least once or twice.... might be easier just to bounce it off him and see what he thinks. Bc in all honesty how many pre-elcamptic patients do you respond to in a year, even if there was a protocol, how effective would it be?

[FL_Medic]

Why not just get the order from d7 on the radio Adam??? If that type of call presents itself, I'll be touching base with the doc at least once or twice.... might be easier just to bounce it off him and see what he thinks. Bc in all honesty how many pre-elcamptic patients do you respond to in a year, even if there was a protocol, how effective would it be?

That's a thought. With that train of thought though, why have protocols for any stable patient? We have a medical director for a reason, while I encourage the use of online medical control, it should be for unforeseen circumstances. Pre-eclampsia is pretty common has a whole. It effects at least 5-8% of all pregnancies, is responsible for 15% of premature deliveries, and 17.7% of maternal deaths per year. We practice evidence-based medicine my man, our bit of anecdotal evidence doesn't mean much. I'm always going to be an advocate of expanding our training, knowledge, and scope.

I understand where you're coming from, but there is a bigger picture. This is within our scope of practice, and would be useful if the situation presented itself. How many medics in our system would call for orders for pre-eclampsia. If not zero, close to it. They would wait, and be ready for the seizure. From the research, that is poor medicine. Not much different than waiting for a CHF patient to go apneic.

[Doczilla]

I don't think Nifty is too far off the mark here proposing that the medic contact medical control and not have this on standing order. This would be an extremely rare event for a medic to witness. I don't know that I've seen medics bring someone like this in to my hospital in the last 4 years. The disease may affect 5% of all pregnancies, but it creates a medical emergency necessitating prehospital intervention in far fewer. When adding a drug to a protocol/standing order, you've got to think about the cost in terms of medication, training, and possible errors. Can the paramedics adequately draw the line in preeclampsia between the patient who needs mag now, and the patient who can wait for it? It's not just a question of BP, but other findings as well. And unlike other disease processes, like respiratory distress, where the medic gets to build his clinical decision making skills over and over, this is an occasion that will happen very few times in his career.

I'm not saying not to have a protocol. I'm saying don't reject the idea of not having a protocol. Just because we can doesn't necessarily mean we should.

'zilla

providing your zen moment for the day

[FL_Medic]

I wasn't rejecting the idea, just stating that it isn't one that would be used. Our medics, unless told otherwise, would not contact medical control for pre-eclampsia. I know, that's a generalization, but for the most part it's true.

Severe Pre-eclampsia:

Systolic BP of 160 mm Hg or higher or diastolic BP of 110 mm Hg or higher on 2 occasions at least 6 hours apart

Proteinuria of more than 5 g in 24-hour period

Pulmonary edema

Oliguria (<400 mL in 24 h)

Persistent headaches

Epigastric pain and/or impaired liver function

Thrombocytopenia

Intrauterine growth restriction

Our protocol would focus o the BP and blurred vision, or headache.

We already carry Magnesium Sulfate. The training would take place at our monthly inservice. With over 500,000 citizens, our service is likely to see this condition a few times. Maybe not me or Nifty, but certainly a few other medics. I have no problem, as stated, with the use of medical control, if our medics were trained to use it.