Scenario # 1 Headache

[BushyFromOz]

Great start Mike and right on the money, although without a UA and protein etc its may just be considered PIH (pregnancy induced hypertension) <<<<<-----SNIP----->>>>>

In regards to the BP are you more concerned with the systolic of 172 or the MAP of 132? (MAP = SYS + DIA x 2 divided by 3), every system is different and our program focuses on the MAP instead of the systolic

All of them

third trimester, systolic and diastolic hypertensiion and/or elevated MAP with the visual disturbance and the eripheral oedama has me interested. If this were hypertension and headache i would be a bit less concerned but it wouldn't change my destination.

Ill draw up some midazolam .01 mg/kg, pop in a line, sit hr legs dependant. 02 if needed.

What's her lung auscultation?

Accessory mucle use?

Oedema anywhere else?

How long has the oedema been present?

Has she had nocturnal dyspnoea?

Are her urinary habits normal? or has she had retention?

The oedema and tenderness in all quadrants is interesting, i wonder if her liver +/- kidneys are crapping out and she is overloaded (ascites etc). Whoever said the foetal death, peritonitis has given me some real food for thought

Edited May 8, 2012 by BushyFromOz

[DFIB]

She needs the higher level hospital with maternal services.

[jinx1764]

Hey Jinx, I emailed a friend of mine to see how he arranges ceu online for people, more to follow. Very good thoughts also, non stimulating transport very smart idea. In regards to the BP are you more concerned with the systolic of 172 or the MAP of 132? (MAP = SYS + DIA x 2 divided by 3), every system is different and our program focuses on the MAP instead of the systolic

Awesome, CE is always appreciated! I was talking mainly systolic but MAP is higher (since our system doesn't focus on MAP which is ironic - we're 30-60 from the Houston medical center but overall our standing orders are conservative which has been a long term compliant with us older medics. Our available meds to admin. are limited. No labetol or verapamil. Which is the main reason I suggested the low stress transport. When your tool box is limited, you get very creative on treating your patients to gain a physical benefit/reaction. It's not always about giving meds, sometimes altering the physical environment goes a long way for pre-hospital treatment, especially when diagnoses are in doubt.

[Inthecity]

I am not a paramedic but all of her symptoms sound so much like mine when I had pre eclampsia/HELLP syndrome. I was admitted to the hospital and given magnesium and labor was induced. When that failed I had an emergency c section.

[Asysin2leads]

Pre-eclampsia, I'd say. Take the ride nice and easy, no lights, no sirens, to the woman's hospital. Make very clear that if deterioration occurs, you might have to divert to the closest ER. It's a bit of a sticky situation. I would be hard pressed to justify allowing symptomatic hypertension to continue unabated for the 45 minute ride. On the other hand, there is a danger in any of the treatment modalities. Nitroglycerin can be associated with hypotension and fetal hypoxemia in pregnant females. Benzodiazepines should be approached very gingerly, as they can be associated with teratogenic effects. Some of them, such as quazepam and temazepam have even wound up in Category X for pregnancy risk.

Magnesium Sulfate works well for eclamptic seizures, but I'm not sure of how much effect it will have on the BP and the symptomatic effects it is causing. It's not ethical to transport someone with 9/10 on the pain scale for 45 minutes, so, according to the literature I've read, the best bet may be a bolus of morphine sulfate for the ride. Morphine is listed as class C for pregnancy risk, which means that it should only be administered if the benefit to the patient outweighs the risk to the fetus. I personally would be comfortable in saying alleviating the pain is justifiable considering the relatively low risk to the fetus.

The case is hard because the patient is just sick enough to warrant an intervention. If she was seizing it would be easy to figure out what to do, but she isn't.

[Kiwiology]

Maternal hypertension with pre-eclampsia although a DDX would be a neurogenic cause e.g. sub arachnoid haemmorhage or a stroke but this is unlikely

She needs to go to a major hospital with OB/gynae capability without delay; put a drip in and give some analgesia, get her out the house and get some wheels moving

My assessment of her is status 1 or immediately life threatening problem

There is no role for a helicopter

Edited May 8, 2012 by Kiwiology

[flightmedic608]

Ah. We shared one of your BKs for a while. Thought that might've been it.

I thought about med availability after I posted. Most of the local services here have labetolol on their ambulances. They don't, however, have hydralazine. If available, verapamil may also be an option.

With med administration keep an eye out for dropping the BP too quickly (especially if giving both labetolol and mag), respiratory depression and pay attention to the monitor for rhythm changes.

Hey Mike what program do you work for? Yes Labetolol is one of the first line drugs given in an OB case like this, some OB protocols are based on a 20, 40, 60 mg escalating dose until BP is under control. This is an interesting case in regards to what each EMS has available and how they are allowed to practice with it.. Resp depression and hyptotension two concerns, as well as DTRs

All of them

third trimester, systolic and diastolic hypertensiion and/or elevated MAP with the visual disturbance and the eripheral oedama has me interested. If this were hypertension and headache i would be a bit less concerned but it wouldn't change my destination.

Ill draw up some midazolam .01 mg/kg, pop in a line, sit hr legs dependant. 02 if needed.

What's her lung auscultation?

Accessory mucle use?

Oedema anywhere else?

How long has the oedema been present?

Has she had nocturnal dyspnoea?

Are her urinary habits normal? or has she had retention?

The oedema and tenderness in all quadrants is interesting, i wonder if her liver +/- kidneys are crapping out and she is overloaded (ascites etc). Whoever said the foetal death, peritonitis has given me some real food for thought

Fantastic follow up questions, breath sounds, clear and equal excursion. No dyspnea/increased WOB other than noted from being in her gestational state. Edema as noted, no notcturnal dyspnea. Urine output has been about the same throughout.

Pre-eclampsia, I'd say. Take the ride nice and easy, no lights, no sirens, to the woman's hospital. Make very clear that if deterioration occurs, you might have to divert to the closest ER. It's a bit of a sticky situation. I would be hard pressed to justify allowing symptomatic hypertension to continue unabated for the 45 minute ride. On the other hand, there is a danger in any of the treatment modalities. Nitroglycerin can be associated with hypotension and fetal hypoxemia in pregnant females. Benzodiazepines should be approached very gingerly, as they can be associated with teratogenic effects. Some of them, such as quazepam and temazepam have even wound up in Category X for pregnancy risk.

Magnesium Sulfate works well for eclamptic seizures, but I'm not sure of how much effect it will have on the BP and the symptomatic effects it is causing. It's not ethical to transport someone with 9/10 on the pain scale for 45 minutes, so, according to the literature I've read, the best bet may be a bolus of morphine sulfate for the ride. Morphine is listed as class C for pregnancy risk, which means that it should only be administered if the benefit to the patient outweighs the risk to the fetus. I personally would be comfortable in saying alleviating the pain is justifiable considering the relatively low risk to the fetus.

The case is hard because the patient is just sick enough to warrant an intervention. If she was seizing it would be easy to figure out what to do, but she isn't.

I agree the headache should be addressed, by doing so you may have an effect on the blood pressure. My points of prority would be maternal well being: ABC (as normal), analgesia, sedation and BP management (working from with your ability). preparing for potential seizure activity. As you stated this case is difficult because you know she is ill, but which direction to take. I too would take the nice quiet ride to the womens center. I would most likely position the patient on her left side and provide a dark non stimulating atmosphere.

Maternal hypertension with pre-eclampsia although a DDX would be a neurogenic cause e.g. sub arachnoid haemmorhage or a stroke but this is unlikely

She needs to go to a major hospital with OB/gynae capability without delay; put a drip in and give some analgesia, get her out the house and get some wheels moving

My assessment of her is status 1 or immediately life threatening problem

There is no role for a helicopter

Yeah Kiwi, I agree no role for helicopter, and when I present the cases I will do so based primarily on GR pre-hospital intervention. And I agree with your assessment that she is immed life threatening.

Continuing the case....

Great posts so far, I think we are all in agreement that she is quite ill and needs tertiary maternal care. I am attempting to present cases that will focus on GR pre-hospital transport. Not GCCT or flight programs. That being said.......after starting transport, obtaining IV of crystalloid and providing IV analgesia, the patient begins to have tonic/clonic seizure activity.......you are now 35 mins away from womens center and 22 min from community hospital.

Edited May 8, 2012 by flightmedic608

[Kiwiology]

We do not carry magnesium in NZ so the only option here would be knock her down with midazolam until she stops seizing

If that doesn't work technically she would come under the "poor airway and/or breathing with GCS < 10" criteria for RSI; although anaesthetising, paralysing and intubating her may not be the best idea it's a roundabout way to terminate her seizure (or just cover it up) and avoids the hypoxia and hypercarbia that would be associated with a seizure

Keep going towards the big hospital; there is no role for "stopping off" first to get something done because meaningful intervention is going to be carried out at the tertiary centre and ~10 minutes means SFA

[jinx1764]

That being said.......after starting transport, obtaining IV of crystalloid and providing IV analgesia, the patient begins to have tonic/clonic seizure activity.......you are now 35 mins away from womens center and 22 min from community hospital.

Well that just sucks. She's moved from pre-eclampsic to eclampsic and previous measures have failed. It's time to give diazepam or whatever anti-seizure medication your service uses such as Ativan, (we carry diazepam only) and shit and get. She's going to need advance material care and emergency C-section (assuming the baby can even be saved at this point). While the community hospital is a few minutes closer, I wouldn't place bets on the staff doing a bang up job with this case. Between 22 and 35 mins and the difference in care, I'd say the dash for the womens center is worth it, but you'd better have a helluva driver who knows what they're doing.

I'd also get my intubation and RSI medications prepped, depending on if she needs it and depending on which way she goes. Total crap out or if I need to knock her down. Either way her brain functions need to be aggressively protected.

FYI- I used to work part-time for a neuropsychologist and once of his jobs was to rehab pts. One lady was a eclampsia survivor - baby didn't survive and her IQ dropped from being a lawyer to a data entry clerk. Seriously, she experienced that much neurological damage from the event.

[rock_shoes]

Was the patient hyper-reflexic? If treating as pre-eclampsia magnesium sulfate. 4g/20min to start then 2-4g/hour or so. Monitoring for hypotension and any cardiac arrythmias along the way. As previously mentioned be prepared for seizure activity and potential need to intubate. Pain management I would be looking at Fentanyl over morphine. Working to bring down that BP might do more than anything for reducing this patient's pain. Better to wait a moment and give the mag a chance before jumping on the narcotic bandwagon too quickly.

Edited May 8, 2012 by rock_shoes