Scenario # 1 Headache

[Inthecity]

When I had severe pre eclampsia it wasnt caught right away and turned into full blown HELLP syndrome

http://en.wikipedia.org/wiki/Hellp_syndrome I dont know how many people in here have heard of that because it is pretty rare. The only cure is delivering the baby no matter how premature the baby is. I am not a medic but I do have experience with pre eclampsia and HELLP so I would get the patient to the hospital asap for delivery, My bp the day I delivered was 200/115. I had magnesium sulfate and an emergency c section. My daughter was only 5 weeks early luckily but it was still a horrible experience. Especially considering I developed sepsis and post partum pre eclampsia as well and was in ICU for 5 days.

[DartmouthDave]

Hello,

Sorry to hear that Inthecity. I am glad the baby is doing well. =)

I am a late to this thread and I just worked my way through 5 pages of posts. An excellent discussion.

I would treat her with a MgSO4 loading dose and an infusion. I would give this some time to work before I would tube her. If the Mg breaks the seizurs (...or benzo..) she may not need a tube. She is young (high medabolic demand) and pregnant (reduced FRC and increased medabolic demand). Her time to desat will be very fast EVEN if she was preoxygenated. Tubing her would be high risk and with luck we may be able to avoid it.

Second, their could be some other pathology here. HTN + head ache could be Posterior reversible encephalopathy syndrome (PRES), SAH, AVM, et al.... She need to get to a hospital more management.

I would like to write more but it is time to run.

Cheers

[rock_shoes]

I realize I actually completely contradicted myself with the last post. I said at first you shouldn't divert unless there was an unmanageable airway, but as I was typing while I was reading, I then realized that the ER can provide some beneficial interventions like nitroprusside or dilantin, both of which as I found out can be used to treat pre-eclampsia. When I write things its usually me thinking kind of out loud, so if I present my rationale its not intended to teach or correct, I'm just saying my understanding of situations, which obviously can change as I learn more about certain things. Some ALS units in certain areas do indeed have some really advanced equipment, I wasn't sure what was available to your particular unit, which is why I was saying you should divert and have the ER intervene, and then have the transport go by speciality care with an RN later on, unless you happen to have access to fun things like nipride on your ambulance already. I threw super-ninja in there because a friend of mine who was a Navy Corpsman and an RN had a patch made up that said "RN: Rescue Ninja."

I try to look at every question in EMS from every angle, the medical, the ethical, the medicolegal, and the operational. My crack about being called on the carpet simply meant that I could see, from a QA/QI stand point, having to sit and defend your actions to a medical director or supervisor, no matter if you decided to divert or not to divert, there are merits and drawbacks to each decision, and in a case like this, you need to be really on the ball and be ready to sit down and explain why you did what you decided to do.

If your service carried labetalol, that would be helpful, but I personally wouldn't be comfortable attempting to control the seizures with IV boluses of diazepam, and using something like nitropaste or nitro-spray to control the hypertension, and attempting an RSI all at once if access to other options are available. To me that's like trying to turn a screw with a knife; you might be successful but its not really what the knife's intended use is for.

Hard to say if vasodilators, beta blockers etc. are going to be that beneficial. The standard is MgSO4 maxed out before going to anything else with benzos to help control seizures as needed. Midazolam, Nitro drip, metoprolol, MgS04 are all stocked on the ambulances I've been spending time on of late. I would be calling a friend (doc) as soon as MgSO4 and midazolam weren't doing the trick then bypassing straight to the closest facility capable of dealing with a premie/eclamptic. These two patients are way beyond what the small town health centre is capable of dealing with.

[flightmedic608]

I think we are all in agreement that as this case progressed, the decision making became increasingly difficult. I am always interested in others critical thinking on a patient who is truly an emergent one in the pre-hospital and hospital arena. I am grateful that I have had an opportunity to present a case that so many have been able to participate in, I hope that some have been able to take something from it. If people are still interested I will post another case on Sunday night. Is there any particular genre that people are interested in? medical vs trauma...adult vs pedi? Shoot me an pm or email and let me know what you are interested in reviewing.

[jinx1764]

And don't forget the other issue floating around the States right now which would directly impact this patient. Drug shortages. My service is already ouf of Mag and Dopamine and we're borderline on Valium and Etomidate (have one box of each in storage left, we're up to using expired Etomidate) The hospitals are in the same boat, so the question becomes: even if you take this patient to the closes ER for medication stabiization, will they have enough of the right meds on hand? Can they do (well) and emergency c-section meds don't work (meds aren't always successful) and can they care for a preemie long enough to transfer out? The specility hospital will at least have the knowledge on hand and will likely have first dibs on the necessary meds for those specialty cases. One hopes. Got the word today, in fact, that some meds might take up to 3 years before the shortage is eased because of some drug companies (like Lilly) having gone of out biz.

[Asysin2leads]

Eli Lilly isn't out of business, at least not that I've heard. Mag sulfate and valium shortages are due to manufacturing problems at Hospira, and should be released in late May. Etomidate apparently has problems with raw materials.

[island emt]

Just got a memo yesterday that 7 out of 8 hospitals in our region are at critical levels of Epinephrine. 1:10,000 / 1:10000.

they will be getting us some form or dilution to work with in the next few weeks.

Now how can half a state not have stocks of adrenaline /epi for prehospital use.

They have a weekly list that goes out to let us know what shortages there are at this time.

The list gets longer every week.

[Kiwiology]

No drug shortages here and our drugs come from all the same pharmaceutical companies, weird ....

[DFIB]

Great scenario, flightmedic. You are obviously a wonderful teacher. I will be looking forward to the next one.

[Eydawn]

Killer scenario, sorry I missed it while it was in the discussion phase! Excellent trains of thought from everyone.

Man! Definitely a call you would not have to run...

Wendy

CO EMT-B