flightmedic608 Posted May 8, 2012 Author Posted May 8, 2012 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 Interesting about not carrying Mg++, any thoughts on why? I agree with Midazolam, Lorazepam etc. One question if you plan to secure airway in this patient, are you concerned about the use of paralytics and if so why would you be? And I totally agree with the decision to transport to a woman/infants 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. Hey J again great points, inline with what Kiwi stated. 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. For discussion purposes, lets say the patient's DTR were between 3-4, (3 - increased but normal, 4 - markedly hyperactive with clonus). Mg++ administration great idea, and I agree with agressive pain management and BP managment.
Kiwiology Posted May 8, 2012 Posted May 8, 2012 (edited) Interesting about not carrying Mg++, any thoughts on why? I agree with Midazolam, Lorazepam etc. One question if you plan to secure airway in this patient, are you concerned about the use of paralytics and if so why would you be? And I totally agree with the decision to transport to a woman/infants hospital. Magnesium is most likely not carried because doing so would not be cost effective given that its use would be extremely rare In my mind foggled state I cannot think of any contraindications to teh suxamethoniumz that this lady has Edited May 8, 2012 by Kiwiology
flightmedic608 Posted May 8, 2012 Author Posted May 8, 2012 My biggest thought about administration of any paralytic whether a intermediate or long acting would be that it would (1) cease the physical seizure manifestation, but (2) would not discontinue the neuro seizure activity. I believe that I would administer a short acting (such as succinycholine) to obtain airways control though, taking into account the difference that a pregnant female presents for airway management: Airway, Oxygen and RSI To avoid fetal hypoxia, use high-flow oxygen. In compromised respiratory settings, pregnant women have an increased tendency toward rapid development of hypoxemia. Anticipate higher potential for regurgitation of gastric contents and aspiration; thus, antiemetics and NG are strong considerations. Failed intubation is more common in pregnancy because of physiologic and anatomical changes that can lead to difficult intubation including:10 laryngeal edema from water retention lingual, nasal mucosa swelling from capillary engorgement increased facial adipose tissue affecting space for maneuvering laryngoscope handle increased abdominal contents elevating diaphragm with anterior shifting larynx morbid obesity (heavier than 300 pounds): mask ventilation may also be difficult due to increased intra-abdominal pressure and low chest compliance.11 Transplacental passage is insignificant at usual dose for intubation relaxation. If a paralytic agent is used, it crosses placenta in dose- dependent fashion and will cause fetal heart rate tracing to become non-reactive.12 Induction agents such as thiopental, propofol, and etomidate appear to have a positive benefit vs. risk when used in the critical setting for pregnant women This seizure complicates treatment because it is caused by a metabolic condition.
DFIB Posted May 8, 2012 Posted May 8, 2012 (edited) My biggest thought about administration of any paralytic whether a intermediate or long acting would be that it would (1) cease the physical seizure manifestation, but (2) would not discontinue the neuro seizure activity. I believe that I would administer a short acting (such as succinycholine) to obtain airways control though, taking into account the difference that a pregnant female presents for airway management: Airway, Oxygen and RSI To avoid fetal hypoxia, use high-flow oxygen. In compromised respiratory settings, pregnant women have an increased tendency toward rapid development of hypoxemia. Anticipate higher potential for regurgitation of gastric contents and aspiration; thus, antiemetics and NG are strong considerations. Failed intubation is more common in pregnancy because of physiologic and anatomical changes that can lead to difficult intubation including:10 laryngeal edema from water retention lingual, nasal mucosa swelling from capillary engorgement increased facial adipose tissue affecting space for maneuvering laryngoscope handle increased abdominal contents elevating diaphragm with anterior shifting larynx morbid obesity (heavier than 300 pounds): mask ventilation may also be difficult due to increased intra-abdominal pressure and low chest compliance.11 Transplacental passage is insignificant at usual dose for intubation relaxation. If a paralytic agent is used, it crosses placenta in dose- dependent fashion and will cause fetal heart rate tracing to become non-reactive.12 Induction agents such as thiopental, propofol, and etomidate appear to have a positive benefit vs. risk when used in the critical setting for pregnant women This seizure complicates treatment because it is caused by a metabolic condition. Considering all the complications and difficulties that arise from a Rapid Sequence Intubation would a Rapid Sequence Airway be a more viable option in this case? We could always use RSA as a bridge to RSI if the need arises. Edited May 8, 2012 by DFIB
flightmedic608 Posted May 8, 2012 Author Posted May 8, 2012 Considering all the complications and difficulties that arise from a Rapid Sequence Intubation would a Rapid Sequence Airway be a more viable option in this case? We could always use RSA as a bridge to RSI if the need arises. Interesting proposition. I would think that each provider would have to done his or her own airway assessment prior to begining tranport (i.e. Mallampatti, Lemon) and also go forward with their best clinical judgement. Personally, I consider LMA, surgical airway etc as second line in my difficult airway thought process.
jinx1764 Posted May 8, 2012 Posted May 8, 2012 Based on the above question, I'd say it really comes down to the medic's experience running the call. I would not allow an inexperienced medic to attempt one of their first RSI's on this patient if I were their FTO. No arrogance intended, but I have top notch intubation skills (years of practice) and even I'd been hesitant to intubate this patient unless it were absolutely necessary. However, if you're going to protect the airway, if she's that critical, it's best to go all the way and get it right the first time. Secondary airway adjundants (even with NG tubes) increase aspiration risk when they're removed and they will be once you hit the ER. If diazepam doesn't stop her seizures and her bp keeps raising (whether or not your service can effectively treat it) her neurological functions need to protected, thereby hopefully protecting the fetus. Any medication cross over to the fetus is secondary at this point because they're dying and in the box our options are limited. This is kitchen sink time; you save the mother life/quailty as best as you can and hope to hell saving her saves her baby. 1
DFIB Posted May 8, 2012 Posted May 8, 2012 (edited) Wouldn't our patient easily be pre-oxigenated while avoiding gastric distention as well as the Sellick Maneuver via the gastric isolation drainage tubes. And don't those gastric isolation drainage tubes protect against broncho-aspiration in the event that a ET tube is required? This is not an backhanded assertion but an honest question. Edited May 8, 2012 by DFIB
Asysin2leads Posted May 8, 2012 Posted May 8, 2012 I would start a mag sulfate drip if she started seizing, definitely, but now we're in another quandry. On the one hand, while she is seizing, she is effectively not ventilating, and if left to seize, the fetus and her will go hypoxic, which will be disasterous. On the other hand, benzodiazepines have potential teratogenic effects, diazepam, midazolam, lorazepam, even alprazolam are all Class D's, and from what I can tell the benzos that aren't Class D are Class X, and in my book, Class D would stand for DON'T! The question at this point is there anything the local ED could set her up with that would control the seizures without as great a risk to the fetus as our options? From what I can see the options are pretty limited. Tegretol, Phenobarb, Depakote, those are all still Class D, and maybe someone can comment if they are even useful in acute seizure activity. I think this is the day you should have called in sick.
paramedicmike Posted May 8, 2012 Posted May 8, 2012 Definitive treatment in this case is delivery. That's what's best for mom and baby. The question is which facility will offer the better options? The closer community hospital will not likely have the resources to care for a 28 weeker even though the baby is potentially viable. The women's center will certainly have those resources available. Start the mag. Manage the seizures as best as possible. Control the airway if needed (up to and including RSI if available). Get on the phone and ask if the community hospital can manage both patients, expect them to laugh at me, and plan on continuing to the women's center.
DFIB Posted May 8, 2012 Posted May 8, 2012 I would start a mag sulfate drip if she started seizing, definitely, but now we're in another quandry. On the one hand, while she is seizing, she is effectively not ventilating, and if left to seize, the fetus and her will go hypoxic, which will be disasterous. On the other hand, benzodiazepines have potential teratogenic effects, diazepam, midazolam, lorazepam, even alprazolam are all Class D's, and from what I can tell the benzos that aren't Class D are Class X, and in my book, Class D would stand for DON'T! The question at this point is there anything the local ED could set her up with that would control the seizures without as great a risk to the fetus as our options? From what I can see the options are pretty limited. Tegretol, Phenobarb, Depakote, those are all still Class D, and maybe someone can comment if they are even useful in acute seizure activity. I think this is the day you should have called in sick. Are we at the crossroads where we have to try to save at least one of our patients? And when we treat pregnant women although we are aware that we have two patients which one takes priority? The mom or the baby? As far as teratogenic effects I don't know exactly what they are but this kid is going to most likely be delivered within hours of arrival at the hospital. Could it handle the drugs for that time?
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