jinx1764 Posted May 9, 2012 Posted May 9, 2012 I'd say it's a definite crossroads. IMO the mother takes priority. Not because the baby is worth less, but because in this limited scenario, she's the one I can do the most for and the better she fares, the more likely her baby will fare better as well. No guarantees but you've got to make a choice because making no choice is always wrong. You have to understand too, just because you're giving high risk meds, you don't have to max the doses. Give the minimums to get the job done; you can always give a bit more if needed within your dosage range. No need to max her and the baby out just because you can. Less is more and if you can give her less and still manage her condition, thereby managing the baby's condition. Maybe everybody might end up having a good day. You've just got to get them to the womens center in stable condition. You don't have to over think this too much within good decisions of meds vs airway vs sz etc. There's so much going wrong, you've just got to balance her on the razor's edge for enough time until the docs can save the baby then effectively manage her condition without the risk to the fetus. Plus, after the delivery, many of the symptoms will begin to resolve themselves with advanced care.
Asysin2leads Posted May 9, 2012 Posted May 9, 2012 (edited) 28 weeks is the beginning of the third trimester, and while its past the cusp of extra-utero survivability, but still young enough that some development normally still occurs, such as formation of pulmonary surfactant and the like. Teratogenic means literally, giving birth to a monstrosity, and in parlance means it can cause birth defects, such as the children born to mothers who took thalidomide being born with no arms, and babies born to mothers who came in contact with finasteride being born without genitals. At 28 weeks there's not any chance of not developing limbs or genitalia, but I imagine a teratogen could still cause you some problems in utero. From this article I found it says that after the embryonic stage at 9 weeks, "Teratogens taken during this period can result in improper organ functioning, delayed growth, but seldom result in birth defects" I fully agree that if push comes to shove we need to focus on the mother's survival, but I'm still wondering if diverting to the ER round the bend couldn't provide us with better options. I doubt it. From my better understanding of how teratogens affect development, I think the risk is fairly low to the fetus at this stage, so I'd probably start the mag as soon as the seizure started, and if it was still going on after 5 minutes or drop some diazepam and cross my fingers. Here's a link to the article I got my information from, though I should warn you that there are some pictures of birth defects that might give you the willies: http://wikis.lib.ncs...pment_in_Humans I've dealt with one full blown eclampsia case in my career and it was a doozy. The venous pressure was so high it shot the IV catheter out and the blood spray looked like something from Saving Private Ryan, and no you wiseasses, it wasn't in an artery. We did the mag and benzo routine, we were able to control the seizures and get to a specialty hospital, but I never found out how the case turned out. Edited May 9, 2012 by Asysin2leads 1
flightmedic608 Posted May 9, 2012 Author Posted May 9, 2012 28 weeks is the beginning of the third trimester, and while its past the cusp of extra-utero survivability, but still young enough that some development normally still occurs, such as formation of pulmonary surfactant and the like. Teratogenic means literally, giving birth to a monstrosity, and in parlance means it can cause birth defects, such as the children born to mothers who took thalidomide being born with no arms, and babies born to mothers who came in contact with finasteride being born without genitals. At 28 weeks there's not any chance of not developing limbs or genitalia, but I imagine a teratogen could still cause you some problems in utero. From this article I found it says that after the embryonic stage at 9 weeks, "Teratogens taken during this period can result in improper organ functioning, delayed growth, but seldom result in birth defects" I fully agree that if push comes to shove we need to focus on the mother's survival, but I'm still wondering if diverting to the ER round the bend couldn't provide us with better options. I doubt it. From my better understanding of how teratogens affect development, I think the risk is fairly low to the fetus at this stage, so I'd probably start the mag as soon as the seizure started, and if it was still going on after 5 minutes or drop some diazepam and cross my fingers. Here's a link to the article I got my information from, though I should warn you that there are some pictures of birth defects that might give you the willies: http://wikis.lib.ncs...pment_in_Humans I've dealt with one full blown eclampsia case in my career and it was a doozy. The venous pressure was so high it shot the IV catheter out and the blood spray looked like something from Saving Private Ryan, and no you wiseasses, it wasn't in an artery. We did the mag and benzo routine, we were able to control the seizures and get to a specialty hospital, but I never found out how the case turned out. Great post Asys, its hard to think or somethimes say outloud, but the fetus really is a secondary consideration with this case. Maternal well being = fetus well being period. Utilizing what medications most ALS unit have, starting Mg++ and benzos are your best route right now. Although I do suspect that most ALS units dont carry enough Mg++ to effectively cease her seizure activity. I also would quickly take the RSI path, hypoxia will be detrimental to both. My personal thoughts on community ED vs women/infants center is mixed, if I could successfully secure airway and begin ventilation, was well as decrease seizure activity I would continue to tertiary care. I think what a community hospital ED would give you would be access to airway management (if needed) and an expanded pharmacy to treat seizure activity, but would they be able to perform an emergent c-section if needed and what about neonatal resusciatation? Very difficult questions, I am glad this case has give opportunity for so much thought. I'd say it's a definite crossroads. IMO the mother takes priority. Not because the baby is worth less, but because in this limited scenario, she's the one I can do the most for and the better she fares, the more likely her baby will fare better as well. No guarantees but you've got to make a choice because making no choice is always wrong. You have to understand too, just because you're giving high risk meds, you don't have to max the doses. Give the minimums to get the job done; you can always give a bit more if needed within your dosage range. No need to max her and the baby out just because you can. Less is more and if you can give her less and still manage her condition, thereby managing the baby's condition. Maybe everybody might end up having a good day. You've just got to get them to the womens center in stable condition. You don't have to over think this too much within good decisions of meds vs airway vs sz etc. There's so much going wrong, you've just got to balance her on the razor's edge for enough time until the docs can save the baby then effectively manage her condition without the risk to the fetus. Plus, after the delivery, many of the symptoms will begin to resolve themselves with advanced care. J, I agree the best treatment for this patient would be delivery. 1
DFIB Posted May 9, 2012 Posted May 9, 2012 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. I feel that I want to return to this question. As a student I want to be aware of my better options. I know you guys can help. I mean does RSA have merit? Does anyone have experience with them or would prefer to intubate because you know you are good or because that is the way it is usually done? Should I abandon the idea of RSA as viable option?
flightmedic608 Posted May 9, 2012 Author Posted May 9, 2012 (edited) I feel that I want to return to this question. As a student I want to be aware of my better options. I know you guys can help. I mean does RSA have merit? Does anyone have experience with them or would prefer to intubate because you know you are good or because that is the way it is usually done? Should I abandon the idea of RSA as viable option? Sorry D, wasnt trying to not answer your question and it is valid. Personally, I will choose the most definative airway that I can place, usually RSI with oral ETT. My thoughts on airways adjuncts such as LMA, King etc is that they are secondary and although they have a place, they dont do well in transport (my personal experience and those of my peers etc) The LMA has great uses in the OR where gastric contents are usually known, and patients are being induced by an CRNA or an Anesthesiologist. I know there has been literature written about RSA with a known difficult airway and that may be a provider to provider choice. I would read any literature, take any class and practice as much as you can, so that you can make an informed decision. I hope this answers your question. I think Jinx had written that most secondary devices will be changed out, she is correct. Although that are a great secondary airway they are not definative. Edited May 9, 2012 by flightmedic608
DFIB Posted May 9, 2012 Posted May 9, 2012 Sorry D, wasnt trying to not answer your question and it is valid. Personally, I will choose the most definative airway that I can place, usually RSI with oral ETT. My thoughts on airways adjuncts such as LMA, King etc is that they are secondary and although they have a place, they dont do well in transport (my personal experience and those of my peers etc) The LMA has great uses in the OR where gastric contents are usually known, and patients are being induced by an CRNA or an Anesthesiologist. I know there has been literature written about RSA with a known difficult airway and that may be a provider to provider choice. I hope this answers your question. I think Jinx had written that most secondary devices will be changed out, she is correct. Although that are a great secondary airway they are not definative. Thanks, I have read some articles that refer to an OR setting but really had no point of reference for field EMS. So in training I should endeavor to become proficient with ETT and leave the supraglottics for the EMT's, I suppose,
jinx1764 Posted May 9, 2012 Posted May 9, 2012 I agree with flightmedic. As long as ET is considered the definitive airway, I will always attempt it first and foremost. We have protocols for our ALS fire depts to use king airways in cardiac arrests as their first line airway, but only during cardiac arrest. Meanwhile, our MICU units (just another fancy name for ALS dual paramedic units in Texas) carry kings but consdier them secondary if ET is unable to be obtained. The main problem I've been seeing (and other veterans too) is the tendancy for new medics to skip harder to master skills like ET and IV (compared to IO drills) especially EJ's in favor of these 'easier' skills. Then these medics go years without masatering the essentials and when they're leads and the shit hits the fan they and their newbie have a very small tool box. I've been in this biz 19+years and I don't allow any medic I FTO to skip an EJ or an ET attempt, ever. Even if it ends up FPO, they're still getting that attempt under they're belt before I allow them to try secondary adjuncts. All the fancy tools and such in the world will never take the place of a seasoned medic with an ET tube or an IV cath. with a critical pt. They're all tools and they have they're place and they all need to be mastered. 1
Asysin2leads Posted May 9, 2012 Posted May 9, 2012 Flight, the only reason I think you could justify diverting to the closest ED would be either an unmanageable airway, or some wonder drug I'm missing out on that is better suited then a benzo to treat the seizure activity. It would really come down to a good faith decision on the part of the provider, and one you'd have to expect to be called onto the carpet for one way or the other and have to defend your position. I'm starting to lean towards the closest ER route, simply because even with an airway this patient is not stable, and according to another article I've read maternal hypertension is a big factor in causing stillbirth due to uteroplacental insufficiency. According to the same article, nitroprusside is in pregnancy Class C, so maybe the local ER could hook her up, as it does find use in cases of severe pre-eclampsia. Yeah, I think in this case I'm going to say benzos, Mag, and then divert to the closest ER, if they're not a bunch of morons. If everything goes according to plan they can set her up with some good drips to nipride and/or dilantin and then we can come back later with an RN and some infusion pumps and get her up to the speciality center. Unless of course you are super-ninja-paramedic-RN and have that stuff already to rock. If that's the case, set up shop and have at it.
flightmedic608 Posted May 9, 2012 Author Posted May 9, 2012 (edited) Flight, the only reason I think you could justify diverting to the closest ED would be either an unmanageable airway, or some wonder drug I'm missing out on that is better suited then a benzo to treat the seizure activity. It would really come down to a good faith decision on the part of the provider, and one you'd have to expect to be called onto the carpet for one way or the other and have to defend your position. I'm starting to lean towards the closest ER route, simply because even with an airway this patient is not stable, and according to another article I've read maternal hypertension is a big factor in causing stillbirth due to uteroplacental insufficiency. According to the same article, nitroprusside is in pregnancy Class C, so maybe the local ER could hook her up, as it does find use in cases of severe pre-eclampsia. Yeah, I think in this case I'm going to say benzos, Mag, and then divert to the closest ER, if they're not a bunch of morons. If everything goes according to plan they can set her up with some good drips to nipride and/or dilantin and then we can come back later with an RN and some infusion pumps and get her up to the speciality center. Unless of course you are super-ninja-paramedic-RN and have that stuff already to rock. If that's the case, set up shop and have at it. Yeah, I’ll agree this case presents many challenges. I would weigh the benefit for the patient to divert by looking at every clinical aspect that I was presented with -- airway, blood pressure, seizure activity and the ability to continue transport safely. I dont ever base my decisions on if I will be "called onto the carpet" as you put it, I base my critical thinking on what is placed in front of me. I am a firm believer that with the sickest patient, the more hands and minds available the better for the patient. Please don’t confuse how I state the reasons for diverting as if I do not understand the physiology of this patients disease process. I make my clinical decisions based off of my experience in transport, what I have studied and what benefit each decision I make is going to be for the patient. I don’t consider any aspect of my clinical care to be super or ninja like, I attempt to give the most prudent and safe care that I can. This is a case that gives me pause, because I know that the patient needs tertiary OB care (most likely an emergent cesarean), but as the ALS provider you are at a crossroad when this patient takes a turn for the worse. My intentions of presenting case(s) are not for people to misinterpret my statements as anything other than being my thoughts and critical thinking. I present in a hope that we can all learn from each others practice (as a community), not to use words like super or ninja. I am not finsihed learning, nor will I ever be. Edited May 9, 2012 by flightmedic608
Asysin2leads Posted May 9, 2012 Posted May 9, 2012 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.
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