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All Updates, Guidelines, ICU, Resus

Life threatening post partum haemorrhage

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A mother may experience life-threatening haemorrhage after delivery of her baby. What can the resuscitation doctor do?
Rosen’s Emergency Medicine describes four main differential diagnoses: uterine atony, genital tract trauma, retained placental tissue, and coagulopathies, or the “four Ts”: tone, trauma, tissue, and thrombin.
As well as resuscitation with fluid and blood products and urgent obstetric and anaesthetic referral, efforts should be made to restore uterine tone with manual and pharmacological means, and consider tamponade of the haemorrhage.
The MOET (Management of Obstetric Emergencies & Trauma) Course outlines the following interventions for major obstetric haemorrhage:

  • Empty uterus: deliver fetus if undelivered / remove placenta or retained products (this may need to be done digitally according to Rosen)
  • Oxytocin / ergometrine / prostaglandin
  • Massage & bimanual compression of uterus
  • Repair genital tract injury
  • Uterine packing or Rusch balloon
  • Compression of aorta
  • Surgical or interventional radiological options: internal iliac or uterine artery ligation, hysterectomy, arterial embolisation

A review of the different balloon tamponade devices available describes the urological Rusch balloon, the dedicated Bakri balloon, a condom sutured to a Foley catheter, multiple Foley catheters, and the Sengstaken-Blakemore tube (SBT). In order for the SBT balloon to reach the uterine fundus, either the tip of the catheter can be cut and the gastric balloon inflated, or the SBT can be folded and the oesophageal balloon inflated. Normal saline is used to inflate the balloon until tamponade is achieved. If the cervix is dilated, vaginal packing may be necessary to prevent migration of the balloon out of the uterus..
The Royal College of Obstetricians and Gynaecologists published 2009 guidelines on PPH. The full text is available here. After commencing resuscitation, summoning help, considering the ‘four T’s’, and examining the patient they recommend:

  • Bimanual uterine compression (rubbing up the fundus) to stimulate contractions.
  • Ensure bladder is empty (Foley catheter, leave in place).
  • Syntocinon 5 units by slow intravenous injection (may have repeat dose).
  • Ergometrine 0.5 mg by slow intravenous or intramuscular injection (contraindicated in women with hypertension).
  • Syntocinon infusion (40 units in 500 ml Hartmann’s solution at 125 ml/hour) unless fluid restriction is necessary.
  • Carboprost 0.25 mg by intramuscular injection repeated at intervals of not less than 15 minutes to a maximum of 8 doses (contraindicated in women with asthma).
  • Direct intramyometrial injection of carboprost 0.5 mg (contraindicated in women with asthma), with responsibility of the administering clinician as it is not recommended for intramyometrial use.
  • Misoprostol 1000 micrograms rectally.

Balloon tamponade may then be attempted in cases of uterine atony pending surgical haemostasis if necessary.
As with all life-threatening emergencies, the resuscitation doctor should have a plan, and know his or her options regarding personnel, facilities and equipment. We recommend a closer look at the articles and guidelines referenced above in formulating your own plan as to how you might save a young mother’s life.

All Updates, Guidelines, Resus, Trauma

Spinal Cord Injury Guidelines

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The Paralyzed Veterans of America produce a number of evidence-based guidelines for management of spinal cord injury and its complications that may be useful for the critical care doctor, downloadable from here.
The most relevant to frontline professionals is the Early Acute Management in Adults with Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals. A summary of the major recommendations from this document can be found here.

All Updates, PHARM, Trauma

Pre-hospital intubation for head injury: ?no benefit

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A systematic review of pre-hospital intubation for head injured patients failed to show evidence of benefit of tracheal intubation or invasive ventilation. The authors acknowledge the lack of methodological quality in the studies reviewed and the predominance of US paramedic-delivered intubations without the use of anaesthetic drugs.
Pre-hospital tracheal intubation in patients with traumatic brain injury: systematic review of current evidence
Br J Anaesth. 2009 Sep;103(3):371-86

All Updates, PHARM, Trauma

Pre-hospital intubation 'success' at a US centre

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Of 203 patients attending a US Level 1 trauma centre who had pre-hospital airway management, 25 (12%) had unrecognised oesophageal intubations.
Patients were treated in the field by fire rescue personnel of various municipalities and with different experience levels. Patients transported by air were significantly more likely to be successfully intubated than those transported by ground, perhaps due to both increased experience and the use by air crews of succinylcholine. The authors in their discussion contrast these results with those of European studies which report higher success rates with pre-hospital systems that employ emergency physicians and anaesthetists.
Prehospital intubations and mortality: a level 1 trauma center perspective
Anesth Analg. 2009 Aug;109(2):489-93

All Updates, PHARM, Resus, Trauma

Vehicle Rollover

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Vehicle rollover as an indicator of mechanism of injury was investigated in a study examining accident databases and the medical literature. Only 2.4% of crashes involved rollovers but they accounted for one third of occupant deaths.
Some facts on vehicle rollover from the article:

  • Rollover is defined as a vehicle overturned by at least one quarter turn (at least onto its side).
  • Some rollovers involve many quarter turns and the final resting position may be on the vehicle’s side, roof, or back on its wheels.
  • Factors that cause a vehicle to roll over include trajectory (i.e., turning vs. straight), vehicle type, and speed (precrash velocity may be the most predictive factor)

The importance of vehicle rollover as a field triage criterion
J Trauma. 2009 Aug;67(2):350-7

Acute Med, All Updates, Resus

Myocardial infarction not so common in LBBB?

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An observational cohort study of 7937 ED visits by patients presenting with chest pain or ‘ischemic equivalent’ (shortness of breath for which ACS was considered a possible cause) was done to examine the relationship between left bundle branch block (LBBB) on the ECG and the incidence of acute myocardial infarction (AMI). No difference was observed in the rates of AMI in patients with new or presumed new LBBB, old LBBB, and no LBBB. The authors suggest that this large cohort of undifferentiated ED patients may be more reflective of the true prevalence of AMI in LBBB (7.3% in this study) and question the appropriateness of a liberal fibrinolytic strategy for such patients. Another argument for primary PCI?
Lack of association between left bundle-branch block and acute myocardial infarction in symptomatic ED patients
Am J Emerg Med. 2009 Oct;27(8):916-21

All Updates, Kids, Resus

How to spot paediatric myocarditis

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The most common aetiology of heart failure in previously well children is myocarditis. A review of 62 cases whose final diagnosis was viral myocarditis showed that common features included:

  • multiple visits / evaluations before the diagnosis was made
  • initial misdiagnosis as respiratory disease (eg. pneumonia, asthma)
  • presenting symptoms of shortness of breath, vomiting, poor feeding, lethargy, fever
  • signs included hepatomegaly (50%), tachypnoea, respiratory distress
  • although a normal heart rate for age was found in 41(66%) patients, ALL patients had an abnormal ECG
  • Most had abnormal chest x-rays

The take home messages regarding this rare disease are that initial misdiagnosis is common, do not expect a resting tachycardia, look for hepatomegaly, CXR signs, and particularly ECG abnormalities.
Pediatric myocarditis: presenting clinical characteristics
Am J Emerg Med. 2009 Oct;27(8):942-7

Acute Med, All Updates, Resus

12 Lead ECG Features of Proximal LAD Occlusion

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An ECG pattern is described in chest pain patients which signifies proximal LAD artery occlusion found at angiography: precordial ST-segment depression at the J-point followed by peaked, positive T-waves. Lead aVR displays also displayed slight ST-segment elevation in the majority of cases.
A letter in response points out that this finding was first reported in 1947.
Persistent precordial “hyperacute” T-waves signify proximal left anterior descending artery occlusion
Heart 2009;95;1701-1706