Laboring Under Pressure Episode 2: Postpartum Hemorrhage with Dr. Kiersten Williams
Release Date: 01/08/2024
Episode 963: Antihypertensives and Emergency Room Considerations
Emergency Medical Minute
Contributor: Alec Coston, MD Educational Pearls: For patients presenting to the emergency room with hypertension, clinicians should determine if it is isolated and uncomplicated, or involves comorbidities with more complex underlying pathophysiology. For uncomplicated and isolated hypertension, first-line treatment is thiazide diuretics. How do thiazide diuretics work to treat hypertension? Thiazide diuretics work by blocking sodium and chloride resorption in the kidneys. “Where sodium goes, water follows,” thus promoting diuresis and lowering blood pressure. Examples...
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Episode 962: HEART Score
Emergency Medical Minute
Contributor: Taylor Lynch, MD Educational Pearls: How do we risk-stratify chest-pain patients? One option is the HEART score This score predicts a patient’s 6-week risk of a major adverse cardiac event. Ex. Cath procedure, CABG, PCI, death H stands for History Ask 1) Was the patient diaphoretic? 2) Did they have nausea and/or vomiting? 3) Did the pain radiate down the right or left arm? 4) Was it exertional? Yes to one = one point. Two or more = two points. E stands for EKG One point for left ventricular hypertrophy, t-wave inversions, new bundle-branch blocks. No points for first...
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Episode 961: Cell Phone Sign
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: A prospective study at the Mayo Clinic Rochester was conducted to examine whether patients actively using their phones on initial assessment in the ED was associated with higher discharge rates The study included 292 patients, and only about 15% of patients were on their phone The patients on their phone tended to be a younger demographic Scribes were trained to record the data during their shifts The results did show that patients on their phone have a higher rate of discharge 94% chance of discharge if the patient is on their phone 64%...
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Episode 960: Frank's Sign - A Marker for Coronary Artery Disease
Emergency Medical Minute
Contributor: Travis Barlock MD Educational Pearls Frank’s sign is a curious physical exam finding first described in the literature in 1973 Bilateral earlobe creases are recognized as a marker of coronary artery disease and cerebrovascular disease Some studies have found an increase in all-cause mortality in patients with bilateral diagonal earlobe creases The pathophysiology is still not fully understood One 2020 study found histopathological changes associated with diagonal earlobe creases, potentially linking them via a model of hypoxia/reoxygenation References Elliott WJ,...
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Episode 959: The KLM Flight Disaster and Lessons in Healthcare Communication
Emergency Medical Minute
Contributor: Taylor Lynch, MD Educational Pearls: The KLM Flight Disaster, also known as the Tenerife Airport Disaster, occurred on 27 March 1977. It involved the collision of two Boeing 747 passenger jets from KLM and Pan Am Airlines, resulting in 583 fatalities. What fell through the cracks to cause this incident? The captain of the KLM flight believed he had received clearance from air traffic control to take off, when in fact he had not. This captain was one of the most senior pilots in the organization, and the culture often saw senior pilots as infallible and not to be questioned....
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Episode 958: Intranasal Fentanyl
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: How do we take care of kids in severe pain? There are many non-pharmacologic options for pain (i.e. ice, elevation) as well as more conventional medication options (i.e. acetaminophen, NSAIDS) but in severe pain stronger medications might be indicated. These stronger medications include options such as IV morphine, a subdissociative dose of ketamine, as well as intranasal fentanyl. Intranasal fentanyl has many advantages: Studies have shown it might be more effective early on in controlling pain, as in the first 15-20 minutes after...
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Episode 957: Cardiac Asthma
Emergency Medical Minute
Contributor: Travis Barlock, MD Educational Pearls: Wheezing is classically heard in asthma and COPD, but it can be the result of a wide range of processes that cause airflow limitation Narrowed bronchioles lead to turbulent airflow → creates the wheezing Crackles (rales) suggest pulmonary edema which is often due to heart failure Approximately 35% of heart failure patients have bronchial edema, which can also produce wheezing COPD and heart failure can coexist in a patient, and both of these diseases can cause wheezing It’s vital to differentiate whether the wheezing is due to the...
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Episode 956: Psychedelics and Risk of Schizophrenia
Emergency Medical Minute
Contributor: Jorge Chalit-Hernandez, OMS3 Educational Pearls: Psychedelics are being studied for their therapeutic effects in mental illnesses, including major depressive disorder, post-traumatic stress disorder, anxiety, and many others Classic psychedelics include compounds like psilocybin, LSD, and ayahuasca MDMA and ketamine are often included in psychedelic research, but have a different mechanism of action than the others Their mechanism of action involves agonism of the 5HT2A receptor, among others Given their resurgence, there is an increase in recreational use of these substances ...
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Episode 955: Cardiac Effects of COVID-19
Emergency Medical Minute
Contributor: Ricky Dhaliwal, MD Educational Pearls: What factors are considered in a COVID-19 infection? The viral load: Understood as the impact of SARS-CoV-2 viral particles infecting host cell tissue itself (utilizing ACE-2 receptors). Pro-Inflammatory Response: Post-infection, the body's downstream systemic cytokine release (can be both normal or hyperactive, aka “cytokine storm”). What cardiac impacts have been observed with COVID-19? Arrhythmias: The mechanism of COVID-19 infection and arrhythmias is believed to be multifactorial. However, evidence suggests T-cell-mediated...
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Episode 954: Combo Rescue Inhalers - New Guidelines
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: What is a Rescue Inhaler? A rescue inhaler is a medication for people with asthma to quickly reverse the symptoms of an asthma attack. Historically albuterol (Short Acting Beta Agonist (SABA)) monotherapy has been the mainstay rescue inhaler. This is because albuterol works fast and is relatively cheap. \n\n What are Combination Rescue Inhalers? Combination rescue inhalers contain a fast-acting bronchodilator as well as an inhaled corticosteroid (ICS) The steroid helps to reduce some of the chronic airway inflammation that is...
info_outlineContributor: Kiersten Williams MD, Travis Barlock MD, Jeffrey Olson MS2
Summary:
In this episode, Dr. Travis Barlock and Jeffrey Olson meet in the studio to discuss a clip from Dr. Williams’ talk at the “Laboring Under Pressure, Managing Obstetric Emergencies in a Global Setting” event from May 2023. This event was hosted at the University of Denver and was organized with the help of Joe Parker as a fundraiser for the organization Health Outreach Latin America (HOLA).
Dr. Kiersten Williams completed her OBGYN residency at Bay State Medical Center and practices as an Obstetric Hospitalist at Presbyterian/St. Luke’s Medical Center in Denver, Colorado.
During her talk, Dr. Williams walks the audience through the common causes and treatments for post-partum hemorrhage (PPH).
Some important take-away points from this talk are:
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The most common causes of PPH can be remembered by the 4 T’s. Tone (atony), Trauma, Tissue (retained placenta), and Thrombin (coagulopathies).
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AV malformations of the uterus are probably underdiagnosed.
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Quantitative blood loss is much more accurate than estimated blood loss (EBL).
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The ideal fibrinogen for an obstetric patient about to deliver is above 400 mg/dl - under 200 is certain to cause bleeding.
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Do not deliver oxytocin via IV push dose, it can cause significant hypotension.
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Tranexamic Acid is available in both IV and PO and can be administered in the field. The dose is 1 gram and can be run over 10 minutes if administered via IV. It is best if used within 3 hours of delivery.
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When performing a uterine massage, place one hand inside the vagina and one hand on the lower abdomen. Then rub the lower abdomen like mad.
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A new option for treating PPH is called the JADA System which is slimmer than a Bakri Balloon and uses vacuum suction to help the uterus clamp down.*
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Another option for a small uterus is to insert a 60 cc Foley catheter.
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In an operating room, a B-Lynch suture can be put in place, uterine artery ligation can be performed, and as a last resort, a hysterectomy can be done.
*EMM is not sponsored by JADA system or the Bakri balloon.
References
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Andrikopoulou M, D'Alton ME. Postpartum hemorrhage: early identification challenges. Semin Perinatol. 2019 Feb;43(1):11-17. doi: 10.1053/j.semperi.2018.11.003. Epub 2018 Nov 14. PMID: 30503400.
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Committee on Practice Bulletins-Obstetrics. Practice Bulletin No. 183: Postpartum Hemorrhage. Obstet Gynecol. 2017 Oct;130(4):e168-e186. doi: 10.1097/AOG.0000000000002351. PMID: 28937571.
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Federspiel JJ, Eke AC, Eppes CS. Postpartum hemorrhage protocols and benchmarks: improving care through standardization. Am J Obstet Gynecol MFM. 2023 Feb;5(2S):100740. doi: 10.1016/j.ajogmf.2022.100740. Epub 2022 Sep 2. PMID: 36058518; PMCID: PMC9941009.
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Health Outreach for Latin America Foundation - HOLA Foundation. (n.d.). http://www.hola-foundation.org/
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Kumaraswami S, Butwick A. Latest advances in postpartum hemorrhage management. Best Pract Res Clin Anaesthesiol. 2022 May;36(1):123-134. doi: 10.1016/j.bpa.2022.02.004. Epub 2022 Feb 24. PMID: 35659949.
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Pacheco LD, Saade GR, Hankins GDV. Medical management of postpartum hemorrhage: An update. Semin Perinatol. 2019 Feb;43(1):22-26. doi: 10.1053/j.semperi.2018.11.005. Epub 2018 Nov 14. PMID: 30503399.
Produced by Jeffrey Olson, MS2 | Edited by Jeffrey Olson and Jorge Chalit, OMSII