Laboring Under Pressure Episode 2: Postpartum Hemorrhage with Dr. Kiersten Williams
Release Date: 01/08/2024
Episode 913: Vasopressors after ROSC
Emergency Medical Minute
Contributor: Travis Barlock MD Educational Pearls: Recent study assessed outcomes after ROSC with epinephrine vs. norepinephrine Observational multicenter study from 2011-2018 285 patients received epineprhine and 481 received norepinephrine Epinephrine was associated with an increase in all-cause mortality (primary outcome) Odds ratio 2.6; 95%CI 1.4-4.7; P = 0.002 Higher cardiovascular mortality (secondary outcome) Higher proportion of unfavorable neurological outcome (secondary outcome) Norepinephrine is the vasopressor of choice in post-cardiac arrest care References ...
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Podcast 912: Narcan (Naloxone)
Emergency Medical Minute
Contributor: Taylor Lynch, MD Educational Pearls: Opioid Epidemic- quick facts Drug overdoses, primarily driven by opioids, have become the leading cause of accidental death in the U.S. for individuals aged 18-45. In 2021, opioids were involved in nearly 75% of all drug overdose deaths The rise of synthetic opioids like fentanyl, which is much more potent than heroin or prescription opioids, has played a major role in the increase in overdose deaths What is Narcan AKA Naloxone? Competitive opioid antagonist. It sits on the receptor but doesn’t activate it. When do we give Narcan?...
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Episode 911: Anticholinergic Toxicity
Emergency Medical Minute
Contributor: Taylor Lynch MD Educational Pearls: Anticholinergics are found in many medications, including over-the-counter remedies Medications include: Diphenhydramine Tricyclic antidepressants like amitriptyline Atropine Antipsychotics like olanzapine Antispasmodics - dicyclomine Jimsonweed Muscaria mushrooms Mechanism of action involves competitive antagonism of the muscarinic receptor Symptomatic presentation is easily remembered via the mnemonic: Dry as a bone - anhidrosis due to cholinergic antagonism at sweat glands Red as a beet - cutaneous vasodilation...
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Episode 910: Cellulitis Recovery Timeline
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: How fast does cellulitis recover? A recent prospective cohort study took a look at this question. The study included 300 adults with cellulitis (excluding those with peri-orbital cellulitis or abscesses) in two emergency departments in Queensland, Australia. They collected data from initial and follow-up surveys at 3, 7, and 14 days, and compared clinician and patient assessments at day 14. Improvement was fastest between day 0 and day 3, with gradual progress thereafter. At day 14, many still had skin redness and swelling, though...
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Episode 909: Prehospital Blood Pressure Management in Suspected Stroke
Emergency Medical Minute
Contributor: Aaron Lessen MD Educational Pearls: A recent study assessed EMS treatment of high blood pressure in the field 2404 patients randomized to prehospital treatment (1205) vs. usual care (1199) Included patients with prehospital BP greater than 150 mm Hg The treatment arm’s BP goal was 130-140 mm Hg The primary efficacy outcome was functional status 90 days out Stroke was confirmed by imaging upon hospital arrival On arrival, the mean SBP of the treatment arm was 159 mm Hg compared with 170 mm Hg in the usual care group No significant difference in...
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Episode 908: Sympathomimetic Drugs
Emergency Medical Minute
Contributor: Taylor Lynch MD Educational Pearls: Overview: Sympathomimetic drugs mimic the fight or flight response, affecting monoamines such as dopamine, norepinephrine, and epinephrine Limited therapeutic use, often abused. Types: Amphetamines: Methamphetamine, Adderall, Ritalin, Vyvanse MDMA (Ecstasy) Cocaine (Both hydrochloride salt & free based crack cocaine) Theophylline (Asthma treatment) Ephedrine (For low blood pressure) BZP, Oxymetazoline (Afrin), Pseudoephedrine (Sudafed) MAO Inhibitors (treatment-resistant depression) Mechanisms: Act on adrenergic and dopaminergic...
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Episode 907: Wide-Complex Tachycardia
Emergency Medical Minute
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Episode 906: Case Study of Hypernatremia
Emergency Medical Minute
Contributor: Aaron Lessen MD Educational Pearls: The case: A gentleman came in from a nursing home with symptoms concerning for sepsis. He was hypotensive, hypoxic, febrile, and mentally altered. His past medical history included previous strokes which had left him with deficits for which he required a feeding tube. Initial workup included some point of care labs which revealed a sodium of 165 mEq/L (normal range 135-145) Hypernatremia What causes it? Dehydration, from insufficient fluid intake. This might happen in individuals who cannot drink water independently, such as...
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Episode 905: Oseltamivir (Tamiflu) for Influenza
Emergency Medical Minute
Contributor: Aaron Lessem MD Educational Pearls: Oseltamivir (Tamiflu) is an antiviral medication used commonly to treat influenza Trials show that the medication reduces the duration of illness by less than 1 day (~16 hours in one systematic review) Benefit only occurs if taken within 48 hours of symptom onset Must be taken for 5 days A 2024 meta-analysis reviewed 15 randomized-controlled trials for the risk of hospitalization No reduction in hospitalizations with oseltamivir in patients over the age of 12 No difference in high-risk patients over the age of 65 or those...
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Episode 904: Cardiovascular Risks of Epinephrine
Emergency Medical Minute
Contributor: Aaron Lessen MD Educational Pearls: Epinephrine is essential in the treatment of anaphylaxis, but is epinephrine dangerous from a cardiovascular perspective? A 2024 study in the Journal of the American College of Emergency Physicians Open sought to answer this question. Methods: Retrospective observational study at a Tennessee quaternary care academic ED that analyzed ED visits from 2017 to 2021 involving anaphylaxis treated with IM epinephrine. The primary outcome was cardiotoxicity Results: Out of 338 patients, 16 (4.7%) experienced cardiotoxicity. Events included...
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