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Laboring Under Pressure Episode 3: Hypertensive Disorders of Pregnancy with Dr. Kiersten Williams

Emergency Medical Minute

Release Date: 09/12/2024

Episode 937: Pneumomediastinum show art Episode 937: Pneumomediastinum

Emergency Medical Minute

Contributor: Megan Hurley MD Educational Pearls: What is the mediastinum? The thoracic cavity is separated into different compartments by membranes The lungs exist in their own pleural cavities, and the mediastinum is everything in between The mediastinum extends from the sternum to the thoracic vertebrae and includes the heart, the aorta, the trachea, the esophagus, the thymus, as well as many lymph nodes and nerves. What is a pneumomediastinum? Air in the mediastinum How can pneumomediastinum be categorized? Traumatic Ex. Stab wound to the trachea Ex. Boerhaave’s...

info_outline Episode 936: Etomidate vs. Ketamine for Rapid Sequence Intubation show art Episode 936: Etomidate vs. Ketamine for Rapid Sequence Intubation

Emergency Medical Minute

Contributor: Ricky Dhaliwal MD Educational Pearls:  Etomidate was previously the drug of choice for rapid sequence intubation (RSI) However, it carries a risk of adrenal insufficiency as an adverse effect through inhibition of mitochondrial 11-β-hydroxylase activity A recent meta-analysis analyzing etomidate as an induction agent showed the following: 11 randomized-controlled trials with 2704 patients Number needed to harm is 31; i.e. for every 31 patients that receive etomidate for induction, there is one death The probability of any mortality increase was 98.1% ...

info_outline Episode 935: Pregnancy Extremis - TOLDD show art Episode 935: Pregnancy Extremis - TOLDD

Emergency Medical Minute

Contributor: Aaron Lessen MD Educational Pearls: Pregnant patients at high risk of cardiac arrest, in cardiac arrest, or in extremis require special care A useful mnemonic to recall the appropriate management of critically ill pregnant patients is TOLDD T: Tilt the patient to the left lateral decubitus position This position relieves pressure exerted from the uterus onto the inferior vena cava, which reduces cardiac preload If the patient is receiving CPR, an assistant should displace the uterus manually from the IVC towards the patient’s left side O: Administer high-flow...

info_outline Episode 934: Subendocardial Ischemia show art Episode 934: Subendocardial Ischemia

Emergency Medical Minute

Contributor: Travis Barlock MD Educational Pearls: What is the ST segment? The ST segment on an ECG represents the interval between the end of ventricular depolarization (QRS) and the beginning of ventricular repolarization (T-wave).  It should appear isoelectric (flat) in a normal ECG. What if the ST segment is elevated? This is evidence that there is an injury that goes all the way through the muscular wall of the heart (transmural) This is very concerning for a heart attack (STEMI) but can be occasionally caused by other pathology, such as pericarditis What if the ST...

info_outline Episode 933: Benign Convulsions with Gastroenteritis show art Episode 933: Benign Convulsions with Gastroenteritis

Emergency Medical Minute

Contributor: Alec Coston MD Educational Pearls: Causes of seizures in a fairly well-appearing child with diarrhea: Electrolyte abnormalities: hypocalcemia, hyponatremia Also hyperkalemia which causes arrhythmias and syncope - can appear like seizures Hypoglycemia If the child has diarrhea and appears very sick, differential diagnosis may include: Hemolytic uremic syndrome (HUS): simultaneous occurrence of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury Typically caused by Shiga-like toxin producing Escherichia coli (also known as EHEC, or...

info_outline Episode 932: Induction Agent Hypotension show art Episode 932: Induction Agent Hypotension

Emergency Medical Minute

Contributor: Aaron Lessen MD Educational Pearls: Induction agent selection during rapid sequence intubation involves accounting for hemodynamic stability in the post-intubation setting Many emergency departments use ketamine or etomidate A recent study sought to explore the rates of post-induction hypotension of ketamine compared with propofol Single center retrospective cohort study of patients between 2018-2021 Ketamine and propofol were both significantly associated with post-induction hypotension Ketamine adjusted odds ratio = 4.50 Propofol adjusted odds ratio = 4.88 50%...

info_outline Episode 931: Naloxone in Cardiac Arrest show art Episode 931: Naloxone in Cardiac Arrest

Emergency Medical Minute

Contributor: Aaron Lessen MD Educational Pearls: Can opioids cause cardiac arrest? Opioids can cause respiratory suppression and the subsequent low oxygen levels can lead to arrhythmias and eventually cardiac arrest. In 2023, 17% of out-of-hospital cardiac arrests (OHCA) were attributable to opioids. Given that this is a rising cause of cardiac arrest, should we just treat all cardiac arrest with naloxone (Narcan)? Naloxone is correlated with an increased chance of return of spontaneous circulation (ROSC) Additionally, a wide variety of individuals can be exposed to opioids and...

info_outline Episode 930: Holding Costs show art Episode 930: Holding Costs

Emergency Medical Minute

Contributor: Aaron Lessen MD Educational Pearls: A study evaluated the patient-care impact and financial costs of holding patients in the ED, a nationwide issue Prospective, observational study of acute stroke management Conducted at a large urban, comprehensive stroke center The study evaluated patients in multiple categories:  admitted to med/surg admitted to med/surg but held in the ED admitted to the ICU Admitted to ICU but held in the ED Examined the amount of time nurses and providers spent with each patient This was analyzed in conjunction with the...

info_outline Episode 929: Traumatic Aortic Injury show art Episode 929: Traumatic Aortic Injury

Emergency Medical Minute

Contributor: Aaron Lessen MD Educational Pearls: Aortic injury occurs in 1.5-2% of patients who sustain blunt thoracic trauma Majority are caused by automobile collisions or motorcycle accidents Due to sudden deceleration mechanism accidents Clinical manifestations Signs of hypovolemic shock including tachycardia and hypotension, though not always present Patients may have altered mental status Imaging Widened mediastinum on chest x-ray, though not highly sensitive CT is more sensitive and specific, and signs of thoracic injury include an intimal flap, aortic wall...

info_outline Laboring Under Pressure Episode 4: Obstetric Emergency in South Africa with Dr. Meghan Hurley show art Laboring Under Pressure Episode 4: Obstetric Emergency in South Africa with Dr. Meghan Hurley

Emergency Medical Minute

Laboring Under Pressure Episode 4: Obstetric Emergency in South Africa with Dr. Meghan Hurley Contributors: Meghan Hurley MD, Travis Barlock MD, Jeffrey Olson MS3 Show Pearls Map of South Africa Referenced South Africa Geography Lesson There is a big disparity between Cape Town and its neighbor Khayelitsha. Cape Town is the legislative capital and economic hub of South Africa, known for its infrastructure, tourist attractions, and developed urban areas. Khayelitsha Township is a large informal settlement on the outskirts of Cape Town, with limited infrastructure and services compared to...

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Contributor: Kiersten Williams MD, Travis Barlock MD, Jeffrey Olson MS3

Show Pearls

  • Hypertensive disorders of pregnancy are one of the leading causes of maternal mortality worldwide.

  • Hypertension (HTN) complicates 2-8% of pregnancies

  • The definition of HTN in pregnancy is a systolic >140 or diastolic >90, measured 4 hours apart

  • There is a range of HTN disorders

    • Chronic HTN which could have superimposed preeclampsia (preE) on top

    • Gestational HTN in which there are no lab abnormalities

    • PreE w/o severe features

      • Protein in urine

      • Urine protein >300 mg in 24 hours

      • Urine Protein to Creatinine ratio of .3

      • +2 Protein on urine dipstick

    • PreE w/ severe features

      • Systolics above 160 mmHg

      • Diastolics above 110 mmHg

      • Headache, especially not going away with meds, or different than previous headaches

      • Visual changes, anything that lasts more than a few minutes

      • RUQ pain, which could present as heartburn

      • Pulmonary edema

      • Low platelets, if <150 perk up ears, <100 definitely look into

      • Renal insufficiency, creatinine 1.1 or higher or doubling of baseline

      • Impaired liver function

      • Note: Hemoconcentration and LDH >600 are not diagnostic but worth paying attention to

  • Treatment

    • Labetalol, IV

      • Avoid in bradycardia, asthma, or myocardial disease

      • Quick up titrate, with dosing regimens such as 20-20-40 or 20-40-80 (mg)

    • Hydralazine, IV

      • 5 mg starting, then another 5 mg then 10 mg if not working

    • Nifedipine, Oral

      • Can cause a headache

    • Goal is not to normalize BP but bring it down slowly

  • How to give magnesium

    • Start with 6 g or 4 g over 20 minutes if the patient is small or has bad kidney function

    • Follow with 2 g per hour or 1 g per hour

    • Don’t give in myasthenia gravis

  • What should you do if the patient progresses to eclampsia (seizures)

    • Magnesium is the best drug

    • Can use phenytoin or benzos IV as an alternate

    • Diazepam is available PR which is a good option if you don’t have IV access

    • IM magnesium is doable but painful, mix with lidocaine and split dose between the butt cheeks

  • Facts about post-partum PreE

    • 20% of women will have HTN post-partum

    • Most resolve by 6 weeks

    • If it lingers past 6 months this is chronic HTN

    • If the patient has severe features (see above) they desevere 24 hours on magnesium while being monitored on the L&D floor

    • Post-partum is the most common time for strokes

    • Providers can be much more aggressive with HTN treatment because the fetus is no longer being exposed

    • Enalapril is safe in breast feeding

    • Some patients might need to give up breast feeding to be on even more aggressive HTN therapy

    • Are NSAIDs safe while breastfeeding?

      • Motrin is pretty safe

    • Pulm edema is a risk, be careful with fluids

  • Last pearl: Put pregnant patients in left or right lateral decubitus while in ER or put a folded towel under their hip to help with venous return which can also help with nausea

 

References

  1. Metoki, H., Iwama, N., Hamada, H., Satoh, M., Murakami, T., Ishikuro, M., & Obara, T. (2022). Hypertensive disorders of pregnancy: definition, management, and out-of-office blood pressure measurement. Hypertension research : official journal of the Japanese Society of Hypertension, 45(8), 1298–1309. https://doi.org/10.1038/s41440-022-00965-6

  2. Rana, S., Lemoine, E., Granger, J. P., & Karumanchi, S. A. (2019). Preeclampsia: Pathophysiology, Challenges, and Perspectives. Circulation research, 124(7), 1094–1112. https://doi.org/10.1161/CIRCRESAHA.118.313276

  3. Reed, B. (2020, May 2). ‘They didn’t listen to me’: Amber Rose Isaac tweeted about her death before dying in childbirth. The Guardian. https://www.theguardian.com/us-news/2020/may/02/amber-rose-isaac-new-york-childbirth-death

  4. Reisner, S. H., Eisenberg, N. H., Stahl, B., & Hauser, G. J. (1983). Maternal medications and breast-feeding. Developmental pharmacology and therapeutics, 6(5), 285–304. https://doi.org/10.1159/000457330

  5. Wilkerson, R. G., & Ogunbodede, A. C. (2019). Hypertensive Disorders of Pregnancy. Emergency medicine clinics of North America, 37(2), 301–316. https://doi.org/10.1016/j.emc.2019.01.008

  6. Wu, P., Green, M., & Myers, J. E. (2023). Hypertensive disorders of pregnancy. BMJ (Clinical research ed.), 381, e071653. https://doi.org/10.1136/bmj-2022-071653

 

Produced by Jeffrey Olson, MS3 | Edited by Jeffrey Olson and Jorge Chalit, OMSIII