loader from loading.io

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

Emergency Medical Minute

Release Date: 09/12/2024

Episode 925: Table Sugar for Tongue Entrapment show art Episode 925: Table Sugar for Tongue Entrapment

Emergency Medical Minute

Contributor: Aaron Lessen, MD Educational Pearls: Pediatric case study where the child’s tongue was stuck in the opening of a hard plastic drink lid Entrapment restricts circulation which causes fluid to build and the tongue becomes more edematous with time There is a risk of ischemia with prolonged entrapment Initially tried 2% viscous lidocaine for analgesia and lubricant The ER recognized that this mucosal, edematous tongue could benefit from the trick for ostomies and rectal prolapses → table sugar! Sugar granules absorb water which decreases tissue edema This option...

info_outline Episode 924: Pregnancy Cold Remedies show art Episode 924: Pregnancy Cold Remedies

Emergency Medical Minute

Contributor: Megan Hurley, MD Educational Pearls: Fevers Tylenol Up until 20 weeks NSAIDs are ok but after 20 weeks they are contraindicated Can limit the amount of amniotic fluid produced Can lead to growth restriction Can cause premature closure of the ductus arteriosus Cough Cough drops Humidifier Guafenesine and dextromethorphan (Mucinex) is not well studied but is probably ok with caution in certain circumstances such as post-tussive emesis causing poor PO intake and weight loss Congestion Flonase (Fluticasone nasal spray) Nasal rinses Humidifier 1st...

info_outline Episode 923: Blunt Cerebrovascular Injury show art Episode 923: Blunt Cerebrovascular Injury

Emergency Medical Minute

Contributor: Travis Barlock MD Educational Pearls: Assessment of head and neck vascular injury due to blunt trauma Symptomatic patients require screening head and neck CT angiography EAST guidelines include the following criteria for a screening CT angiography in blunt head trauma: Unexplained neurological deficits Arterial nosebleed GCS < 6 Petrous bone fracture Cervical spine fracture Any size fracture through the transverse foramen LeFort fractures type II or type III EAST guidelines include a grading scale for vascular injury: Grade I: Luminal irregularity...

info_outline Episode 922: Chest Tube Irrigation show art Episode 922: Chest Tube Irrigation

Emergency Medical Minute

Contributor: Aaron Lessen, MD Educational Pearls: Hemothorax: blood in the pleural cavity, most commonly due to chest trauma Treatment: thoracostomy tube for blood drainage helps to avoid clotting, scarring, and infection A recent study looked at patients with hemothorax who either received or did not receive thoracic irrigation with saline Evaluated incidence of secondary intervention, such as video-assisted thoracoscopic surgery (VATS), for persistent hemothorax Patients who received irrigation had a slight decrease in secondary intervention frequency Multi-center study -...

info_outline Episode 921: Pediatric Hypoglycemia show art Episode 921: Pediatric Hypoglycemia

Emergency Medical Minute

Contributor: Taylor Lynch, MD Educational Pearls: When it comes to hypoglycemia, the age dictates possible causes Neonate: Hormonal deficiency Congenital Adrenal Hyperplasia (21-hydroxylase deficiency, 11β-hydroxylase deficiency) Primary or Secondary Adrenal Insufficiency leading to cortisol deficiency  Hypopituitarism Inborn errors of metabolism Systemic infection (Under 30 days old should trigger a full infectious workup) Toddler Accidental ingestions Sulfonylureas such as glipizide or glyburide Older children Addison’s Disease (Hypocortisolism) ...

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

Emergency Medical Minute

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...

info_outline Episode 920: Pediatric Growth Estimates show art Episode 920: Pediatric Growth Estimates

Emergency Medical Minute

Contributor: Sean Fox, MD Educational Pearls: Newborns may lose up to 10% of their birth weight in the first week of life Weight loss is greatest in exclusively breastfed infants Should regain birth weight by age 2 weeks Newborns should gain an average of 30g (1 oz) per day in the first 3 months of life Some will gain more and some will gain less Infants double their birth weight by 6 months of life and triple their weight by 12 months A 1-year-old should weigh on average 10 kg (22 lbs) A 3-year-old should weigh on average 15 kg (33 lbs) 2-year-olds are between 10-15 kg...

info_outline Episode 919: EKG Criteria for Adenosine show art Episode 919: EKG Criteria for Adenosine

Emergency Medical Minute

Contributor: Travis Barlock, MD Educational Pearls: SVT: supraventricular tachycardia Pharmacotherapy for SVT includes drugs that block the AV node, such as adenosine EKG criteria before adenosine administration in SVT Regular rhythm Monomorphic: ​​all QRS complexes are identical If the EKG is polymorphic, with QRS complexes displaying changing morphologies, it is unsafe to administer adenosine  Adenosine can worsen polymorphic VTach and lead to VFib References Ganz, Leonard I., and Peter L. Friedman. “Supraventricular Tachycardia.” New England Journal of...

info_outline Episode 918: Automated Blood Pressure Cuffs show art Episode 918: Automated Blood Pressure Cuffs

Emergency Medical Minute

Contributor: Aaron Lessen, MD Educational Pearls: How does an automated blood pressure cuff work? Automated blood pressure cuffs work differently than taking a manual blood pressure. While taking a manual blood pressure, one typically listens for Korotkoff sounds (turbulent flow) while slowly deflating the cuff. An automatic blood pressure cuff only senses the pressure in the cuff itself and specifically pays attention to oscillations in the pressure caused by when the pressure of the cuff is between the systolic (heart squeezing) and diastolic (heart relaxed) pressures. These...

info_outline Episode 917: Heat-Related Illnesses show art Episode 917: Heat-Related Illnesses

Emergency Medical Minute

Contributor: Megan Hurley, MD Educational Pearls:  Heat cramps Occur due to electrolyte disturbances Most common electrolyte abnormalities are hyponatremia and hypokalemia Heat edema Caused by vasodilation with pooling of interstitial fluid in the extremities Heat rash (miliaria) Common in newborns and elderly Due to accumulation of sweat beneath eccrine ducts Heat syncope Lightheadedness, hypotension, and/or syncope in patients with peripheral vasodilation due to heat exposure Treatment is removal from the heat source and rehydration (IV fluids or Gatorade) ...

info_outline
 
More Episodes

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