*With the exception of programs from the ACCEL series, each of which qualifies for up to 4 Category 1 CME credits.
NEW Audio-Digest Emergency Medicine
Volume 30, Issue 04
February 21, 2013
ED Deliveries with Complications Rachel Chin, MD,
Clinical Controversies: Use of Steroids in Pediatric Infections Peggy S. Weintrub, MD
Highlights from Topics in Emergency Medicine, sponsored by the Department of Emergency Medicine, University of California, San Francisco, School of Medicine
The following is an abstracted summary, not a verbatim transcript, of the lectures/discussions on this audio program.
Emergency Medicine Program Info Accreditation InfoCultural & Linguistic Competency Resources
Obstetric and Pediatric Issues in the ED
Highlights from Topics in Emergency Medicine, sponsored by the Department of
Emergency Medicine, University of California, San Francisco, School of Medicine
The goal of this program is to improve the emergency department management of pregnant patients and children with acute infections. After hearing and assimilating this program, the clinician will be better able to:
1. Determine the etiology of hypertension in pregnant patients.
2. Diagnose and treat acute abdominal pain in pregnant patients.
3. Resolve complications during labor and delivery.
4. Reduce the risk for hearing loss associated with meningitis.
5. Improve the long-term outcome of patients with septic arthritis.
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and planning committee reported nothing to disclose.
ED Deliveries with Complications
Rachel Chin, MD, Professor of Clinical Emergency Medicine, University of California, San Francisco, School of Medicine
Physiology of pregnancy: vital signs — pregnant women have increased heart rate (≈20 beats/min higher by third trimester) and decreased blood pressure (BP; systolic BP ≈100 mm Hg in second and third trimester); cardiac output, stroke volume, and plasma volume all increase during pregnancy; mass of red blood cells (RBCs) increased; increase in RBC mass does not occur as quickly as increase in plasma volume, resulting in physiologic anemia and slight respiratory alkalosis
Complications of Pregnancy
Preeclampsia: hypertension (new onset or worsening of chronic hypertension) in pregnant woman after 24 wk gestation; occurs in ≤7% of pregnancies (most often in first pregnancies); risk factors — obesity; young age; lack of prenatal care; multiple gestations; low socioeconomic status; diagnostic triad — hypertension, proteinuria, and facial edema; etiology — unknown; one study from Journal of Reproductive Immunology found that women exposed to antigens from partner’s seminal fluid before pregnancy had lower incidence of preeclampsia; definition of hypertension in preeclampsia — systolic BP> 140 mm Hg and diastolic BP> 90 mm Hg or, increase in systolic BP and diastolic BP of 30 mm Hg and 15 mm Hg above baseline levels, respectively; other signs and symptoms — proteinuria; facial edema; rapid weight gain; decreased urine output; headache; blurred vision; nausea; vomiting; right upper quadrant or epigastric pain; complications — eclampsia; abruption; cerebral edema; stroke; renal failure; hemolytic anemia; thrombocytopenia; liver problems; retinal damage; pulmonary edema; emergency management — induce labor if infant at term; consider inducing labor if infant preterm; lay patient on left side to alleviate pressure on vena cava; slowly decrease patient’s BP; administer steroids to patient if infant aged <34 wk to mature lungs before delivery
Eclampsia: signs and symptoms — same as in preeclampsia, plus seizures and coma; occurs in <1% of pregnancies; clinical management — intravenous (IV) magnesium sulfate best anticonvulsant; Lancet study found magnesium sulfate superior to phenytoin and diazepam for treatment and prevention of recurrent seizures in pregnant patients; give patient pure oxygen; position patient on left side; administer 4-g bolus of IV magnesium sulfate, followed by IV drip of 2 g/hr; 5 g in each buttock (total of 10 g) if no IV access available; administer steroids to mature lungs of infant; magnesium sulfate — reduces risk for recurrent seizures, maternal mortality, and neonatal morbidity; acts as potent vasodilator and neuroprotective agent; maintain serum level of 4 to 7 mg/dL; titrate dose to maintain deep tendon reflex if serum measurement not possible; side effects of magnesium sulfate — drowsiness, flushing, diaphoresis, hyporeflexia, and hypocalcemia; calcium gluconate used to remedy toxicity of magnesium sulfate (loss of deep tendon reflex, ataxia, pulmonary edema, and respiratory paralysis); signs of toxicity — loss of deep tendon reflexes, somnolence, slurred speech, muscular paralysis, respiratory difficulty, cardiac arrest
Hypertensive emergencies in pregnancy: hydralazine — arterial vasodilator; give 5 mg, repeated every 20 min to total dose of 20 mg, then start infusion of 5 to 10 mg/hr; must wait 20 min after each dose to avoid hypotension; labetalol — nonselective α- and β-antagonist; start with 20 mg and double every 10 min to total dose of 300 mg; then infuse at 1 to 2 mg/min; less reflexive tachycardia and hypotension than with hydralazine
Placental abruption: premature separation of placenta from uterus; risk factors — older age; hypertension; multigravida; preeclampsia; trauma; cocaine toxicity; signs and symptoms — mild to moderate vaginal bleeding (bleeding not always apparent because it may be concealed at fundus of uterus); continuous stabbing abdominal pain; uterus rigid and tender between contractions; signs and symptoms of hypovolemia; fetal distress; pearl — placental abruption must be ruled out in pregnant patient with hypovolemic shock out of proportion to visible bleeding, or third trimester abdominal pain; management — IV oxygen monitor; place patient on left side to decrease pressure on vena cava; provide supportive care for hypovolemic shock; send patient to operating room (OR) if fetal distress detected
Placenta previa: occurs when placenta implants directly over cervix; signs and symptoms — painless bright red vaginal bleeding after any vaginal penetration; uterus soft and not nontender; signs and symptoms of hypovolemia proportional to observed blood loss; may have reflexive contractions; management — bed rest; vaginal rest (tampon use contraindicated); supportive care; patient will require cesarean delivery; administer steroids if infant < 34 wk gestational age; pearl — vaginal examination contraindicated in pregnant patients within third trimester who have vaginal bleeding until location of placenta known (may dislodge clot and cause more bleeding)
Introduction: 3 stages of labor; contraction and dilation (first stage) may last ≤12 hr in nulliparous women and ≤6 hr in multiparous women; delivery of baby (second stage); delivery of placenta (third stage); consultation with new patient — important to develop rapport with new patient and gather vital information; ask patient about number of children, when water broke, color of water, prenatal care, expectations for complications, prescription medications, drug and alcohol use; ask patient if she feels need to push or have bowel movement; signs of imminent delivery — patient feels need to have bowel movement; crowning; rupture of amniotic sac; regular contractions 1 to 2 min apart lasting up to 60 sec; call for pediatrician, obstetrician, and someone from neonatal intensive care unit
Equipment for childbirth: childbirth pack should include sterile gloves, surgical scissors, hemostats, bulb syringe, towels, gauze, sponges, baby blankets, sanitary napkins, and plastic bag
Procedure: stretch labia so that infant’s head does not stick; support head and perineum; apply downward pressure to decrease pressure on urethra; prevent explosive delivery (should be slow and controlled process); check for nuchal cord (may be wrapped multiple times around); may pull cord over infant’s head or clamp cord if it does not come over infant’s head to treat nuchal cord (do not clamp cord until shoulder dystocia ruled out); must have anterior portion of shoulder out of vagina before cord clamping and cutting attempted; check airway and neck, suction airway after cord dealt with; delivery — gently glide head out and down to deliver anterior shoulder; pull up to deliver posterior shoulder once anterior shoulder clears mother; do not push so hard as to damage brachial plexus; after delivery — support infant’s head, shoulders, and feet when holding baby; keep infant’s head lower than feet to facilitate drainage; suction mouth; keep baby warm with blankets; clamp and cut cord (first clamp applied 4 in from baby, second clamp applied 2 in from first clamp, cut cord in between clamps); flick infant’s feet and rub back to stimulate; administer blow-by oxygen if baby’s heart rate <100 beats/min or if baby has persistent central cyanosis; resuscitation performed based on Apgar score (evaluation of infant’s pulmonary, cardiovascular, and neurologic function); resuscitate baby if Apgar score <7; score of 7 to 10 normal score determined at 1 min and 5 min postpartum; delivery of placenta — may take ≤30 min (especially long if infant preterm); ensure that placenta completely delivered; do not attempt to pull placenta out; massage uterus to stimulate contraction and vasoconstriction; last steps — examine perineum and cervix for lacerations; consider administering oxytocin (Pitocin) to decrease bleeding (20 units in 1 L normal saline); estimate bleeding postdelivery; administer oxytocin, methylergometrine (Methergine), or carboprost (Hemabate) if patient has excessive bleeding; methylergometrine contraindicated if patient has hypertension; carboprost contraindicated if patient has respiratory problems, eg, asthma
Shoulder dystocia (SD): infant’s anterior shoulder stuck behind mother’s pubic bone; impairs infant’s breathing ability and compresses umbilical cord; occurrence of SD unpredictable; some association with larger infants; McRoberts maneuver — commonly used method to assist in delivery of pregnant women with SD; mother placed on back with her knees pushed toward her ears; place suprapubic pressure on abdomen to dislodge infant’s shoulder; speaker mentions other techniques to fix SD but recommends McRoberts position
Breech presentation: infant’s legs present first; place mother in standard delivery position; administer high-flow oxygen; allow legs to emerge spontaneously (do not pull on infant’s legs); remove arms once legs come out; instruct another person to apply suprapubic pressure when head begins to emerge; prepare for resuscitation
Limb presentation: place mother in Trendelenburg position; administer high-flow oxygen; put pressure on presenting limb to decrease pressure on umbilical cord; send patient to OR
Clinical Controversies: Use of Steroids in
Peggy S. Weintrub, MD, Clinical Professor of Pediatrics and Chief, Pediatric Infectious Diseases, University of California, San Francisco, School of Medicine
Mononucleosis (MN): studies indicate that steroids may shorten duration of fever; steroids not shown to alleviate other symptoms (eg, fatigue, sore throat, malaise) of MN; no apparent harm in using steroids, but use not indicated for treatment of uncomplicated MN; complications — steroids may be indicated for complications of infection with Epstein-Barr virus (EBV); steroids indicated in patients with MN and hemolytic anemia, idiopathic thrombocytopenic purpura, myocarditis, or impending airway obstruction (eg, swollen tonsils); patients who respond to steroids do so within 1 or 2 days; no agreement on dose, but short burst sufficient
Tuberculosis (TB): steroids indicated in patients with pericarditis, meningitis, or endobronchial disease (in children) caused by TB; endobronchial disease — these children have lymph nodes that may impinge on airway; x-ray may show Ghon complex and lobar infiltrate; start steroids along with therapy for TB
Steroids for meningitis: animal model — rabbits with meningitis have large inflammatory response to antibiotic therapy immediately after treatment; animals had increased levels of tumor necrosis factor (TNF), interleukin-1, and white blood cells (WBCs) in cerebrospinal fluid (CSF) after antibiotic therapy; this data consistent with clinical dogma that treatment of meningitis initially makes patient feel worse; study found that administration of steroids before antibiotic treatment diminished inflammatory response to antibiotics (WBCs and TNF did not increase); administration of steroids after antibiotic treatment had no effect on inflammatory response; study found that severity of inflammatory response to antibiotics correlated with outcome; studies in children — examined effect of steroid (dexamethasone) on incidence of hearing loss in patients treated with antibiotics for meningitis; study concluded that dexamethasone effective in reducing risk for hearing loss associated with meningitis; majority of patients in study had meningitis caused by Haemophilus influenzae type B; some patients in group had pneumococcal disease, but number too small to draw conclusion about effectiveness of dexamethasone for pneumococcal meningitis; Central and South American study — examined effect of steroid use on neurologic outcomes and sequelae in patients treated for meningitis; found no difference for severe hearing loss and trend in that direction for use of hearing aids; study found that steroid use did not cause significant harm to patients with viral meningitis; no statistically significant difference in incidence of gastrointestinal (GI) bleeding; studies not supportive of steroid use — several studies concluded that steroids ineffective in reducing inflammatory response to antibiotics; given before or after (up to 4 hr) antibiotic therapy; speaker concludes that these studies prove that steroids should always be administered before antibiotics; results of study skewed because of late administration of steroids; antibiotic penetration — data suggest that administration of steroids decreases ability of vancomycin to penetrate into CSF; this effect not supported as clinically significant and never associated with clinical failure; variation of organisms — different causative organisms associated with varying degrees of purulence; pneumococcus makes most pus, H influenzae makes second most, and Neisseria meningitidis makes least pus; speaker asserts that justified to assume benefit of steroids found in patients with H influenzae meningitis translates to patients with pneumococcal meningitis; no evidence for effectiveness of steroids in patients with meningococcal disease; clinical algorithm — if patient suspected to have meningitis and has condition (eg, immunocompromise, papilledema) that might delay lumbar puncture (LP), get blood culture and give steroids and antibiotics before patient gets computed tomography (CT), and perform LP if CT negative; if no complicating condition, perform LP, get blood culture, and administer steroids and antibiotics; discontinue therapy if LP negative for bacterial meningitis; Cochrane review — examined effects of steroids on patients (adults and children) with meningitis; found that steroid use reduced incidence of hearing loss and decreased mortality in patients with H influenzae meningitis; steroid use of no benefit to patients with meningococcal disease; contraindications — steroids contraindicated for meningitis in infants aged <6 wk, in patients already started on antibiotics, and those infected with N meningitidis
Septic arthritis: dexamethasone administered in patients with septic arthritis to preserve long-term function of infected joint and shorten duration of symptoms; study found that patients with septic arthritis given dexamethasone had better long-term outcome and increased joint function, compared to patients given placebo; methicillin-sensitive Staphylococcus aureus primary pathogen in this study; second study — study of patients with septic arthritis found use of steroids associated with shortened acute course of infection (fewer days with pain, range of motion restored more quickly); this study allowed administration of antibiotics before steroids; patients in this study infected with Kingella kingae (less aggressive pathogen); UCSF protocol for suspected septic arthritis — obtain usual baseline diagnostic tests; perform joint aspiration before administering steroids and antibiotics; consider waiting to administer steroids and antibiotics if joint aspiration not available; may initiate treatment before aspiration if convinced of infection (not ideal); grade 2C evidence for this protocol
Drs. Chin and Weintrub spoke at Topics in Emergency Medicine, held September 9, 2011, in San Francisco, CA, and sponsored by the Department of Emergency Medicine, University of California, San Francisco, School of Medicine. For future CME activities by the University of California, San Francisco, School of Medicine, visit their web page: http://emergency.ucsf.edu/cme/. The Audio-Digest Foundation thanks the speakers and University of California, San Francisco, School of Medicine for their cooperation in the production of this program.
Brouwer MC et al: Nationwide implementation of adjunctive dexamethasone therapy for pneumococcal meningitis. Neurology 2010 Oct 26;75(17):1533-9; Dennis AT: Management of pre-eclampsia: issues for anaesthetists. Anaesthesia 2012 Sep;67(9):1009-20; Harel L et al: Dexamethasone therapy for septic arthritis in children: Results of a randomized double-blind placebo-controlled study. J Pediatr Orthop 2011 Mar; 31:211; Heckenberg SG et al: Adjunctive dexamethasone in adults with meningococcal meningitis. Neurology 2012 Oct 9;79(15):1563-9; Hoffman MK et al: A comparison of obstetric maneuvers for the acute management of shoulder dystocia. Obstet Gynecol 2011 Jun;117(6):1272-8; Koelman CA et al: Correlation between oral sex and a low incidence of preeclampsia: a role for soluble HLA in seminal fluid? J Reprod Immunol 2000 Mar;46(2):155-66; McLaurin R, Geraghty S: Placenta praevia, placental abruption and amphetamine use in pregnancy: A case study. Women Birth 2012 Dec 18; Pfausler B, Schmutzhard E: Controversies in Neurology, Vienna, 2012: Steroids in bacterial meningitis. J Neural Transm 2012 Dec 20; Ricard JD et al: Levels of vancomycin in cerebrospinal fluid of adult patients receiving adjunctive corticosteroids to treat pneumococcal meningitis: a prospective multicenter observational study. Clin Infect Dis 2007 Jan 15;44(2):250-5; Vest AR, Cho LS: Hypertension in pregnancy. Cardiol Clin. 2012 Aug;30(3):407-23
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