Breech Delivery + NRP

This case is written by Dr. Donika Orlich. She is a PGY5 Emergency Medicine resident at McMaster University who also completed a fellowship in Simulation and Medical Education last year.

Why it Matters

All deliveries in the Emergency Department are considered high risk. Further, in most departments, both delivery and neonatal resuscitation are rare events. However, Emergency physicians must be prepared to manage all presentations – including breech delivery! This case highlights several important components of managing these rare presentations, including:

  • The need to adequately prepare the room (if time permits)
  • The importance of calling for a second physician to be available to manage the neonate upon delivery
  • How to safely perform a breech delivery
  • The step-wise progression of neonatal resuscitation post-delivery

Clinical Vignette

EMS Patch: “We have a 19 F complaining of severe abdominal pain onset 1 hour ago. She denies being pregnant, but looks almost full term to us. Contractions seem to be about 1 minute apart. Patient’s Vitals as follows: HR 120, BP 140/85, RR 20, O2 100% on RA. ETA 2 minutes.”

Case Summary

A 19-year-old female presents with EMS in active labour. She denies any history of pregnancy and has had no prenatal care. On examination, infant will be in breech position. The learner must deliver the infant from breech presentation. Following this, the neonate will will present lifeless, and require resuscitation.

Download the case here: Breech + NRP

 

Postpartum Hemorrhage and NRP

This case is written by Dr. Donika Orlich. She is a PGY5 Emergency Medicine resident at McMaster University who also completed a fellowship in Simulation and Medical Education last year.

Why it Matters

Deliveries in the Emergency Department are, by definition, high risk deliveries. However, they are relatively rare. This case highlights some of the “worst case scenarios” that one may face after a delivery in the ED. In particular, it showcases:

  • The key first steps required for NRP in the 60 seconds after delivery
  • The later stages of NRP, including CPR and intubation
  • The approach to a patient with postpartum hemorrhage, including transfusion, fundal massage, administration of uterotonics, and a search for retained products

Clinical Vignette

EMS Patch: “We have a 26 year-old female who is 38 weeks pregnant and appears to be in active labor. She is complaining of severe abdominal pain and has had some vaginal bleeding. We don’t see any crowing yet, but the patient feels the baby’s head is about to come out. Patient’s Vitals as follows: HR 120, BP 140/85, RR 20, O2 100% on room air. ETA 2 minutes.”

Case Summary

The team receives advanced notification from EMS about a woman who is imminently delivering. Upon arrival, delivery will be uncomplicated, but the neonate will appear lifeless. Neonatal resuscitation should be initiated. Eight minutes into the neonatal resuscitation, the team leader will be notified that the mother continues to hemorrhage and is becoming hypotensive. They must begin concurrent workup and management of the mother while continuing to run the neonatal resuscitation. Second & third line medical therapies for uterine atony will be needed, and also manual uterine exploration and packing. Early consultation should be made to NICU, ICU, OB, and Interventional Radiology.

Download the case here: PPH and NRP Combined Case

Obstetrical Trauma

This case is written by Dr. Donika Orlich. She is a PGY5 Emergency Medicine resident at McMaster University who completed a fellowship in Simulation and Medical Education last year.

Why it Matters

The management of a late-term pregnant trauma patient poses unique challenges. In particular, this case highlights the following:

  • The need for manual uterine displacement
  • The importance of considering uterine rupture or abruption as part of the primary or secondary survey (and how this necessitates a pelvic exam)
  • The challenge associated with controlling the noise and chaos in the trauma bay when multiple consultants are present
  • How difficult it is to break bad news about two patients at once to the father

**Special note: please be aware that this case has the potentially to be distressing to learners. As such, if you are to run it, please have resources available to help learners should they be affected by the weight of this case.

Clinical Vignette

You are working in a tertiary care emergency department and receive an EMS Patch: “33F who appears quite pregnant coming to you from an MVC. Belted driver. Prolonged extrication at the scene (30mins). Altered LOC and hypotensive on scene. Current vitals: HR 150, BP 80/50, RR 40, O2 90% on NRB, CBG 6. 1L NS bolus going. ETA 5 minutes.”

Case Summary

A 33 year old G2P1 female at 32 weeks GA presents with blunt trauma following an MVC. She will be hypotensive due to both hypovolemic shock from a pelvic fracture and obstructive shock from a tension pneumothorax. Fetal monitoring will show the fetus in distress with tachycardia and late decelerations. Early airway intervention should be employed, with thoughtful selection of drugs for sedation and paralysis given the pregnancy. After intubation, the patient will remain hypotensive. She will require massive transfusion and coordination of care between orthopedics, general surgery, and obstetrics. The patient’s husband will also arrive after intubation and the team must give him the bad news.

Download the case here: Obstetrical trauma case

ECG for the case found here:

Sinus tachycardia

(ECG source: http://i0.wp.com/lifeinthefastlane.com/wp-content/uploads/2011/12/sinus-tachycardia.jpg)

CXR for the case found here:

CXR Tension ptx

(CXR source: http://cdem.phpwebhosting.com/ssm/pulm/pneumothorax/images/cxr_ptx_3.png)

Pelvic XR for the case found here:

Pelvic X-ray post binder

(PXR source: https://drhem.files.wordpress.com/2011/11/5-4-6.jpg)

Normal pericardial U/S for the case found here: 

Left lung U/S with no lung sliding found here: 

RUQ U/S showing FF found here: RUQ FF

(All U/S images are courtesy of McMaster PoCUS Subspecialty Training Program)

Ruptured Ectopic

This case is written by Dr. Kyla Caners. She is a PGY5 Emergency Medicine resident at McMaster University and is also one of the Editors-in-Chief here at EMSimCases.

Why it Matters

Ectopic pregnancy is a can’t miss diagnosis in Emergency Medicine. This case highlights just how sick patients with ruptured ectopic pregnancies can be. Some important learning points include:

  • The importance to having an approach to the undifferentiated patient with syncope and hypotension
  • The need to order a βHCG in women of child-bearing age who present with syncope
  • The rapid stabilization of a patient with intraperitoneal hemorrhage using massive transfusion.

Clinical Vignette

26 year old female presents after a syncopal episode at home. She immigrated from Cambodia two weeks ago to work as a live-in nanny, but has been feeling unwell for the last 3 days. The patient speaks limited English, but the family she is staying with said she has been vomiting the past few days and was unable to get out of bed this morning. When she tried, she because quite dizzy and then passed out.

Case Summary

26 year-old female, recently immigrated from Cambodia, presents after a syncopal episode at home. At the case outset, she complains of feeling “a little dizzy” and has a HR of 100 and a BP of 90/60. Once the team initiates care, the patient will say she has to vomit and then become poorly responsive and more hypotensive. The patient does not know that she is pregnant, so the team will have to consider the diagnosis early and use bedside U/S to point them in the right direction. The team will then need to initiate a massive transfusion and arrange for surgery. If the ectopic pregnancy is not recognized, the patient will become persistently more hypotensive until she has a PEA arrest.

Download the case here: Ruptured Ectopic

RUQ U/S for the case found here:

RUQ FF

Abdominal U/S with no IUP for the case found here:

(All U/S images are courtesy of McMaster PoCUS Subspecialty Training Program.)

ECG #1 for the case found here:

Sinus tachycardia

(ECG source: http://cdn.lifeinthefastlane.com/wp-content/uploads/2011/12/sinus-tachycardia.jpg)

ECG #2 for the case found here:

normal-sinus-rhythm

(ECG source: http://cdn.lifeinthefastlane.com/wp-content/uploads/2011/12/normal-sinus-rhythm.jpg)

Post-intubation CXR for the case found here:

Post-Intubation

Post Intubation

(CXR source: https://emcow.files.wordpress.com/2012/11/normal-intubation2.jpg)

 

Eclampsia with Apnea Secondary to Magnesium Sulfate Administration

This case was written by Dr. Kyla Caners from McMaster University. Dr. Caners is a PGY4 Emergency Medicine resident and one of the editors-in-chief at EMSimCases.

Why It Matters

This case highlights three important aspects of managing an eclamptic patient:

  • Early administration of magnesium sulfate
  • Adding an anti-hypertensive agent if the blood pressure remains elevated after magnesium administration
  • Recognition of apnea as a side effect of magnesium administration; calcium gluconate is an antidote

Clinical Vignette

Miranda Hamm presents to your local tertiary care ED complaining of a headache. She is a 30 year old G1P0 at 32 weeks. She has had a headache since last night. This morning she started feeling nauseous and began vomiting. Now her vision feels blurred, so she came for assessment.

Case Summary

A 30 year-old female, G1P0 at 32 weeks, presents to the ED with headache, blurred vision, nausea, and vomiting. Her arrival BP is 175/115. As the team coordinates her initial workup, the patient will begin to seize. She will not stop seizing until magnesium sulfate is given. The patient will then require intubation for respiratory depression. The patient will also remain hypertensive, requiring administration of an appropriate antihypertensive agent. The case will end post intubation when the patient has been referred to OB.

Download the case here: Eclampsia Case

Post-intubation CXR for case found here:

Post Intubation

Post Intubation

(CXR source: https://emcow.files.wordpress.com/2012/11/normal-intubation2.jpg)