This weeks’ case was written by Dr. Amy Hildreth who is an emergency physician and assistant program director for the EM residency at Naval Medical Centre in San Diego.
Why it Matters
Resuscitative hysterotomy is fortunately a rare procedure, however, as with other high impact, low occurrence procedures in emergency medicine, it can be life saving! Equally as important as the procedure itself are the crisis resource management (CRM) components involved in managing two critically ill patients; the mother and the baby.
This case was designed to highlight the management of a pregnant trauma patient, the procedure of resuscitative hysterotomy, and the CRM principles involved. It is not for the faint of heart!
A 30 y/o female was found unresponsive in an SUV that rolled over after being side swiped on the highway going approximately 70 mph (~110kph). The patient has a large, gravid abdomen and, as she was wheeled into the resuscitation bay, the pulse was lost.
The team receives advance notification from EMS about a 30 year-old female who is visibly pregnant and was in a car accident. Upon arrival to the ED the patient loses pulses and CPR begins. The team must begin ACLS/ATLS and proceed to resuscitative hysterotomy. After delivery they should begin neonatal resuscitation and continue management of the mother. Early consultation should be made to trauma surgery, NICU, and OB.
This case is written by Drs. Nadia Primiani and Sev Perelman. They are both emergency physicians at Mount Sinai Hospital in Toronto. Dr. Primiani is the postgraduate education coordinator at the Schwartz/Reisman Emergency Centre. Dr. Perelman is the director of SIMSinai.
Why it Matters
Most emergency physicians have some degree of discomfort when a woman in her third trimester presents to the ED for any complaint. When that woman presents in acute distress, the discomfort is increased even further! This case takes learners through the management of a patient with a pregnancy-induced cardiomyopathy, reviewing:
- The importance of calling for help early
- The fact that all pregnant patients at term must be presumed to have difficult airways
- That the treatment of the underlying medical condition is still the primary focus – in this case, BiPap, definitive airway management, and ultimately, inotropic support
You are working in a community ED and your team has been called urgently by the nurse to see a 38 year old female who is G2P1 at 36 weeks gestational age. She was brought in by her sister, who is quite agitated and upset, saying “everybody has been ignoring her symptoms for the last 4 weeks.” The patient has just experienced a syncopal episode at home.
A 38-year-old female G2P1 at 36 weeks GA presents with acute on chronic respiratory distress in addition to chronic peripheral edema. She undergoes respiratory fatigue and hypoxia requiring intubation. She then becomes hypotensive which the team discovers is secondary to cardiogenic shock, requiring vasopressor infusion and consultation with Cardiology/ ICU.
ECG for the case found here:
(ECG source: https://lifeinthefastlane.com/ecg-library/dilated-cardiomyopathy/)
CXR for case found here:
(CXR source: https://www.med-ed.virginia.edu/courses/rad/cxr/postquestions/posttest.html)
Cardiac Ultrasound for the case found here:
(U/S source: http://www.thepocusatlas.com/echo/2hj4yjl0bcpxxokzzzoyip9mnz1ck5)
Lung U/S for the case found here:
(U/S source: http://www.thepocusatlas.com/pulmonary/)
RUQ FAST U/S Image found here:
(U/S source: http://sinaiem.us/tutorials/fast/us-ruq-normal/)
OB U/S found here:
(U/S source: https://www.youtube.com/watch?v=SKKnTLqI_VM)