Transcript November 2014 - CE OB - Advocate Health Care

OB EMERGENCIES
NOVEMBER 2014 CE
CONDELL MEDICAL CENTER EMS SYSTEM
IDPH SITE CODE: 107200E-1214
Prepared by: Sharon Hopkins, RN, BSN, EMT-P
Revised 11/19/14
1
OBJECTIVES
 Upon successful completion of this module, the EMS
provider will be able to:
1. Define obstetrical terms
2. Describe the physiological changes to the patient who is pregnant.
3. Describe potential complications in the antepartum and post
partum periods.
4. Describe EMS interventions for a variety of obstetrical delivery
emergencies following the Region X SOP.
5. Identify imminent delivery.
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OBJECTIVES CONT’D
6. Describe components of an obstetrical kit and the use of the contents.
7. Discuss post-partum depression.
8. Actively participate in review of selected Region X SOP’s.
9. Actively participate in case scenario discussion.
10. Actively participate in return demonstration of BVM use with a neonate.
11. Actively participate in return demonstration of use of the meconium
aspirator.
12. Actively participate in return demonstration of use of a BVM in a
neonate.
13. Successfully complete the post quiz with a score of 80% or better.
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TERMINOLOGY OF PREGNANCY
 Prenatal period – time from conception until delivery of fetus
 Antepartum – time period prior to delivery
 Post partum – time interval after delivery
 Gravidity – number of times pregnant
 Parity – number of pregnancies to full term
 Fetus – a developing human in the womb
 Neonate – the first 30 days of life for the infant
 Estimated date of confinement (EDC) – estimated birth date
4
TERMINOLOGY CONT’D
 Placenta – temporary blood-rich structure; lifeline for the fetus
 Transfers heat
 Exchanges O2 and carbon dioxide
 Delivers nutrients
 Carries away wastes
 Bag of waters – amniotic sac; surrounds and protects fetus;
volume varies from 500 – 1000ml
 Perineum – the skin between the vaginal opening and the anus
 Nuchal cord – cord wrapped around the fetal neck
5
PHYSIOLOGICAL CHANGES DURING
PREGNANCY
 Pregnancy is a normal and natural process
 A woman’s body will undergo many changes in preparation for
carrying another life
 Complications are uncommon but you must be prepared for
them
 Pre-existing medical situations could be aggravated during
pregnancy and develop into acute problems
6
PHYSIOLOGICAL CHANGES OF
PREGNANCY
 Nausea and vomiting due to hormonal changes
 Delayed gastric emptying
  in renal blood flow
 Kidneys may not be able to keep up with filtration and reabsorption
 Bladder displaced anteriorly and superiorly
 More likely to be ruptured in trauma
 Urinary frequency
 Loosened pelvic joints due to hormonal changes
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PHYSIOLOGICAL CHANGES CONT’D
  in oxygen demand and consumption
 Diaphragm pushed up by enlarging uterus  lung capacity
  in cardiac output to 6-7 L/min by end of 2nd trimester
 Average in resting non-pregnant female is 4.9L/minute
  in maternal blood volume by 45%
 Can lose 30-35% total blood loss before change in vital signs are
evident
  venous return to right atrium with gravid uterus compressing
inferior vena cava
8
FETAL BLOOD SUPPLY
 No direct link between mother’s blood and infant
 Mother’s blood flows to the placenta
 Placenta supplies blood to the fetus
 Placenta acts as a barrier protecting the fetus
 Some items cross the placental barrier and can affect the fetus
Alcohol
Some medications – Valium Versed, oral diabetic meds, narcotics,
some antibiotics, steroids
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UMBILICAL CORD
 A flexible, rope-like structure approx. 2 feet long
 Contains 2 arteries, 1 vein
 Transports oxygenated blood to fetus
 Returns relatively deoxygenated blood to placenta
 Fetus can twist and turn in the uterus and get wrapped up in
cord
 Fetus can “tie umbilical cord into a knot”
10
NORMAL PREGNANCY – 20 WEEKS & TERM
11
ANTEPARTUM COMPLICATIONS
 Vaginal bleeding
 Ectopic pregnancy
 Placenta previa
 Abruptio
 Hypertensive disorders
 Preeclampsia, eclampsia
 Supine Hypotensive Syndrome
12
VAGINAL BLEEDING
 May occur at anytime during the pregnancy
 If early, patient may not even realize they are pregnant
 In the field, exact etiology cannot be determine
 Keep heightened suspicion that vaginal bleeding may be related
to patient being pregnant
 This could prove an emotional time for the patient and family
 Being supportive is important to these patients
13
ECTOPIC PREGNANCY
 Fertilized egg has implanted outside the normal uterus
 Patient often presents with abdominal pain
 Starts diffuse and them localizes to lower quadrant on affected side
 Patient may not even be aware that they are pregnant
 If in fallopian tube and tube ruptures, maternal death due to
internal hemorrhage is a real possibility
 Abdomen becomes rigid with  pain
 Often referred shoulder pain on affected side
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PLACENTA PREVIA
 Abnormal implantation of placenta on lower half of uterine wall
 Cervical opening partially or completely covered
 Placenta can start pulling away from attachment starting at 7th
month
 Painless bright red vaginal bleeding
 Uterus usually soft
 Potential for profuse hemorrhage
 Definitive treatment is cesarean section
delivery
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ABRUPTIO PLACENTA
 Premature separation of normally
implanted placenta from uterine wall
 Life threat for mother and fetus
 20-30% mortality for fetus
 Signs & symptoms depend on extent of abruption
 Can have sudden sharp, tearing pain and stiff, board like abdomen
 Vaginal bleeding could range from none to some
 Blood could be trapped between placenta and uterine wall
 Maintain maternal oxygenation and perfusion
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PRE-HOSPITAL CARE OF ANTEPARTUM
BLEEDING
 Maintain high index of suspicion
 Treat for blood loss
 Positioning – lay or tilt left
 Monitor for adequate oxygenation
 Providing supplemental oxygen is also for benefit of the fetus
 Maintain adequate perfusion
 Consider fluid challenge as needed
 200 ml increments with ongoing assessment/ evaluation
 Expedited transport; transport as soon as possible
 Early report to receiving facility
17
HYPERTENSIVE DISORDER OF PREGNANCY
 Major cause of maternal, fetal and neonatal morbidity and
mortality
 Morbidity – presence of a disease state
 Mortality – relating to death
 A common medical problem in pregnancy
 Includes gestational hypertension (hypertension that develops
during pregnancy usually after the 20th week) and pre-existing
hypertension (typically defined as a blood pressure > 140/90)
18
PREECLAMPSIA
 Most common hypertensive disorder of pregnancy
 Increased risk in diabetic, those with history of preeclampsia,
and those carrying more than one fetus
 Progressive disorder; most commonly seen last 10 weeks of
gestation, during labor, or first 480 postpartum
 Have a 30 mmHg increase in systolic B/P and 15 mmHg increase
in diastolic B/P over baseline
19
SIGNS AND SYMPTOMS PRE-ECLAMPSIA
 Elevated blood pressure
 Headache
 Visual disturbances – blurred vision, flashing before the eyes
 Severe epigastric pain
 Vomiting
 Shortness of breath
 Tissue edema related to third spacing with fluid shift into tissues
 Swelling of face, hands, and feet
20
ECLAMPSIA
 Most serious side of hypertensive disorders of pregnancy
 Generalized tonic-clonic seizure activity
 Often preceded by flashing lights or spots before their eyes
 Epigastric pain or pain RUQ often precedes seizure
 Note grossly edematous patient with markedly elevated B/P
 High mortality rates for mother and fetus
 Definitive treatment is delivery
 EMS needs to provide support until delivery at closest
appropriate facility
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MANAGING SEIZURES DURING PREGNANCY
 Positioning of patient
 To protect from harm, protect airway
 Maintain patent airway
 Potential need for intermittent suction
 Support ventilations
 Patient’s respirations altered during active seizure activity
 Will need supportive ventilations especially in presence of long
lasting seizure activity
 Manage seizure with Versed 2 mg IN/IVP/IO every 2 minutes up
to 10 mg (does cross the placental barrier; could depress fetus) 22
SUPINE HYPOTENSIVE SYNDROME
 Usually occurs in 3rd trimester
 Gravid uterus compresses inferior vena cava when mother lies
supine
 Mother may experience dizziness
 Evaluate for volume depletion versus positioning problem
 Place mother in left lateral recumbent position (“lay left”) for
assessment, treatment, and transportation to prevent this
problem
23
IDENTIFYING IMMINENT DELIVERY
 Mother entering the 2nd stage of labor
 Measured from complete dilation of cervix (10cm) to delivery of fetus
 Could last 50-60 minutes for first pregnancy
 Contractions strong lasting 60-75 seconds and 2 -3 minutes apart
 Membranes may rupture
 Has urge to push
 Perineum bulging
 Crowning evident when head or other presenting part is evident at
vaginal opening during a contraction
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OB KIT CONTENTS
AND ADD-ONS
Cap
ID bands
25
STEPS TO TAKE DURING DELIVERY
 Try for a private area if out in public
 Place patient on her back with room to flex knees and hips
 Prepare equipment – OB kit
 Coach mother to breath between contractions and to push with
contractions once crowning is evident
 Support head as it emerges
 Check for nuchal cord
 Clear the airway with a bulb syringe if secretions present
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DELIVERING THE BABY
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DELIVERY CONT’D
 Gently guide baby’s head downward
 Facilitates delivery of upper shoulder
 Then gently guide baby’s body upward
 Facilitates delivery of lower shoulder
 Rest of baby quickly delivers
 Be prepared!
 Infant will be slippery!
 Note time of delivery – when baby totally out
 Keep baby in head down position
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DELIVERING THE BABY
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USE OF BULB SYRINGE
 Routine suctioning is no longer recommended
 Suctioning has been associated with bradycardia and other
problems
 Suctioning is limited to necessity
 If performed, suction MOUTH, then nose
 Suctioning the nose is the stimulus to breath
 Want the airway clear prior to stimulation to take a breath
 Infant will not start to breath until their chest clears the birth canal
and can then expand
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DELIVERING THE BABY
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NORMAL APPEARANCE OF NEWLY BORN
 Infants will be wet and
slippery
 Covered with a cheesy like
substance that wears off
shortly after delivery
 Hands and feet may be
cyanotic longer that other
parts of the body
 Extremities should be actively
moving
32
NEWLY BORN APPEARANCE
 Risk for blood and body
fluid contamination
during all deliveries
 Have high regard for use
of appropriate PPE’s!
 Drying off preserves heat
and acts as a stimulus by
the rubbing activity
33
INITIAL ASSESSMENT OF NEWBORN
 Begin steps of inverted pyramid as you are assessing newborn
 Begin to dry infant; change to dry towel as needed
 Cold infants can deteriorate quickly
 Infants have difficult time generating & maintaining body heat; they cannot
shiver to generate heat
 Suction with bulb syringe only when secretions are present
 Suctioning when not necessary associated with bradycardia and other
problems
 Assess newborn as soon as possible after birth
 Normal respiratory rate averages 30-60 breaths per minute
 Normal heart rate ranges from 100 – 180 beats per minute
34
INVERTED PYRAMID
(Always needed)
(Infrequently
needed)
35
APGAR SCORE
 Developed in 1953 by Dr. Apgar, a surgeon turned anesthesiologist
 An assessment is taken at 1 and 5 minutes after birth
 The 1 minute score reflects how well the infant tolerated the birthing
process and indicates need for early intervention
 The 5 minute score reflects how well the infant is tolerating being outside
the womb as well as response to interventions provided
 The higher the score (closer to 10), the better the infant’s transition
 Early duskiness of distal extremities is common often leading to a
1 minute score of 9
 The score does NOT predict the future health of the child
36
APGAR CONT’D
 Any score less than 7 merits an intervention
Supplemental airway
Clearing the airway
Physical stimulation
Rubbing the back
Flicking the bottom of the foot
 Most low initial scores at 1 minute improve with the usual
interventions listed at the top of the pyramid and by the 5
minute assessment, are usually at higher, acceptable scores
 Providing assessment/reassessment will be key
37
38
CARE OF THE CORD
 Do not pull on the cord
 Avoid cutting the cord prematurely
 Want the last kick of blood available to be delivered to the infant
 Once the cord has stopped pulsating and gone limp, can prepare to
clamp and tie it
 Place one clamp 8 inches from newborn’s navel
 Place 2nd clamp about 2 inches further away
 Cut exposed cord between the clamps – it’s tougher than anticipated
 Continue to assess the newborn’s end of exposed cord for any bleeding39
CARE OF THE CORD
 There is no rush to clamp and cut the cord
 You want to give enough time for all blood possible to infuse from
mother to the placenta to the infant
 Infant's have a very limited blood volume to begin with (80 ml/kg)
40
PREVENTING HEAT LOSS
 Heat loss can be life threatening for the newborn
 Most heat loss is via evaporation while wet with amniotic fluid
 Can lose heat via convection depending on temperature of room
and movement of air around newborn
 Can lose heat via conduction if in contact with cooler objects
 Can radiate heat to colder nearby objects
41
PRESERVING THE NEWBORN’S BODY
TEMPERATURE
 Dry the newborn immediately after birth
 Maintain a warm ambient temperature
 Close all windows and doors
 Replace wet towels with dry
 Keep infant wrapped and head covered to prevent heat loss
 Mother holding the newborn transfers her body heat
42
NEWBORN RESUSCITATION
 Additional efforts required when the respiratory rate is decreased,
heart rate <100, or there is decreased muscle tone
 Attempt positive pressure ventilations via BVM
 Rate of 40- 60 breaths per minute
 Watch that the volume is enough to make the chest rise and fall
 Reassess after 30 seconds
 IF heart rate is 60 -100 beats per minute
 Continue positive pressure ventilation
 IF heart rate is less than 60
 Begin chest compressions at a ratio of 3:1; reevaluate every 30 seconds
43
3RD STAGE OF LABOR – PLACENTAL STAGE
 Uterus continues to contract
 Cord appears to lengthen
 May have increase in bloody
discharge
 If delivered, transport with
mother to the hospital
44
COMPLICATIONS – PROLAPSED CORD
 Umbilical cord visible prior to delivery
 Cord will be compressed if fetus passes through birth canal
 Goal
 Prevent mother from
delivering vaginally
45
PROLAPSED CORD
 This is one of the complications you want to visually check for as
quickly as possible once on the scene of an imminent delivery
 If the cord is visible protruding from the vagina
 Elevate the mother’s hips
 Instruct patient to pant during contractions or just keep her breathing
during a contraction
 Place gloved hand into vagina between pubic bone and presenting part
 Monitor cord between fingers for pulsations
 Keep exposed cord moist with dressings and keep warm
 Transport with hand in place – DO NOT REMOVE YOUR FINGERS
46
MECONIUM STAINING
 Occurs in approximately 10-15% of deliveries
 Meconium is dark green and can be of thin or thick consistency
 Fetal distress and hypoxia cause meconium to pass from the fetal GI
tract into the amniotic fluid
 If infant is breech, meconium staining is anticipated and expected as
the abdomen is compressed in the birth canal
 Meconium aspiration increases neonatal mortality rate
 If aspirated can obstruct small airways & cause aspiration pneumonia
and lead to respiratory distress
47
NORMAL MECONIUM STOOL
 Usually passed within 480 of birth
 Typically transitions to normal stool beginning
by day 4
 Meconium is thick, dark almost black stool
normally found in the infant’s intestines
 Becomes a problem when aspirated or
otherwise blocks the infant’s small airways
48
MECONIUM – THIN OR THICK?
 If thin, may not require any intervention if infant is vigorous
 No problems with respiratory rate
 Normal muscle tone
 Heart rate over 100 beats per minute
 Bulb syringe easily takes care of most cases of meconium
 Infant is not vigorous – will need interventions
 Decreased respirations
 Decreased muscle tone
 Heart rate < 100 beats per minute
49
IF INTERVENTION REQUIRED FOR MECONIUM
 If interventions required, must move quickly
 You have limited time to intervene
 You must be proactive and anticipate use of equipment
 Suctioning with meconium aspirator needs to be performed prior to
the infant’s need to take their first breath
 If you are organized and efficient, you MAY get the opportunity
to suction twice
 You probably won’t get the opportunity for more than two
attempts
50
EQUIPMENT FOR MECONIUM ASPIRATION
 Suction tool
 Suction force turned down to 80 mmHg
 Meconium aspirator
 Intubation blade and handle
 2 ETT of anticipated size
 Additional ETT sized below and above anticipated size to use
 Stylet
 Neonatal BVM
51
PRESENCE OF MECONIUM
 Suctioning must occur prior to infant being stimulated
 It is more efficient if performed as a team effort in the
non-vigorous infant
 Provide blow-by oxygen during procedure to keep environment
oxygen enriched
 Blade can be left in position as first ETT is removed
 Assistant should be ready to attach meconium aspirator to
proximal end of ETT as soon as stylet is removed
 New, clean ETT with stylet needs to be prepared & ready to be used
as soon as 1st ETT is removed
52
MECONIUM ASPIRATOR
 Connect small end of meconium aspirator
to suction connecting tube
 Set suction down to 80 mmHg
 Endotracheal tube inserted using blade and handle
 Meconium may obscure your view
 Wider end of aspirator connected to proximal end of ETT
 Thumb placed over suction port while withdrawing ET tube
within 2 seconds
 Discard ETT after 1 sweep and use new ETT if 2nd attempt made
53
SUPPORTIVE VENTILATION
 Proper positioning is a small towel under the torso
 Volume is enough to make the chest rise gently
 Rate is 40-60 breaths per minute
 Do not flow oxygen into the infant’s
eyes or put pressure over the eyes
 Newborns are sensitive to vagal
stimulation and will respond with
bradycardia
54
NUCHAL CORD
 Cord is wrapped around the infant’s neck
 Problem exists if the cord is too tight and prevents infant from
delivering
 Remember: fetus is receiving their oxygen and blood supply via the
cord
 If cord clamped and cut prematurely, infant needs to be delivered
without delay to begin to ventilate on own
 Goal:
 If cord too tight for infant to deliver, then unwrap or clamp & cut
 Prevent mother from pushing until cord is unwrapped or cut
55
POSTPARTUM HEMORRHAGE
 Loss of more than 500 ml of blood immediately following delivery
 500 ml = 2 cups = 16 oz = 1 pint = 1 pound by weight of soaked pad
 Most common cause is uterine atony – lack of uterine tone; failure
of uterus to contract after delivery
 Occurs more frequently in multigravida and more common
following multiple births or births of large infants
 Rely on clinical appearance of mother and vital signs
 Uterus often feels boggy on palpation
 Need to perform fundal massage
56
FUNDAL MASSAGE – 2 HANDED TECHNIQUE
 Must NOT be performed until after delivery of the placenta
 Is a 2 handed technique
 Performed to get uterus to
contract to minimize blood
loss
 Need the uterus to firm up
 Should feel like a grapefruit
or fist
57
FETAL ALCOHOL SYNDROME (FAS)
 Life long effects started from the womb
 When the mother drinks, alcohol crosses the placenta and
passes to the fetus
 Alcohol affects neurons and the central nervous system (CNS) of
the fetus
 Damages physical structures and growth
 Defects more pronounced as the child grows
58
CRISIS AT BIRTH
 If FAS is suspected:
 Anticipate a small weight newborn
 Anticipate a newborn who may need some resuscitative
efforts
 Assisted ventilations
 Extra attention to be kept warm due to typically a smaller
birth weight
59
FETAL ALCOHOL SYNDROME (FAS)
 Signs and symptoms noted at birth related to effects of
hypoglycemia and dehydration
 Newborn has a “hangover” following binge drinking of the
mother
 Typical appearance
 Underweight; “skinny”
 Irritable
 Poor reserves
 Changes in facial features
60
FETAL ALCOHOL
SYNDROME
61
FETAL ALCOHOL SYNDROME (FAS)
 All defects last a lifetime
 Neurological defects include
 Motor skills; poor pace of walking
 Memory impairment; learning disabilities
 Poor social skills
 Potential for heart murmur, joint defects, hearing problems, renal
problems
62
SIDS
 Sudden infant death syndrome describes the unexplained
sudden death of an infant
 Major cause of death in infant’s first month of life
 Most victims appear healthy prior to death
 There is still no cause of SIDS but theories do exist
 Stress in infant possibly from infection or other factors
 A birth defect
 Failure to develop
 A critical period of rapid growth
63
SIDS
 SIDS cannot be prevented or predicted
 Death seems to occur during sleep
 There are no warning signs or symptoms
 Parents will need emotional support
 Parents will often blame themselves
 “I should have…”
 “I should not have…”
 Each case is handled individually in regards to EMS response
64
POST PARTUM DEPRESSION
 Many symptoms may be experienced by the new mother
 EMS responding to “an accident” may be caring for a mother
experiencing postpartum depression
 Our biggest fear is that the patient may be experiencing issues
that may take over and lead them to do harmful things to
themselves and/or the children
 Just be alert to potential situations that may be more than they
appear to be
 Like the MVC that may be a suicide attempt
65
POST PARTUM DEPRESSION SYMPTOMS
 Being overwhelmed, irritated, angry, no patience
 Feel this is more than just “hard”; feels like she can’t handle being a
mother
 Sadness to the depth of their soul
 Inability to stop crying
 Can’t concentrate; feel disconnected
 Having thought of running away, or of hurting self or the baby
 Confused and scared
66
CASE SCENARIO DISCUSSION
 Review the following cases and determine what your
general impression is
 Discuss what your intervention needs to be
 Refer to the Region X SOP’s as necessary
67
CASE SCENARIO #1
 EMS is called to the scene of a mother who is in labor
 What questions are important to ask early?
 Number of pregnancies
 Due date
 Known complications
 Previous labor history if any
 If bag of waters are intact or broken
 The duration and frequency of contractions
 In report, provide weeks of gestation and not the months
 Provides more precise picture of age of infant (i.e.: premature or not)
68
CASE SCENARIO #1
 What indicates that delivery is imminent?
Crowning
Bulging of the perineum
Contractions that are lasting 60-75 seconds and coming every
2-3 minutes
Urge to push
Feeling that she wants to have a bowel movement
69
CASE SCENARIO #1
 What is assessed with the APGAR score?
 A – appearance or coloring
 Fingers and toes often bluish for a few minutes
 P – pulse
 Best to have a pulse over 100 beats per minute
 G – grimace or reflexes
 Grimacing, coughing, sneezing are good to see
 A – activity or muscle tone
 Want to see flexed extremities
 R – respiratory effort
 Want to hear a strong cry
70
CASE SCENARIO #1
 What are the interventions listed at the top of the inverted
pyramid that each newborn typically receives?
 Drying – to prevent heat loss by evaporation
 Warming the infant to stop the heat loss
 Stimulation by touching and rubbing the infant
 Flicking the bottom of the feet or rubbing the back if more tactile
stimulation is required
 Keeping the newborn in a head down position to facilitate drainage
from the lungs
71
CASE SCENARIO #2
 You have arrived on the scene and determined that you will
need to deliver a newborn
 During assessment and in preparation of the event, you notice
dark, thick greenish-black flecks of material in the leaking bag of
waters
 What does this indicate?
 Evidence of meconium staining
 What does this mean?
 If not a breech delivery, the fetus may be in distress and require
extra resuscitative efforts
72
CASE SCENARIO #2
 What equipment do you need to prepare?
 Neonatal BVM
 Meconium aspirator
 Several endotracheal tubes
 Several stylets
 Blade and handle
 Oxygen source
 Suction device – turned down to 80 mmHg
73
CASE SCENARIO #2
 What assessment of the newborn would indicate a need
to use a meconium aspirator?
 If the infant is not vigorous
 The respiratory rate is decreased
 There is decreased muscle tone – newborn is limp
 Heart rate is below 100 beats per minute
 Remember: a bulb syringe works just fine for most
situations involving the presence of meconium at birth
 Depress the bulb prior to inserting into the mouth and nose
74
CASE SCENARIO #3
 You are on the scene and have just assisted the mother in
delivering her 3rd child
 The infant is not as responsive to drying and stimulation as you
feel they should be and extremities are dusky
 You want to provide blow-by oxygen
 How would you deliver blow-by oxygen?
 Hold a source of oxygen next to the infant's nose and mouth and let
the oxygen source “blow-by”
75
CASE SCENARIO #3
 The infant is not responding to the blow-by efforts
 The respiratory rate is low and the heart rate is less than 100
 What is your next intervention?
 Begin positive pressure ventilations at 40-60 breaths per minute
 Ventilate with small puffs of air
 Reevaluate every 30 seconds
76
CASE SCENARIO #3
 What would you do if the pulse remained
between 60 and 100?
 Continue positive pressure ventilations
 Reassess every 30 seconds
 What would you do if the pulse dropped
below 60 in the newborn?
 Begin chest compressions
 3 compressions to 1 ventilation
 Depress the sternum 1/3 the AP diameter of the chest on lower half of sternum
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CASE SCENARIO #4
 You are on the scene for a patient who fell
 Upon your arrival you note an unresponsive adult on the floor
who is obviously pregnant
 Your patient is in a tonic-clonic seizure
 What is your general impression?
 First thought is eclampsia
 Need to consider an epileptic seizure
 Need to be thinking possible hypoglycemia
 Need to determine presence of head injury
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CASE SCENARIO #4
 What are your actions during this on-going seizure activity?
 Protect the patient from harm
 Maintain a patent airway
 Suction available
 Turn patient on left side
 Also avoids supine hypotensive syndrome
 Consider supporting ventilations via BVM
 1 breath every 5-6 seconds (10-12 breathe per minute)
 Obtain any medical history available
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CASE SCENARIO #4
 What medication is used in the presence of seizure
activity in the patient who is pregnant?
 Versed 2mg IN/IVP/IO
 May repeat every 2 minutes titrated to desired effect
 Maximum dose of 10 mg
 If seizure activity continues or reoccurs, contact Medical
Control for additional orders of Versed up to an additional
10 mg
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CASE SCENARIO #4
 What would be important to relay in your face to face hand-off
report with this case once at the hospital?
 Fact that Versed was administered
 Versed crosses the placental barrier
 If administered close to the time of delivery, may witness side effects in the
newborn related to the Versed
Respiratory depression
Hypotension
 Would be important for OB to try to differentiate if signs or
symptoms are due to the condition of the newborn or related to
interventions performed
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BIBLIOGRAPHY
 Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles & Practices, 4th edition. Brady. 2013.
 Mistovich, J., Karren, K. Prehospital Emergency Care 9th Edition. Brady. 2010.
 Region X SOP’s; IDPH Approved January 6, 2012.
 http://www.primehealthchannel.com/fetal-alcohol-syndrome-pictures-symptoms-statisticsand-treatment.html
 http://www.emedicinehealth.com/postpartum_depression/article_em.htm
 http://www.nlm.nih.gov/medlineplus/ency/article/003402.htm
 http://www.pphprevention.org/pph.php
 http://calsprogram.org/manual/volume1/Section4_Path/05-PATH4NeonatalEmergencies13.html
 http://www.cdc.gov/vhf/ebola/hcp/procedures-for-ppe.html
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