MEDICAL EMERGENCIES (2) - Free State Department of Health
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Transcript MEDICAL EMERGENCIES (2) - Free State Department of Health
MEDICAL EMERGENCIES
(2)
Dr. Gillian Lamacraft
Anaesthetic Specialist
University of the Free State
Agenda
Pre-eclampsia/Eclampsia
Coagulopathy
Fetal Distress
Video on cricothyrotomy
Failed intubation
Video on MH
Anaesthesia and Pre-eclampsia
Emergency delivery at level 1 :
fetal distress, placental
abruption
Spinal or General Anaesthetic
Anaesthetic Considerations in
PE
Urgency of situation
Fluid balance
BP control (Mg?)
Difficult intubation
Complicated PE
eg coagulopathy ?
Fluid balance and PE
Pathology – vasospasm, leaky
capillaries intravascular fluid deficit.
Crystalloids vs colloids
Renal failure vs pulmonary oedema.
Fetal distress and dehydration.
Post-delivery reduction in colloid
oncotic pressure.
Fluids and PE
Hospital protocol
usual maintenance 1ml/kg/hr crystalloid.
oliguria(<0.5ml/kg/hr) 2ml/kg fluid
challenge.
Monitor fluid balance
Peripheral route for CVP line
Beware CVP >6cmH2O
Spinal Anaesthesia and PE
Safer than GA
BUT must be well hydrated
Platelets >100x109/l
Caution with fluids
Preload 300-500ml colloid
Judicious use of vasopressors
General Anaesthesia and PE
Difficult intubation
*equipment and ET tubes
Blood pressure controlled preinduction
++Pressor response to intubation
CVA
Pulmonary oedema
Reducing the Intubation
Response
MgSO4 30mg/kg + alfentanil
7.5g/kg
4g Mg in 200ml N Saline over
20minutes
Fentanyl 2-3g/kg
Delivery within 10 minutes
Labetalol 5 – 10mg
Reducing the Extubation
Response
Lignocaine up to 1.5mg/kg
Esmolol 1.5mg/kg
Neuromuscular Blockade and
Magnesium
Prolongs action of SUX.
Reduces SUX fasciculations.
Potentiates non-depolarising drugs.
Intermittent boluses of SUX +atropine
100mg SUX + 0.5mg atropine made up to 10ml in
water: 1-2ml boluses.
Eclampsia and Anaesthesia
Seizure: magnesium 4g IV over 510 minutes then maintenance.
Most patients drowsy/irritable
GA.
Spinal can be used if no
contraindications.
Coagulopathy
Associated with PE
Isolated thrombocytopenia
HELLP
DIC
HELLP SYNDROME
Haemolytic anaemia
Elevated Liver enzymes
Low Platelets
Severe variant of PE
(HELLP)
High
maternal and perinatal
mortality
May not have BP or proteinuria
Older, multiparous
Epigastric pain, nausea +
vomiting
HELLP and Anaesthesia
As for PE + coagulopathy
Rate of platelet decline
Blood components
Post-op ICU
Renal failure (7.4%)
Deterioration in coagulopathy
DIC
(Disseminated Intravascular
Coagulopathy)
Procoagulant
IV fibrin
Depletion clotting factors and platelets
Activation fibrinolytic system
Fibrin degradation products
anticoagulant
Obstetric Triggers For DIC
Tissue thromboplastin
Placental abruption
Amniotic fluid embolism
Endothelial damage
HELLP
Hypotensive conditions
G-ve sepsis, massive haemorrhage
Tests for DIC
Prolonged APTT, PT, thrombin
times
fibrinogen and anithrombin III
platelets
fibrin degradation products, D
dimers
DIC Treatment
Remove cause
Supportive
Bleeding:
FFP
cryoprecipitate
Platelets
Fetal Distress
Inadequate oxygen delivery
Tachycardia then bradycardia
Treat reversible causes, eg:
Maternal
hypoxia
Hypotension
Prolonged uterine contraction
(TNT 50-100g)
Umbilical cord compression
Categories of Emergency CS
URGENCY
(time to delivery)
Stable (2 hours)
Spinal or GA?
EXAMPLE
spinal
Previous CS in
labour
Urgent (1hour)
spinal
Failure to progress
Emergency (30mins)
One attempt
spinal/GA
Severe FH rate
abnormality
Immediate
GA
Ruptured uterus
Video on Cricothyrotomy
Consider early in Obstetric Failed
Intubation Scenario
PROTOCOL FOR FAILED INTUBATION
Video of Malignant
Hyperthermia
Rare but treatable cause of
anaesthetic-related death.
Ca release in sarcoplasmic
reticulum
Stimulates muscular contraction
Treatment: dantrolene
ANY QUESTIONS?
TELEPHONE: 051 405 3307
(Dept Anaesthesia)
E-mail: [email protected]