Case: pregnant, preterm, seizure, shoulder dislocation

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
TrishPish

TrishPish

New Member
7+ Year Member
Joined
Feb 3, 2015
Messages
8
Reaction score
0
Ortho wants you to provide sedation for this pregnant lady (32 weeks GA) who had a fall after seizing earlier today.
She has dislocated her right shoulder and they failed to do a closed reduction in the ED after ketamine and propofol.
They would like you to administer sedation and if that fails, open and reduce in the OR.
She's otherwise healthy, no issues during pregnancy and just waking up from her sedation.
How would you assess and manage?
Members don't see this ad.
 
I just want to point out that, based on a recent study, ketamine and propofol vs only propofol have about the same level of airway complications. One can maintain SV or obstruct the airway with both, except that ketafol gives a smoother anesthesia (as expected from the analgesic effect, probably the reason it was used here). Funny thing, it was an EM study.
 
  • Like
Reactions: 1 user
Tell pateint risks and benefits and get OB on board in case they want to monitor during the case.
Prop, sux, tube.. and go from there..
 
Members don't see this ad :)
(Disclaimer -- I wasn't involved in this, not even sure if it was a real case or an embellishment for educational purposes.)

Any concerns about the seizure beforehand?

To FFP's note, would propofol alone probably been best for the attempted reduction given the history of seizure earlier?
 
I usually use just propofol for dislocation reductions.
 
NPO is an issue.
Fetal monitoring is an issue.
GA is an issue.
Would an interscalene block be enough for an open reduction?

Ketamine is controversial in epilepsy, it's not clearly linked to seizures.
 
Last edited by a moderator:
Are you thinking GA an issue for risk of preterm labor?

Unfortunately, as you're going through your assessment with her (she says she's never had a seizure before, but she doesn't seem to have great antenatal care when she says this pregnancy, her first, is fine), she begins to seize again.

Differential and what's the next step?
 
labs please... including LFTs.
 
  • Like
Reactions: 1 user
TrishPish said:
Are you thinking GA an issue for risk of preterm labor?

Unfortunately, as you're going through your assessment with her (she says she's never had a seizure before, but she doesn't seem to have great antenatal care when she says this pregnancy, her first, is fine), she begins to seize again.

Differential and what's the next step?
Click to expand...
GA as a risk for preterm labor, for fetal distress, and aspiration (more than with well-titrated propofol while maintaining airway reflexes).

Next step is not the differential. Next step is treating the seizure. Which I would, with propofol.

Now comes the differential for the seizure, especially after a fall. I bet you invented that second seizure just to point out that preop assessment. :)

I would love an H&P first, especially about previous diagnosis of epilepsy and skipping meds. Also IV drugs are not to be forgotten.

One big things labs and vitals wouldn't necessarily show: organic causes of seizing. That includes tumor, post-fall epidural or intracerebral hematoma etc.. I bet she did not have an MRI in the ED.
 
Last edited by a moderator:
It also matters how urgent the reduction of the dislocation is. Is there any associated vascular/nerve injury?
 
Seizure in pregnant lady = A nice pre-ecclampsia work-up. If she has progressed to Ecclampsia, perhaps they can do a joint case with the OBs delivering the baby.
 
Yep. Seizure in pregnant lady = definitely eclampsia as first thought, until proven otherwise.

But, in this case, I have a feeling it's not that easy (they would not have wasted time in the ED with the shoulder). Or is it? :)
 
Members don't see this ad :)
This is a good case.

I agree with everything here so far.

I would be anxious to relocate the shoulder but I wouldn't jump into it until I knew why she seized.
 
Pregnant woman having repeated seizures and has a dislocated joint:
At this point I would induce GA smoothly and avoid Ketamine, secure the airway, place on vent with Propofol drip, manage the BP, send labs including drug screen, I might allow the ortho guy to pull on the shoulder in the meantime to attempt a closed reduction under better conditions but if that fails we are going to wait until the clinical picture is clear before contemplating an open orthopedic procedure.
 
Planktonmd said:
Pregnant woman having repeated seizures and has a dislocated joint:
At this point I would induce GA smoothly and avoid Ketamine, secure the airway, place on vent with Propofol drip, manage the BP, send labs including drug screen, I might allow the ortho guy to pull on the shoulder in the meantime to attempt a closed reduction under better conditions but if that fails we are going to wait until the clinical picture is clear before contemplating an open orthopedic procedure.
Click to expand...
So why place this pt on a propofol infusion? tell us what you are thinking here because I'm sure many just read right past that part.
 
Ketamine also not good for fetal cognitive development. seems a very odd choice given the clinical picture.
 
How urgent is it to reduce it? If she's eclamptic, the baby's gotta come out, and it's reasonable to do so at 32 WGA. Can she get a section done under general, have ortho come in while ob closes?
 
The patient may or may not have issues, i don't really care if bp is normal and no active seizure i'll do a 10 cc lidocaine ISB an punt her out to the ortho/ob team
 
Planktonmd said:
Propofol is a good anti epileptic.
Click to expand...

Maybe....

The package insert says it can cause seizures. We have seen that at our institution.

Propofol will absolutely stop the consequence of seizures - it may not stop the electrical activity of the seizure. Is the electical activity harmful though?

I wonder if the best choice would be midazolam, then defend your choice with science should the baby be born with a cleft problem. (32 weeks in the belly....)
 
epidural man said:
Maybe....

The package insert says it can cause seizures. We have seen that at our institution.

Propofol will absolutely stop the consequence of seizures - it may not stop the electrical activity of the seizure. Is the electical activity harmful though?

I wonder if the best choice would be midazolam, then defend your choice with science should the baby be born with a cleft problem. (32 weeks in the belly....)
Click to expand...
If you give enough Propofol you will get burst suppression and there will be no seizures.
That's why it's recommended for treating refractory status epilepticus.
 
Not something I'd heard about before, but the package insert states:
"""
When DIPRIVAN Injectable Emulsion is administered to an epileptic patient, there may be a risk of seizure during the recovery phase.
"""

And then a less than 1% incidence with causal relationship unknown in Anesthesia or ICU sedation.

We use it commonly in ECT to terminate longer than necessary seizures.

Lets just proceed with the local anesthetic induced seizures from the ISB and see what happens next...
 
Considering she's just undergone sedation I don't think consenting her for ISB would be an option, informed consent and all.
 
epidural man said:
The package insert says it can cause seizures. We have seen that at our institution.
Click to expand...

I bet at least 98.435% of "seizures" reported after administering propofol are just myoclonic activity.

Propofol isn't near as bad as etomidate (or methohexital!) in that regard, but it does make a lot of patients twitchy.

epidural man said:
I wonder if the best choice would be midazolam, then defend your choice with science should the baby be born with a cleft problem. (32 weeks in the belly....)
Click to expand...
The best drug is probably magnesium. :)
 
You must log in or register to reply here.
Next unread thread

Similar threads

A
Intraop shivering? seizure?
Replies
21
Views
1K
anbuitachi
A
W
Case discussion: why acidosis?
Replies
40
Views
1K
IlDestriero
IlDestriero
M
Case logs
Replies
7
Views
1K
Ashers
Ashers
woopedazz
Interscalene for shoulders: Concentrated vs dilute local?
2
Replies
51
Views
2K
anbuitachi
A
D
Shoulder reduction
2
Replies
64
Views
3K
GassYous
GassYous
Top