OB Case

[Ventil8]

---

Members don't see this ad.

Sitting in Grand Rounds (5 min from L&D ORs)... pager hits...

"New pt seizing, please assist"

I drop my breakfast in the trash and head over, reviewing my plans with my CA-1.

Come to find they moved pt to the OR, and her clonus caused pulled her IV. Fetal HR 50s for "2 minutes".

Sweet...


What would you do-- Baby's down, no IV, active seizure, no know medical hx (she litterally rolled in and started seizing). Estimate termish baby, OBs with scalpels out...

Your thoughts?

 

[Idiopathic]

im ketamine, sux, tube, IV, cut

 

[Idiopathic]

Sounds like fun. Maybe try some IM benzos, then get an IV. If that doesn't work and it needs to go now, I might mask the lady and intubate her while she is spontaneously breathing and then get an IV. What did you end up doing?

really...

 

[pgg]

im ketamine, sux, tube, IV, cut

Agreed, IM succ will have hit well before she has an IV and will be the fastest way to get adequate intubating conditions. She needs a tube & oxygen. I'd argue that if she's actively seizing you don't need the ketamine and may be better off without it. Tube in, gas on, delivery.

Doesn't ketamine potentiate seizures?

Yes which is why I would be inclined not to use it. She sure isn't going to remember anything regardless of what you do.

 

[pgg]

Like I said, I might...

I think attempting to mask ventilate an actively seizing person is likely to be futile and will just delay placement of an endotracheal tube. I suppose it couldn't hurt if you've got nothing else to do while you're waiting for the IM succ.

Another advantage to giving IM succ immediately is that when she stops the fish-wiggle her O2 consumption will drop dramatically.

 

[pgg]

Correct me if I'm wrong, but I thought volatiles have some anticonvulsant activity.

They do; volatiles have even been used to treat status epilepticus. Isoflurane will give you burst suppression around 1.3 MAC (IIRC) and an isoelectric EEG around 2 ... in this case though you're going to be limited by uterine atony if you crank up the gas.

Presumably they'll have delivered the baby within a couple minutes, someone will have obtained IV access, and then the benzos can flow while the gas stays under 1/2 MAC or so.

While seizures aren't good for you, the priority here isn't to stop the seizure, it's to deliver oxygen and deliver the kid. If the seizure goes on for an extra couple minutes after she's intubated, while they cut and you obtain IV access, no big deal.

It'd probably be a good idea to start loading magnesium intraop too, because she'll certainly need it for a while postpartum, recognizing that it too might contribute to uterine atony.

 

[pgg]

To clarify: I wasn't going to mask ventilate, just let her breathe sevo through the mask, to allow for intubation and/or IV access.

I don't know, I still see a couple problems with that.

She's still actively seizing, so there's no spontaneous ventilation going on. Even if she was, a mask induction in an adult will take forever to get good intubating conditions. IVs are hard to start in seizing patients. She's already induced; the only thing missing is a muscle relaxant.

If the seizure's done, she's post-ictal and won't remember a thing. The kindness of a bit of sevo or an IV induction agent is probably unnecessary ... though she'd still have one hell of a hemodynamic response to the DL, and that might be undesirable. Could be she's popped a vessel in her head and that's why she's seizing. While eclampsia is the obvious first reason for a term pregnant woman to be seizing, it's not the only reason. I wouldn't throw stones at someone who chose to mask ventilate while awaiting IV access.

 

[dhb]

IM Sux + Midaz sounds like a good option.

 

[LongSnow]

IM sux/atropine - one whole vial sux (200mg) + Atropine 1 mg mixed together in a big syringe, inject into deltoid. Intubate, turn on inhaled agent, get IV. If starts wiggling before Iv placed, give more IM sux and crank agent.

 

[huktonfonix]

IM succ. mask ventilate when able with 100% O2. Baby HR will likely improve with that alone. CHECK OTHER VITALS. What if her BP is 220/110? Sure it could be artifact, or from the seizures, but it could also be severe preeclampsia. Are you really going to go ahead and DL, intubate, risk further increases in BP and possible cerebral hemmorhage? I would say, paralyze, mask ventilate with 100% O2 (+/- volatile), then IV, then intubate if neccesary. Unless shes a really hard stick it shouldnt take more than a minute to obtain IV access. At least then you can administer vasoactive drugs, fluids, etc... as needed. If you perform a C/S prior to obtaining IV access, youre just asking for trouble.

 

[pgg]

Are you really going to go ahead and DL, intubate, risk further increases in BP and possible cerebral hemmorhage?

In an actively seizing patient, will there be a hemodynamic response to DL?

I thought no, but now that I think about it, I'm not so sure. Certainly unconsciousness doesn't preclude such a response, so seizure involvement of just the cortex wouldn't block the reflex. But I thought cortical seizures also involved thalamus, amygdala, and hippocampus; given that seizures interfere with the spinothalamic tract (pain) I didn't think it was possible for pain to produce a sympathetic response during a seizure.

I'm probably overthinking this, or maybe I'm entirely wrong about the anatomy, but the question stands - will pain from DL (or surgical stimulus for that matter) produce a hemodynamic response in a seizing patient?

 

[Idiopathic]

probably, since pain processing does not rely on higher order neurons

and the jury is out on ketamine and seizures...many people report that it wont potentiate seizure activity in non-epileptics and also some report that its neuroprotectivity may be beneficial in such situations, especially if your patient is hypoxic already.

i suspect this patient has already aspirated, as well, so i suction the ETT out before ventilating, no matter what the O2 sats are

 

[Idiopathic]

IM succ. mask ventilate when able with 100% O2. Baby HR will likely improve with that alone. CHECK OTHER VITALS. What if her BP is 220/110? Sure it could be artifact, or from the seizures, but it could also be severe preeclampsia. Are you really going to go ahead and DL, intubate, risk further increases in BP and possible cerebral hemmorhage? I would say, paralyze, mask ventilate with 100% O2 (+/- volatile), then IV, then intubate if neccesary. Unless shes a really hard stick it shouldnt take more than a minute to obtain IV access. At least then you can administer vasoactive drugs, fluids, etc... as needed. If you perform a C/S prior to obtaining IV access, youre just asking for trouble.

i dont know, you have more experience than me, im sure, but I want a secure airway first...maybe a proseal LMA is the right answer

 

[huktonfonix]

i dont know, you have more experience than me, im sure, but I want a secure airway first...maybe a proseal LMA is the right answer

Its all risk/benefit. Basically its weighing the risks of losing the airway (hypoxia), vs potential cerebral hemmorhage (most common cause of mortality in preeclampsia if this is what her diagnosis turns out to be) vs aspiration (which I see as the least lethal in this patient at this point) as well as the fetal considerations. My thinking is that if you are able to stabilize the patient, then the fetus may stabilize as well. the only problem is we dont know how long the patient and fetus have been compromised. However, I dont think its wise to proceed without IV access in this patient regardless. A proseal is a good temporary compromise and may decrease aspiration risk compared to mask ventilation and if you are really short handed can free up your hands while you obtain IV access. Intralingual succ may also have a faster onset than IM, but may be difficult to administer if shes seizing.

 

[pgg]

probably, since pain processing does not rely on higher order neurons

I thought the first stop in the ascending pain pathway is the thalamus, which isn't exactly higher order (ie not cortical), but it's not brainstem either. Maybe vagal afferents (ie, from the int branch sup laryngeal nerve and RLN) are different?

(Maybe ElmerJFudd can reassure me that neuroanatomy was a useless MS1 class.)

When we do ECT, we see a sympathetic response due to the seizure, after the initial parasympathetic bit. Epileptic seizures cause an increase in sympathetic outflow. This suggests to me that 1) this seizing patient is probably already as sympathetically charged as she's going to get, and 2) that any reflex arc that involves sympathetic outflow isn't going to be functioning normally. Maybe I'm wrong, I don't know what the right answer is.

weighing the risks of losing the airway (hypoxia), vs potential cerebral hemmorhage (most common cause of mortality in preeclampsia if this is what her diagnosis turns out to be) vs aspiration (which I see as the least lethal in this patient at this point) as well as the fetal considerations

Airway's already lost. Agree that aspiration is way down the list of feared complications since aspiration & ARDS are treatable, unlike hypoxic brain injuries to the patient or fetus.

The brain bleed risk gives me pause. If I found a patient in a hallway, unconscious for an unknown reason (and not in need of chest compressions), I definitely wouldn't intubate them without an induction agent for exactly that reason.

Anyway, I've had a few hours to think about how I'd do it. Would like to hear how the OP handled it given only a few seconds ... 🙂

 

[Jeff05]

sz in pregnancy - ddx: eclampsia, LA toxicity (not here), tumor/infection/other metabolic.

issues
1. maternal seizure: hypoxia, aspiration (full stomach), hypertension (if sz related to preecl.)
2. fetal distress - likely hypoxia.

#1: call for help immediately. you will need a second/third pair of hands here. then ABC.

mother is critical - must stabilize before addressing fetal distress.
as team leader calm staff and direct members to specific tasks: apply monitors, start IV, call for blood products, etc.

1. sux/midaz IM and tube or LMA supreme (if can't intubate) - 100% o2 with 0.3 mac gas
2. IV - this is a tough call, but, this patient is potentially coagulopathic. if they cut her and you can't give fluid/pressor because you opted to save baby first - you're in a bind.
3. cut

 

[pgg]

2. IV - this is a tough call, but, this patient is potentially coagulopathic. if they cut her and you can't give fluid/pressor because you opted to save baby first - you're in a bind.

I read the original scenario to mean that she'd arrived at L&D, had time for an IV to be placed and normal FHR documented, and then she seized and was taken to the OR. If they say the baby's been down for 2 minutes, then we're approaching the permanent disability window.

Once the airway's secured (either ETT or LMA) and the mother is getting oxygen and a bit of gas, I would direct the OBs to cut while I and/or my help started an IV. Even if she's coagulopathic she won't bleed out and die in the first two minutes. But those couple of minutes might make all the difference in the world to the baby.

With IO access to the sternum as an easy, reliable, low morbidity first backup to a PIV, I'm not worried about being unable to obtain access within a few minutes.

I don't think waiting for IV access is a wrong answer though ...

 

[proman]

If she's seizing it turns into eclampsia (by definition, semantics I know). There's no way I would think of extubating. To ICU intubated +/- head CT on the way.

 

[Jeff05]

uterine blood flow is 700-900ml/min at term. if she's coagulopathic and opens up - she will lose 50% of her blood volume in 3-5 min. you won't see ANY veins by then.

so flip side...

if you're sure that you can pop in the IV i would do that first - the extra 15 seconds won't matter to the baby, but could mean difference between life and death for mother.

 

[Idiopathic]

well ill tell you what the real right answer is: you dont let the surgeons do anything until youve secured an airway and IV access for mom. the baby is not your concern here (for boards purposes that is)

 

[pgg]

well ill tell you what the real right answer is: you dont let the surgeons do anything until youve secured an airway and IV access for mom. the baby is not your concern here (for boards purposes that is)

Oh I agree the oral board answer is going to be IV then cut. In real life though some things can be done in parallel. It's all well & good to say the baby doesn't matter - and I've argued that side of the debate before too, maybe even on this forum. Unfortunately a gorked baby is a potentially multiple-decade-long burden and tragedy for the parents, and that risk DOES factor into my real world decision tree.

But I read this forum to challenge my own views ... if the overwhelming consensus here though is that I'm a cowboy for letting the OBs cut while the IV is being placed, I may have to reconsider that approach.

And of course it's entirely possible, maybe even likely, that once you're delivering oxygen to mom the FHR will climb back up to the 140s and you can take your sweet time getting ready to cut.

 

[DrDre']

Issues:
Seizing pt unk etiology
Poss aspiration (tons of people seize every day without aspiration)
Anoxic fetus

Priority 1 Mother
priority 2 baby

Mother:
Short seizures don't harm or kill pts (usually). Often self-terminate

ABCs as always

Unless she had horrific habitus :
IM sux, atropine and ketamine

Call for glide, US machine if near.

Intubate. If not drop LMA and put her on low pressure PPV so hands are free.

If IV sites are scarce go immediately to R IJ with US, long IV. IV in place in 30 seconds.

If no US and poor neck anatomy, Subclavian while surgeons are cutting.


Why temporize for either pt? Baby is gonna be braindead any minute.

Mother's seizure will be quick to stop or not. Treating it before ABCs isn't necessary.

Ketamine has rumor of pro-convulsant.

I just read yesterday that it can TERMINATE seizures (likely in induction doses) which I would be giving.

Great case.

 

[Arch Guillotti]

If IV sites are scarce go immediately to R IJ with US, long IV. IV in place in 30 seconds.

You must have things pretty sweet in Compton as far as help and logistics. There is absolutely no way an ultrasound could be located, plugged in and fired up within 30 seconds in my experience.

 

[SleepIsGood]

Why atropine?

my question exactly, why atropine? In peds, for the 'underdeveloped' sympathetic system when giving sux one needs atropine....

I say forget about midaz,etc....reach back, give 200mg of sux IM, then intubate or place LMA. Have RN start IV. Give inhal agents,etc.

I dont know about you guys but trying to go to the pyxis or whatever to get midaz just takes too much time...awareness in emergent c/s is an expected experience...chances are though she isnt going to remember anything anyways....once the iv is in and the airway is ok, benzos,etc can be given.

 

[aredoubleyou]

I think the priority in my mind is to secure the airway and get the baby out now. Its very unlikely that she'll bleed out before you can get an IV. The OBs should infiltrate with lidocaine (yea, yea seizures) while the IM sux is being pushed. Tube in, cut, dial up the anesthetic as you search for an IV. The listing of priorities into mother versus baby I think is over simplified. If your worried about litigation, its coming regardless with a gorked baby, and the OBs are going to through you under the bus since they got the pt in the room within 2 minutes. When you have a secured airway and a catheter in a vein you can control the BP and terminate the seizures. Theres no way to know if intubating her without anesthesia caused her hed bleed if it were present. With the info given theres no reason to think that this baby cant be rescued without significant disability, so its a risk id be willing to take.

 

[huktonfonix]

I think the priority in my mind is to secure the airway and get the baby out now. Its very unlikely that she'll bleed out before you can get an IV. The OBs should infiltrate with lidocaine (yea, yea seizures) while the IM sux is being pushed. Tube in, cut, dial up the anesthetic as you search for an IV. The listing of priorities into mother versus baby I think is over simplified. If your worried about litigation, its coming regardless with a gorked baby, and the OBs are going to through you under the bus since they got the pt in the room within 2 minutes. When you have a secured airway and a catheter in a vein you can control the BP and terminate the seizures. Theres no way to know if intubating her without anesthesia caused her hed bleed if it were present. With the info given theres no reason to think that this baby cant be rescued without significant disability, so its a risk id be willing to take.

How many OBs have you come across that are going to be proficient in administering lidocaine for a C/S under local? What do you intend to do when she bleeds a couple of liters in a few minutes and you have no IV access? Intrasseous access was mentioned which is a good suggestion, but not exactly readily available in most places (probably have to call down to the ER to get it). If the baby was fine prior to the seizure as the OP says, then stabilizing the mother will most likely stabilize the baby. No need to panic in this situation. Thats what the OBs do too often. As previously mentioned some things can be compromised and accomplished concurrently such as performing the C/S with suboptimal airway protection (i.e. LMA proseal) but I dont think IV access is a point you can compromise. Stuff happens, veins blow or disappear, and suddenly you're looking at a few minutes for IV access or needing to scramble for a central line or ultrasound.

 

[DrDre']

The atropine is not for the sux. It is for the glyco. Ketamine causes profound sialorrhea. Why add laryngospasm to the mix? Also, if mom continues to be hypoxic, your atropine may help a sqosh...


Arch, the US would take a while to turn on. While that was being rev'ed up, I would try anatomic IJs or SC depending on habitus and all( if not a PIV, of course)

I used to carry around a 3 1/4" 14 ga angiocath. You can place an IJ or SC in seconds, even sterile. Later, thread a guidewire and seldinger, or totally replace once pt is stable.

Compton has great US. I got two at the Compton swap meet.

Why atropine?

 

[Mista Suprane]

Compton has great US. I got two at the Compton swap meet.

did you get those with the $35 gift certificate you won on the $20 sack pyramid? please tell me you didn't already blaze your $20 sack of endo. 🙂

 

[urge]

I'm late to the party but anyway...


Quick ABC. Assuming she is still alive then I would slap an O2 mask and ask for someone to place monitors while I look for an IV. None of this IM stuff some of you are referring. Nobody approaches the pt until there is an IV.

 

[pgg]

This is the first approach in this thread that I think is actually unreasonable ...

Quick ABC. Assuming she is still alive then I would slap an O2 mask

She's actively seizing, and is likely to be apneic or obstructing. A facemask probably isn't going to help at all. It might, but at a minimum, someone should be taking care of her airway ... seems to me that ought to be the anesthesiologist.

and ask for someone to place monitors while I look for an IV. None of this IM stuff some of you are referring. Nobody approaches the pt until there is an IV.

Is it OK if someone approaches the patient to take care of the 'A' in ABC while you're looking for an IV? The IV is a job that can (should) be delegated if the airway is yet unsecured. What the patient and baby need most is oxygen; stat delivery may or may not be necessary. The IV shouldn't hold up ventilation.


I arrived at a code once where the usual dozen+ spectators were milling around aimlessly and asked who was running the code. Dr _____, the general surgeon, I was told. Where was he? Hunched over, zeroed in on the subclavian line he was trying to start while no one else was doing a thing. That was a disaster. God knows the surgeon isn't going to take charge and direct things in a crisis, so that leaves us.

I don't think this patient is best served by holding up the show while the most qualified person in the room tackles the peripheral IV task.

 

[bmk]

hay every one i hope that you all student or all the members of this forum will be happy and living healthy life any ways
i m a student of BUSINESS MANAGEMENT And i have project on the following persanlity traits can any body help me out that what that it means with human behaviour.

Slide 3 .O {color:black; font-size:149%;} a:link {color:#CCCCFF !important;} a:active {color:#3333CC !important;} a:visited {color:#B2B2B2 !important;} Myers-Briggs Type Indicator (MBTI)
A personality test that taps four characteristics and classifies people into 1 of 16 personality types.
Personality Types
•. .Extroverted vs. Introverted (E or I)
•. .Sensing vs. Intuitive (S or N)
•. .Thinking vs. Feeling (T or F)
•. .Judging vs. Perceiving (P or J)
Score is a combination of all four (e.g., ENTJ)

 

[aredoubleyou]

How many OBs have you come across that are going to be proficient in administering lidocaine for a C/S under local? What do you intend to do when she bleeds a couple of liters in a few minutes and you have no IV access? Intrasseous access was mentioned which is a good suggestion, but not exactly readily available in most places (probably have to call down to the ER to get it). If the baby was fine prior to the seizure as the OP says, then stabilizing the mother will most likely stabilize the baby. No need to panic in this situation. Thats what the OBs do too often. As previously mentioned some things can be compromised and accomplished concurrently such as performing the C/S with suboptimal airway protection (i.e. LMA proseal) but I dont think IV access is a point you can compromise. Stuff happens, veins blow or disappear, and suddenly you're looking at a few minutes for IV access or needing to scramble for a central line or ultrasound.

You could be right about the lidocaine proficiency, Ive seen it once and it was not as smooth as advertized for sure. The main purpose is to keep her pressures down as the anesthetic catches up. On the IV, in this instance, I think I would still not wait to get access, sustained fetal HR in the 50's for a couple minutes to me means every second counts. If the pt was hypotensive or obviously hypoxic - with a easy explanation for why the baby was crashing, then I agree that stabalizing mom will stabalize baby. Seizures alone in a non-hypoxic, normo- or hypertensive pt doesnt clearly explain to me why the intrauterine environment is so bad, and I wouldnt wait to get the baby out.

 

[urge]

ABC in an alive pt pressumes they are breathing and circulating blood. If that's the case I'm going for the IV.

Not breathing-mask.
No HR-cpr + section.

 

[urge]

Urge, what if they are in status? You gonna hold down their arm?

Rectal thiopental!

 

[DrDre']

Rectal midaz or valium as well, if available


Agree, Dreamy.
The kid may benefit from the atropine and it won't hurt home. Glyco if it was somesort of elective "dart" for a psych pt or something like that...

This is a good thread

Medeival **** right there...

Dre...you can give IM glyco too. Atropine will cross over to the kid, glyco won't. Unless, you think the atropine will help the kid too.

Atropine + Physio changes of pregnancy + Ketamine + Seizures + Sux (i believe tachy in adults)...That heart's going to be partying.

 

[gaspasser2004]

I'll assume that the patient is on the OR table with the safety straps tying her down while she is actively seizing.

Let the OB's start the C-section under local 😱

While they are saving the baby, IM benzos to terminate seizure.

Once seizure is terminated, test ability to mask. If you can mask the patient, then proceed to get IV. If you can't mask the patient, then IM succinycholine to get an airway.

Once IV is in, IV thiopental (or propofol) plus succinylcholine, then endotracheal intubation.

If can't get peripheral IV, try IJ, subclavian. If can't get central line, think of IO access.

I think one of the hardest things about anesthesia is prioritization of competing issues. For example, we would all love to start a ruptured AAA with a cordis, swan, A-line, rapid infusion device and a cooler full of blood but sometimes all you have is an 18 gauge IV from the ER. For this OB case, we all would love to have a non-seizing patient with IV access if the C-section is STAT. Like another poster already said, in an actively seizing patient the airway is already lost. Let the OB's cut the baby out while you terminate the seizure and manage the airway. The great thing about OB (versus ENT for instance) is that their stuff is down there and our stuff is up here.

 

[LongSnow]

Why atropine?

The atropine is for the slobber. Works pretty well IM for this purpose.

 

[aredoubleyou]

I'll assume that the patient is on the OR table with the safety straps tying her down while she is actively seizing.

Let the OB's start the C-section under local 😱

While they are saving the baby, IM benzos to terminate seizure.

Once seizure is terminated, test ability to mask. If you can mask the patient, then proceed to get IV. If you can't mask the patient, then IM succinycholine to get an airway.

Once IV is in, IV thiopental (or propofol) plus succinylcholine, then endotracheal intubation.

If can't get peripheral IV, try IJ, subclavian. If can't get central line, think of IO access.

I think one of the hardest things about anesthesia is prioritization of competing issues. For example, we would all love to start a ruptured AAA with a cordis, swan, A-line, rapid infusion device and a cooler full of blood but sometimes all you have is an 18 gauge IV from the ER. For this OB case, we all would love to have a non-seizing patient with IV access if the C-section is STAT. Like another poster already said, in an actively seizing patient the airway is already lost. Let the OB's cut the baby out while you terminate the seizure and manage the airway. The great thing about OB (versus ENT for instance) is that their stuff is down there and our stuff is up here.

I'd argue that the seizure is the least of the problem here, dont screw around with IM benzos, get the IM sux in and establish an airway. Also, the lidocaine will only get you so far, by the time the IM benzos hit, and your seeing if you can mask her, the BP is 250 since they're cutting into uterus. Also, I wouldnt bother masking, but I wouldnt completely disagree with you if shes breathing well. Totally agree and great points on last paragraph.

 

[Idiopathic]

so i say ketamine for two reasons, one pain control, two its in my box, along with sux and local anesthetic. (you cant give anything else IM that is going to be able to help with pain from the incision, can you?) i can give it IM, and i secure an Airway first and make sure that Circulation is handled afterwards. Especially considering I may be alone.

i think that if you dont do things in this way, you may end up masking an unstable patient through a local-assisted C-section and then you are screwed

 

[Idiopathic]

all good points, gaspasser, but would you really feel comfortable with a formerly seizing/now obtunded pregnant patient with a full stomach being masked while you get an IV? seems like a recipe for something...

 

[Jeff05]

i would NOT give ketamine to this patient. she is actively seizing. inducing status epilepticus would not be prudent.

 

[huktonfonix]

I'll assume that the patient is on the OR table with the safety straps tying her down while she is actively seizing.

Let the OB's start the C-section under local 😱

While they are saving the baby, IM benzos to terminate seizure.

Once seizure is terminated, test ability to mask. If you can mask the patient, then proceed to get IV. If you can't mask the patient, then IM succinycholine to get an airway.

Once IV is in, IV thiopental (or propofol) plus succinylcholine, then endotracheal intubation.

If can't get peripheral IV, try IJ, subclavian. If can't get central line, think of IO access.

I think one of the hardest things about anesthesia is prioritization of competing issues. For example, we would all love to start a ruptured AAA with a cordis, swan, A-line, rapid infusion device and a cooler full of blood but sometimes all you have is an 18 gauge IV from the ER. For this OB case, we all would love to have a non-seizing patient with IV access if the C-section is STAT. Like another poster already said, in an actively seizing patient the airway is already lost. Let the OB's cut the baby out while you terminate the seizure and manage the airway. The great thing about OB (versus ENT for instance) is that their stuff is down there and our stuff is up here.

So if the seizure is TERIMINATED and you CANT mask, then you would give IM succinylcholine to obtain an airway? If the patient is spontaneously breathing and stable that is an absolutely terrible idea. If the patient is already hypoxic then I suppose you have nothing to lose. If you think the patients muscle tone in some way is impeding intubation, then there may be an argument for the sux. However, should probably be dropping down the airway algorithm reallllly quickly if this was the case anyway.

And comparing the above case to the ruptured AAA is apples and oranges. Now, would you start the ruptured AAA if they were seixing, had no IV, and an unsecured airway? Im not saying the baby doesnt matter, but I think it would be absolutely ridiculous to place the mother at that much increased risk by not securing IV access for medications/fluids first.

As others have mentioned ABCs come first which means I would make sure I had CONTROL over the patients airway, whether that is by mask, LMA, or ETT (preferably ETT, but if shes a difficult intubation and maskable, I would be willing to risk aspiration if the fetus is truly in distress. Mask with trendelenburg, cricoid, suction ready. or proseal LMA.) However, with potential need for rapid fluid and pressors it seems unwise to proceed without some form of IV access.

 

[Idiopathic]

ok well we can agree to disagree on this

 

[aredoubleyou]

i would NOT give ketamine to this patient. she is actively seizing. inducing status epilepticus would not be prudent.

The seizure can EASILY be terminated after an airway and IV is established.

 

[Jeff05]

The seizure can EASILY be terminated after an airway and IV is established.

how long of a seizure does it take to cause permanent neurological damage?

if ketamine had a useful role in this situation, one could consider the pros/cons of its use. however, i do not see any benefit or need for using ketamine in this case.

gaspasser, i would not start a AAA without an introducer/a line/product. it the patient is still alive, it means there is some tamponade in effect. once they open it's a bloodbath. not sure, what you meant with that reference as starting that case with an 18g is a death sentence for the patient.

same holds POTENTIALLY true here. mother always, always comes first. everyone obviously wants to save the baby, but the road to hell is paved with good intentions. here the priority is clear. establish airway and IV access. then cut. we can debate doing things in tandem, but, i believe, if this case was started without an IV and there was maternal morbidity/mortality - it would be very difficult to defend in court.

 

[Ventil8]

Wow-- plenty of good conversation out there!

We put on the O2, took a deep breath (ourselves) and did IM Sux, intubate, IV, then 2 of midaz and some thiopental, Mg++.

Baby was ok, got tubed and extubated day 1

Mom, however, had a more interesting course. C\S was fine. Extubated. Clearly post ictal-- should we really have pulled it?

Then social issues took over-- grandma (homeopathic midwife) refused to allow the OBs to run post partum mg. She seized and aspirated 1 hour later. Reintubated to ICU. Doing okay.

Didn't use ketamine b/c increases szs, IM versed would have been nice, but absolutely didn't want to wait for "amnesia" before sux in. She was tonic-clonic when I walked in, rapid shallow breaths-- probably wouldn't have gotten us too much as far as improving FRC O2...

2nd IV taped down (not to IVF) incase of repeat sz and pulling existing IV.

Thanks for all the replies!

 

[Arch Guillotti]

Then social issues took over-- grandma (homeopathic midwife) refused to allow the OBs to run post partum mg

??? Unbelievable

 

[Arch Guillotti]

gaspasser, i would not start a AAA without an introducer/a line/product. it the patient is still alive, it means there is some tamponade in effect. once they open it's a bloodbath. not sure, what you meant with that reference as starting that case with an 18g is a death sentence for the patient.

Reminds me of a pretty good thread froma while back:

http://forums.studentdoctor.net/showthread.php?t=478127

To quote JPP (since I can't figure out how to quote from a different thread):

"They had all that stuff in place and the guy died anyway.

Ya gotta open the belly with or without lines.

This guy had lines, and he died.

I think the absolutely most important part of this whole equation is a deft surgeon.

Without that all the other stuff doesnt matter.

But I maintain to not waste precious time if you experience technical trouble.

Proximal control with a x-clamp in cdazy fast fashion is what'll save this guy."

 

[aredoubleyou]

how long of a seizure does it take to cause permanent neurological damage?

if ketamine had a useful role in this situation, one could consider the pros/cons of its use. however, i do not see any benefit or need for using ketamine in this case.
.

I agree that there is no need for ketamine (only muscle relaxant in this case), BUT, i think it is very very very (did i mention very) unlikely that ketamine will potentiate the seizure (that is already occuring and will continue to occur) to the point that a slug of STP after the iv is established isnt going to terminate it.

Also disagree that the mother comes first in a purely linear fashion, if you have an airway, the overwhelming probability is that you'll get an IV. If this kid is brain damaged because it took you 10 minutes to get an IV, its not only (IMHO) uneccessary but you'll likely fry in court as well. I think your f'd either way, and it comes down to weighing the probabilities of a bad outcome.

 

[aredoubleyou]

Wow-- plenty of good conversation out there!

We put on the O2, took a deep breath (ourselves) and did IM Sux, intubate, IV, then 2 of midaz and some thiopental, Mg++.

Baby was ok, got tubed and extubated day 1

Mom, however, had a more interesting course. C\S was fine. Extubated. Clearly post ictal-- should we really have pulled it?

Then social issues took over-- grandma (homeopathic midwife) refused to allow the OBs to run post partum mg. She seized and aspirated 1 hour later. Reintubated to ICU. Doing okay.

Didn't use ketamine b/c increases szs, IM versed would have been nice, but absolutely didn't want to wait for "amnesia" before sux in. She was tonic-clonic when I walked in, rapid shallow breaths-- probably wouldn't have gotten us too much as far as improving FRC O2...

2nd IV taped down (not to IVF) incase of repeat sz and pulling existing IV.

Thanks for all the replies!

did you have the obs wait until you had an iv to cut - i think the timing of this might be the largest point of disagreemnet among people here. just curious. If you did, would you have done the same if it were a 22g that got pulled out from a hand that looked rather veinless on quick inspection?