OB Case

[Idiopathic]

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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.

it has been mentioned how important pain relief is to this woman and you will not get the 5 minutes needed to allow for fentanyl to work, thats my only point. ill put up with the potential for seizure prolongation and give IV bzd anyway after the incision.

 

[Idiopathic]

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?

it scares me that people are suggesting that you allow the OB to cut without an IV.

 

[gaspasser2004]

I'm happy to hear everything went okay for this patient.

I think everything goes back to prioritization of issues:

If the patient is seizing and the baby is stable, then stabilize the patient first before doing a section.

If the patient is seizing and the baby is crashing, start a C-section under local while you simultaneously work to abate the seizure, establish airway, IV.

In an emergent situation with a crashing patient who has no IV, mask the patient (even if full stomach) and get IV before going further with the airway (this is what BLS/ACLS says to do in cardiac arrest).

In an emergent situation with a crashing patient who has no IV, if mask ventilation is impossible, then IM succinycholine to secure airway with endotracheal tube before IV.

If a ruptured AAA is wheeled emergently into your OR, take all the time in the world to get lines if the patient is hemodynamically stable.

If a ruptured AAA is wheeled emergently into your OR and is hemodynamically unstable, the fifteen minutes you take to get A-line, cordis, swan will kill them when all they really need is their belly opened and aorta cross clamped.


For this OB case with a crashing baby, my priorities were as follows:

1. The baby is crashing and has little if no reserve - get the baby out now, even if it means doing it under local.

2. The patient is seizing = bad. Terminate the seizure while the OB's are getting the baby out. I admit that succinylcholine would terminate the musculoskeletal effects of the seizure, but that would do nothing for the underlying brain-frying event.

3. A maskable airway is good enough until you get an IV in this emergency situation. Is this ideal? No. Would I mask a pregnant patient with a presumed full stomach for an elective C-section? Hell no. In this god forsaken situation would I mask a pregnant patient with a full stomach and then get an IV before going further with advanced airway management? Yes.


Now say the patient was seizing and the baby was stable

1. Terminate the seizure (we can agree to disagree on whether to do this with IM succinylcholine or benzos)

2. Manage the airway. Again, a maskable airway is a good enough airway until you get an IV.

3. Once you have an advanced airway (ETT) and IV, then proceed to C-section.

 

[pgg]

it scares me that people are suggesting that you allow the OB to cut without an IV.

Have you ever placed an IO line?

I have 1000x as much confidence in my ability to get an IO line in <30 seconds than I have in any OB, anywhere, anytime, to actually start a section under local.

 

[pgg]

In an emergent situation with a crashing patient who has no IV, mask the patient (even if full stomach) and get IV before going further with the airway (this is what BLS/ACLS says to do in cardiac arrest).

The BLS/ACLS protocols are different in pregnancy. Specific goals are
1) airway should be secured early to miminize aspiration risk
2) cesarean delivery within 5 minutes if gestational age >24 weeks

Given that effective chest compressions are essentially impossible in the presence of a gravid uterus, maternal survival is likely going to be contingent upon immediate delivery.

 

[Narcotized]

In this god forsaken situation would I mask a pregnant patient with a full stomach and then get an IV before going further with advanced airway management? Yes.

Why are you adamant about having an IV before intubating?

 

[proman]

BTW how good is this scenario for the oral boards? Or, is this one just a bit too complicated with no real right answer?

 

[6stringsdown]

For this OB case with a crashing baby, my priorities were as follows:

2. The patient is seizing = bad. Terminate the seizure while the OB's are getting the baby out. I admit that succinylcholine would terminate the musculoskeletal effects of the seizure, but that would do nothing for the underlying brain-frying event.

3. A maskable airway is good enough until you get an IV in this emergency situation. Is this ideal? No. Would I mask a pregnant patient with a presumed full stomach for an elective C-section? Hell no. In this god forsaken situation would I mask a pregnant patient with a full stomach and then get an IV before going further with advanced airway management? Yes.

Say you give IM succs, and even though it's still "frying the brain", wouldn't that be easier and quicker to get an IV in, than masking and waiting (in the absence of IM midaz)? I suppose i never compared rate of relaxation betw/ IM succs and PIAs though, so I may be way off here.

 

[xjohns1]

Why are you adamant about having an IV before intubating?

i think this is the most interesting and important question to arise from this discussion: where in the sequence do you require the iv?

i think trying to reiterate fundamental guiding principles here is important because there will be great temptation in the moment to deviate from them. firstly, your number one priority is the well-being of the mom, followed closely by the baby--mom first, baby second. getting the baby out is not the number one priority though you will be pressed to think so (by nervous ob's). i would not subject mom to additional substantial risk for the benefit of the baby. secondly, not having iv access is substantial risk. it's easy to imagine where some of that risk comes from (uncontrolled hypertension on laryngoscopy in this pt already at risk for cerebral hemorrhage, laryngospasm, bronchospasm, surgical hemorrhage, uterine atony, hypotension in response to anesthetics) and not so easy to imagine every other bad scenario requiring iv access for therapy. but, i think it is very clear that not having iv access is substantially risky in this situation. the longer you go without it, the greater the risk to mom (and thus to baby).

i'd give im benzo up-front to abort seizure. it might help you get iv access if you can abort the seizure and will give amnesia if you end up giving sux without induction (though it's doubtful a seizing or postictal pt will have recall). there seems little downside to giving the benzo at this point--no bridges burned yet. i would try to hold off on sux until i get an initial assessment of the iv situation.

i would delegate iv access to an ob nurse while i tried to initially manage the airway non-invasively. if a nurse can't get it easily and quickly, it should make you wonder how difficult it would be to get yourself if you decide to proceed initially without access. i understand we're better at establishing iv access than ob nurses, but it would make me think twice about proceeding if the nurse says, 'i see nothing.' how does the neck look if you really got into trouble peripherally? i.o. is not an option for me and i suspect most (no experience, equipment not available).

i agree with parallel activity here: ob's dressing, draping, splashing while you look for access.

it's a tough situation but i think that if you couldn't quickly enough get iv access before starting, it's too dangerous to start and then struggle while bad things could happen that you could do nothing about.

if you must free your own hands from the airway to look for access, i'd consider the least invasive way to do that first. maybe an lma with someone maintaining cricoid pressure (maybe less hemodynamic swings than with dl). but, i'd intubate the trachea with i.m. sux if an lma were not tenable (still seizing, resisting lma placement, etc.) and i needed my hands for iv access; here you can justify the risk of proceeding with airway management before establishing iv access. then--before the ob's cut--i'd establish iv access, and i would not permit them to proceed without it. i think you can't justify the risk to mom. she has her airway secured and the next intervention that will decrease her risk and increase her safety is iv access, not cesarean section. it may take only a minute to pop in something, but if it's difficult you don't want to be struggling while the uterus is atonic, mom is bleeding out and hypotensive, and you have no way to treat these problems.

it's indefensible to proceed for the sake of the baby while exposing mom to substantially more risk. you may get away with it (and everyone will feel great). but if you don't, you may have a baby (healthy or not) and a dead or morbid mom and everyone will be looking at you asking why you thought it would be better to proceed without iv access. getting away with things (even if the alternative is rare) is very dangerous because it is self-reinforcing. this is, in my opinion, why it is essential to be faithful to the fundamental principles all the time.

 

[dhb]

Good post xjohns but all of what has been talked about should be replaced in the clinical picture.
Is the patient an easy stick ? if you see a forearm full of veins i don't see any reason to delay anything and you can do every thing in parallel.
If her arm is so fat you don't even see a vein in the hand the situation is different although what are you going to do then delay for 5+ min while you fiddle around?

It could also be argued that the treatment for eclampsia is delivery of the baby and if you delay that you are not giving appropriate care...

I think this is a situation where if something goes wrong there will always be an angle to attack you for what you did or did not do. So you have to take your best shot depending on how the situation presents.

I'm a little bit surprised about the hypertension and head blees comments; if she is actively seizing her blood pressure is surely high already (especially if eclamptic) adding a dl will not double her BP. I have never seen a 300mmHg BP; when you intubate a patient somewhat awake the BP usually tops out at around 220 240 so bleeding would be pretty low on my concern list.

 

[huktonfonix]

Good post xjohns but all of what has been talked about should be replaced in the clinical picture.
Is the patient an easy stick ? if you see a forearm full of veins i don't see any reason to delay anything and you can do every thing in parallel.
If her arm is so fat you don't even see a vein in the hand the situation is different although what are you going to do then delay for 5+ min while you fiddle around?

It could also be argued that the treatment for eclampsia is delivery of the baby and if you delay that you are not giving appropriate care...

I think this is a situation where if something goes wrong there will always be an angle to attack you for what you did or did not do. So you have to take your best shot depending on how the situation presents.

I'm a little bit surprised about the hypertension and head blees comments; if she is actively seizing her blood pressure is surely high already (especially if eclamptic) adding a dl will not double her BP. I have never seen a 300mmHg BP; when you intubate a patient somewhat awake the BP usually tops out at around 220 240 so bleeding would be pretty low on my concern list.

Yes, it should be taken in the clinical picture but no you still shouldnt start without an IV. If it looks that easy then it shouldnt take more than 30 seconds to obtain access should it? If thats the case, it should be done before incision.

The cure for eclampsia IS delivery of the baby, but do you think that she is magically cured once the baby is out? Seizures can and do frequently happen post delivery. In other words, the few minutes you take to ensure a patent airway (mask, tube, LMA)/IV access will do much more to prevent morbidity/mortality than using those few minutes to deliver the baby quicker. Yes, those few minutes may matter more for the baby, but thats been debated here already.

Regarding the HTN and head bleed comments. Her BP may very well be high from the seizures/sypmathetic stimulation already. All the more reason to obtain IV access to lower it prior to DL and especially incision because intracerebral hemmorhage is the leading cause of mortality in preeclampsia. And seizures in a pregnant female with no prior history (which we must assume givne no preop info) is preeclampsia. That is a point which must be understood. Of course if she is hypoxic and is unmaskable, then you should of course try laryngoscopy even without lowering the BP since hypoxia will kill faster than the cerebral hemmorhage, but thats a different story.

 

[xjohns1]

Good post xjohns but all of what has been talked about should be replaced in the clinical picture.
Is the patient an easy stick ? if you see a forearm full of veins i don't see any reason to delay anything and you can do every thing in parallel.
If her arm is so fat you don't even see a vein in the hand the situation is different although what are you going to do then delay for 5+ min while you fiddle around?

yes.

It could also be argued that the treatment for eclampsia is delivery of the baby and if you delay that you are not giving appropriate care...

i disagree that this would be a cogent argument.

I think this is a situation where if something goes wrong there will always be an angle to attack you for what you did or did not do. So you have to take your best shot depending on how the situation presents.

i don't mean to be antagonistic, but this is sloppy thinking. you may end up in court or "attacked" with a bad outcome on either the maternal or fetal end. the strategy here is not to throw up your hands and say, 'i'm going to court regardless, so i'm going to do what feels right.' i feel strongly that the only defensible position is waiting for the iv. if there is a poor fetal outcome you may end up in court but you will have a defense that will be supported by the standard of care. if there is a poor maternal outcome because you wanted the baby out before an iv and the lack of iv access contributed to the poor maternal outcome, you will have no defense and will have not met the standard of care.

 

[dhb]

so you agree that you'll be in court anyway 😉