31 Dec 2020

December 31, 2020

Written by REBEL Crit
Introduction: Respiratory failure is an uncommon but important complication in pregnancy and the postpartum period, occurring 1 in 500 pregnancies.1 Respiratory failure can result from pregnancy-related conditions, conditions exacerbated by pregnancy, or pathologies common to the general population (Table 1). Understanding of respiratory failure and mechanical ventilation in pregnant patients is limited by the relative rarity of the condition as well as the exclusion or underrepresentation of pregnant patients in the majority of the trials that have informed our understanding of respiratory failure. As such, respiratory failure in this vulnerable population is a stressful emergency that requires understanding of the anatomical and physiological changes of gestation as well as meticulous preparation for a difficult airway. 
Medical Categories: Obstetrics and Gynecology, Resuscitation
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16 Dec 2020

December 16, 2020

Written by REBEL Cast, REBEL Core
Take Home Points
  • This is a resuscitative hysterotomy - focus is on saving the mother first. Delivering the fetus can improve venous return thus increasing chance to save mom
  • Don’t focus on gestational age to make the decision - if you think the belly is big enough to be causing compression of vascular structures, the procedure is indicated
  • Once you’ve made the decision - it’s go time. The faster you do it, the more likely you can salvage mom and the fetus
  • Large vertical incision to maximize exposure, locate uterus, vertical incision with scalpel and extend with scissors
Medical Categories: Obstetrics and Gynecology
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11 Nov 2020

November 11, 2020

Written by REBEL Cast, REBEL Core
Take Home Points
  • Watch for continued bleeding in excess of 500 ml or bleeding that is “more than normal.” Call it postpartum hemorrhage and start resuscitation
  • Call your obstetric and/or surgical consultants early as operative intervention is often required
  • Replace intravascular volume with blood products
  • Uterine atony is the most common cause of postpartum hemorrhage. Begin treatment with uterine massage and uterotonic medications
  • Consider the development in DIC when patients continue to bleed despite appropriate management
Medical Categories: Obstetrics and Gynecology
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25 May 2020

May 25, 2020

Written by REBEL EM
“You’re working a shift in whatever the lower acuity version is of your department. So maybe it’s fast track, maybe you call it an urgent care. Whatever it is, it’s a unit where they take doctors, who trained for 7 or 8 years to become expert resuscitationists, and make us spend all day seeing sniffles, sore throats and chronic back pain in a manner that I can only assume was designed specifically to make us all exceptionally crazy. But, either way: that’s where you’re working. You’ve taken care of a young woman, you’ve treated her ailments, you’ve decided what’s wrong with her. And you’re deciding you are going to prescribe a few medications for her and send her on her way. You’ve answered all of her questions and you are walking out the door, your hand is on the door handle and she says “Oh, but doc, did I tell you I’m currently breastfeeding my 6-month old baby? Can I even take these medications?” And your heart stops. And you freeze. And your hand is still on the door handle. And the first thought that goes through your head is “Oh my God, I have no idea.” Because you, like most of us, had one lecture on medications in pregnancy and lactation back in your second year of medical school and you have no idea what you learned. That’s your first thought. “Oh my god, I have no idea.” Your second thought is “Oh my god, I have 8 more patients that just got triaged, while I had that thought. What am I gonna do?” Your third thought then is that you breathe a sigh of relief and you go “It’s ok, I’ve got an ED pharmacist. I’ll just ask her.” But then you’re horrified again because you realized it’s Saturday! And while you work in a 24/7/365 emergency department, your department has decided to staff this one crucial member for just business hours from Monday through Friday. And you think “That’s terrible.” And now you’re back to horror. Because, again, you don’t know what to do. And another 8 patients have been triaged and they all have chronic back pain and they’re asking why they haven’t been seen yet. And you’re still in that room and your hand is still on the door. Now you think “I don’t know. I don’t know.” “Honestly lady, I don’t know, you probably should just pump and dump.” Out of an abundance of caution we always just revert back to “You should pump and dump.” But I’m going to argue that that’s probably not the best strategy.”
Medical Categories: Obstetrics and Gynecology
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16 Apr 2020

April 16, 2020

Written by REBEL EM
Background Information: Nausea and vomiting during pregnancy most commonly occurs during the first trimester. If left untreated, the development of hyperemesis gravidarum can lead to further complications characterized by dehydration and electrolyte abnormalities.1 Ondansetron, a 5-HT3 receptor antagonist has quickly become the most frequently prescribed drug in the United States for nausea and vomiting during pregnancy.2 With the creation of an oral dissolving tablet in 2006, Ondansetron’s popularity as an antiemetic continues to rise. In fact, a study from 2014 shows that nearly a quarter of all pregnant women in the United States are using it.3 There is uncertainty in the literature as to the association between Ondansetron and birth defects. While some studies report there is no increased risk in congenital abnormalities among women who took this antiemetic early in pregnancy, other evidence suggests it may be associated with cleft palate and cardiac malformations.2 The authors of this study sought to investigate the association between exposure to Ondansetron during the first trimester of pregnancy and risk of congenital malformations in newborns using a national cohort of publicly insured pregnant women.
Medical Categories: Obstetrics and Gynecology, Toxicology
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