1. Obstetrical and Pediatric Emergencies 2014 Compulsory CME

2. 2 Acknowledgments 2014 Obstetrical and Pediatric Emergencies CME Working Group AJ Grass, ACP, TEMS Dave Stavrou, ACP, PRPS Jason Benaim, ACP (c), TEMS Jason Tremblay, ACP, PRPS Patrick McColm, ACP, PRPS Nicole Foxwood, ACP, PRPS

3. 3 General Objectives By the end of this CME, Paramedics should be able to: Assess and anticipate first and second trimester obstetrical emergencies Develop and implement a treatment plan in anticipation of third trimester obstetrical emergencies. Recognize and provide prehospital care to common complications around the delivery of neonates Assess and manage the critically ill neonatal and pediatric patient

4. 4 Topics Ectopic pregnancy emergencies Pre-Eclampsia and Eclampsia HELLP syndrome Midwives role Abnormal delivery presentations Meconium staining Spontaneous abortion and D&C Assessment and management of the critically ill child Pediatric respiratory distress Sepsis in pediatric population embryology.med.unsw.edu.au

5. 5 Epidemiology of Pediatrics and OB-GYN Emergencies Most common cause of maternal death in developed countries: Sepsis and infection 2.1% Ectopic pregnancy 4.9% Abortion 8.2% Hemorrhage 13.4% Emboli 14% Hypertensive disorders 16.1% Other: 21.3% (C-section complications and anaesthesia)

6. 6 Ectopic Pregnancy Definition: Implementation of a developing fetus outside the uterus. Most commonly in the uterine tubes (fallopian tubes). www.mayoclinic.com

7. 7 Ectopic Pregnancy Paramedics should always exercise a high level of suspicion of an ectopic pregnancy in every female patient in fertility age who is presenting with acute abdomen Missed or irregular menses Abdominal pain Signs of shock Possible vaginal bleeding Recent Hx of PID, abortion, surgery

8. 8 Ectopic Pregnancy (Suspected Rupture) ABCs and administer oxygen Cardiac monitor, obtain vital signs q5 min IV access appropriate size for fluid bolus Prepare resuscitative measures Reassess frequently and notify receiving hospital

9. 9 Pre-Eclampsia and Eclampsia Pre-Eclampsia: a condition during pregnancy that is characterized by hypertension and protein in the urine Untreated, may progress to seizures (eclampsia) and can be fatal to mother and fetus Causes are still unclear and thought to be related to a combination of factors: Genetic Autoimmune Age (teens and over 40) Structural abnormalities of the uterus and/or the placenta blood vessels

10. 10 Pre-Eclampsia and Eclampsia Common Signs and Symptoms High blood pressure (usually above 140/90) Presence of protein in the urine Swelling, sudden weight gain Headaches and changes in vision

11. 11 Pre-Eclampsia and Eclampsia

12. 12 Pre-Eclampsia and Eclampsia Eclampsia = Seizure Coma Brain damage Maternal and/or fetal death https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcS4TncSZ9jUq3- p7mOXBY_gKjdD5xfjUKX5FDr-9hAT53G8_QIK

13. 13 Eclampsia - treatment Pre Hospital Treatment: Midazolam 0.1mg/kg to a max of 5mg IV Midazolam 0.2mg/kg to a max of 10mg IM, IN or Buccal In Hospital Treatment: Delivery of the baby Magnesium Sulfate Beta blocker Diuretics data:image/jpeg;base64,/9j/4AAQSkZJRgABAQAAAQABAAD/2wCEAAkGBhQSERMSExQUFBUUFxcVFxcXFBUXFBUVFhUVFBYYFRQbGyYeFxojHBQWIC8gIycpLCwsFR8xNTAqNSYrLCoBCQoKDgwOGg8PGikkHyQtNCwsLCwtLSosKSwsLywsLCwsLCwsLCwsLCwsLCwsLCwvKSwsLCwsLCwpLCwsKSwsLP/AABEIALIBGgMBIgACEQEDEQH/xAAbAAACAgMBAAAAAAAAAAAAAAAABQQGAgMHAf/EAEYQAAIBAgMEBwQHBAgGAwAAAAECEQADBB IhBQYxQRMiUWFxgZEyobHBBxQjM0Jy0SRSgvAVFjRDYrLC4XODk6LS8WOSs//EABoBAAIDAQEAAAAAAAAAAAAAAAADAQIEBQb/xAAzEQACAQIDBQYFBAMBAAAAAAAAAQIDEQQSITEyQVFhEyJxkbHwFEKBodEjweHxBTNSFf/aAAwDAQACEQMRAD8A7jRRRQAUUUUAFFFFABRRRQAUUUUAFFFFACnH7xpbbIqXLrf/ABrIGsasSAKiHeO8eGGC/nvoPcJpFirJS8yMQHktGYTDEkGpQwmns/GuQ8bLM1KLXvqjqLDU7JxafvoxiNuYj9zDj/mk/AUDbt/ 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14. 14 HELLP Syndrome H emolysis, E levated L iver enzymes and L owered P latelets Most severe form of Pre-Eclampsia 5-12% of Pre-Eclamptic patients develop HELLP Can be mistaken for the flu, gallbladder, gastritis or hepatitis

15. 15 HELLP Syndrome HELLP Syndrome: Headache and visual disturbances GI signs and symptoms. RUQ and epigastric or sub-sternal tenderness Bleeding Swelling 25% mortality rate!

16. Vanden Hoek T L et al. Circulation. 2010;122:S829-S861 Copyright © American Heart Association, Inc. All rights reserved.

17. Left uterine displacement with 1 and 2-handed technique Vanden Hoek T L et al. Circulation. 2010;122:S829-S861 Copyright © American Heart Association, Inc. All rights reserved.

18. 18 Midwives Role Education for the pregnant woman Carrying out examinations to establish and monitor normal pregnancies Recognizing the warning signs of abnormality in mother or infant and refer to a physician Supervising and assisting with spontaneous deliveries Taking emergency measures in the event of a crisis Examining and carrying for the newborn infant Carrying and advising for the mother and her family in the postpartum period

19. 19 Working together with a Midwife Paramedics and Midwives will work cooperatively in making decisions and providing quality patient care to the mother and neonate during an out- of-hospital birth. www.dreamstime.com

20. 20 Spontaneous Abortion Primary cause during early pregnancy (<20 weeks): Genetic mutation Other causes of abortion: Substance abuse Environmental toxins Immune compromise Diabetes Infection Smoking Trauma

21. 21 Breech Delivery Proper technique for delivering a breech: http://www.primary-surgery.org/ps/vol1/html/images/img-0151.png

22. 22 Prolapsed Cord A condition when the umbilical cord drops through the open cervix into the vagina ahead of the baby Potential risk of severe ischemia to cord and baby Life threatening event to baby Management: ensure cord is wet and wrapped

23. 23 Prolapsed Cord Prehospital Treatment: If the cord is protruding through the vaginal vault then keep moist with sterile saline and gauze. DO NOT INSERT FINGERS INTO THE VAGINA. Repositioning of the mother may restore/ improve perfusion to the baby. If the cord is prolapsed against a presenting part, i.e. the head, then insert two gloved fingers into the vagina and gently elevate the presenting part away from the cord.

24. 24 Shoulder Dystocia The McRoberts Manoeuvre and suprapubic pressure http://www.aafp.org/afp/2004/0401/p1707.html

25. 25 Nuchal Cord Very common The cord wrapped around the neonatal neck Can cause hypoxia if not corrected http://www.lookfordiagnosis.com/mesh_info.php?term=Nuchal+Cord&lang=1 http://cord-clamping.com/2011/11/04/cord-around-the-neck-what-parents-practitioners-should-know/

26. 26 Meconium Is the bowel movement of the fetus Appears mustard yellow, brown or black Liquid, pasty or very sticky http://newborns.stanford.edu/images/mec-vernix.jpg

27. 27 Meconium Aspiration http://calsprogram.org/manual/volume3/Sectio n20/NRPGraphics/4_nrp_3_a.jpg

28. The Critically I ll Child www.wellsphere.com

29. 29 The Critically I ll Child Airway Breathing Circulation Disability Exposure

30. 30 PALS Overview

31. 31 The Critically I ll Child img.medscape.com/pi/emed/ckb/clinical_procedures/799 26-1413466-1948389-2040427tn.jpg Appearance Tone Interactiveness Consolability Speech/Cry Work of Breathing Abnormal airway sounds Abnormal positioning Retractions Nasal flaring Head bobbing Circulation to Skin Pallor Mottling Cyanosis

32. 32 The Critically I ll Child Airway Assessment Abnormal sounds: Gurgling Snoring Stridor Grunting Coughing Breathing Assessment Determine the respiratory rate Determine the depth of breathing Look for increased effort of breathing Listen for breath sounds Perform pulse oximetry

33. 33 The Critically I ll Child Circulatory System Assessment Control bleeding Count pulse Assess skin colour Assess skin temperature Check capillary refill

34. 34 Pediatric Vital Signs

35. 35 The Critically I ll Child Management Principles Airway: Positioning Suctioning Airway adjuncts Positive pressure ventilation Confirmation methods (including ETCO2) Complications

36. 36 Calculating Size and Depth of ETT

37. 37 The Critically I ll Child Respiratory distress Respiratory failure Respiratory arrest Cardiopulmonary arrest

38. 38 Respiratory Illnesses Asthma Pertussis -Whooping Cough Bronchiolitis Croup http://www.youtube.com/watch?v=VEXn2X95HS0 http://www.youtube.com/watch?v=S3oZrMGDMMw http://www.youtube.com/watch?v=y0MEDVb2SSM http://www.youtube.com/watch?v=Qbn1Zw5CTbA

39. 39 Sepsis and Septic Shock Sepsis – Systemic infection Causes: Meningitis Pneumonia Wound infection UTIs Occult infections http://aapredbook.aappublications.org/content/1/SEC131/SEC217/F1300.large.jpg

40. 40 Sepsis and Septic Shock Management of Sepsis and Septic Shock PPE Airway Respiratory support Circulatory support Early antibiotic therapy http://www.healthytravelblog.com/wp-content/uploads/2012/03/antibiotics_jpg.jpg

41. 41 References Bush, D. E. (2013). Preeclampsia foundation. Retrieved December 16, 2013, from Preeclampsia foundation: http://www.preeclampsia.org/ Cleveland Clinic Prolapsed Cord. (n.d.). Retrieved 12 17, 2013, from Clevland Clinic: http://my.clevelandclinic.org/healthy_living/pregnancy/hic_umbilical_cord_prolapse.aspx Markenson, D. D. (2002). Pediatric Prehospital Care. Upper Saddle River, New Jersey: Brady, Prentice Hall. Ministry of Health and Long Term Care. (2007). BLS Patient Care Standards Obstetrical Conditions. In M. o. Care, BLS Patient Care Standards (pp. 5-24). Government of Ontario. PR, M. E. (1994). The effects of benzodiazepine use during pregnancy and lactation. Reprod Toxicol. 1994 Nov-Dec;8(6):461-75, 461-75. Stanford University School of Medicine. (2013). Stanford School of Medicine Meconium staining photos. Retrieved December 17, 2013, from Stanford University Website: http://newborns.stanford.edu/PhotoGallery/CordMec.html Steven D Burdette, M. F. (2012, april 11). Systemic Inflammatory Response Syndrome. Retrieved 12 19, 2013, from Medscape : http://emedicine.medscape.com/article/168943-overview.