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OB Emergencies for Dummies

(Not so). OB Emergencies for Dummies. Goals/Objectives. Collegial sharing of lessons learned Checklists; what works OB checklists: what’s out there AF attempt at standardized protocols Drugs and dosages commonly used in some emergency situations

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OB Emergencies for Dummies

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  1. (Not so) OB Emergencies for Dummies Presenters: Maj Karin Van Doren, Maj Niki Kamboris & Capt Gretchen Waldvogel

  2. Goals/Objectives • Collegial sharing of lessons learned • Checklists; what works • OB checklists: what’s out there • AF attempt at standardized protocols • Drugs and dosages commonly used in some emergency situations • TeamSTEPP principles in communications & drills

  3. CHECKLISTSGeneral background info • 30 Oct 1935: Test flight of Boeing’s Model 299 Maj Hill, expert pilot…Fiery crash; deaths due to “pilot error”— “too much airplane for one man to fly”. • 2001: Peter Pronovost: central line placement "Safe Patients, Smart Hospitals” (2010). • Dr AtulGawande (2007) Classic Article “The Checklist” (2009) The Checklist Manifesto: How to Get Things Right (book)

  4. Effective Checklists & Strategiesfrom Aviation to Medicine • Checklists are focused, unambiguous, succinct • No unintended consequences from checklist use • Evidence based, discrete tasks identified • Team work training, improve communication--Time outs/pt hand-offs • Non punitive incident reporting • Standardization • Simulator training

  5. ChecklistsWhat they can’t solve • Errors due to lack of skills, training or experience • Checklists can standardize behavior but not “attention” • Practice issues when there is no established “gold standard” • Support/cultural change when Leadership is not engaged

  6. The original Pronovovst “checklist”for central line placement Based on CDC recommendations: • Wash hands • Use full-barrier precautions (drape pt from head to toe) • Clean skin with chlorhexidine • Avoid use of femoral site, if possible • Remove any unnecessary catheters

  7. Success aided by: • Involvement from the top down: senior executives of health care system requested participation in study • “Daily goal sheets” implemented to improve clinician-to-clinician communication • Comprehensive unit –based safety program: assisted by patient safety/infection control depts • At least one MD and one RN team led each new step

  8. Success… • Terminology standardized—NNIS (Nat’l Nosocomial Infections Surveillance System/CDC) definition of catheter-related blood stream infection used • Exact definition of central catheter, which could include a central catheter which was peripherally inserted • Defined “catheter day” so time of indwelling catheters would match

  9. Post Partum Hemorrhage • Rate of maternal death by PPH increased 26 – 28% since 1994: uterine atony not explained by increased rates of c/s, VBAC, maternal age, multiple birth, HTN, diabetes Callaghan (2010) Bateman (2010) • Maternal deaths tripled between 1996-2006 (CMQCC) • Nationwide, blood transfusions increased 92% during deliveries between ‘97-’05 Kuklina (2009) • Aviano: Sentinel event

  10. Changes of pregnancy • Maternal blood volume  50%; plasma volume more than RBC vol: slight hgb/hct -fulfills perfusion demands of low-resistance uteroplacental unit, reserve for blood loss Coagulation system: Increase in clotting factors/decrease fibrolytic activity Uterine ctx: crisscrossing muscle bundles, occlude, contract, retract following expulsion of placenta: living ligature/physiologic sutures

  11. Can we have an effective checklist? • Response to PPH is reactive not proactive • There is no established “Gold Standard” for PREVENTION of PPH • There is no one consensus for management of PPH, but many avenues • Triggers: Response based on clinical appearance (it may be too late…) • IN US clinically accepted >500 ml (vag) 1000 ml (c/s) Does not take into account initial volume status, arbitrary, may be clinically irrelevant to hemodynamic compromise (CMQCC)

  12. Current recommendations • “Known” risk factors: 39% of cases had one or more: Numerically, more women die with no known risk factors WHO, ACOG, SGOC recommendations (1A): • InjectableOxytocin by skilled provider. 10 mu IM or 20 mu+ IV in IVF after delivery of anterior shoulder

  13. Recommendations • Objective quantification of blood loss: Graduated collection containers, weigh blood soaked chux/pads (CMQCC, WHO) • Vital sign triggers (NHS, CMQCC) • If it isn’t working, don’t waste time…move on (CMQCC) • After 2 units PRBC start FFP then 1RBC:1FFP:1 PLT (CMQCC, Iraq theatre: Borgman, M. )

  14. NHS Triggers • RR (red) < 10 > 30 • RR (Amber) 21-29 • O2 sat less than 95% (red) • T greater than 38 C (red) • Pulse (red) > 120 <40 • P (Amber) > 100 <50 • Pain 2-3 (red) but not 2-3/10: 2 means moderate, 3 severe pain • SBP >170 <80 (red) • >160 < 90 (amber) • DBP >110 (red) • > 100 ( amber) • DBP No lower limit • No uterine tone

  15. CMQCC Triggers • EBL > 500 ml or hemodynamic instability (vag) • HR ≥ 110 • BP ≤ 85/45 or noted > 15% drop • 02 sat < 95%

  16. Current AF triggers Calculate MAP every 15 min for first 6 hours ; Want MAP > 65 mmHG MAP = (2x DBP) + SBP 120/80 = MAP of 93 3 Or SBP-DBP = x , then x ÷ 3, then add that number to DBP RR first trigger

  17. Emergency OB Medications Capt Gretchen Waldvogel

  18. Uterotonic Agents • Oxytocin (Pitocin) • Methylergonovine (Methergine) • Carboprost (Hemabate) • Misoprostol (Cytotec)

  19. Oxytocin **First line treatment for PP Hemorrhage Action: Stimulates the upper uterine segment of the myometrium to contract rhythmically, constricts spiral arteries and decreases blood flow to uterus. Dose: 10mu injected Intramuscularly or 20-60mu in 1000ml

  20. Methergine • Action: Causes smooth muscle contraction in upper/lower uterine segments • Dose: 0.2mg IM, may be repeated PRN every two to four hours or Intrauterine by MD • Contraindicated in pts with Pre-Eclampsia or Hypertension because it causes raised blood pressure • Adverse Effects: nausea and vomiting

  21. Hemabate • Action: Enhances uterine contractility and causes vasoconstriction • Dose: 0.25mg intramuscularly or Intrauterine by provider, can be repeated every 15 min for a total dose of 2mg • Contraindicated in pts with Asthma, Cardiac disease • Side Effects: Nausea, vomiting, DIARRHEA, hypertension, and flushing • Consider Immodium therapy as countermeasure

  22. Cytotec • Action: Increases uterine tone and decreases postpartum bleeding • Dose: 200mcg-1000mcg sublingually, orally, vaginally, or rectally • **Recommended 1000mcg rectally • Side Effects: Shivering, pyrexia, and diarrhea • ** Not approved by FDA for this indication

  23. Magnesium Sulfate Hypertensive Disorder

  24. Magnesium Sulfate • Action: Acts peripherally to produce vasodilation • Dose: Adjusted for situation, Loading VS. Maintenance dose • ---Can be given IM if no IV access • Side Effects: Flushing, sweating, nausea, fatigue, hypotension, CNS depression, depressed reflexes and respiratory effort

  25. Safety Issues • ** Use pre-mixed preparations from the pharmacy • ---Compatible with LR or NS • All doses given should be on IV pump and Buretrol/Volutrol should be used • For all boluses, set VTBI at 100ml • Total IV intake should be 125ml/hr unless otherwise ordered by MD

  26. Hypertension Box Aids • Labetalol • Hydralazine Hydrochloride • Diazepam (Valium) • Calcium Gluconate 10%

  27. Labetalol • Use multidose vial 100mg/20ml (5mg/ml) • Compatible with LR, NS, D5LR, D5W, D5 1/4NS Give IVP over 2 min Take B/P every 5 min Initial dose usually 20mg with increasing doses of 40-80mg every 10min until max dose of 300mg Doses using 100mg/20ml vial: -20mg ordered: give 4ml -40 mg ordered: give 8ml -80mg ordered: give 16ml

  28. Hydralazine Use 20mg/ml single use vial Dose is 5mg (0.25ml) Compatible with LR, NS Give IVP over 1min, SLOW IVP Take B/P every 5min Initial dose done, then wait 20min before giving next dose, onset of action is 10-20min Repeat doses 5mg (0.25ml) to 10mg (0.50ml) every 20min up to total dose of 20mg If giving 10mg dose(0.50ml) give slowly over at least 2 min DO NOT GIVE HYDRALAZINE IN THE SAME IV LINE AS MAGNESIUM SULFATE (Either turn off the Magnesium Sulfate and flush the line or start a second IV)

  29. Diazepam Use 10mg/2ml Tubex (5mg/ml) **Turn off Magnesium Sulfate Infusion and Disconnect From IV** Compatibility: give directly into IV at closest port to patient. Not recommended to mix with any solution. Has variable stability in NS, LR, and D5W Give 5mg/ml over at least 1 min May repeat doses in 10 min up to a dose of 20mg (Minimum of 10 min wait time)

  30. Calcium Gluconate 10% Use 10ml single use vial containing 100mg/ml (1 GM total dose) **Discontinue Magnesium Sulfate Infusion and Disconnect From IV** Compatible with LR, NS, D5LR, D10W, D5NS, D5W Give Slowly, Use Entire Vial Give at rate of 2ml/min OR Give the entire dose over 3 to 5 min Patient should be hooked up to an EKG if able- Especially if you need to repeat doses Stop After 3 Doses OR 3 GM

  31. Team STEPPS PrinciplesinCommunication/Drills/Lessons Learned

  32. Why use Team Stepps? • Goal: Produce highly effective medical teams that optimize the use of information, people and resources to achieve the best clinical outcomes. • Teams of individuals who communicate effectively and back each other up dramatically reduce the consequences of human error

  33. PUTTING Team STEPPS IN ACTION • MOES (Mobile Obstetric Emergency Simulator) - simulated various scenarios (breech, stat c/s, shoulder dystocia, PPH, NRP, etc) - various “issues” or areas for improvement brought to light - continued drills, repetition strengthened use of Team Stepps principles

  34. MOES TRAINING FEEDBACKS • COMMUNICATION ISSUES: • overhead paging system, call phones, training day?, who is in charge?, communication with clinic to L&D staff • SBAR vital to role clarity, proper hand-off and situational awareness • Closed-loop communication promotes understanding of order, report, etc. • Shared mental model promotes universal understanding of the scenario and what’s needed

  35. MOES TRAINING FEEDBACKS, cont’d • LOGISTICAL ISSUES: • lack of standardization with supplies, medication access, knowledge of use of equipment, code blue vs. rapid response • Creation of emergency med boxes, med cards and algorithms binder • Standardized location of supplies in all LDR’s • Re-trained on use of equipment not consistently utilized • Revision of code blue MDGI with addition of RRT (Rapid Response Team)

  36. MOES TRAINING FEEDBACKS, cont’d • MOTIVATION: staff motivation level high • increased occurrence/depth of training scenarios raises awareness of areas of self-improvement, empowers staff • Positive feedback on what we did well (debriefs) • Builds teamwork, rely on strengths of each member • Leadership supportive- makes changes when identified to promote patient safety

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