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Hello all, after being inactive a few years from being in school, I find myself having more time and access to sitting down and reading for enjoyment. If people are interested I will post a weekly case scenario, that I have personally been involved in the care of, reviewed at M&M rounds or have gotten premission to present in this forum. Please dont think that by presenting cases I feel as though I have nothing to learn, I present so that I may have an opportunity to continue learning. That being said here is Case #1, I will attmept to present straight forward as well as complicated cases....

Case Presentation: 17 yo f calls EMS with a complaint of with progressing vision loss and unbearable headache over the past day. She is a primigravid black female 28 3/7weeks gestation due for hospital/PCP exam tomorrow. Up to this point has had normal pregnancy and takes PNV. No significant past medical history and no family history of significant disorders or disease. Her major complaint is dioplia with bright light and loss of peripheral vision. Headache is rated as a 9/10 on a pain scale, which radiates to temporal region. No SROM, minimal contraction lasting 5 min at 15 min intervals throughout last four hours. Papillary edema, pitting x2 lower extremities. All quadrant tenderness.

Initial Vitals: are as follows:RR 24 BP 172/113 HR 99 Temp 99, closest women's hospital is 45 min by gr, community hospital with no maternal services is 12 min by gr.....

Disucssion points: Differential diagnosis, treatment thoughts, transport thought

Edited by flightmedic608
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This is awesome that you are planning on doing this. Too bad you can't get us approved for CEU's on this.

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There might be a way, I have to check on something. I know that some EMS web sites host CEUs for recert. Ill follow up and let you know.

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Nice. Welcome back, 608. What's the tail number of the a/c in your pic?

My primary differential for this patient is pre-eclampsia. Got a UA to go along with what you've presented? (Yes, I know this is a prehospital forum but a guy can dream, can't he?)

Treatment wise I'd have mag on hand in case she seizes. Treatment for hypertension, in discussion with the doc, would include labetolol and possibly hydralazine.

I'd like to get her to the women's center (Brigham and Women's?). I wouldn't necessarily want to fly her... hard to deliver a kid in a BK.

That's just me to start.

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What was her BP at the beginning of pregnancy? Does her BP change or pain lessen when laying on her left side? The edema is not very bad and if she has double vision what was her Cincinnati stroke scale evaluation?

PIH would be more common than a stroke but I would like to rule a stroke out. In fact I am going to lean toward stroke until proven otherwise.

What country is she in? Has she traveled recently to a third world country? The fever and all quadrant tenderness may be indicative of an infectious process, Does she present nausea, vomiting, or diarrhea?

Edited by DFIB

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What a great idea, both the scenarios and possible CEU's. Would take advantage of both. As for this scenario - possible diagnoses: pre-eclampsia/eclampsia is the obvious starting point, but pregnant women have been known to suffer HTN and CVA without eclampsia. even pre-hospital treatment is the soon except for magnesium.

Treatment: I would start with basic supportive care: O2, large bore IV, EKG with Mag for eclampsia and be prepared for treating further HTN. Though protocols differ on when to treat HTN do to collateral circulation. Usually it doesn't start until BP goes over 200 diastolic. Some protocols may also be willing to treat with pain meds for HA which will likely lower BP as a side effect.

Transport- immediate transport. Personally I would attempt transport to the woman's hospital at 'fast non emergency depending on traffic condition etc" as long as pt's condition remains stable or improves enroute. I say this because emergency rarely saves much time, is dangerous and with pt's BP and HA, the noise and stress of emerg. traffic will likely worsen pt's condition. However, if pt's condition worsens, upgrading to emergency and/or changing transport to closer facility if distance allows for pt stabilization and tier up transfer.

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Nice. Welcome back, 608. What's the tail number of the a/c in your pic?

My primary differential for this patient is pre-eclampsia. Got a UA to go along with what you've presented? (Yes, I know this is a prehospital forum but a guy can dream, can't he?)

Treatment wise I'd have mag on hand in case she seizes. Treatment for hypertension, in discussion with the doc, would include labetolol and possibly hydralazine.

I'd like to get her to the women's center (Brigham and Women's?). I wouldn't necessarily want to fly her... hard to deliver a kid in a BK.

That's just me to start.

Great start Mike and right on the money, although without a UA and protein etc its may just be considered PIH (pregnancy induced hypertension) First the tail number on that BK is N271NE... great thoughts on treatment, but most als systems in the US do not carry Labetolol or Hydralazine..what other choices do you think might be appropriate in this case? Nice thought on having Mag++ ready for administration...what are some of the side effect(s) that we would be careful to watch for during a 45 min GR transport? And yes BWH would be a great choice for care for this patient....

What was her BP at the beginning of pregnancy? Does she have edema in her feet or hands? If she has double vision what was her Cincinnati stroke scale evaluation? Does her BP change or pain lessen when laying on her left side?

PIH would be more common than a stroke but I would like to rule a stroke out.

What country is she in? Has she traveled recently to a third world country? The fever and all quadrant tenderness may be indicative of an infectious process, Does she present nausea, vomiting, or diarrhea?

Very good questions D, lets say for a moment this patient is not aware of any issues with BP during first and second trimester. And if you scroll up I described how her edema presents. She is in the US, and has not recently traveled...and very nice catch on the quadrant tenderness, what other differentials can lead to having tenderness in all four quadrants? No N/V/D

What a great idea, both the scenarios and possible CEU's. Would take advantage of both. As for this scenario - possible diagnoses: pre-eclampsia/eclampsia is the obvious starting point, but pregnant women have been known to suffer HTN and CVA without eclampsia. even pre-hospital treatment is the soon except for magnesium.

Treatment: I would start with basic supportive care: O2, large bore IV, EKG with Mag for eclampsia and be prepared for treating further HTN. Though protocols differ on when to treat HTN do to collateral circulation. Usually it doesn't start until BP goes over 200 diastolic. Some protocols may also be willing to treat with pain meds for HA which will likely lower BP as a side effect.

Transport- immediate transport. Personally I would attempt transport to the woman's hospital at 'fast non emergency depending on traffic condition etc" as long as pt's condition remains stable or improves enroute. I say this because emergency rarely saves much time, is dangerous and with pt's BP and HA, the noise and stress of emerg. traffic will likely worsen pt's condition. However, if pt's condition worsens, upgrading to emergency and/or changing transport to closer facility if distance allows for pt stabilization and tier up transfer.

Hey Jinx, I emailed a friend of mine to see how he arranges ceu online for people, more to follow. Very good thoughts also, non stimulating transport very smart idea. In regards to the BP are you more concerned with the systolic of 172 or the MAP of 132? (MAP = SYS + DIA x 2 divided by 3), every system is different and our program focuses on the MAP instead of the systolic

Edited by flightmedic608

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Very good questions D, lets say for a moment this patient is not aware of any issues with BP during first and second trimester. And if you scroll up I described how her edema presents. She is in the US, and has not recently traveled...and very nice catch on the quadrant tenderness, what other differentials can lead to having tenderness in all four quadrants? No N/V/D

If combined with rebound tenderness it could be generalized peritonitis. It could also be an placenta abruptio. Some food Toxins will produce generalized tenderness and headache but I would expect other Gi symptoms as well. EDIT: She could also have a fetal death. How long since she felt her baby move?

I think this is a high priority patient that needs to be transported by air.

What are the baby's fetal heart rate?

What does N/V/D mean?

Edited by DFIB

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WIthout giving much away and telling the end result, nice thoughts on the differentials, no rebound tenderness just generalized tenderness upon palpation.... Lets say that its a weather day (and RW is not flying) which hospital would you choose? FHT upon ausculatation in 130-140s...no Nausea/Vomiting/Diarrhea (N/V/D)

Edited by flightmedic608

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Ah. We shared one of your BKs for a while. Thought that might've been it.

I thought about med availability after I posted. Most of the local services here have labetolol on their ambulances. They don't, however, have hydralazine. If available, verapamil may also be an option.

With med administration keep an eye out for dropping the BP too quickly (especially if giving both labetolol and mag), respiratory depression and pay attention to the monitor for rhythm changes.

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