Rural hospital Freakouts!

[TechMedic05]

System-

"and I rag on the nurses.. who cares??" We do. They're professionals. In many cases they know more than you or I. We want to be professionals, too. Professionals don't go 'ragging on' nurses in forums all that often. If you don't wish to be professional, bye

"because you dont share my point of view on my own opinion is rather sordid!!! You must be the belle of the ball! " No, we don't share all of your points. And that's okay. Not everyone needs to agree on everything. Others were trying to converse about logic and reasons why someone would think that, and even a little further education. Which leads to:

"So I did my research on eclampsia...." Thank you.

" I think we can all differentiate btw an emergency where u need to go NOW.. then something where we first have to fix the problem and then go." NOW. There's only about one or two times when you need to go NOW, opposed to now. I'm thinking prolapsed umbilical cord or breech presentation could result in rather hasty transports. If the patient is already in a semi-appropriate facility [an ER] and they can effectively initiate treatment to help stabilize her for transport of any length, they should. Wait, no. They NEED to.

"We dont really use fixed wing and our helicopters are unfortunately reserved for " true emergencies " this one not being one!" If this is not a "true emergency" in this system, then helicopters must never be used there. Nobody, I believe, was trying to quarterback the call, but as far as 'sick' patients go, between mom and baby, it doesn't get too much worse in this field.

All food for thought.

"unfortunately I dont deal well with " wanker " and glib comments! " Well, when things don't make sense, and it's tough to differentiate who panicked, it happens. Thick skin. Get as much as you can. Buy, rent, steal, borrow, take, lease, obtain any way possible. And as far as ribbing goes - as mentioned - It's not so nice to rib nurses, doc's, janitors, patients - but we sure as hell can do it to ourselves. most often it's constructive in nature...sometimes.

"As I roam around the forums I do hope to learn some new stuff..." Glad to have ya, hope you enjoy yourself here! Input is always welcome, and there's centuries of advice to be given. We're all here to learn, too.

That's all. I can't speak for everyone [Right, Ace?] about not being antagonistic, but if the general consensus brings up a few good points, there's probably a good reason. That's it.

:wink:

Tech

[Ace844]

I'm not sure what you mean, although well said and great points "tech," and good morninng and

You have south of the border approval::

I wonder how someone who states they researched eclampsia and learned about the pathgenesis of this Dx, and then again say 'IT'S NOT A REAL EMERGENCY'?!?!?!!? Perhaps they were hoping to

Anyhow, I hope that this individual continues to learn and I would say more, except [marq=up:e3871161a5]OUCH![/marq:e3871161a5] I am told....

ACE844

[TechMedic05]

G'morning, Ace.

Perhaps we should rename ourselves...

You can be Benjamin Franklin Pierce, and I'll be BJ Honeycutt.

Nice graphic, I always knew you were a straight shooter.

I'm trying a new approach - It's called "playing nice." We'll see what it gets me. Apparantly I angered a few local squads around here at one point. Things are better - but my partner at the time made a good point: "Whenever you say something stupid, or someone's angry, just compliment them, like: "Dude, who's got that wicked sweeeet lightbar on the truck out there?" and all will be good. It's worked the one time I've had to use it.

So, yeah. We'll see if we can get Lordie there some constructive education here. Again, not out here to be the bad guy [all the time] :wink:

[Ace844]

"systemlord,"

Ok, Lets try this another way...

Here's what 'E-medicine.com says;

(http://www.emedicine.com/med/topic633.htm @ Eclampsia

Last Updated: October 5, 2005 Rate this Article

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Synonyms and related keywords: seizures in pregnancy, toxemia of pregnancy, coma in pregnancy, preeclampsia, cerebral vasospasm, focal ischemia, hypertensive encephalopathy

AUTHOR INFORMATION Section 1 of 10

Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

Author: Stephanie R Fugate, DO, Consulting Staff, Department of Obstetrics and Gynecology, Woodbridge Family Health Clinic

Coauthor(s): Gregory E Chow, MD, Fellow in Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Washington School of Medicine

Stephanie R Fugate, DO, is a member of the following medical societies: American College of Obstetricians and Gynecologists

Editor(s): Bruce A Meyer, MD, Chief, Department of Obstetrics and Gynecology, UMass Memorial Health Care System, Chair, Professor, Department of Obstetrics and Gynecology, University of Massachusetts Medical School; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Antonio V Sison, MD, FACOG, Program Director, Department of Obstetrics and Gynecology, Robert Wood Johnson University Hospital Hamilton; Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Assumption Community Hospital; and Lee P Shulman, MD, Professor of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University; Chief, Division of Reproductive Genetics, Department of Obstetrics and Gynecology, Prentice Women's Hospital, Northwestern Memorial Hospital)

***{Note, their are some big guns in OB medicine who authored this... One MIGHT TAKE THAT INTO CONSIDERATION}*** [/font:c9f44e0bf2]

Eclampsia

Background: Eclampsia is defined as seizure activity or coma unrelated to other cerebral conditions in an obstetrical patient with preeclampsia. While most cases present in the third trimester of pregnancy or within the first 48 hours following delivery, rare cases have been reported prior to 20 weeks' gestation or as late as 23 days postpartum. Eclampsia has also been described without prior development of preeclampsia.

Pathophysiology: Many investigators have proposed genetic, immunologic, endocrinologic, nutritional, and even infectious agents as the cause for preeclampsia/eclampsia. Despite extensive research, no definitive cause has been identified. Presumably, the placenta and fetal membranes play a role in the development of preeclampsia because of the prompt resolution of the disease following delivery. A common pathway thought to be associated with the development of preeclampsia is utero-placental ischemia. Uteroplacental ischemia is postulated to predispose to the production and release of biochemical mediators that enter the maternal circulation, causing widespread endothelial dysfunction and generalized arteriolar constriction and vasospasm.

Preeclampsia/eclampsia creates a functional derangement of multiple organ systems, such as the central nervous system and the hematologic, hepatic, renal, and cardiovascular systems. The severity depends on medical or obstetric factors.

Systemic derangements in eclampsia include the following:

Cardiovascular

Generalized vasospasm

Increased peripheral vascular resistance

Increased left ventricular stroke work index

Decreased central venous pressure

Decreased pulmonary wedge pressure

Hematologic

Decreased plasma volume

Increased blood viscosity

Hemoconcentration

Coagulopathy

Renal

Decreased glomerular filtration rate

Decreased renal plasma flow

Decreased uric acid clearance

Hepatic

Periportal necrosis

Hepatocellular damage

Subcapsular hematoma

Central nervous system

Cerebral edema

Cerebral hemorrhage

Frequency:

In the US: Approximately 5% of pregnancies are complicated by preeclampsia. Of these patients, 0.5-2% progress to eclampsia. The incidence is increased in women of low socioeconomic status, extremes of age, and primigravid state. Both preeclampsia and eclampsia account for significant maternal and fetal morbidity and mortality.

Mortality/Morbidity: Eclampsia accounts for approximately 50,000 maternal deaths worldwide annually. In the United States, the maternal mortality rate from eclampsia has been reduced with early diagnosis and aggressive management and is currently less than 1%. The fetal mortality rate from eclampsia has also decreased but still remains at approximately 12%.

Maternal complications of eclampsia may include permanent CNS damage from recurrent seizures or intracranial bleeds, renal insufficiency, and death. Causes of neonatal death include prematurity, placental infarcts, intrauterine growth retardation, abruptio placentae, and fetal hypoxia.

Race: Racial predilection is unclear. A higher incidence of this condition may exist in African Americans.

Sex: Only females are affected.

Age: Preeclampsia/eclampsia affects women of all ages, but the frequency is increased in nulliparous women younger than 20 years. Women older than 40 years with preeclampsia have 4 times the incidence of seizures compared to women in their third decade of life. Other risk factors include the following:

Nulliparity and age older than 35 years

Preexisting hypertension or renal disease

Poor prenatal care

Strong family history of preeclampsia/eclampsia

Systemic lupus erythematous

Obstetric conditions associated with an abundance of chorionic villi (eg, twin gestations, molar pregnancies, triploidy, nonimmune hydrops fetalis)

Medical Care: Eclamptic convulsions are life-threatening emergencies and require the proper treatment to decrease maternal morbidity and mortality.

Presentation: If the patient develops convulsions at home, she usually is brought to the hospital in a comatose (ie, postictal) condition. These patients should be cared for by a team of qualified physicians (preferably obstetricians) and nurses. Patients should undergo continuous intensive monitoring. They should be placed in a monitored labor room with minimal noise and external stimuli.

Initial management: As with any seizure, the initial management is to clear the airway and administer adequate oxygenation. The patient should be positioned in the left lateral position to help improve uterine blood flow and obstruction of the vena cava by the gravid uterus. The patient should be protected against maternal injury during the seizure, ie, the guardrails should be up on the bed, a padded tongue blade is placed between the teeth, and secretions are suctioned from the patient's mouth.

Intravenous access: After the seizure has ended, a 16- to 18-gauge intravenous line should be obtained for drawing specimens for laboratory studies and administering fluids. Intravenous fluids should be limited to isotonic solutions to replace urine output and about 700 mL/d to replace insensible losses.

Control of the seizure: Do not attempt to shorten or abolish the initial seizure. A syringe containing 2-4 g of magnesium sulfate should be the only anticonvulsant at the bedside. Magnesium sulfate is administered intramuscularly or intravenously to decrease and prevent further convulsions.

Laboratory workup: A complete blood count, chemistry panel, and liver function tests should be conducted. A urinalysis should be sent to evaluate for proteinuria, and a 24-hour urine collection for protein should be initiated.

Hypertension control: Record blood pressure every 10 minutes. Control blood pressure (diastolic 90-100 mm Hg) with administration of antihypertensive medications (ie, hydralazine, labetalol).

Monitoring: Carefully monitor the neurologic status, urine output, respirations, and fetal status for all patients. An indwelling Foley catheter should be placed in the bladder to help collect and record urine output.

Invasive monitoring: Pulmonary artery pressure monitoring may be necessary for accurate fluid management in eclamptic patients. This is particularly important in patients who have evidence of pulmonary edema or oliguria/anuria.

Assessment of medical condition: Once the seizure is controlled and the patient has regained consciousness, the general medical condition is assessed. Induction of labor may be initiated when the patient is stable.

Delivery

Delivery is the treatment for eclampsia after proper stabilization. If the patient is undelivered, no attempt should be made to deliver the infant either vaginally or by cesarean delivery until the acute phase of the seizure or coma has passed. The mode of delivery should be based on obstetric indications but should be chosen with an awareness of the fact that vaginal delivery is preferable from a maternal standpoint.

In the absence of fetal malpresentation or fetal distress, oxytocin should be initiated to induce labor in the following situations:

At 30 weeks' gestation or greater, irrespective of the cervical dilation or effacement

Prior to 30 weeks' gestation with a favorable cervix

Patients with an unfavorable cervix with a gestational age of 30 weeks or less, once stabilized, should be delivered electively by cesarean delivery. This approach is preferred because pregnancies prior to 30 weeks' gestation with eclampsia have a higher risk of complications intrapartum. Intrapartum complications include the following:

Fetal growth retardation (30%)

Fetal distress (30%)

Abruption (23%)

Fetal monitoring

Fetal heart rate and intensity of the contractions should be monitored closely. Fetal bradycardia is a common finding following the eclamptic seizure and has been reported to last from 30 seconds to 9 minutes. The interval from the onset of the seizure to the fall in the fetal heart rate is typically 5 minutes. Transitory fetal tachycardia may occur following the bradycardia.

During the recovery phase, the fetal heart rate tracing may reveal a loss of beat-to-beat variability and late decelerations. The mechanism for the fetal tracing abnormalities is most likely due to a decrease in uterine blood flow caused by the intense vasospasm and uterine hyperactivity during the convulsion. If the fetal heart tracing does not improve following a seizure, other conditions should be considered. Growth restricted and preterm fetuses may take longer to recover following a seizure. Consider placental abruption if uterine hyperactivity remains and fetal bradycardia persists.

Surgical Care:

Patients with eclampsia may need to be delivered immediately by cesarean delivery, depending on the maternal and fetal condition. Stabilize the patient before initiating cesarean delivery during the acute phase because delivery may aggravate oliguria and other manifestations of the disease.The anesthesiologist should be informed of the maternal condition and may be helpful if endotracheal intubation or an operative delivery is necessary.

For nonemergent cesarean delivery, epidural anesthesia is preferred and can be induced in a steplike fashion, being careful not to cause maternal hypotension.

The use of spinal anesthesia is controversial because of the possibility of extreme sympathetectomy, resulting in maternal hypotension and uteroplacental insufficiency.

Consultations:

An experienced obstetrician should be consulted immediately.

Consider consultation with a maternal-fetal medicine specialist, with transport to a tertiary care site after stabilization if it is in the fetal or maternal best interest.

In the event of prematurity or fetal compromise, a pediatrician or neonatologist should be consulted.

Diet:

Patients with eclampsia should have nothing by mouth until medically stabilized.

During a seizure, maintaining the patient's airway and being careful to help avoid aspiration of stomach contents is important.

Activity:

Strict bedrest

Left lateral hip roll to help improve uterine blood flow to the fetus

HOPE THIS HELPS,

ACE844

[akflightmedic]

Beautiful reply Ace!!!

I am so proud of you. You said everything for me and made it much mroe interesting.

From a flight medic position, this is a critical emergency and could have been flown. The only concerns with flight however, would be all the external noise, stimuli, etc...added stress on the mom and baby. Additionally, should she start to deliver it would be a wee bit cramped and personel would be limited. By ground, you have more working room and should take at least 1 extra person for the unexpected.

[Ace844]

Thanks AK, glad you finally approve :wink: 8)

ANY ONE ELSE ALSO NOTICE THE LACK OF ANY MENTION OF TOCO USE OR ACCEL-DECELL CONSIDERATION HERE AS WELL?!?!?!??! HMMMM :roll:

[Dustdevil]

I think my head is going to explode.

The respectable way to react here would have been to humbly admit he made a huge mistake in judgement and learn from the experience, and earn a little respect.

An acceptable, though less respectable reaction would have been to silently crawl away in shame and not say anything else, letting the thread die.

The sad thing is that this person either still has no clue how wrong he is, or is unwilling to admit it. That's unforgivable.

I think the full of extent of his "research" was talking to Barry the retarded supervisor again.

Time to pick a new mentor, Systemlord. Barry is a loser and is leading you down the path of disgrace.

[Ace844]

I think my head is going to explode.

The respectable way to react here would have been to humbly admit he made a huge mistake in judgement and learn from the experience, and earn a little respect.

An acceptable, though less respectable reaction would have been to silently crawl away in shame and not say anything else, letting the thread die.

The sad thing is that this person either still has no clue how wrong he is, or is unwilling to admit it. That's unforgivable.

I think the full of extent of his "research" was talking to Barry the retarded supervisor again.

Time to pick a new idol, Systemlord. Barry is a loser.

"Dust,"

That was aweful kind and generous of you to say that. Are you sure you didn't get hit in the head by a trowel recently in the sandbox??? Where's that fire and brimstone your famous for?

I'm confused.... :wink:

ACE844

[TechMedic05]

Ace, pal.

I seriously think I just had a seizure while reading your line of animations.

I'm going to try and do it again now.

[Ridryder 911]

Geez, Just to show you ... "stupid is stupid does". you might have discussed with your physician, partner, etc... on what status this was, and I truly doubt that they described that it was not an emergency, of the scenario was like you described. If you become offended so be it. If you did do a research as you stated, then you found out as well the dangers as other has so pointed out.

One should be able to defend themselves when making such statements and allowing the continuation of such, to be determined not by ignorance but refusing facts. It is unreasonable and just simply poor that you are unable to interpret what an emergency is. Surf other forums, they will inform you as well. If your partner or even your physician(s) needs to educated and informed, there are plenty, including myself that could present facts, research, literature and web links, but I really do doubt that is the case.

Now, what does scare me, is what do you think an emergency is?

As far as helo, one needs to be extremely careful in a chopper. The noise level, and the " flickering" effect the blades produce a strobe effect (which could increase seizures). Placing a an eye mask to reduce the light, etc.. which will help.

R/r 911