Read Rosen & Barkin's 5-Minute Emergency Medicine Consult Online
Authors: Jeffrey J. Schaider,Adam Z. Barkin,Roger M. Barkin,Philip Shayne,Richard E. Wolfe,Stephen R. Hayden,Peter Rosen
Tags: #Medical, #Emergency Medicine
Rosen & Barkin's 5-Minute Emergency Medicine Consult (570 page)
BOOK: Rosen & Barkin's 5-Minute Emergency Medicine Consult
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ETIOLOGY
DIAGNOSIS
History
Lab
TREATMENT
PRE HOSPITAL
First Line
FOLLOW-UP
DISPOSITION
Admission Criteria
See Also (Topic, Algorithm, Electronic Media Element)
- Preeclampsia
- Incomplete placental implantation and underperfusion
- Leads to decreased angiogenic growth factor and increased maternal placental debris in circulation
- Incomplete placental implantation and underperfusion
- Eclampsia
- 1/3 of patients with eclampsia did not have hypertension prior to seizure
- 1/3 of patients with eclampsia did not have hypertension prior to seizure
- Risk factors:
- Extremes of reproductive age
- Primagravida
- Multiple gestations
- Molar pregnancy, hydatidiform mole
- Smoking
- Increased body mass index
- Diabetes, collagen vascular diseases
- Pre-existing hypertension or renal disease
- History of preeclampsia with prior pregnancies (7.5–10% increased risk)
- Independent risk factors for eclampsia
- Nulliparity
- Maternal age
- GH
- Nulliparity
- Extremes of reproductive age
DIAGNOSIS- GH
- Normotensive prior to 20 wk gestation
- SBP >140 or DBP >90 on 2 separate measurements
- Severe: SBP >160 and DBP >110
- Normotensive prior to 20 wk gestation
- Preeclampsia
- GH and proteinuria
- 300 mg protein on 24 hr urine
- 1+ protein on urinalysis
- Mild:
- SBP <160 mm Hg or
- DBP <110 mm Hg
- Normal platelets
- Normal liver function tests
- No cerebral symptoms
- SBP <160 mm Hg or
- Severe:
- SBP >160 or DBP >110
- 5 g protein on 24 hr urine
- 3+ proteinuria on 2 occasions
- Oliguria
- Thrombocytopenia
- Right upper quadrant pain
- Impaired liver function
- Cerebral symptoms
- Intrauterine growth restriction
- Vision changes
- Pulmonary edema
- SBP >160 or DBP >110
- GH and proteinuria
- HELLP Syndrome
- Hemolysis
- Elevated liver enzyme
- Low platelets
- May present with:
- Pulmonary edema
- Renal failure
- Liver failure
- Sepsis
- Pulmonary disease
- Stroke
- Pulmonary edema
- Hemolysis
History
- History of preeclampsia
- Parity
- Weight gain
- Leg swelling
- Abdominal pain
- Nausea/vomiting
- Shortness of breath
- Headache
- Visual changes
- Jaundice
- Stroke symptoms
- Check serial BP
- Palpate abdomen carefully, especially RUQ
- Assess extremities for edema
- Perform neurologic exam:
- Deep tendon reflexes
- Mental status changes
- Visual acuity
- Deep tendon reflexes
- Serial BP measurements
- Urinalysis
- CBC, LFTs, BUN/creatinine, uric acid
- US
- Fetal monitoring
- Head CT depending on severity of presentation
Lab
- Urinalysis:
- Protein >1+ correlates to 30 mg/dL
- >1+ requires 24 hr urine collection
- Urine sediment for RBC, WBC, casts
- Protein >1+ correlates to 30 mg/dL
- CBC
- LFTs
- BUN/creatinine
- Uric acid
- LDH
- d
-dimer - Fibrinogen levels
- Coagulation studies
- US:
- Gestational age
- Fetal viability/distress
- Oligohydramnios
- Gestational age
- Fetal monitoring, nonstress test
- Head CT: Rule out mass or hemorrhage
- Lumbar puncture: Rule out infection or subarachnoid hemorrhage
- Urine toxicology: Rule out substance abuse:
- Cocaine
- Methamphetamine
- Cocaine
- Essential hypertension
- Renal or collagen vascular disease
- Hydatidiform mole, hydrops fetalis
- Drug abuse
- Epilepsy
- Encephalitis
- Meningitis
- Encephalopathy
- Brain tumor
- Intracranial hemorrhage
TREATMENTPRE HOSPITAL
- ABCs
- Oxygen
- Place patient in left lateral decubitus position
- ABCs
- 100% oxygen
- Left lateral decubitus position (reduces pressure on inferior vena cava, enhancing cardiac return/output)
- Maternal cardiopulmonary monitoring
- Magnesium sulfate (MgSO
4
) for seizures
- Make arrangements for emergent C-section
- MgSO
4
for seizure treatment and prophylaxis - Hydralazine or labetalol for BP control
- Goal is to lower BP by 25% initially and then to <160/100 over subsequent hours
- Goal is to lower BP by 25% initially and then to <160/100 over subsequent hours
- Mg toxicity:
- Hypotension
- Loss of patellar reflex
- Respiratory depression
- Decreased urine output
- Elevated creatinine
- Calcium gluconate to reverse
- Hypotension
- Intubate for airway protection/hypoxia or if seizures refractory to interventions
- Tocographic and fetal monitoring
- OB consult:
- All cases along GH–preeclampsia–eclampsia spectrum
- Expectant management if <30 wk gestation
- Delivery >30 wk
- Emergent delivery for severe symptoms: Induction vs. C-section
- All cases along GH–preeclampsia–eclampsia spectrum
First Line
- MgSO
4
: 10 g IM or 4 g IV; followed by 1–2 g/hr IV infusion:- MgSO
4
bolus should not exceed 1 g/min - Serum Mg goal: 4–7 mEq/L
- MgSO
- Hydralazine: 5–20 mg IV
- Labetalol: 10 mg IV initially, then 5–10 mg increments for desired effect
- Valium: 5–10 mg IV if no response to MgSO
4 - Fosphenytoin: 15–20 mg phenytoin equivalents (PE) IV × 1 (max. 150 mg PE/min IV)
- Phenytoin: 15–18 mg/kg IV, not to exceed 25–50 mg/min, for persistent seizure activity
- Calcium gluconate: 1 g IV
FOLLOW-UPDISPOSITION
Admission Criteria
- Preeclampsia
- Eclampsia
- HELLP syndrome
- ICU, labor and delivery, OR
- Isolated hypertension with workup negative for preeclampsia
- Asymptomatic
- Close obstetric follow-up assured
- Follow-up with OB as above
- Return to ED:
- Headache
- Abdominal pain
- Leg swelling
- Decreased urination
- Shortness of breath
- Headache
- Delivery is the definitive treatment for preeclampsia and eclampsia
- BP of 130/80 mm Hg in a pregnant woman requires investigation
- Postpartum presentation: Consider preeclampsia/eclampsia in patient up to 30 days postpartum presenting with:
- Edema
- Shortness of breath
- Headache
- Seizure
- Edema
- Airway considerations in preeclamptic or eclamptic patients:
- Reduced internal diameter of airways due to engorgement
- Airway edema may be present
- Use smaller-diameter endotracheal tube
- Use fiberoptic guidance if available
- High risk for aspiration
- Reduced internal diameter of airways due to engorgement
- Deak TM, Moskovitz JB. Hypertension and pregnancy.
Emerg Med Clin N Am.
2012;30:903–917. - Leeman L, Fontaine P. Hypertensive disorders of pregnancy.
Am Fam Physician
. 2008;78:93–100. - Podymow T, August P. Antihypertensive drugs in pregnancy.
Semin Nephrol
. 2011;31:70–85. - Sibai BM. Etilogy and management of postpartum hypertension-preeclampsia.
Am J Obstet Gynecol
. 2012;206:470–475. - Yancey LM, Withers E, Bakes K, et al. Postpartum preeclampsia: Emergency department presentation and management.
J Emerg Med.
2011;40;380–384. - Yoder SR, Thornburg LL, Bisognano JD. Hypertension in pregnancy and women of childbearing age.
Am J Med
. 2009;122:890–895.
See Also (Topic, Algorithm, Electronic Media Element)
BOOK: Rosen & Barkin's 5-Minute Emergency Medicine Consult
10.22Mb size Format: txt, pdf, ePub
ads
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