ED Muskoka Physicians - Living the Dream

PPH sim recap

February 16, 2023 by Leave a Comment

For the ED in situ simulations this month we ran through a case of a woman arriving in labour with EMS, imminently delivering.

Learning Point 1: This patient should come to the ER, NOT be sent upstairs in an elevator.

Call for OB nurses to come down to US with FHR monitor, PANDA warmer, delivery kit etc.

After delivery, she beings bleeding. How do we approach a post-partum hemorrhage in the ER? 

  • Address the 4 T’s (and start with Tone!)

Learning Point 2: Oxytocin – Always give Oxytocin 10units IM or 3units IV with delivery of the anterior shoulder for prevention of PPH. Once PPH identified, can put 40units in 1L NS and run at 250cc/hr (10units/hr)

Learning Point 3: Physical maneuvers first – bimanual compression of the uterus, place a Foley Catheter to empty the bladder.

Learning Point 4: Secondary medications – 

  • TXA 1g IV
  • Misoprostol 200mcg (New SOGC guidelines recommend SL/PO – NOT PR)
  • Ergotamine 0.25mg IM
  • Carboprost (Hemabate) 0.25mg IM or IMM

*These are all available in the ADU but must be drawn out individually

OR can be found in the PPH kit on the floor

  • Resuscitate the patient – all our usual principles apply. 
  • Consider DIC screen/empiric fibrinogen (RiaSTAP)
  • Call for Help (Remember CODE OB gets you OR staff/surgery mobilized)

Learning Point 5: Bakri Balloon – 

If required for packing the uterus, this is found in the PPH kit on the floor, or in the OR 

In Dr. Branigan’s eloquent words: 

The goals of this simulation involve the principles of patient safety – the right care (skill sets, equipment and drugs) in the right place (in this case the ED due to imminent delivery).  It is a process to look at clinical knowledge (imminent delivery, PPH 4 Ts and treatment strategies) and organizational knowledge (who is your team and how do you call them, where is your equipment and your drugs)

I will attach the case we used in a group reply to this email, along with the new SOGC guideline if you are motivated to review it.  If you have a quiet shift and want to verbally review this case with the nurses on shift to make sure everyone knows where to find the medications and equipment etc feel free to refer to this! Hopefully little tidbits of education like this can help with group morale 🙂

Filed Under: Education, OB/GYN, Simulations Tagged With: ,

Peds Asthma simulation follow-up: November 24/25 2022

November 28, 2022 by Leave a Comment

Hi Team –

We ran a simulation of a pediatric asthma case in both ER departments this week (Dr. Sawula led in Bracebridge and Dr. Jewell in Huntsville) and wanted to share a few learning points that came out of the case. Thanks to everyone who participated at both sites. There was some great discussion! The following info has been circulated to our nursing team at both sites as well.

This was a case of a 2 year old boy presenting with a severe asthma exacerbation, unresponsive to usual initial therapies (Ventolin/Atrovent/Steroids) i.e. Status Asthmaticus, progressing towards respiratory failure.

Learning points:

  1. PRAM Score – a really useful scoring tool to help quantify severity, track progress over time in ER, and create a common language to speak with our pediatricians. We do not currently use a formal asthma clinical pathway or orderset in our ER, however, we should be ensuring our management reflects this standard of care. A copy of the PRAM scoring tool is posted on the wall in Triage in Huntsville
  2. IV Magnesium Sulfate – is a 3rd line agent (after Ventolin/Atrovent/Steroids) – consider using if moderate to severe score and not improving after 1st hour of treatment. Dose is 25-50mg/kg/dose (max 2g) over 20-30 min, watch for hypotension and bradycardia. Must be on continuous cardiac monitoring.
  3. IV Ventolin (Salbutamol) – option in severe cases unresponsive to above therapies (including no response to continuous nebulized Ventolin) and possibly progressing towards respiratory failure. Ottawa Manual has a resource for how to dilute/administer this uncommonly used drug. YES we have it available. Sick Kids PICU doc should be contacted if this is being considered as this is an ICU-level therapy but can get started while waiting for transfer team. Generally Sick Kids recommends NO loading dose, but starting maintenance dose at 1-2mcg/kg/min and titrating q10min up to 5mcg/kg/min (Max 20mcg/min)
  4. Oxygenation/Ventilation – for impending respiratory failure, consider Heated/Humidified High Flow Nasal Cannulae. We have nasal prongs and flow rates appropriate for smallest kids so this is a good option. RT can set this up for us. We do NOT have masks small enough to do BiPap/CPAP on kids <20kg. We do have neonatal CPAP/PPV via the Neopuff T-piece resuscitator, which can technically work up to 10kg, but this does require hands on ventilation. **There is a high risk of mortality with intubation (high risk pneumothorax, impaired venous return, CV collapse… all sorts of badness), so last resort of management.

See this SickKids Webinar for more education on managing a severe asthma exacerbation pending transfer to a tertiary care hospital
https://www.youtube.com/watch?v=EXjPgtvCQfM

Hope these brief summaries after simulations help keep us on the same page. As always, if there are any topics you want reviewed please let Heather, Emma or I know. Stay tuned for December dates!

Filed Under: Education, Paediatrics, Respirology Tagged With: , ,