Clinical Case 074: Resus a deux
This is the scariest case I have done for a while, strap yourself in it is a tough one! Going to lay it out and let you guys tell me how you would approach it as it is one of those scenarios where there are a lot of decisions made and resources mobilised in an instant. Apologies to the Specialists reading this – we are going to cross some departmental divides in rapid fire on this case!
It is 6:00 AM, you are coming to the end of a long night shift. It is quiet now, you are fighting the Sandman! Suddenly the ambulance phone rings…. ” we are bringing in a 20 yo woman who might have an ectopic, suffering abdo pain for a few hours and now has had a PV bleed. She thinks she is pregnant, though not sure of dates…”
OK, now you are awake. You go into the Resus bay and get your big IVs, some warm fluids, and emergency drugs ready. Maybe wake up the lab crew if she looks unstable and needing some red cells. You even call the Obs/Gynae surgeon to let them know she might be required sooonish.. will let her know.
5 minutes later the ambo crew arrive. Things seem calm, the patient is not in much pain, there is however a lot of blood on the trolley as you transfer her over. You start taking the history and reaching for the IV when she starts screaming… AH AH, AH “There it goes again”. The penny drops, she is in labour. A quick feel of her belly reveals a fundus at the umbilicus which is hard and contracting. Time to switch algorithms friends.
OK, you call for the midwife from the labour ward to attend ASAP. The patients obs: P = 130, BP 80/50, RR 20, she is grunting with contractions, there is a lot of blood coming PV now. IV fluids running in and you ask for the lab to bring O neg ASAP and process your bloods urgently.
As the midwife arrives you glove up for an examination – time to play Obstetrician. We need to know where we are on the partogram to make the next call – imminent delivery or off to theatre. The Midwife is searching for a fetal pulse with the Doppler – there is a heart rate of about 200. You have a look, blood, blood, blood – but wait what is that… you feel a tiny foot protruding from the nearly fully dilated cervix. Time to change algorithms again. We need back up, pronto. Get the OBs doc in here ASAP please… BUT – she is out on an early morning ride about 15 minutes out-of-town! Bugger.
You call for the Neonatal Resus cot and all the paraphernalia ASAP. But as it is arriving Mum-to-be give a big cry and delivers a breach. No time to waste you need to get that bub out. You can feel the umbilical cord pulsing, but it is fast and weak. One more contraction and the head is out… followed by a huge blood clot and a gush of fresh red blood.
The young lady is looking pale, clammy and nor has a pulse of 150, BP = 70/40. What to do?
The baby is tiny, we are not accustomed to guessing weights and gestation at this stage. Initially he took a few gasps of air but is now apneic – you pick him up and onto the Resus cot. A, B…. is this the right thing to do? How can we work out gestation, viability of a resus?
Meanwhile the midwife has jumped in and managed the third stage – but the cord has broken and the placenta remains in utero, the bleeding is continuing… she needs to go to theatre to fix this.
If it comes down to a choice of resources do we take mother to theatre, your back-up is still a way off. Do we keep resuscitating this baby, who hasn’t taken any spontaneous breaths since you started IPPV and is looking pretty floppy but has a pulse of 110/min?
OK team. This isn’t a real case – but I have been through a few similar ones over the years – and they are scary!
There is a 30 minute Google Hangout discussion on Case 074 now available!
What a difficult situation. And what the hell was the O+G doing heading out of town when you where expecting an unstable ectopic huh? 🙂
Meets the definition of a disaster, your resources at present are overwhelmed.
-urgent controll of life threatening meternal hemorrhage, likely secondary to retained placenta with concurrent resuscitation (remembering the ALSO song about tone, trauma, tissue, and thrombin)
-resuscitation of infant of unclear gestation but likely on border of viability
BUT other way to think about this is in terms of skills required
-You have IV access for Mum
– nurse can make up and start syntocinon 30IU in 500mL NaCl 0.9% start at 240mL/hr
– Start O neg blood as soon as available, otherwise crystalloid IV up to 2L, orderlys can squeeze pump sets
– need at least 1 more doc on site to be able to go to OT, so cant get to theatre until you have backup so may as well have 2 backup docs on their way (preferably one a paediatrician!). You also need more nursing staff, call paeds nurse down from ward and theatre team in.
-Baby needs intubation, not a skill you can expect of your midwife
-could consider intubating baby while awaiting backup to get to OT as long as other staff were able to manage hemodynamic resus of mother
-if Mum crashed whilst attending to baby, ie, PEA/ loss of conciousness of loss of spontaneous resps then I would ask midwife to continue to bag bub until help arrived whilst I resuscitated Mum.
-Bub should be in a plastic bag for warmth and resuscitaire on to maintain temp
-get paed nurse on arrival to set up for umbi line/IVC for bub and check baby’s obs and BSL
I am looking forward to reading everyone else’s take on the situation
Fantastic website Casey