OB Emergencies for Dummies

(Not so)

Presenters: Maj Karin Van Doren, Maj Niki Kamboris & Capt Gretchen Waldvogel

Goals/Objectives

1. Collegial sharing of lessons learned2. Checklists; what works3. OB checklists: what’s out there4. AF attempt at standardized protocols5. Drugs and dosages commonly used in some

emergency situations6. TeamSTEPP principles in communications &

drills

CHECKLISTSGeneral background info

• 30 Oct 1935: Test flight of Boeing’s Model 299Maj Hill, expert pilot…Fiery crash; deaths due to “pilot error”— “too much airplane for one man to fly”.

• 2001: Peter Pronovost: central line placement "Safe Patients, Smart Hospitals” (2010). • Dr Atul Gawande (2007) Classic Article “The

Checklist” (2009) The Checklist Manifesto: How to Get Things Right (book)

Effective Checklists & Strategiesfrom Aviation to Medicine

• Checklists are focused, unambiguous, succinct• No unintended consequences from checklist use• Evidence based, discrete tasks identified• Team work training, improve communication--

Time outs/pt hand-offs • Non punitive incident reporting• Standardization• Simulator training

ChecklistsWhat they can’t solve

• Errors due to lack of skills, training or experience– Checklists can standardize behavior but not

“attention” • Practice issues when there is no established

“gold standard”• Support/cultural change when Leadership is

not engaged

The original Pronovovst “checklist”for central line placement

Based on CDC recommendations:Wash handsUse full-barrier precautions (drape pt from

head to toe)Clean skin with chlorhexidineAvoid use of femoral site, if possibleRemove any unnecessary catheters

Success aided by:

• Involvement from the top down: senior executives of health care system requested participation in study

• “Daily goal sheets” implemented to improve clinician-to-clinician communication

• Comprehensive unit –based safety program: assisted by patient safety/infection control depts

• At least one MD and one RN team led each new step

Success…

• Terminology standardized—NNIS (Nat’l Nosocomial

Infections Surveillance System/CDC) definition of catheter-related blood stream infection used

• Exact definition of central catheter, which could include a central catheter which was peripherally inserted

• Defined “catheter day” so time of indwelling catheters would match

Post Partum Hemorrhage

• Rate of maternal death by PPH increased 26 – 28% since 1994: uterine atony not explained by increased rates of c/s, VBAC, maternal age, multiple birth, HTN, diabetes Callaghan (2010) Bateman (2010)

• Maternal deaths tripled between 1996-2006 (CMQCC)

• Nationwide, blood transfusions increased 92% during deliveries between ‘97-’05 Kuklina (2009)

• Aviano: Sentinel event

Changes of pregnancy• Maternal blood volume 50%; plasma

volume more than RBC vol: slight hgb/hct-fulfills perfusion demands of low-resistance

uteroplacental unit, reserve for blood lossCoagulation system: Increase in clotting

factors/decrease fibrolytic activityUterine ctx: crisscrossing muscle bundles,

occlude, contract, retract following expulsion of placenta: living ligature/physiologic sutures

Can we have an effective checklist?• Response to PPH is reactive not proactive• There is no established “Gold Standard” for

PREVENTION of PPH• There is no one consensus for management of PPH,

but many avenues• Triggers: Response based on clinical appearance (it

may be too late…)• IN US clinically accepted >500 ml (vag) 1000 ml (c/s)

Does not take into account initial volume status, arbitrary, may be clinically irrelevant to hemodynamic compromise (CMQCC)

Current recommendations

• “Known” risk factors: 39% of cases had one or more: Numerically, more women die with no known risk factors

WHO, ACOG, SGOC recommendations (1A):• Injectable Oxytocin by skilled provider. 10 mu

IM or 20 mu+ IV in IVF after delivery of anterior shoulder

Recommendations

• Objective quantification of blood loss: Graduated collection containers, weigh blood soaked chux/pads (CMQCC, WHO)

• Vital sign triggers (NHS, CMQCC)

• If it isn’t working, don’t waste time…move on (CMQCC)

• After 2 units PRBC start FFP then 1RBC:1FFP:1 PLT (CMQCC, Iraq theatre: Borgman, M. )

NHS Triggers

• RR (red) < 10 > 30 • RR (Amber) 21-29• O2 sat less than 95%

(red)• T greater than 38 C

(red)• Pulse (red) > 120 <40• P (Amber) > 100 <50

• Pain 2-3 (red) but not 2-3/10: 2 means moderate, 3 severe pain

• SBP >170 <80 (red)• >160 < 90 (amber)• DBP >110 (red)• > 100 ( amber)• DBP No lower limit• No uterine tone

CMQCC Triggers

• EBL > 500 ml or hemodynamic instability (vag)• HR ≥ 110• BP ≤ 85/45 or noted > 15% drop• 02 sat < 95%

Current AF triggers

Calculate MAP every 15 min for first 6 hours ;Want MAP > 65 mmHGMAP = (2x DBP) + SBP 120/80 = MAP of 93 3Or SBP-DBP = x , then x ÷ 3, then add that

number to DBP

RR first trigger

Emergency OB Medications

Capt Gretchen Waldvogel

Uterotonic Agents

• Oxytocin (Pitocin)

• Methylergonovine (Methergine)

• Carboprost (Hemabate)

• Misoprostol (Cytotec)

Oxytocin

**First line treatment for PP Hemorrhage

Action: Stimulates the upper uterine segment of the

myometrium to contract rhythmically, constricts spiral arteries and decreases blood flow to uterus.

Dose: 10mu injected Intramuscularly or 20-60mu in 1000ml

Methergine

• Action: Causes smooth muscle contraction in upper/lower uterine segments

• Dose: 0.2mg IM, may be repeated PRN every two to four hours or Intrauterine by MD

• Contraindicated in pts with Pre-Eclampsia or Hypertension because it causes raised blood pressure

• Adverse Effects: nausea and vomiting

Hemabate

• Action: Enhances uterine contractility and causes vasoconstriction

• Dose: 0.25mg intramuscularly or Intrauterine by provider, can be repeated every 15 min for a total dose of 2mg

• Contraindicated in pts with Asthma, Cardiac disease • Side Effects: Nausea, vomiting, DIARRHEA,

hypertension, and flushing• Consider Immodium therapy as countermeasure

Cytotec

• Action: Increases uterine tone and decreases postpartum bleeding

• Dose: 200mcg-1000mcg sublingually, orally, vaginally, or rectally

• **Recommended 1000mcg rectally• Side Effects: Shivering, pyrexia, and diarrhea

• ** Not approved by FDA for this indication

Magnesium Sulfate

Hypertensive Disorder

Magnesium Sulfate

• Action: Acts peripherally to produce vasodilation

• Dose: Adjusted for situation, Loading VS. Maintenance dose

• ---Can be given IM if no IV access• Side Effects: Flushing, sweating, nausea,

fatigue, hypotension, CNS depression, depressed reflexes and respiratory effort

Safety Issues

• ** Use pre-mixed preparations from the pharmacy

• ---Compatible with LR or NS• All doses given should be on IV pump and

Buretrol/Volutrol should be used• For all boluses, set VTBI at 100ml• Total IV intake should be 125ml/hr unless

otherwise ordered by MD

Hypertension Box Aids

• Labetalol

• Hydralazine Hydrochloride

• Diazepam (Valium)

• Calcium Gluconate 10%

Labetalol– Use multidose vial 100mg/20ml (5mg/ml)

– Compatible with LR, NS, D5LR, D5W, D5 1/4NS

Give IVP over 2 minTake B/P every 5 min

Initial dose usually 20mg with increasing doses of 40-80mg every 10min until max dose of 300mg

Doses using 100mg/20ml vial:-20mg ordered: give 4ml-40 mg ordered: give 8ml

-80mg ordered: give 16ml

HydralazineUse 20mg/ml single use vial

Dose is 5mg (0.25ml) Compatible with LR, NS

Give IVP over 1min, SLOW IVPTake B/P every 5min

Initial dose done, then wait 20min before giving next dose, onset of action is 10-20min

Repeat doses 5mg (0.25ml) to 10mg (0.50ml) every 20min up to total dose of 20mgIf giving 10mg dose(0.50ml) give slowly over at least 2 min

DO NOT GIVE HYDRALAZINE IN THE SAME IV LINE AS MAGNESIUM SULFATE(Either turn off the Magnesium Sulfate and flush the line or start a second IV)

Diazepam

Use 10mg/2ml Tubex (5mg/ml)**Turn off Magnesium Sulfate Infusion and Disconnect From

IV**

Compatibility: give directly into IV at closest port to patient. Not recommended to mix with any solution. Has variable

stability in NS, LR, and D5W

Give 5mg/ml over at least 1 minMay repeat doses in 10 min up to a dose of 20mg

(Minimum of 10 min wait time)

Calcium Gluconate 10%Use 10ml single use vial containing 100mg/ml

(1 GM total dose)**Discontinue Magnesium Sulfate Infusion and Disconnect From IV**

Compatible with LR, NS, D5LR, D10W, D5NS, D5WGive Slowly, Use Entire Vial

Give at rate of 2ml/minOR

Give the entire dose over 3 to 5 min

Patient should be hooked up to an EKG if able-Especially if you need to repeat doses

Stop After 3 Doses OR 3 GM

Team STEPPSPrinciplesinCommunication/Drills/Lessons Learned

Why use Team Stepps?

•Goal: Produce highly effective medical teams that optimize the use of information, people and resources to achieve the best clinical outcomes.

• Teams of individuals who communicate effectively and back each other up dramatically reduce the consequences of human error

PUTTING Team STEPPS IN ACTION

• MOES (Mobile Obstetric Emergency Simulator) - simulated various scenarios (breech, stat c/s,

shoulder dystocia, PPH, NRP, etc) - various “issues” or areas for improvement

brought to light - continued drills, repetition strengthened use

of Team Stepps principles

MOES TRAINING FEEDBACKS

• COMMUNICATION ISSUES: • overhead paging system, call phones, training day?, who

is in charge?, communication with clinic to L&D staff

• SBAR vital to role clarity, proper hand-off and situational awareness

• Closed-loop communication promotes understanding of order, report, etc.

• Shared mental model promotes universal understanding of the scenario and what’s needed

MOES TRAINING FEEDBACKS, cont’d

• LOGISTICAL ISSUES:• lack of standardization with supplies, medication access,

knowledge of use of equipment, code blue vs. rapid response

• Creation of emergency med boxes, med cards and algorithms binder

• Standardized location of supplies in all LDR’s• Re-trained on use of equipment not consistently utilized• Revision of code blue MDGI with addition of RRT (Rapid

Response Team)

MOES TRAINING FEEDBACKS, cont’d

• MOTIVATION: staff motivation level high • increased occurrence/depth of training scenarios

raises awareness of areas of self-improvement, empowers staff

• Positive feedback on what we did well (debriefs)• Builds teamwork, rely on strengths of each

member• Leadership supportive- makes changes when

identified to promote patient safety

Lessons Learned

• MOES, huddles, drills, debriefs promote Team STEPPS principles

• Proof of importance of SBAR/communication to decrease patient errors

• Confidence builder for response to emergency situations

ReferencesACOG, Practice Bulletin Number 76, Postpartum Hemorrhage, 2006.Bateman, B. et al (2010), The epidemiology of postpartum hemorrhage in a large,

nationwide sample of deliveries, Anesthesia and Analgesia, 110(5) 1368-1373.Borgman, M, et al (2007) The ratio of blood products transfused affects mortality

in patients receiving massive transfusions at a combat support hospital, Journal of Trauma, 63: 805-813

California Maternal Quality Care Collaborative, Obstetric Hemorrhage: New Strategies, New Protocol (2010)/ Improving Health Care Response to Obstetric hemorrhage (2010)

Callaghan, W, Kuklina E & Berg C. (2010), Trends in postpartum hemorrhage: United States 1994-2006, American Journal of Obstetrics and Gynecology, 202(4), 353.

Kuklina, E. et al (2009) Obstetric Morbidity in the US 1998-2005, Obstetrics and Gynecology (113), 293-299.

References

Matthews, M., Gulmezoglu, A. & Hill, S (2007) Saving womens lives: evidence-based recommendations for the prevention of postpartum haemorrhage, Bulletin of the World Health Organization, 85(4)

Provonost, P et al (2006), An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU, The New England Journal of Medicine, 335 (26), 2725-2732.

RCOG (2009), Prevention and Management of Postpartum Haemorrhage, Green Top Guideline 52

Smith, J., & Brennan, B. (2009), Management of the Third Stage of Labor, Medscape, eMedicine Specialties, Obstetric and Gynecology, Labor and Delivery

SOGC Clinical Practice Guideline: Active Management of the Third Stage of Labour: Prevention and Treatment of Postpartum Hemorrhage, No 235, Oct 2009.