EMS World

JUN 2015

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EMSWORLD.com | JUNE 2015 45 failure will require dialysis. Patients who are severely symptomatic with hypermag- nesemia can also be treated with calcium gluconate 10-20 mL of 10% solution IV over 3 minutes, or calcium chloride bolus in the setting of cardiac arrest. If magnesium sulfate is not available or seizures don't respond to it, benzodiaz- epines such as diazepam, midazolam or lorazepam can be administered, prefer- ably IV, though the intramuscular route can be utilized if IV access is unobtainable. A caution, though: All benzodiazepines are considered category D pregnancy drugs. Suggested dosing regimens are as follows, though always follow your protocol and/ or consult directly with medical control: • Diazepam: 5–10 mg IV every 5–10 mins. at a rate of 5 mg/min. or less and a maximum dose of 30 mg. • Midazolam: 1–2 mg bolus IV at a rate of 2 mg/min. Repeat every five minutes until seizures stop, to a maximum of 2 mg/kg . • Lorazepam: 4 mg IV at maximum rate of 2 mg/min. Because of the risk of heart failure and acute myocardial infarction, patients with HELLP syndrome should have a 12-lead ECG performed and their cardiac rhythm monitored. Conclusion The patient is placed on the gurney in a semi-Fowler's position and administered oxygen via nonrebreather mask at 15 lpm. The crew considers CPAP but rules it out due to the patient's decreased level of con- sciousness and mental status. A 16-gauge IV catheter is placed and a 1,000-mL bag of normal saline with a macro drip set attached is administered KVO. Upon arrival at the ED, the patient is intubated, the 12-lead ECG repeated and a Foley catheter placed. A chest radio- graph reveals bilateral pulmonary edema. Laboratory findings include increased serum creatinine and aminotransferases, thrombocytopenia, decreased platelets, increased serum bilirubin and hemolysis. The patient is determined to be suffering from postpartum HELLP syndrome com- plicated by DIC and is administered fresh frozen plasma, packed red blood cells and platelets. No urine output is collected from the Foley catheter, and the patient is determined to be in renal failure. Dialysis is planned after the administration of Lasix fails to induce diuresis. The initial presentation of HELLP syn- drome can be subtle and mimic the clinical presentation of a benign viral or bacterial infection. HELLP syndrome develops in less than 1% of all pregnancies but in 10%–20% of pregnancies with preeclampsia, and up to 30% of women who develop HELLP syndrome do so after childbirth, typically within 48 hours. Outcomes for mothers with HELLP syndrome who are identified and receive prompt medical attention are usually good, but complications such as liver dysfunction or failure, renal failure, pulmonary edema and abruptio placentae can occur and contribute to maternal, and possibly fetal, morbidity and mortality. EMS providers should remember this potentially fatal complication of pregnancy in patients both pregnant and recently postpartum. REFERENCES 1. Stone JH. HELLP syndrome: hemolysis, elevated liver enzymes, and low platelets. JAMA, 1998; 280: 559. 2. Sibai BM. HELLP syndrome. UpToDate.com, www.uptodate. com/contents/hellp-syndrome. 3. van Oostwaard MF, Langenveld J. Recurrence of hypertensive disorders of pregnancy: an individual patient data metaanalysis. Am J Obstet Gynecol, 2015; 215(5): 624e1–624e17. 4. Lachmeijer AM, Arngrímsson R, et al. A genome- wide scan for preeclampsia in the Netherlands. Eur J Hum Genet, 2001; 9(10): 758. 5. Sibai BM, Ramadan MK, et al. Maternal morbidity and mortality in 442 pregnancies with hemolysis, elevated liver enzymes, and low platelets (HELLP syndrome). Am J Obstet Gynecol, 1993; 169(4): 1,000. 6. Hepburn IS, Schade RR. Pregnancy-associated liver disorders. Dig Dis Sci, 2008 Sep; 53(9): 2,334–58. 7. Kondrackiene J, Kupcinskas L. Liver diseases unique to pregnancy. Medicina (Kaunas), 2008; 44(5): 337–45. 8. Lee NM, Brady CW. Liver disease in pregnancy. WJG, 2009; 15(8): 897–906. 9. Sibai BM. The HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets): much ado about nothing? Am J Obstet Gynecol, 1990; 162: 311. 10. Simhan HN, Himes KP. Neuroprotective ef fects of in utero exposure to magnesium sulfate. UpToDate.com, www. uptodate.com/contents/neuroprotective-ef fects-of-in-utero- exposure-to-magnesium-sulfate. 11. Echevarria MA, Kuhn GJ. Chapter 104: Emergencies After 20 Weeks of Pregnancy and the Postpartum Period. In: Tintinalli JE, et al., eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7 th ed. New York, NY: McGraw- Hill, 2011. 12. Sibai BM. Diagnosis, controversies, and management of the syndrome of hemolysis, elevated liver enzymes, and low platelet count. Obstet Gynecol, 2004; 103: 981. 13. August P. Management of hypertension in pregnant and postpartum women. UpToDate.com, www.uptodate.com/ contents/management-of-hypertension-in-pregnant-and- postpartum-women. 14. Duley L, Meher S, Jones L. Drugs for treatment of very high blood pressure during pregnancy. Cochrane Database Syst Rev, 2013; 7: CD001449. 15. American College of Obstetricians and Gynecologists, Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy. Obstet Gynecol, 2013; 122(5): 1,122. 16. Lacasse A, Rey E, et al. Nausea and vomiting of pregnancy: what about quality of life? BJOG, 2008; 115(12): 1,484. 17. Lee NM, Saha S. Nausea and vomiting of pregnancy. Gastroenterol Clin North Am, 2011; 40(2): 309. 18. Matthews A, Haas DM, et al. Interventions for nausea and vomiting in early pregnancy. Cochrane Database Syst Rev, 2014; 3: CD007575. 19. Bailit JL. Hyperemesis gravidarium: Epidemiologic fndings from a large cohort. Am J Obstet Gynecol, 2005; 193(3 Pt 1): 811. 20. Laifer SA, Stiller RJ, et al. Ursodeoxycholic acid for the treatment of intrahepatic cholestasis of pregnancy. J Matern Fetal Med, 2001; 10(2): 131. 21. Lee RH, Goodwin TM, et al. The prevalence of intrahepatic cholestasis of pregnancy in a primarily Latina Los Angeles population. J Perinatol, 2006; 26(9): 527. 22. Sibai B, Dekker G, Kupferminc M. Pre-eclampsia. Lancet, 2005 Feb 26; 365(9,461): 785–99. 23. Mjahed K, Charra B, et al. Acute fatty liver of pregnancy. Arch Gynecol Obstet, 2006; 274(6): 349–53. 24. Castro MA, Fassett MJ, et al. Reversible peripartum liver failure: a new perspective on the diagnosis, treatment, and cause of acute fatty liver of pregnancy, based on 28 consecutive cases. Am J Obstet Gynecol, 1999; 181(2): 389–95. ABOUT THE AUTHORS Scott R. Snyder, BS, NREMT-P, is full-time faculty at the Public Safety Training Center in the Emergency Care Program at Santa Rosa Junior College, CA. He is also a paramedic with AMR: Sonoma Life Support in Santa Rosa, CA. E-mail scottrsnyder@me.com. Sean M. Kivlehan, MD, MPH, NREMT-P, is an emergency medicine resident at the University of California, San Francisco. E-mail sean.kivlehan@ gmail.com. Kevin T. Collopy, BA, FP-C, CCEMT-P, NREMT-P, WEMT, is clinical education coordinator for VitaLink/ AirLink in Wilmington, NC, and a lead instructor for Wilderness Medical Associates. E-mail ktcollopy@gmail.com.

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