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Archive for June, 2011|Monthly archive page

To rhogham or not to rhogam?

In Uncategorized on June 28, 2011 at 3:00 am

29yo F g3p1 about 14wks pregnant by LMP presents after being physically assaulted. Patient states she was in an altercation with another female and was punched multiple times to the abdomen. denies any vaginal bleeding but does note some mild abdominal pain. Vital signs are within normal range for her age. Pelvic exam was unremarkable with no vaginal bleeding.

Bedside  US showed +IUP at about 14weeks with FHR at 130bpm

Labs: rh negative. no Rh antibodies.

Teaching Point: Indications for Rhogam.

Remember! The rh prefix is the name of a surface antigen on RBC’s. Rh negative means those RBCs do not have the antigen. Rh positive means they do. Thus, an Rh negative  person has anti-Rh antibodies! Now, in a pregnant female, this could potentially be a problem if they are pregnant with an Rh+ fetus as the anti-Rh antibodies from the mother could potentially cross the placental and destroy fetal RBC’s IF there is mixing of maternal and fetal blood!.

A woman can be sensitized any time the Rh–positive blood mixes with her blood. This can occur if an Rh–negative woman has once had: Vaginal bleeding during pregnancy, induced or spontaneous abortion, Ectopic pregnancy, chrionic villious sampling or trauma. Once sensitized, it takes approximately one month for Rh antibodies in the maternal circulation to equilibrate in the fetal circulation. In summary:

Rh NEGATIVE = BAD = Sensitization = possible death to current fetus plus issues with future pregnancy, therefore TREAT!

Treatment is Rhogam (anti-Rh IG) 50mcg IM if within the first 20wks or 300mcg IM otherwise.

 

Welcome!

In Uncategorized on June 28, 2011 at 1:03 am

Teaching Points officially welcomes all to a new academic year! it’s time for more fun learning and reading. The blog will be updated weekly (as long as the EM gods smile on me)! Please feel free to send any teaching cases to me at yvonne.ezeala@gmail.com!

‘help my baby!’

In Uncategorized on June 10, 2011 at 4:31 pm

A young mother runs into a small community ED screaming ‘Help my baby, i think she’s having seizures!’

The patient is a 15mo female with a hx of asthma. Per mum, patient had been having fevers up to 102.5 at home x1day. Patient had just woken up from sleep (10mins prior to arrival) when mum noticed generalized body stiffness, ‘eyes rolled back’ and general unresponsiveness to name calling. mother denies any trauma, falls, or any ingestions. No prior hx of seizures. No significant birth hx.

Patient is taken emergently to an ED room. IV, O2, Monitor.On exam

Vitals: T@103, 97% on room air, BP 140/60. Hr 120. heart, lungs, and abdominal are wnl. no visible signs of trauma. no rash. PERRL, Patient eyes open and staring into the distance, unresponsive to name calling and generalized body stiffness noted.

Patient was given tylenol PR, labs (cbc, bmp, ua, urine culture and blood cultures) were sent. After 2minutes with no change in the patients neurological status, 0.5mg IV of ativan. After 5mins,with still no change, another 0.5mg IV ativan was given and transport was arrange for the patient’s transferred to the nearby children’s hospital for further care.

Teaching Point: Identification and management of complex febrile seizures.

Usually, febrile seizures present to the ED without any ‘active’ seizures per say and as such, minimal intervention is required. Diagnosis is usually made from history and the patient with their caretakers are usually discharged home with careful instructions.

Definition: A febrile seizure is defined as seizures in the presence of a fever >38C without concurrent CNS infection or other identifiable cause such as electrolyte imbalance, neurologic illness or prior seizure disorder.

Simple febrile seizures are typically generalized, last < 15 min and do not recur within 24h while complex febrile seizures are prolonged, recur more than once in 24h, or are focal.

Complex febrile seizures usually warrant admission and a more extensive search for the cause of the seizure including infection, intracranial trauma and epilepsy.

What are your treatment options?! In peds, POP OUT THE BRASLOW TAPE! This will save you time in trying to figure out dosages!

First line: lorazepam(IV or IM; Ativan) – kids 0.05-0.1mg/kg every 3-5mins. Adult 0.02 -o.3mg/kg (about 2mg IV) every 3-5mins. Consider Diazepam(PR) if IV access is an issue.

Second line: Phenytoin 20mg/kg IV (Rem, IV phenytoin can cause hypotension) or Fosphenytoin 15-20PE/kg IV or Valproate 20-30mg/kg IV.

Third line: Phenobarbital ( its not called a ‘phenobarb coma’ for nothing. If you are getting to this point, the patient should be intubated for airway protection due to their chemically induced and physiologically depressed mental status)

 

Outcome: The child was transferred to the local children’s hospital. Complete workup including EEG, CT head, LP and all cultures were negative. Patient was discharged home in good condition about 3days later.