My wife is dying ...

[SpecialK]

You are responded to a shortness of breath. The patient is a 26-year-old female. Her husband told Control that "it looks like my wife is dying!".

The patient gave birth to her second child about 20 minutes ago but since become very unwell. Delivery was normal and placenta has passed. There's about 250 ml of post-partum blood on a towel but all vaginal bleeding has arrested.

It does indeed look like she is making a concentrated effort to die. She responds to voice, is very pale, skin is mottled and sweaty, she gasps for breath and has had a big vomit on the floor. The vomit has chunky bits and is very frothy and watery looking.

Obs: BP 80/50, PR 120, RR 30, Temp 36.5°, SpO2 82% RA, BGL 7 mmol/l, ECG sinus tachycardia.

O/E the only significant finding is when you listen to her chest; you hear bilateral sounds are some combination of wheezes and crackles.

1. Succinctly describe her primary problem? ("she is dying" is obvious and not acceptable!)
2. Putting lung sounds aside, what does the pattern look like? Is it consistent with the history?
3. What treatment do you provide?
4. You're 20 minutes from a secondary hospital and 50 minutes to a tertiary hospital. Where do you go?
5. HEMS at the tertiary hospital can come out and back you up. They have blood and ultrasound. Do you call for them? Do you want them to come by road or air? What do you do in the meantime?

 

[VentMonkey]

You are responded to a shortness of breath. The patient is a 26-year-old female. Her husband told Control that "it looks like my wife is dying!".

The patient gave birth to her second child about 20 minutes ago but since become very unwell. Delivery was normal and placenta has passed. There's about 250 ml of post-partum blood on a towel but all vaginal bleeding has arrested.

It does indeed look like she is making a concentrated effort to die. She responds to voice, is very pale, skin is mottled and sweaty, she gasps for breath and has had a big vomit on the floor. The vomit has chunky bits and is very frothy and watery looking.

Obs: BP 80/50, PR 120, RR 30, Temp 36.5°, SpO2 82% RA, BGL 7 mmol/l, ECG sinus tachycardia.

O/E the only significant finding is when you listen to her chest; you hear bilateral sounds are some combination of wheezes and crackles.

1. Succinctly describe her primary problem? ("she is dying" is obvious and not acceptable!)
Her second child of a set of twins, or second overall (G=2/ P=2)? I honestly do not know what is her primary problem, but if I had to guess perhaps some sort of internal hemorrhage, possibly related to her delivery, though at least for now after baby, and placenta are delivered it is somewhat controlled. Can I call for an additional unit for baby specifically? I am not taking mother and child in one ambulance at this stage, though I would prepare for her to arrest shortly. My best guess at her diagnosis is HELLP syndrome.
2. Putting lung sounds aside, what does the pattern look like? Is it consistent with the history?
I am not quite sure what you mean when asking what the pattern looks like. At 30, with adventitious breath sounds, a low SPO2, and signs of nearly irreversible shock, I am going to say she is hypoventilating ("gasping"), and this needs to be addressed quickly, or she will undoubtedly die.
3. What treatment do you provide?
Obviously ABC's. Mind you I am a paramedic in The States who doesn't routinely carry blood. If I am double paramedic, and/ or have my nurse, they can establish large bore IV access (bilaterally), begin to infuse crystalloids rapidly, while I work to control her airway. The patient's BGL is within normal limits (7 mmol/l=~126 mg/ dl). I am assuming her pulse is also weak, and thready. Once the airway is secured, and patient is stabilized prepare for transport to an OB capable receiving...
4. You're 20 minutes from a secondary hospital and 50 minutes to a tertiary hospital. Where do you go?
Has the patient had any clinical signs of improvement? I would still like a second ground unit started, and for now the cloest would do, unless there's no OB capabilities, then the extra 30 minutes to me goes without saying. I aim to keep mother and baby going to the same facility.
5. HEMS at the tertiary hospital can come out and back you up. They have blood and ultrasound. Do you call for them? Do you want them to come by road or air? What do you do in the meantime?
What's their ETA after launch? How is the weather? do THEY have any restrictions that may limit accepting the flight? Are they neonate capable/ trained, and if so, great they can take baby, if not then they can take mother, and I will meet them at the ED/ receiving with baby.

As far as what I do in the meantime is stabilize both mother, and child, have someone speak with dad whom I would imagine is understandably in hysterics, and wait for the helicopter, and/ or second ambulance. Which ever is the fastest, most capable, and reasonable in this scenario would be used. It sounds as though the HEMS crew would be, but if for whatever reason the second ground unit is closer than it would take to meet the HEMS crew (still have to set an LZ and prep their arrival, etc.), then the patient, and baby can both go via ground. I don't know that having ultrasound, and/ or blood product right this moment is worth the extra wait, though I guess the blood product can be easily argued.

If for whatever reason the closest receiving does not have OB capabilities you could always still have a second ground ambulance transport mother first (critical patient), and rendezvous with the HEMS crew half way to the ED 50 minutes away, being that she has already been stabilized best she could by us, the ground crews.

 

[SpecialK]

She did not have twins. She is G2P2.

The baby doesn't need any medical intervention. In practical reality, I would happily let dad strap the infant car seat in the front of the ambulance if he wants to go with his wife (which I imagine he would) or he can take both in his car and drive behind the ambulance.

The pattern of her vital signs is, as you said, shock. What type of shock do you think she has? If you think it is hypovolaemic shock, is the level of shock she has consistent with the history of blood loss we can see? What other causes of shock might she have? What is the significance of her breath sounds? If we take away the fact she has just given birth and consider her presentation in any other person what would you call it?

A second ambulance can be the house in 15 minutes and they are coming in the opposite direction from you i.e. if you head towards hospital they are coming from the other direction.

So you have called for HEMS and they have decided it's faster and best for them to come back you up by road. They will arrive in 50 minutes because that is how far they are from you i.e. coming from the large hospital. In the meantime what are you going to do? Are you going to wait for them to come to you or are you going to meet them en-route?

She has not improved; in fact she continues to deteriorate. She is beginning to develop very small purple spots on her skin.

 

[DesertMedic66]

My guess would be a PE

 

[VentMonkey]

She did not have twins. She is G2P2.

The baby doesn't need any medical intervention. In practical reality, I would happily let dad strap the infant car seat in the front of the ambulance if he wants to go with his wife (which I imagine he would) or he can take both in his car and drive behind the ambulance.

The pattern of her vital signs is, as you said, shock. What type of shock do you think she has? If you think it is hypovolaemic shock, is the level of shock she has consistent with the history of blood loss we can see? What other causes of shock might she have? What is the significance of her breath sounds? If we take away the fact she has just given birth and consider her presentation in any other person what would you call it?

A second ambulance can be the house in 15 minutes and they are coming in the opposite direction from you i.e. if you head towards hospital they are coming from the other direction.

So you have called for HEMS and they have decided it's faster and best for them to come back you up by road. They will arrive in 50 minutes because that is how far they are from you i.e. coming from the large hospital. In the meantime what are you going to do? Are you going to wait for them to come to you or are you going to meet them en-route?

She has not improved; in fact she continues to deteriorate. She is beginning to develop very small purple spots on her skin.

Petechial rash, and crackles I don't think a PE is that high up on my differentials. She seems to be in DIC, and in the later stages of an irreversible shock. Her prognosis is poor, but if you're having dad take baby to the ED, we can focus on mom.

Again, what we do in The States isn't really what you may do, nonetheless, this frees up provider wiggle room. I would load mom up and meet the HEMS crew somewhere in between assuming she doesn't code between then and now. Because she only has a certain amount visible doesn't mean it's not hypvolemic, but you definitely got me thinking.

It could be some form of distributive related to something else, I am still not convinced this is a massive PE, though I guess it's possible.

I'll let others continue to chime in on this one...

 

[DesertMedic66]

For me the first 2 things that came into my head were PE and AFE

 

[VentMonkey]

For me the first 2 things that came into my head were PE and AFE

Elaborate?

 

[DesertMedic66]

Elaborate?

For AFE a lot of her symptoms seem to fit. Skin discoloration, respiratory comprise, circulatory comprise, vomiting, pulmonary edema, tachycardia, and that started just after giving birth. If I remember correctly AFE usually occurs during birth or right after birth.

 

[EpiEMS]

Shoot - I had a long response that got deleted.

I was thinking PE or maybe DIC...

She's in profound (likely obstructive, possibly hypovolemic) shock and needs rapid transport to definitive care. As a BLS unit, rapid transport and high flow oxygen administration is my best bet - I do need an ALS intercept, and HEMS would be a great way to do it.

 

[VentMonkey]

For AFE a lot of her symptoms seem to fit. Skin discoloration, respiratory comprise, circulatory comprise, vomiting, pulmonary edema, tachycardia, and that started just after giving birth. If I remember correctly AFE usually occurs during birth or right after birth.

For those unfamiliar with this acronym/ term...
http://afesupport.org/what-is-amniotic-fluid-embolism/

 

[DesertMedic66]

For those unfamiliar with this acronym/ term...
http://afesupport.org/what-is-amniotic-fluid-embolism/

This link provides more info into the common signs and symptoms: http://www.mayoclinic.org/diseases-conditions/amniotic-fluid-embolism/basics/definition/con-20035462

 

[EpiEMS]

For those unfamiliar with this acronym/ term...
http://afesupport.org/what-is-amniotic-fluid-embolism/

Thanks! Wow...that's the kind of thing I've never imagined would happen.
1 in 40,000 deliveries in North America...that's quite rare (the conditions we typically worry about seem to all be below 1:1,000 deliveries based on quick Google-fu).

 

[VFlutter]

Agree with AFE, likely still in the first phase. Intubate, volume resuscitate, and pressors/inotropes. Consider HEMS to an ECMO center. There is some evidence supporting "A-OK, Atropine Ondansetron, Ketorolac

I have seen a few of these and they are some of the sickest patients i've had.

Great article (From Wash U)
http://www.marchofdimes.org/pdf/missouri/AFE_11-21-13.pdf

 

[VentMonkey]

@DesertMedic66 and @Chase good call. Even if this isn't the cause (I highly doubt it; you guys are on it) good material, guys.

 

[SpecialK]

Agree with AFE, likely still in the first phase. Intubate, volume resuscitate, and pressors/inotropes

Which inotrope would you use (if you had the choice)? Would you give it as bolus aliquots or as an infusion?

Considering the "pattern" of her shock would you use a different inotrope than you would normally?

 

[Carlos Danger]

Which inotrope would you use (if you had the choice)? Would you give it as bolus aliquots or as an infusion?

Considering the "pattern" of her shock would you use a different inotrope than you would normally?

Considering the etiology, I would not use an inotrope, I would use a drug that is primarily a vasopressor.

 

[VFlutter]

Considering the etiology, I would not use an inotrope, I would use a drug that is primarily a vasopressor.

Agreed with vasopressors as primary treatment however I think an argument can be made for inotropes given RV dysfunction is a large component as things progress. However you still may have and under filled LV so benefit may be minimal. I like Epi drips for situations like this, i.e. massive PE.

 

[SpecialK]

Shucks. you blokes are stars .... yes, it was amniotic fluid embolism (AFE).

I'd never heard of it, and this was a real case. There have been a number of local cases of women with AFE who have made normal recoveries despite dramatic, accelerated and continued deterioration once they received IV adrenaline infusions.

Here are my thoughts

1. Succinctly describe her primary problem?
She has very severe shock

2. Putting lung sounds aside, what does the pattern look like? Is it consistent with the history?
The "pattern" of her signs and symptoms looks like hypovolaemic shock from partum haemorrhage. However, it is not consistent with only 200 or 300 ml of blood loss. If we do consider her lung sounds but put aside the fact she has recently delivered a baby this pattern of shock and her lung sounds screams anaphylaxis in any other patient. Indeed, there is a large immune component to AFE similar to anaphylaxis.

3. What treatment do you provide?
Well, a little debatable but high flow oxygen and IV access. If I had blood I would give her blood. I would also give her an IV adrenaline infusion.

4. You're 20 minutes from a secondary hospital and 50 minutes to a tertiary hospital. Where do you go?
I have a firm preference for going straight to the tertiary hospital. I would however in this case, considering she is actively dying in a reasonably uncontrolled manner, ring the secondary hospital (via the Clinical Support Officer in Ambulance Control) and ask if they will accept her first or not.

5. HEMS?
Yes I would ask for HEMS to come out and back me up but via road. At the same time as HEMS came towards me I would head towards them and meet en-route rather than waiting at the scene. There is going to be very limited room to work on this patient in a helicopter and the family cannot go with her.

 

[phideux]

If the HEMS unit is heading your way to intercept, why not just head towards the close hospital to intercept? It is almost the halfway point.

 

[SpecialK]

If the HEMS unit is heading your way to intercept, why not just head towards the close hospital to intercept? It is almost the halfway point.

Because "hospital" does not always equal "definitive care". All hospitals are not created equal.

I don't honestly know if this patient is going to be best served going to the secondary hospital, or if it is worth going to the major hospital. There has been a case series of patients with AFE who despite significant and progressive deterioration have rapidly improved with an IV adrenaline infusion.

I would respond HEMS (in this case they would come out by road) and start heading towards hospital. I'd give the secondary hospital a ring via Control to ask them if they wanted her or if it would be best to take her to the tertiary hospital. Her level of improvement would also guide what I did. If she was not improving then I would take her to the closer hospital.