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What is the Glasgow Coma Score and it’s significance?
Scale relating to severity of TBI that correlates with mortality.
Eyes : 4 spontaneous opening, 3 open to voice, 2 open to pain, 1 none
Voice: 5 oriented 4 confused 3 inappropriate 2 incomprehensible 1 none
Motor: 6 obeys commands, 5 localizes pain, 4 withdraws, 3 flexion, 2 extension, 1 none
< 8 severe (need immediate resuscitation)
9-12 moderate (emergent CT)
13-15 mild (may need head ct)
Treatment of Pre E?
Delivery of the fetus
Magnesium infusion for seizure px
Blood pressure control usually with labetalol or hydralazine (to prevent end organ damage and ICH)
Magnesium levels and PE findings?
Mag tox should always be on ddx of unresponsive pregnant pt
2 normal 5-9 therapeutic 6-12 ecg changes (long PR, wide QRS) >12 weakness, loss of DTRs 15-20 resp arrest, heart block, cardiac arrest
MOA of methergine
Partial Ag/antagonist at 5HT (serotonin) rec on uterine smooth muscle causing contraction, also DA and alpha activity
Avoid in HTN
Dose 200mcg IM for uterine atony
MOA oxytocin
Acts at oxytocin rec on uterus - G protein coupled rec that increases intra-cellular Ca causing smooth muscle contraction
produced by posterior pituitary during labor and after birth for uterine contraction. Also involved in bonding and lactation
Has ADH activity and can cause vasodilation
MOA carbaprost
Synthetic prostaglandin F2? Stimulates uterine myometrial contraction. Also stim GI smooth muscle leading to diarrhea
Can cz bronchospasm
MOA Misoprostol
Cytotec
Synthetic PGE1 that stimulates uterine smooth muscle contraction
Given PR
S/e: diarrhea, fever
Massive transfusion
vs
Massive Transfusion Protocol
Massive transfusion: any situation where patient receives many transfusions (traditionally 10units or more in 24h)
MTP: rapid admin of large amounts of blood (> 6u) in a balanced manner (usually in a fixed 1:1:1) in an attempt to avoid dilutional coagulopathy for the treatment of hemorrhagic shock. Institution specific
Maximal surgical blood ordering schedule
List of commonly performed procedures and corresponding T&C units recommended.
Hospital specific.
Used to avoid unnecessary T&C
Target Pre Ductal SpO2 after birth
1 min 60-65% 2 min 65-70% 3 min 70-75% 4 min 75-80% 5 min 80-85% 10 min 85-95%
Neonatal Resuscitation (NALS)
APGAR 8-10 - stimulate and dry
5-7 - stimulate and dry
3-4 - bag mask (start room air)
0-2 - bag mask consider ETT, vent and CPR
0-30sec Of HR < 100 - bag mask (start RA and titrate FiO2)
30-60sec if HR < 60 - CPR 3:1 comp/breaths
60-90sec if:
HR < 60 - epi (10mcg/kg IV or 100mcg/kg ETT)
HR 60-99 continue supported ventilation
HR > 100 you’re good
Very rarely shock neonate but: 2J/kg
Post resuscitation consider hypothermia (33-34deg x 24h)
APGAR
Quick way to assess how well neonate is adjusting to birthing process and extrauterine life
Appearance (color):
pink(2), peripheral cyanosis (1), cyanotic (0)
Pulse: >100 (2), < 100(1), absent (0)
Grimace (reflex to stim): Strong response (grimace, cough, sneeze) (2), Weak grimace (1), none (0)
Activity (muscle tone): Active movement (2), flexed extremities (1), floppy (0)
Respirations: Strong crying(2), weak (1), none (0)
HR is the last thing to go (so if APGAR 1-2 all they have is a HR)
What are the different targets for anti coagulation drugs?
Platelet inhibitors:
Inhibition of COX2 (TxA2 and PG)
ADP rec antagonist
GIIBIIIA rec antagonist
10a inhibitors
Thrombin inhibitors
Enhance ATIII activity
Vit K antagonist (decrease 2,7,9,10)
Herbs (4Gs) may impair plt fx
Platelet inhibitors
(-) COX2 and thus TXA2 and PG:
ASA and NSAIDS
ADP rec (-): Clopidogrel (Plavix) Pasugrel (Effient) Ticlodipine (Ticlid) Ticagrelor (Brillinta)
GIIbIIIa (-):
Eptifibatide (integrilin)
Tirofiban (aggrastat)
Abciximab (rheopro)
10a inhibitors
LMWH enoxaparin (Lovenox)
Fondaparinux (Arixtra)
Rivaroxaban (Xarelto)
Apixaban (Eliquis)
All have X so block factor X
Renal elimination
Thrombin inhibitors
2 is “da big” guy in coagulation so
Dabigatran (Pradaxa) Argatroban Desrudin Lepirudin Bivalirudin (gtt for CPB in prot sens pt or HIT)
ASRA and LMWH
Pt on LMWH:
Place cath - 12h low dose, 24 high
Pull cath - 12h low dose, 24 high (but shouldn’t have a cath if on high dose)
Want to start LMWH after neuraxial:
Can only start 40 QD low dose LMWH with in-dwelling cath. Wait 6-8h from end of surgery. Second dose not before 24h.
ASRA and Warfarin
Place cath:
5d plus INR 1.5
Pull cath:
When INR 1.5
ASRA and fibrinolytic therapy
Contraindicated
If pt comes to ED with stroke and had bloody neuraxial recently, ideally should wait 10 days for tpa
If cath in place when tpa started, check fibrinogen before d/c
ASRA and IV Heparin
Place cath: Hold 4-6h
Give Heparin in case:
1h after neuraxial
(Controversial if bloody tap, may want to cancel if case is CPB)
Pull cath: 4-6h
ASRA and SQ Heparin
5000 BID: 4-6h to place and to pull
TID dosing and 7500 dosing wait longer?, maybe don’t do it, maybe check ptt?
Is therapeutic (>10000) : wait 24h
LMWH dosing
High dose 1mg/kg
Low dose 40QD or 30 BID
ASRA and anti platelets
NSAIDs ok
ADP rec (-): 7d (clopidogrel, prasugrel, ticagrilor) 10d (ticlodipine)
GIIbIIIa (-):
8h (eptifibitide, tirofiban)
24-48h (abciximab)
ASRA and thrombin (-)
Dabigatran
Place or pull : 5d
Bivalirudin and argatroban - normal coagulation or avoid
