Module 8: Part 3 (47-69)

Question 1

Two thirds of the primary headaches are ____ and ___

Answer 1

tension-type and migraines

Question 2

___ ____ are often circumferential and constricting, a/w scalp tenderness and mild to moderate in severity

Answer 2

Tension type

Question 3

usually pulsating in a unilateral location, nausea and photophobia, aura possible & often history of this type of headache

Answer 3

migraine headaches

Question 4

type of HA where its musculoskeletal &worsened by maternal physical exertion during labor and lack of sleep

Answer 4

Secondary HA

Question 5

Neck and shoulder pain without HX of dural puncture

Answer 5

Secondary HA

Question 6

Headache is a serious premonitory sign in over 50% of women who develop ___

Answer 6

eclampsia (headache, visual disturbances, n/V, seizures, stupor and coma)

Question 7

variable signs but can have evidence of increased ICP (headaches, somnolence, vomiting, confusion) and focal abnormalities

Answer 7

subdural hematoma

Question 8

classic presentation with sudden onset of severe headache, decreased LOC

Answer 8

Subarachnoid hemorrhage

Question 9

Pneumocephalus: (3)

Answer 9

INJECTION OF AIR INTO THE SUBDURAL OR SUBARACHNOID SPACE
ASSOCIATED WITH SUDDEN ONSET OF SEVERE HEADACHE, SOMETIMES NECK PAIN, BACK PAIN OR CHANGES IN MENTAL STATUS
CAN MIMIC PDPH BUT USUALLY RESOLVES IN 1 WEEK

Question 10

Caffeine Withdrawal & Lactation headache

Answer 10

secondary HA

Question 11

PDPH procedural risks (4)

Answer 11

Gauge of needle (25 vs 17 g tuohy)
Pencil point vs. cutting (Quincke)
Orientation of the bevel (parallel to long axis decreased PDPH by 70% compared to perpendicular orientation)
Loss of resistance technique (air or saline)

Question 12

PDPH patient risks (6)

Answer 12

Young age
Female
Low BMI ?
Vaginal > cesarean delivery
Prior history of headache
Previous history of PDPH

Question 13

ICHD-3 definition of PDPH
(6)

Answer 13

Headache occurring within 5 days of lumbar puncture caused by a CSF leak through the dural puncture
Can occur immediately or within minutes of moving to an upright position (sitting or standing)
Resolves within a minute of moving to the supine position
Has one of the following symptoms: headache, neck stiffness, tinnitus, photophobia or nausea
Hearing loss (can improve within an hours of epidural blood patch)
Usually remits spontaneously within 2 weeks or after an autologous blood patch

Question 14

Pathophysiology of PDPH

Answer 14

Continued Leak of CSF from intracranial compartment d/t dural puncture (loss > production)
Loss of cushioning effect of CSF causes brain to sag &creates tension on pain sensitive meninges (most apparent in the upright position)
Loss of CSF causes intracranial hypotension which leads to Reflex cerebral vasodilation
Cerebral hyperemia
Headache symptoms

Question 15

downsides of PDPH (5)

Answer 15

Inability to care for the newborn/Inability to get out of bed
Repeat hospitalization
Need to have a blood patch, Inconvenience, Cost
Diplopia or hearing loss an be permanent or take months to recover
Persistent headaches, backaches and cranial nerve symptoms

Question 16

PDPH TX (7)

Answer 16

Main goal Should be the prevention of PDPH
Talk to the patient
Conservative: Bed rest, hydration, abdominal binder, caffeine (oral or parenteral)
Medications: muscle relaxants and pain meds, gabapentin
Leaving the intrathecal catheter in for 24 hours may dec. epidural patch use (catheter acts to block the hole and decrease of csf)
Saline, morphine
Prophylactic blood patch, early (within 24 hours) or late (after 24 hours)

Question 17

Epidural blood patch

Answer 17

Treatment of choice especially if cranial symptoms
injected blood becomes a small epidural hematoma that decreases the pressure gradient and the rate of CSF leak from the intrathecal space
Blood increases lumbar CSF pressure, restores intracranial CSF pressure and possibly reflex cerebral vasoconstriction

Question 18

percentage of pts that get good relief with epidural blood patch for PDPH

Answer 18

70%

Question 19

epidural blood patch risks

Answer 19

Risks are the same as epidural plus low back pain/hip pain

Question 20

epidural blood patch complications

Answer 20

Infection
Neurologic :Lumbovertebral syndrome, arachnoiditis, radicular back pain;
Compressive complications (lumbovertebral, subdural hematoma, cauda equina)

Question 21

Patient should stay in the supine position after blood patch for how long?

Answer 21

for 1-2 hours, also avoiding Valsalva and heavy lifting

Question 22

Most patients will get almost immediate relief, some delayed up to ___hours
May continue to have neck pressure, back pain/pressure or hours to days

Answer 22

Second blood patch after 24 hours if not relieved may need neuro consult

Question 23

Second blood patch after ___ hours , if not relieved may need neuro consult

Answer 23

24 hrs

Question 24

Trauma affects __-___% of pregnancies

Answer 24

5-7%

Question 25

___-____% of all maternal deaths in US due to trauma Leading cause of non-obstetric maternal and fetal mortality

Answer 25

45-50%

Question 26

Most common causes of trauma in pregnancy

Answer 26

MVA (most common cause of injury-related death) 49-70% Domestic violence 11-25% Falls 9-23%

Question 27

risk factors for trauma in pregnancy

Answer 27

: younger than 25 years old, low socioeconomic status, minority, drugs and alcohol, domestic violence

Question 28

Hemorrhagic shock and brain injury are the most common mechanisms of ___ in pregnant trauma patients

Answer 28

death

Question 29

Obstetric injuries

Answer 29

placental abruption, uterine rupture, preterm labor and direct fetal injury

Question 30

Blunt trauma is ___ times more common than penetrating

Answer 30

10

Question 31

Maternal and fetal mortality higher in this type of trauma

Answer 31

penetrating

Question 32

ATLS in pregnancy

Answer 32

the best initial treatment for the fetus is the provision of optimum resuscitation of the mother and early assessment of the fetus

Question 33

ATLS survey (8)

Answer 33

Maternal airway/cspine Breathing/PaCO2 /oxygen Circulation (LUD, physiologic anemia of pregnancy, hypotension and tachycardia are late signs of hemorrhage in pregnant women) Focused abdominal sonography in trauma (FAST) Brief exam for fractures Fluid resuscitation Damage control Deadly triad

Question 34

Lab tests for ATLS

Answer 34

Evaluation driven by type and severity of injury/trauma Coagulation, type/screen/cross, electrolytes, blood glucose, lactate levels, toxicology screens Kleihauer-Betke test

Question 35

Fetal-maternal hemorrhage

Answer 35

Complication in up to 50% of maternal traumas Fetal-maternal (trans-placental) hemorrhage can occur after trauma and result in maternal isoimmunization Rh negative mom and Rh positive fetus Rh incompatibility (later pregnancies)

Question 36

The deadly Triad

Answer 36

hypothermia, metabolic acidosis, and coagulopathy

Question 37

Cardiac Arrest in Pregnancy (6)

Answer 37

CPR Large bore IVs in the upper extremities Difficult airway, LUD Stop Magnesium and give Calcium Defib: remove fetal monitor No circulation within 4 min of cardiac arrest, cesarean if >20 weeks within 5 min of arrest Continue resuscitation after cesarean delivery

Question 38

Mnemonic for Causes of Maternal Collapse - BEAU-CHOPS

Answer 38

Bleeding/DIC Embolism (coronary, pulmonary, amniotic fluid) Anesthetic complications Uterine atony Cardiac disease (MI, ischemia, aortic dissection, cardiomyopathy) HTN/pre-e/eclampsia Other: ACLS algorithms Placental abruption/previa Sepsis

Question 39

Peri-Mortem Cesarean delivery

Answer 39

Delivery of fetus allows for more blood to be diverted to the mother Decompress the IVC Improve efficacy of chest compressions Initiate cesarean section 4 min into resuscitation