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Medical Emergencies
Raymond O. Powrie, MD
Professor, Medicine and Obstetrics & Gynecology
Alpert School of Medicine at Brown University
Care New England Chief Medical Quality Officer
The Big Five
The Big Four
• Hypoxia
• Hypotension
• Change in
Neurologic
Status
• Arrhythmias
Hypotension
HYPOTENSION
Sinus Abnormal
Rhythm Rhythm
FLUID BOLUSES
Hypoxia Signs of Medication
Hypoxia Other Call
with Infection Bleeding Effects
Bleeding
Get a CXR a Code
Amniotic Pneumo-
Sepsis Tamponade thorax
Hemorrhage Fluid
Embolism
protocol Narrow Pulse Assymetric
Pressure Breath sounds
Change in Neuro Status
Change in
mental status
Unstable
Stable Pulseless
with Pulse
Adenosine iv Amiodarone
PUSH 6 MG 150 mg IV
Intrapartum
Respiratory
Emergencies
Dyspnea and Hypoxia
Acute management
• Provide adequate oxygenation and check ABG
• Make sure you are ready for intubation
• Get a Chest X-ray
• Consider pulmonary edema secondary to
tocolytics, infection, or pre-eclampsia and look
carefully for the latter two
• Examine patient for evidence of cardiac disease
• Consider diagnostic imaging for diagnosis of
pulmonary embolism
• Consider aspiration if recent meal or sedation
• Look for antecedent history to suggest
pneumonia, asthma
• Review medications and recent transfusions
• Obtain a drug screen
Establish adequate
oxygen delivery
• Oxygen delivery
– Nasal prongs
• 1 lpm = 24% FiO2 with each additional lpm
increasing it by 4%
• Maximum flow rate 5 LPM (40% FiO2)
– Venturi mask
• FiO2 24%, 28%, 31%, 35%, 40%, 50%.
– Non re-breather mask
• Up to 80-90% FiO2
– Non-invasive positive pressure ventilation
• CPAP and BiPAP
Acute management
• Provide adequate oxygenation and check ABG
• Make sure you are ready for intubation
• Get a Chest X-ray
• Consider pulmonary edema secondary to
tocolytics, infection, or pre-eclampsia and look
carefully for the latter two
• Examine patient for evidence of cardiac disease
• Consider diagnostic imaging for diagnosis of
pulmonary embolism
• Consider aspiration if recent meal or sedation
• Look for antecedent history to suggest
pneumonia, asthma
• Review medications and recent transfusions
• Obtain a drug screen
Endotracheal Intubation
fluid
overload cardiac
22% 26%
Pulmonary Edema
60 Total cardiac
Congenital
50
Pulmonary
hypertension
40
Ischaemic
30 Rheumatic
20
10
0
1954 1960 1966 1972 1978 1984 1990 1996 2002
• To diagnose it you have to think of it
• Be suspicious of dyspnea with cough
or orthopnea, especially if a woman
is not doing things she normally
might because of them
• Measure pulse and respiratory rate
and get an EKG
Be willing to get some normal
echocardiograms
Order a serum troponin
• Start with
– ceftriaxone 2 g IV once daily with erythromycin 500
mg IV every six hours
• azithromycin 500 mg IV daily may be used as an alternative to
erythromycin if erythromycin is poorly tolerated
• Once patient is afebrile and stable switch to
– erythromycin 250-500 mg PO QID with cefuroxime
axetil 500 mg PO BID for a total antibiotic course of
14 days
• if patient has been treated with azithromycin instead of
erythromycin, this antibiotic can be administered for a 5 day
course only
Acute management
• Provide adequate oxygenation and check ABG
• Make sure you are ready for intubation
• Get a Chest X-ray
• Consider pulmonary edema secondary to
tocolytics, infection, or pre-eclampsia and look
carefully for the latter two
• Examine patient for evidence of cardiac disease
• Consider diagnostic imaging for diagnosis of
pulmonary embolism
• Consider aspiration if recent meal or sedation
• Look for antecedent history to suggest
pneumonia, asthma
• Review medications and recent transfusions
• Obtain a drug screen