Managing Medical and Obstetric Emergencies and Trauma. Группа авторов
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Название: Managing Medical and Obstetric Emergencies and Trauma
Автор: Группа авторов
Издательство: John Wiley & Sons Limited
Жанр: Медицина
isbn: 9781119645603
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10 Other drugs that can be given:Hydrocortisone 200 mg intravenously.Chlorphenamine 10 mg intravenously.
11 If there is persistent bronchospasm despite an adequate dose of adrenaline to stabilise the blood pressure, consider bronchodilators, e.g.:Salbutamol 5 mg via oxygen‐driven nebuliser, or 250 micrograms diluted intravenous slow bolus.Magnesium sulphate 2 g intravenously over 20 minutes.Aminophylline 5 mg/kg intravenously over 20 minutes if not already taking theophylline.
12 Check fetal heart and continuously monitor by cardiotocography. If in cardiac arrest, perform perimortem section. If not in cardiac arrest, consider timing and method of delivery once maternal status is stabilised.
13 Take a 5–10 ml clotted blood sample for serum tryptase as soon as the patient is stable. Plan for repeat sample at 1–2 hours and >24 hours.
14 Plan to insert arterial and central venous pressure lines and transfer the patient to a critical care area.
15 Prevent readministration of possible trigger agents (allergy band, update notes and drug chart, liaise with anaphylaxis lead regarding ongoing investigation and referral (www.bsaci.org) to identify causative agent). Inform the patient, obstetric consultant and GP and report to the Medicines and Healthcare products Regulatory Agency (MHRA, www.mhra.gov.uk/yellowcard).
6.6 Summary
Hypovolaemia is the most common cause of shock in obstetric and trauma patients
A high index of suspicion is essential during assessment to ensure early recognition and prompt resuscitation
In haemorrhagic shock, management requires replacement of lost volume and oxygen carrying capacity, prevention of coagulopathy and immediate control of haemorrhage either by direct compression, splintage or, where necessary, by urgent surgery
Other forms of shock require equal vigilance and early resuscitative measures to restore circulation and tissue perfusion
6.7 Further reading
1 Kemp HI, Cook TM, Harper NJN. UK anaesthetists’ perspectives and experiences of severe perioperative anaphylaxis. Br J Anaesth 2017; 119: 132–9. (Gives details of the Sixth National Audit Project (NAP6).)
2 NAP (National Audit Projects). https://www.nationalauditprojects.org.uk/NAP6home (last accessed January 2022). (Gives resources for the management, investigation and communication required following life‐threatening anaphylaxis.)
CHAPTER 7 Sepsis
Algorithm 7.1 The Sepsis Six
Source: Nutbeam T, Daniels R on behalf of the UK Sepsis Trust. © 2019 UK Sepsis Trust
Learning outcomes
After reading this chapter, you will be able to:
Recognise the septic woman
Commence emergency management
Arrange appropriate investigations and referral
7.1 Introduction and definition
Worldwide sepsis causes 1 in 10 maternal deaths and is the third commonest cause of direct maternal death (Turner, 2019). To reduce avoidable deaths, women with sepsis need to be recognised so that treatment can be initiated early.
In 2017 the World Health Organization (WHO) defined maternal sepsis as a life‐threatening condition defined as organ dysfunction resulting from infection during pregnancy, childbirth, post‐abortion, or postpartum period (Figure 7.1).
Figure 7.1 Approach for implementation of the new WHO definition of maternal sepsis
Source: Statement on maternal sepsis, WHO. © 2017 WHO
The Third International Consensus (2016) definition of sepsis (SEPSIS‐3) for the whole adult population is that sepsis is a life‐threatening organ dysfunction due to a dysregulated host response to infection.
Septic shock is a life‐threatening condition that is characterised by low blood pressure despite adequate fluid replacement, and organ dysfunction or failure. The Third International Consensus definition (SEPSIS‐3) of septic shock is persisting hypotension requiring vasopressors to maintain mean arterial pressure of 65 mmHg or more and having a serum lactate of greater than 2 mmol/l despite adequate volume resuscitation.
These definitions depend on the identification of organ dysfunction in the presence of infection. In the general adult population, a brief bedside tool such as the quick SOFA (sequential organ failure assessment) or qSOFA score is used as described in SEPSIS‐3. The qSOFA score evaluates the presence of three clinical criteria: systolic blood pressure ≤100 mmHg, respiratory rate ≥22 per minute and altered mental status. If two or more of these criteria are present the patient is at increased risk of a poor sepsis‐related outcome and urgent action is prompted. An obstetric modified qSOFA has been produced by the Society of Obstetric Medicine Australia and New Zealand and modifies the systolic blood pressure to ≤90 mmHg, respiratory rate ≥25 per minute and altered mental state. Table 7.1 summarises the organ damage by system caused by sepsis.
Table 7.1 Organ damage caused by sepsis
Source: Plant LA, Pacheco LD, Louis JM. Sepsis during pregnancy and the puerperium. SMFM Consult Series No. 47: Am J Obstet Gynecol 2019; 220(4): B2–B10. © 2019 Elsevier
| Organ system | Clinical features |
|---|---|
| Central nervous system | Altered mental status |
| Cardiovascular system dysfunction | Hypotension from vasodilatation and third spacing; myocardial |
| Pulmonary system | Acute respiratory distress syndrome (ARDS) |
|
Gastrointestinal
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