(Transcript is automatically generated)

Matt: [00:00:00] You know, for EMS providers, this is one of those calls that strikes a little bit of fear because they're so rare. 

Erik: I remember, um, a call on the radio from the charge nurse, get a gurney outside, she's giving birth.

Narrator: You are listening to EMS with your hosts, Erik Axene and Matt Ball. 

Erik: We got a great topic today. Matt. What are we gonna be talking about? 

Matt: OB. Well, we got a lot. We're gonna talk about just a lot. Yeah. General OB patients and kind of what happens to their bodies. And then we're gonna talk about some common OB emergencies and management and all kinds of stuff.

Yeah. Two part series. 

Erik: Yeah. On this parasitic infection. 

Matt: Most women would probably agree with you that you say that. Yeah. Yeah. If you're listening to the podcast, uh, like share, subscribe to our podcast. If you're listening for CE content, we're gonna have two parts. So you'll watch unit one and unit two, but our regular podcast, we're just gonna roll through it, probably take a break in the middle.

Erik: It's a lot of [00:01:00] information on this. Very complicated. Period in a woman's life going through pregnancy, 

Matt: a very complicated, uh, event in an EMS provider's life too, when you get called out to that OB call. Oh yeah. So this is probably one of those calls, I don't know as a physician, but mm-hmm. You know, for EMS providers, this is one of those calls that strikes a little bit of fear because they're so rare. 

Erik: You know, from medical perspective, they're really, uh, this is one of those high risk, high litigation risk type things. Um, a physician can get sued specifically like an obstetrician, actually, I dunno if you know this, they can get sued for birth problems all the way up until the kiddo is 18 years old. 

Matt: Oh, wow. 

Erik: Yeah. So if there's a, something comes up as a problem down the road, you can actually. From what I understand, yeah.

You could be legally held, legally responsible for certain medical malpractice in the birth process postpartum. You know, the stuff the OB obstetrician will take care of all the way up until the uh patient's 18 years old. Wow. [00:02:00] If those problems manifest. Right. I think that's what I understand. 

Matt: Right, that's well, and I think from an EMS perspective, it's, you know, number one, it's a rare call, you know, delivering a baby or dealing with a small, you know, neonate or something. And mom, you know, obviously both, but, um, it's a rare call. But then obvi anything to do with a baby or a pregnant mom. Like everybody, I think most firefighters are protective by nature and so.

You know, you don't want to do anything to hurt a little tiny baby or mom. Yeah. We don't wanna hurt anybody, but especially a little tiny baby and mom. Like, 

Erik: no. 

Matt: Uh, so it, it induces a lot of stress, I think, um, with first responders, 

Erik: we had a, in a patient that had ca uh, come into the ER and it created a bunch of chaos.

She, uh, actually drove her minivan up over the curbs Oh, wow. In in those, the, the handicap spots. Yeah. And drove up onto the sidewalk in front of the, 

Matt: In the ambulance bay? 

Erik: Yeah. Well, no, outside the ambulance bay.

Kind of where the people park. Yeah. And um, I remember, um, call on the [00:03:00] radio from the charge nurse, get a gurney outside.

She's given birth, and we delivered babies, twins. Actually, we delivered baby A in the parking lot in the front bench of a minivan. Wow. And then, uh, got her over after we delivered Baby A, put her over in the gurney and got her inside to the ER. 

Matt: Mm-hmm. 

Erik: Um, and well, baby twin B was breached, so we had to call in the obstetrician, but everything went well eventually.

Uh, but I remember that, like you said, this, these are, these are, um, crazy situations sometimes and they can be intense and scary. You know, being prepared for these things is the low frequency, high stress sort of an event 

Matt: I usually tell my new guys, or when I'm teaching about OB stuff is that this will either be one of the greatest calls of your career or one of the worst calls of your career.

Yeah, yeah. And I've kind of had it both ways. Uh, we, we had a OB call and we showed up, um, and, uh, the lady was, I think she was like 38 weeks, almost [00:04:00] full term and a second baby uhhuh and, uh. We get her in there, she's like, water broke contractions like a minute apart. We get her in the back. And I was never really of the mind, you know, it's kind of a joke in the fire service.

Like, get the duct tape out, duct tape their legs together. We don't want to be delivered. You know, they kind of freak out. I've never real, I never really had that mindset. Like, I mean, and we, and they talk about it a lot when you're taking those classes that, and we talked about it in our CE lecture, lecture.

People have been delivering ba, women have been delivering babies for in caves, you know, for thousands of years. And so it's a very natural thing, like as a. Provider, you most of the time don't have to do much. 

Erik: 99% of the time it's pretty straightforward. Exactly. You're literally just guiding the baby out.

Matt: Yeah. Yeah. And clean it up. Put it on mom. Like nature takes its course. Right. It's not a big deal. Um, and that's how this one went. We, we got mom on the gurney, got her out to the ambulance, and we were going to the hospital. Um, and we delivered. Going 70 miles an hour to the hospital. Oh wow. She [00:05:00] delivered a little baby boy and one of the coolest experiences I ever had.

'cause I called the hospital back. Yeah. Gave an initial report before she delivered. Yeah. Called back after she had delivered and said, Hey, just so you know, you know, we got the baby and we pulled into the ambulance bay and the whole ER staff was sitting out. Happy birthday. And they, the doctors, the nurses.

Oh, that's cool. It was a neat experience for mom. It was a neat experience for me. I thought it was cool. Yeah, neat that mom actually brought him by several times over the next three to four years around his birthday, she would bring him by the fire station. We got to know him really well, but 

Erik: Oh, that's special.

Yeah, it 

Matt: was cool. Cool. So 

Erik: yeah, we don't get that much in the er. Because, you know, we're just that transient place where we save lives and then we hand them off to people. Well, 

Matt: that's what we do too. Yeah. 

Erik: Well, I mean, like, I think it's different though. I think in the firehouse you guys are, I mean, if there was a profession thought of as a hero, it's gonna be the fire department, it's gonna be the firefighters, I think 

Matt: the military, 

Erik: well, no, I, I mean, I agree.

Gosh, yeah, there's, yeah, they, they give their lives up for our freedom. I mean, that's true. That's a different brand [00:06:00] of, of hero heroism, but. Societally. I think you're right up there. Yeah. I mean, as a firefighter, 

Matt: I don't think most firemen would think of themselves as heroic, but there's an old saying from Easy Co.

I don't, I don't consider myself a hero or something. I'm paraphrasing, but I work in the company of heroes. Yeah. I don't consider myself a hero. I work in the company of heroes. 

Erik: Well, that's how you are though. You're humble and, but you are. Well, I think most, but your profession in general is, yeah. 

Matt: I mean, it's the greatest job in the world that, I mean, so anyway, we get to do some cool things and that's, I mean, to be able to be a part of.

Yeah. Uh, bringing a light, we get to deal so much when people are at the end of their life. Yeah. It's a cool experience to be, bring somebody in Yeah. To be at the beginning of life to see that happen. Yeah. And it's much rare, rarer than the other one. Yeah. So I, I looked at it as a, a cool experience for sure.

Erik: Yeah. 

Matt: You know, everything went well. You know, obviously the baby was fine and everything. Yeah. 

Erik: That's a good story. Yes. And those are the, the highlights of a career you get to do stuff like that. Yes, 

Matt: for sure. 

Erik: [00:07:00] And that's part of what we're talking about today. Yes. Is um, those are the great times. But every now and then things go wrong.

Yes. And these patients for lots of reasons can be very difficult and a lot of you gotta really know what you're doing. 

Matt: Yeah. 

Erik: So that's what we're gonna talk about today. 

Matt: Yeah. Some physiologic changes that go through. That a woman goes through Yeah. When she becomes pregnant. Walk us through that. 

Erik: Yeah.

Well, let's, let's start with, uh, yeah. Anatomy and physiology. So some of the anatomy, so the uterus increases in size, a little pear shaped organ. Yep. Almost pair size too. Increases 20 si 20 times. Yeah, 20 times larger in pregnancy. 

Matt: It's like a big old squash. 

Erik: That's right. And the blood vessels they increase too.

Right? Right. So you get these tiny little arteries when you're not pregnant, but when you become pregnant, those arteries get really large, those uterine arteries. 

Matt: Right. 

Erik: And so you've got, you can bleed. 

Matt: Mm-hmm. 

Erik: You can bleed. Yes. And so hemorrhage becomes a big risk with that big organ, real vascular organ.

You get the baby growing inside that placenta, [00:08:00] uh, there's a lot of anatomic changes with the cervix. 

Matt: Mm-hmm. 

Erik: Uh, a lot of anatomic changes. The organs shift around. I was gonna say, yeah. 

Matt: Yep. 

Erik: And, uh, you know, and the, the shifting of organs also decreases the size of the, the lung capacity. So you don't have quite the lung capacity that you do, 

Matt: but you have more oxygen demand, 

Erik: increased oxygen demand, 20% increased oxygen demand, and you actually, even though you decrease, and we talked about this in our election, this is a good thing to remember.

It's a little counterintuitive. You decrease your lung capacity, but you're increasing your tidal volume, 

Matt: right? 

Erik: So you're actually breathing more and larger, right? But you've decreased your lung capacity, so, right, right. That, and with the increased oxygen demand, it really creates some airway issues. 

Matt: So that's one thing to think about is that if you have a pregnant patient, oxygen is huge.

Get 'em on oxygen, get 'em on FI O2. If you're doing positive pressure stuff, peep, you know, is gonna help with oxygenation. Because they're struggling, they need more help. 

Erik: That's right. In fact, and you gotta remember too, that [00:09:00] baby is there. Yes. You're treating two patients. Yes. And I read, uh, you know, any, any woman, any obstetric emergency, high flow oxygen's, just gotta be right there.

Yes. Just, just do it. Yep. Um, increased heart rate, increased respiratory rate, we kind of talked about that. Yep. Um, a lot of hormonal shifts. Yep. I think one of the interesting hormones is elastin. It decreases the, the increases, I guess, the elasticity of some of the ligaments so the pelvis can, uh, be more flexible.

And speaking of which, back to anatomy again, the pelvis is a whole lot different than a woman than in a man. Yes. You know, from the birth canal. 

Matt: Yep. Exactly. 

Erik: I think we hit up all the anatomy and physiology. Pretty amazing though. 

Matt: It is amazing what women's bodies can do when they become pregnant and just Yeah.

It's all the changes that they go through. Yeah. In order to create this life and That's right. Grow this life inside of it, it's, it's pretty, from a medical scientific standpoint, it's pretty amazing. 

Erik: And I think one thing we don't appreciate enough. Before we leave the physiology and the [00:10:00] anatomy is the, the woman's body for that fourth trimester after delivery for those, you know, six to 

Matt: mm-hmm.

Erik: 13 weeks. Mm-hmm. Is getting back to normal again. Right. So when you have that postpartum woman, you've gotta think about some of the things we're talking about today. Even though it's after baby's been delivered, we can't think to ourselves. She's back to normal. Yeah. Like a normal person. No, a postpartum woman's body's a little bit different if there are things that can occur that we have to be aware of.

And I think not just that, but psychiatrically too speaking. Oh yeah. Postpartum depression's a big deal. 

Matt: Yeah. 

Erik: And we have to be. I guess that we're not gonna be talking a lot about that today, but the, uh, the postpartum period for a woman could be very difficult. 

Matt: Well go back to our podcast, uh, with Chief Reardon from Duxbury, Massachusetts, and that touches on that topic extensively.

Erik: Huge. So, yeah. Yeah. Yes. So I think that the anatomy and physiology, those are good. Now, what we're. Focus on [00:11:00] now for the first hour are some of the, just some of the general considerations we should have with a pregnant patient if, um, they're in a certain situation. Yeah. The first one we'll talk about is trauma.

Matt: Yeah. Yeah, you want to, obviously you gotta remember, like you said earlier, they've got that little baby inside of them. Yeah. So you're not just dealing with mom, you're dealing with baby and all those physiologic changes that happened. You've got increased dilation of blood vessels and stuff. A lot more risk of bleeding.

Yep. 

Um, so MVAs mm-hmm. Different types of trauma and universal, I mean, it's, I would think it's pretty universal that, you know, pregnant patients are one of those patients that no matter what you're transporting. Yeah, you're taking to the hospital. Most, uh, every protocol I've ever worked under you are transporting whether mom is mm-hmm.

Whatever mom's condition is, doesn't really matter. You're always taking mom to the hospital because of baby. 

Erik: And then in the er. Now they're not all situations, but a lot of times I wait for the obstetrician to give me [00:12:00]the, the kind of the, uh, the the approval, I guess, or the, what is it? The stamp of approval, like, okay, this safe to go home.

Yeah. Yeah. Oftentimes, we'll even obs them, especially with trauma. Right? Sure. And you said it actually 91% of all the trauma is blunt. Mm-hmm. It's blunt trauma. That's what's gonna get 'em. 

Matt: Mm-hmm. 

Erik: Uh, hemorrhage can occur too. We'll talk about that. Um, when you have blunt trauma to the abdomen, whether it's a seatbelt sign or, or an assault mm-hmm.

Or domestic violence or MVC, the um. With that uterus as big as it is, I mean, it's, it's a high risk for that baby to have damage to the placenta or the uterus. Yep. Yep. And that's what we worry about. 

Matt: Yes. 

Erik: And so we have to be, um, looking for signs of hemorrhage. Mm-hmm. You may not see things obvious from, from your external exam.

Right. Uh, maybe the mechanism, and maybe you'll see some bruising. Yeah, but it, uh, you could have a, a [00:13:00]normal exam and, and have what's called uterine abruption. 

Matt: Mm-hmm. 

Erik: Or placental, sorry, abruption. Mm-hmm. Where the uterus and the placenta are pulling apart from the trauma. Yep. And that could be massive bleeding.

Yeah. And that, and that's obviously life threatening for baby. Yeah. And uh, uterine rupture's another one, right? Yeah. A few massive abdominal blunt trauma. You can rupture that, that uterus that's 20 times bigger than it, than it usually is. Yeah. Puts mom and baby at risk for different reasons. 

Matt: And I remember in our whole blood podcast we talked a lot about, that's one of the main uses of whole blood in the field.

That's right. Is is, uh, uh, postpartum or just pregnant patients in general? Yep. Um. Postpartum hemorrhage or trauma, something like that. Yes. So if you carry blood and you go on that pregnant patient, keep that on your radar. 

Erik: You know, a lot of the emergencies we're gonna talk about with the pregnant women are their hemorrhage.

Matt: Mm-hmm. 

Erik: It's, it's, uh, something. Yeah. Um, what do, what would you say, Matt. I mean, if, if you're gonna teach a new paramedic or [00:14:00] maybe an EMT mm-hmm. About the signs of hemorrhage, how do you approach that as a teacher? I know what I do, but what do you do to to, to teach hemorrhage. Identifying a patient that's in life threatening, you know, hypovolemic shock.

Right. You know, massive acute hemorrhage. What do you, how do you teach your, your new paramedics or EMTs? 

Matt: So obviously if you can't see any external bleeding, so even a regular MVA where somebody sustained blunt trauma, like look at their vital signs shock index is gonna be a huge shock index. Yeah. You know, obviously we know basic EMT, paramedic school, right?

Mm-hmm. The heart's a pump, right? For our fire guys out there, if you need to increase your pressure, if you're losing pressure on your discharge lines, right? What do you do? You turn your pump up faster, right? That's gonna increase your pressure. Well, if you're losing volume. The pump has to increase, uh, its rate, right?

To maintain pressure. Yeah. Right. So the first thing you're gonna see is that heart rate go up to maintain normal blood pressure. Yeah. But then once you start losing enough volume. Your pressure's not gonna [00:15:00] be able to maintain. No. And then your heart rate's gonna continue to go up until you're in decompensated shock, you have no more blood pressure and now your heart rate's low.

Yeah. So shock index is that indicator that, oh man, we are not in a good place. No. And so obviously if you have signs of external hemorrhage, that's pretty obvious to 

Erik: to tourniquet on.

Matt: Pressure, get pressure on that wound pack, the wounds, whatever. But like with postpartum or like, uh, you know, anybody has, uh, an abdominal bleed.

Erik: You can't 

Matt: fix that in animals. You can't fix that. But you can look for signs, you know, do you have a descending abdomen, a hot abdomen? Are they getting pain? We talked about that in arm. In our lecture Yeah. About certain types of pain with, in, um, uh, GI bleeds. 

Erik: Yeah, we should, yeah, we should definitely talk a little bit about that.

That's good. 

Matt: But, uh, yeah, just look for signs of, of hemorrhagic shock, you know, when your vital signs are gonna be, and constantly trending those vital signs, like, where are we going here, are we stabilizing or are we continue to go the wrong direction? Mm-hmm. You know? And then whether you're EMT or a paramedic.

What do your protocols say? Mm-hmm. You know, if you're an EMT, [00:16:00] how close are we? Are there's so many factors that you have to take into account of, do we call for a helicopter? Are we just five minutes away? Are we at a level one trauma? Are we out in the sticks transport? Yeah. So many things to take into consideration when treating those patients.

Erik: That's good. I like that. Um, I, the way that I approach, it's not better, just different 

Matt: mm-hmm. 

Erik: Is I, I, uh, try to help that new student understand what homeostasis is. Mm-hmm. So the body is always trying to balance things. Maintain, yeah. Always trying to balance. And so right now you and I are pretty balanced, right?

And right now your blood pressure's pretty normal. Heart rate's pretty normal. Everything's kind of status quo. Mm-hmm. Your, your, your autonomic nervous system's, kind of monitoring things and just keeping its tabs. Watching the gauges mm-hmm. In the cockpit of your mind, right? Yeah. And then you get in a car accident.

Man, and you're ma, you're bleeding, right? Mm-hmm. So now we're no longer in homeostasis, right? To maintain homeostasis or like a normal blood pressure to perfuse your [00:17:00] organs if you're losing blood. We compensate. And the first thing that we see with hemorrhagic shock, uh, it's actually not the first thing that happens, but it's the first thing we see on the vital signs is the increased heart rate.

Mm-hmm. And you go, we did a lightboard for this. Mm-hmm. When you go through the stages of shock, right? Where you get to ultra mental status, oh yeah. You're getting close to 40%. Yeah. Or 30 to 40% volume loss right now you're getting into, yeah. Dangerous. Danger, danger zone, 

Matt: danger, danger, 

Erik: danger, danger. Uh, hey, so what is, uh, I don't mean to put you on the spot, but what happens?

Well, I'll just say it. The first thing that happens when, if I were to. Slice your, your, um, radial artery in your arm for some reason. Right. It's good 

Matt: vaso restrict and draw those arteries back in it. 

Erik: That's right. So that'll, that'll help to slow the bleeding down. Then you're clotting. And the clotting happens.

Good. The clotting cascade that happens before the blood pressure change. Oh, excuse me, the heart rate change getting. Mm-hmm. But the first compensatory [00:18:00] thing that the body will do to maintain perfusion is to vaso constrict the capacitance vessels in your legs. Right. That's where you store most of your blood.

Yeah. And so it will actually shunt that stored blood up through the vena cava and maintain your preload. Mm-hmm. So actually for the first part of the, the hemorrhagic shock period, like before you've actually, as you're starting to lose blood mm-hmm. The vital signs won't change at all. Mm-hmm. So the body's compensating by doing exactly what you said.

Vasal constriction. Gold star. Good job. Uh, you're not just a pretty face man. Not that either. You're super smart. Yeah. No, that's, that's, a lot of people don't think about that. Mm-hmm. A lot of times, even you and I, when we treat that treat, uh, teach hemorrhagic shock, we say the first thing that changes heart rate.

Matt: Yeah. Yeah. That's the first thing you're gonna see. 

Erik: See, first thing you see. 

Matt: Yes. The first measurable change. Yeah. 

Erik: And eventually though, and what happens in the fire engine if you have to increase the RPMs on that pump? But you're losing water in your re the reserve tank. [00:19:00] Eventually it's gonna, you're gonna run out.

Right? What happens if you start running your, your pump and there's nothing there? You cavitate, cavitate your pump. Yeah. Yeah. So same thing happens in the body. If you get too hypovolemic, eventually the pump cavitates, you cannot maintain pressure. And that's, 

Matt: that's called traumatic cardiac arrest. 

Erik: That's right.

So yeah. There's really two options. You either slow the bleeding that's occurring mm-hmm. Or you fill up the tank. Right. You, you had to do something right. 

Matt: And fill it up with what it's lost. 

Erik: That's right. 

Matt: So putting, you know. Just saline into the body is not replacing what it's saline does not carry oxygen.

No. Yeah. 

You're replacing volume, but you're also blowing out that clotting. Mm-hmm. Cascade that's starting now. You're flushing all that out, which is not helping your trauma patients. That's right. Or your hemorrhage hemorrhagic shock patient. 

Erik: And not only that, we talked about this in our hemorrhage lecture when we played with the sharks, right?

Matt: Mm-hmm. 

Erik: Uh, is that you increase the perms 

Matt: you played with the sharks. I refused to be a part of that. 

Erik: See, you're a smart guy. Uh, the permeability. That increases the permeability and the, the leakiness of the vessels too with, with the fluids. And as we've seen in the literature, [00:20:00] I think they say with acute hypovolemic shock, 250 ccs of fluid may not be harmful.

Yeah. Right. That's about it. Basically. The best. Yes. Real. I mean, you may have to do that. It may be better than nothing. Right. Um, but you've got to get the patient to a place where they can fix the problem. Yes. And with a pregnant patient, the problem could be internal in with a, with a giant uterus and a baby that's at risk.

You, you gotta know when to hightail it to the obstetrician to get to the facility where they can actually fix it. So that's trauma in a nutshell. 

Matt: Yeah. 

Erik: One other thing I'll say though, with the organ shifting, if I was a pregnant woman, where are you gonna put that needle for a tension? Pneumothorax.

Potentially. You're gonna go higher. You gotta go higher. 

Matt: Yeah. Which it's always a good general practice. If you, if you're not sure aim high go a little bit higher than lower. 

Erik: Yeah. But instead of the fourth or fifth rib space in that anterior axillary line, you might want to go third or fourth. Right? Yeah, exactly.

Good. Uh, I think that's, that's important to note. I, I think, um, now trauma's a [00:21:00] good conversation because of some of the anatomic and physiologic changes can create, uh, issues. Um, another thing to think about is sepsis. Sepsis is interesting. Women who are pregnant are an increased risk of getting sepsis because their body's immunosuppressed.

Right. To protect the baby. Sure. So, so women sacrifice their own health and their own, you know, defense mechanism against getting sepsis. Yeah. By being pregnant as a huge risk, again, another harm to the mom. Mm-hmm. In this parasitic infection of pregnancy. Right? Yeah. So, uh, mom's immune systems ramp down more at risk to getting sick.

Mm-hmm. And again, um, sepsis, what do, what do we, how do we identify sepsis? Which I think is the key, 

Matt: right? Yeah. It's totally the key. Yeah, exactly. Again, it's, it's very similar to trauma. You're looking at vital signs, right? Presumed source of infection. Right. Uhhuh, every protocol reads a little bit different on how, what they consider that some protocols say just being a resident of a skilled nursing facility [00:22:00] makes you a candidate for sepsis, which makes sense, right? Yeah, yeah. Um, but yeah, increased heart rate, typically, like my protocol's, a heart rate over 90. 

Erik: Well, wait a minute, Matt. I thought you said that women are pregnant, have an increased heart rate already.

That's right. They do. So you gotta take that. It's even tougher. 

Matt: Yeah, that's right. Makes any. Pre, excuse me, we got dogs growling, water spilling.

Erik: Um, yeah, that wasn't my stomach. That's a pitbull that's right down there.

Matt: We got pit on the floor. That's my buddy. Um, but, uh, yeah, so first off, presume source of infection.

Right? Right. Like ask, and I think this is something, you know, a lot of pre-hospital providers take a little bit for granted. Yeah. That they don't look at that heart rate and that blood pressure and that respiratory rate. Yeah. Right. Look at. What happens when our body ha is fighting off an infection?

Right? Yeah. It's the same thing. Your heart rate increases, your respiratory rate increases because internally it's, that's why we get a temperature because our metabolism is sped up. Yeah. So we get an increased temperature. Right? Yeah. So you gotta look at all those factors. Yeah. And think like, do [00:23:00] we have, did mom potentially have a source of an infection here?

Yeah. And then you look at the vital signs. Yeah. You know, if heart rate's maybe over a hundred now or maybe over one 10 now, or ask mom. Hey, what's your heart rate? Normally run is a good gauge because everybody's a little bit different since you've been pregnant. What has your heart rate been running?

Yeah. You know, and so look at that. Use that in comparison. Look at the respiratory rate end. Tal like we've talked about numerous times with sepsis is a huge indicator. 

Yeah. 

Of what stage of sepsis. You know, first off visit sepsis and then what stage are they in. Um, so again, you have to take all that into context.

Does mom have a fever? Mm-hmm. You know, uh, obviously a huge sign of an infection risk, and then follow your protocols on where to take them, how to treat them. Fluids are gonna be a big deal with that. They have, excuse me, they still have blood, but they're leaky, right? Yep. So saline in that situation, at least right now, that's a good thing, is you want to give them fluids.

Yeah. You make, they need volume. They're not losing bloods, they just need some volume. 

Erik: Yeah. Yeah. They need volume. It, you lose. And, and see [00:24:00] for the woman being metabolic demand is much higher. Mm-hmm. She's, she's, she's got two bodies to take care of

Matt: and now she's sick, so it's even higher.

Erik: And now she's sick. That's right. And, um, we have a, a tendency as providers to see a of a late term pregnant mommy. Mm-hmm. And we anchor on pregnancy. 

Yeah. The belly. Oh my gosh. Right. You know that that whole Please don't have this. Yes, yes. 

And that can actually interfere with what our job is. And that is to identify disease.

We miss a lot of sepsis. Oh yeah. And now we've got a woman. 

Yeah. 

We're focused on the giant baby belly. Yep. Thinking please don't deliver now. 

Matt: Well, and of course your heart rate's one 20. She's might be having a contraction. Exactly. And 

Erik: she's in pregnant, late in pregnancy. 

Matt: Yes, of course. She's breathing fast, faster, she's hurting.

Erik: Yeah. All this is a physiologic response to the pregnancy. Yeah. So sometimes we can see these abnormal vitals and be like, oh, it's pregnancy, right? Yeah. 

Matt: She's just pregnant. 

Erik: It's pregnancy. And forget the second check a temperature. Yes. Or whatever it is. Um, but a woman who is pregnant and sick because of her being immunocompromised, now she's [00:25:00] compensating.

Now her vitals are already abnormal. Now they're worse. Right? Right. These, um, again, that pregnancy can get in the way. We can't anchor on the pregnancy. Pregnant women can, can have emergencies just like us. Mm-hmm. They got meningitis. Yep. Uh, they can have any sort of a septic, sort of a source infection.

Like you talked about. Women actually are at increased risk for, um, uh, urinary tract infections.

Matt: I was gonna, yeah. UTIs 

Erik: and remember the immune system ramped down. Mm-hmm. So they're, they're easier to get sick. So we've really gotta keep our, our beepers on for looking for sepsis in the pregnant patient population.

Yep. So, and management, you started to talk about it. Yep. Fluids are important. Yeah. If you have IV antibiotics Yep. Give them Yep. Um, if you need it, 

Matt: if you have Tylenol for pan for the fever. Yep. You know, safe to give in pregnancy? 

Erik: Uh, well, uh, that's a good question. I know there's been some literature out there.

Yeah. The association is pretty strong with the, um, uh. [00:26:00] So we don't wanna get into the, the, uh, yeah, the weed, the pharmacokinetics. Yeah. 

Matt: Kind of threw that one on you real quick without 

Erik: No, no. I mean, I think it's good that you bring it up because we have to look at the literature and be honest. Right, right, right.

Unfortunately, our society right now, you know, somebody on one side of the aisle says something, the other side of the aisle says, you're an idiot. Yeah, exactly. Yeah. So let's not think about politics at all right now. 

Matt: Right, right. 

Erik: This literature came outta Harvard. Yeah. I'm glad you brought it up actually.

'cause this is interesting, I think. But this literature came outta Harvard where they found an association, not causality, but an association with autism. And there's actually a couple things. It's not just Tylenol. Mm-hmm. There's some other stuff too with uh, uh, uh, with the folate, the, uh, methylfolate. But anyway, that's another issue.

But, um, so Tylenol is a, creates a pretty nasty poison. 

Matt: Mm-hmm. 

Erik: It's a known poison. And we have this enzyme in our [00:27:00] liver that detoxifies that. 

Matt: Mm-hmm. 

Erik: And, uh, when we with Glu glutathione mm-hmm. And, uh, but if you take too much Tylenol, um, it, you know, it, that stuff can linger and create lots of problems.

Yeah. That toxin. Yeah. Ncu, it's called, well, for some reason there's an association with Tylenol in the, in the, uh. Prenatal phase. Mm-hmm. Associating those kiddos with the autism. It was a, a lot, it was a meta-analysis, a bunch of studies that showed an association with it. So, um, if you read RFK's issued memorandum through HHS it was just a, he wasn't saying not to do it.

He was saying beware. 

Matt: Mm-hmm. 

Erik: Beware that there is an association. So he recommended, and I think it's good that obstetricians do this is just look for alternate pain medications. Mm-hmm. Look for alternate ways to treat 

Matt: mom. Well, I'm not talking about for pain. [00:28:00] I'm talking about septic. Oh, true. Mom. Patient with septic raging fever, pre-hospital environment.

Erik: Yeah. I, I, um, 

Matt: because it's kind of risk, versus benefit. 

Erik: If you and I were riding out in teaching our paramedics, we'd have a great discussion about this. Yeah. And we don't have time to get into it today. Yeah. Yeah, but you gotta weigh the risks and benefits. That's what, yeah. Yeah. Like said, 

Matt: how sick is mom? How bad's her fever? Are there other ways we can bring it down? Obviously follow your local protocols. Yeah. Yeah. 

Erik: So giving, giving any medication is not benign. Right. There are always side effects to all medications. Right. And it's, I'm grateful for this new literature that's come out. We have a, we have a better understanding as we develop, increase in technology and understand the literature and a lot of scientific discoveries.

We can make smarter decisions and be better. Yeah. Caretakers of our patients. Yeah. And so this is a consideration is, uh, protecting baby. And that's a lot of what we're talking about today is mom and baby. Yeah. Mom and baby. We, we got two lives at stake here and we gotta think about all these things. Yeah.

So good question though [00:29:00] sepsis, I actually questioned giving Tylenol, uh, long before this literature came out. Um, you know, for decades now I've been recommending as a physician to mm-hmm my patients, uh, who have a kiddo mm-hmm. That's got a fever. It's like mm-hmm. Don't be so quick to just give 'em Tylenol or Motrin or whatever.

Matt: Yeah. Let 'em fight it a little bit. 

Erik: Don't give Motrin to a pregnant woman, by the way, but Yeah. But, um, you know. It's, um, getting a fever is a good thing. Mm-hmm. When you're fighting off an infection, it increases your oxygen offload capability. Uh, it essentially increases your oxygen carrying capacity to offload more oxygen from hemoglobin to the tissues.

Mm-hmm. Our immune system uses oxygen as like a, a bullet, you know, it's like the ammunition of the soldiers that we send those neutrophils and macrophages and phagocytes and all sorts of stuff. They, uh, they use the oxygen free radicals like a bullet to kill the enemy. 

Matt: Mm-hmm. Mm-hmm. 

Erik: And part of the way we get [00:30:00] all that oxygen to the tissues is by increasing our body temperature.

It, it, it shifts the oxygen dissociation curve. Right. And so oftentimes I don't go into the detail with a mom. Let me draw a picture of the oxygen dissociation. I just tell him, I say, don't just willy-nilly give your kids Tylenol when they get a fever, right? Because if my kiddo has a fever and he's playing Legos, he's fine.

I'm worried about the fevers, like, oh, shoot, our kid's sick, but he's playing Legos. He's fine. Like that's a vital sign too, right? Yeah. Don't, don't give him Tylenol. Yeah. Now you got a really sick kiddo that won't get out of bed. He's miserable, won't cry. Won't eat, and won't sleep. Give 'em Tylenol. Yeah. Motrin, whatever.

Matt: Yeah. 

Erik: And now, again, gotta consider the risk benefit with any side effect. Yeah. But same thing's true, the pregnant woman, right? Yeah. You have to consider the fact that this fever is actually helping to fight the infection. 

Matt: Mm-hmm. 

Erik: So what's the risk benefit of giving the Tylenol? Right. Um, I don't know that I would, 

Matt: yeah.

Erik: I don't know that I would, I I think you [00:31:00] get to a certain fever, you run the risk. That's what I'm saying. 

Matt: Yeah. If you were a 103 or 104 Yeah. You know, you might be considerate, but 100.4 I know is usually a cutoff for Yeah. Sepsis, where we would give Tylenol. 

Erik: I think, uh, I think 105 is kind of the temperature that I get concerned at. 

Matt: Yeah. 

Erik: Um, but 103, 104, I mean, follow your local protocols. Right, right, right. But, um, 

Matt: and as a pre-hospital provider, you can always call your medical director. Med can call med control and say, Hey, this is what I got. You know, if you have Tylenol available, you know what, how would you like me to manage this patient?

But good conversation, good talk. 

Erik: Pain management is another issue. Um, you know, opiates are kind of standard of care. I mean, I know we just started IV Tylenol not too long ago, so there are other options. Ketamine is another one. Yep. Safe in pregnancy. A lot of research still coming out there, but follow your local protocols.

Matt: A lot of research on ketamine coming out. Yeah, 

Erik: yeah. 

Matt: All different kind of things, 

Erik: but I think standard of care for pregnant women, opiates would be a just, but just be aware of the fact you could suppress the breathing drive and [00:32:00] baby. Yes. If you're gonna be delivering, and actually mag does that too.

Mm-hmm. So be aware if you've just given mag because of an eclampsia or whatever, that baby's not gonna potentially be breathing. Right? Yeah. 

Matt: Make sure you have 'em on oxygen if you're doing any of those things. And end tidal. To watch their 

Erik: Yeah. 

Matt: Ventilatory effort. Yeah, for sure. 

Erik: Uh, the, one of the topic we had was a cardiac arrest too.

Mm-hmm. Um, a woman in cardiac arrest, I've had. Multiple, unfortunately. Um, in women, in cardiac or pregnant women mm-hmm. In cardiac arrest. And it can be, um, a scary situation. Again, two lives, right? 

Matt: Yep. Yep. 

Erik: Um, and you get a woman in a pregnant woman in cardiac arrest. That's term. You can save both. Yep. You could save both, but at some point you may have to do a hysterotomy.

You may be getting baby out, right? Um, pre hospitally, not pre hospitally. Yeah, I was gonna say. Yeah. Not pre hospitally. Sorry, I'm thinking about the er. Yeah. You know, the perimortem C-section. Yeah. [00:33:00] Um, that being said, boy then if I ever got an online. A call from my guys in the field. 

Matt: Yeah. 

Erik: Telling them what to do.

Yeah. I mean, that may, you may need to do that. 

Matt: I heard of one similar, I won't get into details about it, but it was discussed, I'll say it was discussed mm-hmm. Of maybe because of this very unique, unfortunate situation. It was discussed that the medical director was almost thinking about allowing them to do that.

'cause it might've been the only shot period. Oh yeah. To for the baby. But yeah, I, I mean, yes, it's pro. Probably not gonna be standard of care. No. Anytime soon in the pre-hospital environment. For sure. 

Erik: Now, if you've got a traumatic cardiac arrest and a pregnant woman in car accident, for example, you've got about know four minutes.

I was gonna say I think it's less than five four. Yeah. 

Matt: I think that's what we've looked at. 

Erik: That's what we taught, right? Yeah. 

Matt: Yeah. In our lecture. 

Erik: That's right. So you, if you want to do the perimortem c-section with, with the obstetrician, you get 'em to the hospital. It's gotta be within that four minutes.

Um, that's crazy. I think it was four, maybe five. But [00:34:00] it's quick.

Matt: Not a scale I really wanna perform.

Erik: No, no, no, no. And, and, and, uh, you gotta call ahead. Hopefully that OB's in house when you're going Yeah. Do not do this without permission. No, let me reiterate, follow, do not do that without all your protocols.

Matt: Do not start cutting open pregnant patients. 

Erik: No, absolutely. Yeah. Yeah. Follow your protocols. But this is a rare situation. Very rare where mom is non-viable. So we do chest compressions just to maintain some semblance of cardiac output for baby. Um, but to avoid the anoxic brain injury, we have got to get baby out fast.

Yeah. 

Matt: And if you have ultrasound, you know, you can check for the viability of the fetus. Yep. Mm-hmm. And see if you're trained, even if you're trained on doing that, you know? 

Erik: Yep. And even if baby looks like heart's beating and looking Okay, if mom's in cardiac arrest, 

Matt: oh yeah. It's not gonna last. 

Erik: You know, it's, you're gonna have the anoxic brain injury in that kiddo that's against the cause of cerebral palsy and then multiple other problems with baby we want to try to avoid.

Yep. Uh, but it's not uncommon though to go into cardiac arrest and we, um. [00:35:00] There's the, again, like we talked about, the immune system 

Matt: mm-hmm. 

Erik: The, the body's, uh, immune system being ramped down in that postpartum period. Mm-hmm. These postpartum women are at risk for a postpartum cardiomyopathy. Mm-hmm. It's not common, but, um, it, relatively speaking for pregnant women in that postpartum period with the immune system ramping back up, you can get a postpartum woman in cardiac arrest mm-hmm.

From, uh, really like an acute onset heart failure. 

Matt: Right. 

Erik: Um, I've lost a couple patients I can think of off the top of my head, um, who died from postpartum cardiomyopathy. 

Matt: Mm-hmm. 

Erik: My wife, she's, um, suffered from some of the effects of a postpartum cardiomyopathy. Fortunately, uh, she got her ejection fraction back for the most part, but it's a, it's not a benign thing for pregnancy.

It's a, it's a. A pretty big deal. Yeah. Oh yeah. Um, so for the last part, I, I have a few cases here. Oh, you know what, actually, should we do the BEAU CHOPS thing? The, let's do it. Yeah. So BEAU [00:36:00] CHOPS. Yeah. Things to consider with a woman in cardiac arrest. You know, the O in BEAU CHOPS is the Other. Which is the H's and T's mm-hmm.

That you normally would consider. Right. Anybody. Right. Right. You gotta still think about those, but with the pregnant woman, you've gotta think of bleeding. Mm-hmm. As the reason for being in cardiac arrest. And most of the time that bleeding, you can't fix 

Matt: No, no. That's gonna require surgery. Yeah. Yeah. 

Erik: Um, embolism. Mm-hmm. Um, women. Because of all the hormonal shifts are in, in increased risk of getting a pulmonary embolism. Right. Right. Which isn't part of the H's and T's typically. Right. But the other thing that's interesting is the, um, uh, the am uh, amniotic fluid embolism. Mm-hmm. Uh, you can get that amniotic fluid embolism into mom circulation, and that can be really devastating.

Really bad. Yeah. Um. There are lots of different types of embolisms. Mm-hmm. Pulmon, you get lots of fluids [00:37:00]into the um the vasculature mm-hmm. Uh, that aren't supposed to be there. Right. It can be bad. In fact, I had a, a firefighter who was injecting steroids, or sorry, testosterone. That's a freudian slip and, uh, uh, a 

Matt: wait. I mean, this is just so rare. A firefighter that uses testosterone, come on. That never happens. 

Erik: No. It, it's, it's a real medicine. Yeah. Yeah. Physicians, we prescribe this Yeah. For people with low T. Right. And there's reasons to do it and there are health benefits to it, but. If you're injecting this stuff, you know, this guy just didn't ask, he'd never been taught to aspirate first when he injected himself.

So he's just going in and just injecting. Well, he got into one of a pretty major vein and he got short of breath. He got, and, uh, anyway, it it's a real deal. Yeah. On oil. It's an oil embolism. Yeah. [00:38:00] Is what it is. You get a bunch of oil in your lungs. 

Matt: Hmm. 

Erik: And it, uh, it, it probably won't kill you, but you should, you know, that's, anyway, it could kill you actually.

But anyway, the point is women have that amniotic fluid, right? They've got hormonal shifts that can create blood clots. Mm-hmm. You don't want to throw stuff into the alveolar beds, right. When you're trying to breathe, 

Matt: that's not supposed to be there. 

Erik: Whether it's oil, uh, amniotic fluid or whatever. Yep.

Blood clots. That can, that can be life threatening. Yep. So that's the E Yep. In BEAU CHOPS. Um, anesthesia. Anesthesia. Yep. This is more postpartum stuff. Right. But that's something to think about. Here's the big one. We're actually gonna talk about this in the next hour, so we won't go into detail. Now. Is uterine atony?

Um, you know that that uterus doesn't constrict back up. The vaginal bleeding can continue and become life threatening that postpartum hemorrhage. Cardiac disease. We kind of talked about that. That's the C in chops. 

Matt: Mm-hmm. 

Erik: Uh, H is hypertension. Actually, we're gonna talk about that too [00:39:00] in the next hour.

Yep. We're gonna talk about preeclampsia, eclampsia, pres. Yeah. Uh, with other h's and t's like we talked about placental abruption and rupture. We kind of talked about that here, but we're gonna go into more detail in the next hour again. Right. And then, uh, sepsis. The S we talked about that. Yeah. We didn't talk about that anymore.

Matt: Yeah. 

Erik: Alright, case number one. Okay, so a 31-year-old pregnant female. Her second pregnancy right now, the first one, she had a miscarriage. Okay. Call 911 for severe shortness of breath. What are you thinking? 

Matt: I'm thinking I got a 31-year-old female that's 31 weeks pregnant with shortness of breath. 

Erik: Well, I know what you're gonna do right away. You're gonna put 'em on oxygen. 

Matt: Yeah, yeah, for sure. Yeah. I'm probably gonna try to get a room air set just to kind of see mm-hmm. What, what are they at? But yeah, I'm certainly, uh, that's on the radar, not putting the blinders on, because shortness of breath could have a lot of reasons. She could be bleeding, she could be septic, she could be a lot of different things.

It could just be decreased lung capacity and high increased [00:40:00] oxygen demand. 

Erik: So, so I'll get her on the vitals. I'll get you your vitals here. Mm-hmm. So while I'm getting a vial, you're gonna get history. What are you gonna ask your pregnant patient? 

Matt: Well, we already got her pregnancy history. Yep. Right. Uh, any recent history of trauma?

How, when did this happen? When did, when did she become short of breath? 

Erik: Nope. Uh, no. No history of, um, any trauma. Um, I've been getting worse. My shortness of breath has been getting worse. Um, over the last couple days, 

Matt: does she have any history of asthma? Any, any respiratory, no medical problem issues?

Nothing at all. Nothing allergic to any meds? Nothing. 

Erik: Nope. No allergic to anything. So this has just been, I'm only on my prenatal vitamins. I'm 34 weeks pregnant. 

Matt: 34 weeks pregnant. And this is the first time this has happened during the pregnancy? 

Erik: Yeah. Um, you know, I've been. I'm having a lot of chills and I'm having trouble sleeping at night.

Um, chills A lot of back aches and, Hmm. Okay, so I'm, I'm, uh, it's been the last couple days. 

Matt: Okay. So, 

Erik: okay. I got your vitals now. You ready? Yes. Heart rate 125. Okay. What do you think of that? Yeah. 

Matt: What's her baseline? That's high. 

Erik: Exactly. It's a little high, but you know. [00:41:00] Yeah. 

Matt: Nothing crazy, but it's high.

Anxiety's probably up too, so, 

Erik: yeah. That's the other thing too, is like, how do you differentiate tachycardia 

Matt: from just regular old, she's nervous. 

Erik: She kinda was just in a gunfight, you know? Exactly. It's like, of course he's gonna be tachycardic. Yeah, yeah. 

Matt: Just finished a workout, 

Erik: but she got shot too, so, you know.

Matt: Yeah, yeah, yeah, yeah. Could be, gotta look at the whole picture. 

Erik: You said it earlier actually, and I think this is probably one of the most important things to remember as we talk about these cases, is to reassess. 

Matt: Oh yeah. 

Erik: To get a trajectory. Lots of vitals, lots of points of time. Yes. Heart rate's going up, which Yeah.

Matt: What do we do? Yeah, exactly. 

Erik: Patient's altered now, 

Matt: right? Blood pressure's going down, heart rate's going up. Ooh. Respiratory rate's increasing. Yeah. 

Erik: So this is the first set of vitals you got is 125 tachycardic. Yep. Uh, blood pressure's 95 over 60. Okay. What do you of that? 

Matt: Little on the low side, but little.

It's kind like not crazy. 

Erik: No. And yeah. And in pregnancy, remember

Matt: 125 divided by 95? What's that number? I don't know. Uh, you the math whiz.

Erik: Yeah. That's, that's, that's shock. That's positive Shock index. Yeah. Yeah. But, um. You know, a [00:42:00]perfusing blood pressure in a, in a, you know, a relatively healthy person Right.

Is probably around 70, 75. Right. Some might say minimum of 65. Mm-hmm. But at least between 65 and 75 map. Mm-hmm. Mean arterial pressure. I was gonna say maps. Yeah. Not systolic blood pressure. Yeah. 

If I take 95 over 60, it's gonna be in that range. Yeah. It's gonna be more than 60. Yeah. Yeah. And so, so we actually may have a normal blood pressure, but tachycardia, remember, like we talked about, the first thing that changes, right, is the heart rate.

Yep. I can't think of a reason why we'd be bleeding here, but she is pregnant. We've better ask those questions. 30. What's her temp? Uh, I haven't got the temp yet, but SATs are 90%. Okay. So that's. Concern. I'm sorry, I read around 98%. 

Matt: Oh, 98%. Yeah. Okay. Okay. She's got back pain. So 98 breath sounds, uh, lungs are clear.

Okay. Any history of infection, UTI? Anything? 

Erik: Um, I've been having pain urinating. Okay. Yeah. And my back hurts though. Does she feel warm to the touch? [00:43:00] She does. Okay. 102. 

Matt: Okay, there we go. 

Erik: End tidal's 23. 

Matt: Okay. Yep. She's septic. Yeah. Until proven otherwise. 

Erik: Until proven otherwise. Yes. And then I think because she's pregnant, you gotta be careful, right?

So as mom's compensating for her sepsis, we gotta keep our eye on the other life there too. So I think high flow oxygen's, key 

Matt: oxygen, IVs, fluids aren't gonna hurt her. Yep. Her blood pressure's not, you know, it's not super low, but it's not high either, so, right. But I'm also gonna watch the breathing, make sure fluids don't add additional breathing issues.

Um, but yeah. Sounds, sounds like a septic patient to me. Yep. If that tid stays over my vital signs that I'm checking every five minutes, if it stays that low, um. But IV fluids, oxygen, good. Probably not gonna give the Tylenol right now. 

Erik: What fluid would you give if you had Or, and ringers? Yeah. Yeah. That'd better for sepsis.

Yeah. A lot of agencies don't have that option. Most go with just NS. That's better than nothing. Yeah. Um, [00:44:00]antibiotics if you have it. Yep. So you give those IV fluids and she, her blood pressure just keeps going down. Heart rate's going up. Um, what would you go through next? At what point do we decide to do pressors?

Matt: Yeah, Levophed. I'm going with some Levophed to get her. I'm not worried about the heart rate's. Fine. Yeah. Trying to get that vasoconstriction to keep that pressure up. Yeah. Yeah. Watching that map on my monitor. Yeah. 

Erik: Yeah. It'd be interesting to see studies on pressors. I didn't research this, but I'm gonna give pressors to a woman, uh, pregnant woman regardless.

Well, I mean, if you lose mom blood pressure 

Matt: up. Yeah. If you lose mom, and I mean, if her blood pressure's low, what's, how's baby profusing? We have no way of monitoring. 

Erik: I just wonder with, with, um, with, uh, I, I didn't, again, I didn't research this, I'm just, just thinking out loud right now, but the, which pressor would I choose if I had choices in the ER?

We got all the pressors, right? Mm-hmm. Right, right. So I'm thinking, which one would I do if you only have one? Give it. 

Matt: Yeah. 

Erik: Yeah. I, I can't think of a reason why one would be contraindicated, but there may be a benefit of one over the other. Whether it's epi versus norepi versus dopamine, [00:45:00] there may. Yeah, you're just going 

Matt: for the, like I say, the heart rate's, the heart's doing its job, so it doesn't need any chronotropic help, it just needs some vasoconstriction, is what I'm looking for.

To hopefully get the pressure up. 

Erik: And I think one of the most important things we do with anything in the pre-hospital environment, you've done it as identification 

Matt: and take 'em to the right facility 

Erik: and take the right facility 

Matt: and do what you can do. 'cause you have a viable fetus here. 

Erik: Yeah. 

Matt: You know, the 31 week, that's a viable fetus.

So make sure you go to a facility with that has a NICU 'cause Yep. It's coming a little bit early, might have some issues. And you wanna have the people there that are experts in this area because we're just shotgun medicine and figuring it out. I want an expert up here. 

Erik: Yep, that's right. And you follow your, you know, in certain, certain hospitals will send anybody over 20 weeks straight up.

Yes. Yeah. And, uh, unless there's something life threatening going on. Right. So Right. But, uh, follow your local protocols on this. And then identification again is key. We miss a lot of these and in pregnant women, we focus sometimes on the pregnancy. Oh crap. The pregnancy's not the issue here. May have caused it indirectly, but Right.

[00:46:00] It's the sepsis, right? Yes, yes. So for sure. Alright, you ready for case number two? I guess so. Okay. It's coming. All right. So you're dispatched to a 28-year-old. Okay. Uh, first time pregnant. 

Matt: Okay. 

Erik: Primigravid. Okay. For seizures. 

Matt: Okay, 

Erik: so you're currently, and actually let's, we're going to switch gears a little bit here 'cause we didn't talk about eclampsia, preeclampsia, switch gears like, 'cause these are a little outta order from the way we did it in our lecture.

But 

Matt: hey, you never know what you're gonna get called out to, so you gotta be re ready. 

Erik: So let's say you treated with the mag. According to protocol, and we'll talk about that in a second here. In the second. Yeah. Yeah, yeah, yeah, yeah. And, uh, your patient's, uh, heart rate's 140. Mm-hmm. Um, blood pressure's 150 over 90, which is high from the mm-hmm.

The eclampsia. Um, and, uh, respiratory's 40 SATs are 82. This is after the mag. Is after the mag? Yeah. 

Matt: Well, I would've already had her on oxygen. Yeah, you're on. She's not on. Oh, and it's 82 lung. Let's look. 

Erik: No, no, no. [00:47:00] This okay. This is, this is before. So I would definitely put her on high flow. Yeah, a hundred percent.

Yeah, absolutely. And a physical exam. Everything, uh, is not looking good. She's pink, frothy, sputum, altered, crackles in all lung fields. Um, and she goes pulseless on you. Okay, 

Matt: well, 

Erik: why did she go pulses? What do you, what do you, looks like we're starting chest compressions. Yeah. Yeah. This is a, you know, these, these, the preeclampsia we're gonna talk about later in eclampsia, you go into seizures.

Mm-hmm. It, it, it is not a benign thing. No. This is a life-threatening condition. You gotta get baby out. 

Matt: Yes. 

Erik: And, uh, so this, this mommy, actually, this is a case, a true case that we covered in our lecture. Mm-hmm. And mom and baby survived. Yeah. Uh, but did go into cardiac arrest and mag actually too. You're, it can, it can create some issues we mentioned earlier with breathing for baby.

Mm-hmm. But it's, it's, it is an association. It is a mag. Uh, associated cardiac arrest. Mm-hmm. E clamp in eclampsia. So [00:48:00] anyway, interesting case. Yeah. Yeah. Interesting case to think about and we'll talk more about that in the second. 

Matt: Yeah. Mag mag versus benzos, that's a big conversation with eclampsia. 

Erik: Oh yeah.

And ketamine too, right? Yeah. And ketamine. Yeah. Yeah, yeah, yeah. Yeah. Um, alright, last, last, uh, last case here and then we will wrap it up. Take a little break. Take a break. Before unit three break. Yeah. Alright. Matt, a 27-year-old female. Mm-hmm. Fifth pregnancy. Oh gosh. Uh, this will be her fourth child. Okay.

Um, one. One miscarriage. 

Matt: Okay. 

Erik: She's a driver in an MVC. Mm. 38 weeks pregnant. 

Matt: Mm. 

Erik: Uh, patient's complaining of abdominal pain and left shoulder pain. 

Matt: Mm. Okay. 

Erik: What are the things that we learned that we should be thinking about in a trauma patient? 

Matt: Well, I am, uh, extremely worried about hemorrhage because number one, she's pregnant.

We've talked about that. Number two, she's complaining of left shoulder pain, so I'm a little bit worried about her spleen. Yeah. With preferred pain. So I'm really worried about bleeding. Uh huh Uh, I'm also worried about baby. 'cause if this is number five, she's very prone for that boy to come out quick.[00:49:00]

Erik: Baby's ready. 

Matt: So we got a lot of things that we're looking at here. So is, you know, is she removed from the car? Does she require extrication? We get her out, we get her on the cot, hopefully. 

Erik: Yeah, she's out. You've, she, you're in the back of the ambulance right now. She's got no medical problems. Just her pregnancy, gimme vitals, takes prenatal vitamins, no allergies.

The airbag did deploy. Uh, the patient was restrained. She did not lose consciousness. Um, there were no other occupants in the vehicle except for the baby. Mm-hmm. In utero. Yeah. Um, and vitals. Uh, heart rate 110. Blood pressure 95 over 65. Uh, respiratory rate 25, O2 sat, 99% no fever. 98.6. Okay. End tidal's 30.

We actually talked about the end tidal too remember. End tidal targets are a little lower mm-hmm. In the, the pregnant than the pregnant population anyway. 

Matt: Well, and she's also breathing a little bit faster, but that could be due to anxiety 'cause you just had a car wreck, so, 

Erik: absolutely. 

Matt: I'm not freaking out over any of those numbers right now, 

Erik: but you're gonna watch and you're gonna reassess Oh, a hundred percent like we talked about.

Yeah. Yes. 

Matt: And she's [00:50:00] having abdominal pain. 

Erik: Abdominal pain, where's the pain? So you wanna do physical exam? Yes. So you see a seatbelt sign. Mm-hmm. You got a, uh, bruising across the lower abdomen below her grave mm-hmm. Uterus. Mm-hmm. And then she's got a seatbelt sign across the, uh, the left chest. Mm-hmm.

From the seatbelt, obviously. 

Matt: Okay. So is the left shoulder plane like clavicle pain or she No, just like, 

Erik: just, just left. Just hurts over there. Okay. This patient that I remember, uh, that I had, um, it ended up. Not being anything, but they ended up. Keeping her in the hospital and they delivered, but just to watch.

Yeah. Uh, but in this particular case, um, just like you said, we're gonna continue to monitor them, right? Yes. So you do your physical exam, you've identified a potential emergency mm-hmm. With that, the bruising mm-hmm. When you get that bruising patient pregnant or not. Oh yeah. That bruising pattern is a big significant danger.

Danger. Red flag. Yeah. The energy it takes to make that kind of a seatbelt sign. Yeah. Can rip spleens and livers and, oh, aortas. Yeah. [00:51:00] It's dangerous. So in a pregnant patient with a giant placent uterus place. Yes, exactly. We got to think about placental abruption. Yeah. We gotta think about placental rupture.

Yeah. Um, when you push on, you mentioned this earlier, we should talk about it. Uh, when you push on a pa a patient's belly mm-hmm. There are different brands of tenderness. 

Matt: Right, right. Different brands. 

Erik: When you, when you explain, I have pain, that's pain, that's subjective. Yeah. But when you touch a belly, it's actually quantitative.

Yeah. Um, and we, we, uh, in the ER would ask you, if you told me that her belly was tender by phone, maybe I would ask you, um, is she guarding? Yeah. And, and I would ask you too, is there a rebound? Mm-hmm. Those are the signs of what we call peritonitis. Mm-hmm. You get blood in the back of your abdominal cavities, it is called the retroperitoneum.

Yep. It is incredibly painful. Yes. You don't want anyone to bump the bed. I mean, you are in so much pain. Yes. That is a different brand of [00:52:00] tenderness and if a woman's bleeding internally. Oh gosh. In this context with a 38 week gestation Yeah, you're, you're in big trouble. So just like what you did, the patient's complaining of lightness ahead.

Lightheadedness now. 

Matt: Okay. 

Erik: And so you wanna repeat the vitals? 

Matt: Oh yeah. 

Erik: So what do you expect the, 

Matt: well, I actually want to be going to the hospital. 

Erik: Yeah, we're on our way. Yeah. Lights and sirens. Yes. And the heart rate's up to 130 now. Okay. Blood pressure's down to 85 over 60. Respiratory rate's up to 35.

O2 SATs have maintained no fever and the end tidal is, is coming down. And that makes sense, right? We're breathing faster. Um, this is not moving in the right direction. 

Matt: Yeah, I still want her, I definitely want her on oxygen. I don't really care what her SATs are 'cause it's not a realtime vital sign. So I definitely want her on uhhuh oxygen, uh, IVs and I'm maybe thinking TXA on that.

Erik: Yeah, I think so too. I think TXA gotta think about that unless I had blood. Yeah. Unless you have blood, absolutely. 'cause you, you can't fix it, but you can slow it down. Yeah. Um, actually. [00:53:00] I, I think that's it for the case, but let me ask you a question if you know this. 

Matt: Okay. 

Erik: Uh, but just to close the case out, you're right.

Destination's huge, right? Yes. This 38 weeker. Yeah. Uh, given TXA or blood might be the only thing that we can do. If you're a BLS provider, you can, you know, reverse trendelenburg, get the legs up, right? Uh, lay them on their left side. Yep. Right? Don't occlude the vena cava. Right. Um, but, um, TXA, let's talk about TXA as we close this thing out.

Mm-hmm. Do you know what TXA is? This is really trans acid. It's, yes, that's TXA nice work. 

Matt: Well, but it, but it, it, it, it, uh, let me, let me go back to my educ education. So the body's natural clotting factors, right? It slows down the breakup of the clots. Right? It stabilizes the clot. 

Erik: It stabilizes the clot. That's exactly Good. Good. Yeah. Um, in fact, what I learned, I didn't know this before, so I'm sharing something I just learned too. That's really interesting. So in our body, lysine is an amino acid. That's an essential [00:54:00] amino acid.

Matt: That's what breaks down the clots.

Erik: We, we can't make it. No, no, it doesn't.

Actually, what lysine the amino acid does is it inhibits plasminogen and, uh, fibrin or whatever. That's right, that's right. Uh, to break the clot down, that's 

what Yeah. It, yeah. That's what lysine does. Yes, yes, yes. It's 

amino acid. And so TXA is, it's an analog of lysine. Okay. It's basically a pharmaceutically derived amino acid.

Yeah. 

Matt: Okay. 

Erik: That's what it is. Interesting. It's interesting. I didn't know that. Um, but that's essentially what TXA is. Mm-hmm. It binds to that, uh, receptor to, uh, it basically inhibits the breakdown of the clot Right. By getting in the way. And that's what lysine does. The, the, uh, amino acid essentially. And so TXA comes in, stabilizes the clot so it doesn't bring down Yeah, I thought that was kind of interesting. Yeah, it was a, you know, just goes to show you, you know, we're really smart, you know, medical stuff, technology, right? Yeah. But we're just trying to mimic the body. Oh yeah. The body is [00:55:00] so nice. 

Matt: The body's natural way you're doing things.

That's exactly right. Speed up the heart rate clamp the vessels. Yep. 

Erik: I, I, I learned a lot in preparing for all this stuff. Yeah. This is really amazing. And the whole process of pregnancy is amazing, uh, to discuss it with you on this podcast today. This is amazing. It is. And, and the topic is amazing too.

It's good topic. It's not, not just you, it's uh, yeah, 

Matt: no, it's a good topic. 'cause like I said, this creates a lot of anxiety for Yeah. In hospital and pre-hospital providers. So it's important that we're constantly studying up on these things and putting this back on our brain, because you never know when you're gonna get that call to handle one of these situations.

Erik: That's right. And in this hour we didn't even get to the birth process. No, we didn't get that. I mean, we're just talking about the pregnant body and the physiologic and anatomic changes, which is phenomenal and amazing, like you said. But yes. And then we talked about some of the, the, the, the implications with trauma, with sepsis, with pain control.

Mm-hmm. Ran through a few cases. We really haven't even gone to the actual process of birthing yet. Yeah. Of delivery. So we'll do that in the next hour. 

Matt: [00:56:00] Yeah. We'll take a break and we'll do that in the next half.

Narrator: Thank you for listening to EMS, the Erik and Matt Show.