Laboring Under Pressure Episode 4: Obstetric Emergency in South Africa with Dr. Meghan Hurley

Contributors: Meghan Hurley MD, Travis Barlock MD, Jeffrey Olson MS3

Show Pearls

Map of South Africa Referenced

South Africa Geography Lesson

• There is a big disparity between Cape Town and its neighbor Khayelitsha.

• Cape Town is the legislative capital and economic hub of South Africa, known for its infrastructure, tourist attractions, and developed urban areas.

• Khayelitsha Township is a large informal settlement on the outskirts of Cape Town, with limited infrastructure and services compared to the city center. Many residents live in informal housing.

• This disparity is the lasting effect of how land was divided up and populations were moved around during Apartheid.

• Apartheid was a policy of segregation that lasted from 1948 to 1994.

How does medical education work in South Africa?

• Medical education in South Africa typically follows a 6-year undergraduate program directly after high school

• Registrars our the equivalent of Resident in America. They are graduated doctors who work in hospitals under the supervision of senior doctors as they progress toward becoming specialists.

Pearls from the case and the discussion afterward

• Whole blood from a draw can be used instead of urine on a POC pregnancy test. Wait a little bit longer before making a determination because blood is more viscous. Although the casettes are not approved for whole blood several studies have shown this to be efficacious.

• Free fluid in the abdomen and a pregnancy of unknown location is a rupture ectopic until proven otherwise.

• Appendicitis can present on the left side. Most commonly from an extra appendix, but can also result from situs inversus or mid-gut malrotation. This presentation can also be the result of an atypically large appendix.

• Fever is common in appendicitis (~40%) and becomes less common with older patients.

• Don’t be falsely reassured by a normal hemoglobin in acute bleeding because patients bleed whole blood and the hemoglobin concentration is not affected. These patients should be resuscitated with whole blood.

• Give rhesus factor negative blood to female patients of childbearing age to prevent them from developing antibodies to the rhesus factor which can lead to Rh disease in future pregnancies.

• Rhogam can be given in cases of ruptured ectopic pregnancies to lower the risk of alloimmunization.

• Blood transfusions carry the risk of lung and heart injury from the extra volume. The treatment for this condition is to diurese the patient.

Other topics discussed include the complications of working in a South African township hospital at night, the epidemiology of burns, and the importance of global health.

References

1. Akbulut S, Ulku A, Senol A, Tas M, Yagmur Y. Left-sided appendicitis: review of 95 published cases and a case report. World J Gastroenterol. 2010 Nov 28;16(44):5598-602. doi: 10.3748/wjg.v16.i44.5598. PMID: 21105193; PMCID: PMC2992678.

2. Barash, J. H., Buchanan, E. M., & Hillson, C. (2014). Diagnosis and management of ectopic pregnancy. American family physician, 90(1), 34–40.

3. Fromm C, Likourezos A, Haines L, Khan AN, Williams J, Berezow J. Substituting whole blood for urine in a bedside pregnancy test. J Emerg Med. 2012 Sep;43(3):478-82. doi: 10.1016/j.jemermed.2011.05.028. Epub 2011 Aug 27. PMID: 21875776.

4. Moris, D., Paulson, E. K., & Pappas, T. N. (2021). Diagnosis and Management of Acute Appendicitis in Adults: A Review. JAMA, 326(22), 2299–2311. https://doi.org/10.1001/jama.2021.20502

5. Sowder AM, Yarbrough ML, Nerenz RD, Mitsios JV, Mortensen R, Gronowski AM, Grenache DG. Analytical performance evaluation of the i-STAT Total β-human chorionic gonadotropin immunoassay. Clin Chim Acta. 2015 Jun 15;446:165-70. doi: 10.1016/j.cca.2015.04.025. Epub 2015 Apr 25. PMID: 25916696.

Produced by Jeffrey Olson, MS3 | Edited by Jeffrey Olson and Jorge Chalit, OMSIII

Contributor: Taylor Lynch, MD

Educational Pearls:

What is neutropenic fever?

• Specific type of fever that is seen in cancer patients and other patients with impaired immune systems

• These patients are highly susceptible to infection

• Typically occurs 7-10 days after the last chemotherapy dose, this is when the immune system is the weakest

• It is useful to know the specific type of malignancy. For example, heme malignancies (ALL, AML, etc.) have more intense chemo and are at higher risk of neutropenic fever

• To qualify as a neutropenic fever, a patient must have one recorded temperature greater than 38.3 degrees C or be over 38 degrees C for one hour.

• The severity of the neutropenic fever is established by the absolute neutrophil count. Abs neutrophil count under 1500 is mild, less than 1000 is moderate, less than 500 is severe.

• Also look at monocytes (cell that becomes a macrophage). Less than 200 is very concerning

What is the workup and treatment?

• Obtain a panculture (culture blood from both arms and all indwelling lines), obtain urine culture, and get a chest x-ray.

• Do not preform a rectal exam or obtain a rectal core temperature. This could cause bacteremia.

• Treat with Cefepime (broad range and includes pseudomonas but not MRSA). If there is concern for MRSA add vancomycin.

• Admit with Neutropenic precautions (gowns, gloves, mask, positive pressure room)

References

1. Peseski, A. M., McClean, M., Green, S. D., Beeler, C., & Konig, H. (2021). Management of fever and neutropenia in the adult patient with acute myeloid leukemia. Expert review of anti-infective therapy, 19(3), 359–378. https://doi.org/10.1080/14787210.2020.1820863

2. Zimmer, A. J., & Freifeld, A. G. (2019). Optimal Management of Neutropenic Fever in Patients With Cancer. Journal of oncology practice, 15(1), 19–24. https://doi.org/10.1200/JOP.18.00269

Summarized by Jeffrey Olson, MS3 | Edited by Meg Joyce & Jorge Chalit, OMS3

Contributor: Jorge Chalit-Hernandez, OMS3

• Typically presents with biliary colic

• • Right upper quadrant abdominal pain lasting more than 30 minutes and subsiding over several hours

  • Often associated with fatty meals but not always

• Must rule out other causes of pain

• • Peptic ulcer disease - typically presents with epigastric pain

  • Pancreatitis - pain that radiates to the back or family history of pancreatitis

• Laboratory workup

• • LFTs including ALT, AST, and alkaline phosphatase are within the reference range

  • Lipase and amylase within the reference range

• Imaging workup

• • RUQ ultrasound is unremarkable

  • Upper endoscopy with ultrasound can help rule out peptic ulcer disease and small stones

  • HIDA scan may show a reduced gallbladder ejection fraction below 30-35% or it may be normal

  • • Opiates may give false-positive results

• Opiates can sometimes make biliary colic worse due to their contractile effect on the sphincter of Oddi

• Some patients may benefit from surgical intervention i.e. cholecystectomy

• • Classic biliary-type pain (best predictor of response to cholecystectomy)

  • Pain for > 3 months duration

  • Positive HIDA scan

References

1. Alhayo S, Eslick GD, Cox MR. Cholescintigraphy may have a role in selecting patients with biliary dyskinesia for cholecystectomy: a systematic review. ANZ J Surg. 2020;90(9):1647-1652. doi:10.1111/ans.16003

2. Arshi J, Layfield LJ, Esebua M. Mast cell infiltration and activation in the gallbladder wall: Implications for the pathogenesis of functional gallbladder disorder in adult patients. Ann Diagn Pathol. 2021;54:151798. doi:10.1016/j.anndiagpath.2021.151798

3. Carr JA, Walls J, Bryan LJ, Snider DL. The treatment of gallbladder dyskinesia based upon symptoms: results of a 2-year, prospective, nonrandomized, concurrent cohort study. Surg Laparosc Endosc Percutan Tech. 2009;19(3):222-226. doi:10.1097/SLE.0b013e3181a74690

4. Joehl RJ, Koch KL, Nahrwold DL. Opioid drugs cause bile duct obstruction during hepatobiliary scans. Am J Surg. 1984;147(1):134-138. doi:10.1016/0002-9610(84)90047-3

5. Mahid SS, Jafri NS, Brangers BC, Minor KS, Hornung CA, Galandiuk S. Meta-analysis of cholecystectomy in symptomatic patients with positive hepatobiliary iminodiacetic acid scan results without gallstones. Arch Surg. 2009;144(2):180-187. doi:10.1001/archsurg.2008.543

Summarized & Edited by Jorge Chalit, OMS3

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Contributor: Taylor Lynch MD

• Supraventricular tachycardias (SVTs) arise above the bundle of His

• • The term SVT includes AV nodal reentrant tachycardia (AVNRT), atrioventricular reentrant tachycardia (AVRT), atrial tachycardia, atrial fibrillation, atrial flutter, and multifocal atrial tachycardia

• AVNRT is the most common form of SVT

• • Paroxysmal

  • Spontaneous or provoked by exertion, coffee, alcohol, or thyroid disease

  • More common in women (3:1 women:men ratio)

  • HR 160-240

  • Narrow complex with a normal QRS

• Unstable patients receive synchronized cardioversion at 0.5-1 J/kg

• Valsalva maneuver is attempted before pharmaceutical interventions

• • Increases vagal tone at the AV node to slow conduction and prolongs its refractory period to normalize the conduction

  • Traditionally, patients are asked to bear down, but this only works in 17% of patients

  • REVERT trial assessed a modified valsalva that worked in 43% of patients

• Adenosine

• • Slows conduction at the AV node by activating potassium channels and inhibiting calcium influx

  • Extremely uncomfortable for most patients

  • Not commonly used anymore

• Nondihydropyridine calcium-channel blockers are preferred

• • A 2009 RCT investigated low-infusion CCBs compared with adenosine bolus

  • The study found a conversion rate of 98% in the CCB group vs. adenosine group at 86.5%

  • The main adverse effect of CCB is hypotension, which a slow infusion rate can mitigate

  • Diltiazem dose is 0.25 mg/kg/2min and repeat at 0.35 mg/kg/15 minutes or slow infusion at 2.5 mg/min up to a conversion or 50 mg total

References

1. 1. Appelboam A, Reuben A, Mann C, et al. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): A randomised controlled trial. Lancet. 2015;386(10005):1747-1753. doi:10.1016/S0140-6736(15)61485-4

2. Belz MK, Stambler BS, Wood MA, Pherson C, Ellenbogen KA. Effects of enhanced parasympathetic tone on atrioventricular nodal conduction during atrioventricular nodal reentrant tachycardia. Am J Cardiol. 1997;80(7):878-882. doi:10.1016/s0002-9149(97)00539-0

3. Lim SH, Anantharaman V, Teo WS, Chan YH. Slow infusion of calcium channel blockers compared with intravenous adenosine in the emergency treatment of supraventricular tachycardia. Resuscitation. 2009;80(5):523-528. doi:10.1016/j.resuscitation.2009.01.017

4. Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society [published correction appears in Circulation. 2016 Sep 13;134(11):e234-5. doi: 10.1161/CIR.0000000000000448]. Circulation. 2016;133(14):e506-e574. doi:10.1161/CIR.0000000000000311

Summarized & Edited by Jorge Chalit, OMS3

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Contributor: Aaron Lessen, MD

Educational Pearls:

• Pediatric case study where the child’s tongue was stuck in the opening of a hard plastic drink lid

• Entrapment restricts circulation which causes fluid to build and the tongue becomes more edematous with time

• • There is a risk of ischemia with prolonged entrapment

• Initially tried 2% viscous lidocaine for analgesia and lubricant

• The ER recognized that this mucosal, edematous tongue could benefit from the trick for ostomies and rectal prolapses → table sugar!

• • Sugar granules absorb water which decreases tissue edema

• This option avoids sedation and aggressive treatment

References

1. A Young Girl with Tongue Swelling
   Jarjour, Jane et al. Annals of Emergency Medicine, Volume 84, Issue 3, 317 - 318

Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS3

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Contributor: Megan Hurley, MD

Educational Pearls:

Fevers

• Tylenol

• Up until 20 weeks NSAIDs are ok but after 20 weeks they are contraindicated

• • Can limit the amount of amniotic fluid produced

  • Can lead to growth restriction

  • Can cause premature closure of the ductus arteriosus

Cough

• Cough drops

• Humidifier

• Guafenesine and dextromethorphan (Mucinex) is not well studied but is probably ok with caution in certain circumstances such as post-tussive emesis causing poor PO intake and weight loss

Congestion

• Flonase (Fluticasone nasal spray)

• Nasal rinses

• Humidifier

• 1st generation anti-histamines (Diphenhydramine, Doxylamine, etc.)

• • However, these tend to have more side effects such as fatigue, drowsiness, and dizziness

  • Concider switching to a 2nd generation (Cetirizine, Loratidine, etc.) during the day

Disease specific treatments

• Flu (A and B) gets tamiflu (Oseltamivir)

• Covid gets paxlovid (Nirmatrelvir/ritonavir)

• Antibiotics for suspected pneumonia

Additional recommendations

• Elevating the head of bed

• Nasal strips

• Stay well hydrated

• Tea

• Ice chips

• Echinacea

• Zinc

• Rest

Avoid

• NSAIDs

• Pseudophedrine

• Afrin (Oxymetazoline)

• Combined meds in general

References

1. Antonucci, R., Zaffanello, M., Puxeddu, E., Porcella, A., Cuzzolin, L., Pilloni, M. D., & Fanos, V. (2012). Use of non-steroidal anti-inflammatory drugs in pregnancy: impact on the fetus and newborn. Current drug metabolism, 13(4), 474–490. https://doi.org/10.2174/138920012800166607

2. Black, E., Khor, K. E., Kennedy, D., Chutatape, A., Sharma, S., Vancaillie, T., & Demirkol, A. (2019). Medication Use and Pain Management in Pregnancy: A Critical Review. Pain practice : the official journal of World Institute of Pain, 19(8), 875–899. https://doi.org/10.1111/papr.12814

3. D'Ambrosio, V., Vena, F., Scopelliti, A., D'Aniello, D., Savastano, G., Brunelli, R., & Giancotti, A. (2023). Use of non-steroidal anti-inflammatory drugs in pregnancy and oligohydramnios: a review. The journal of maternal-fetal & neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians, 36(2), 2253956. https://doi.org/10.1080/14767058.2023.2253956

Summarized by Jeffrey Olson MS3 | Edited by Meg Joyce, MS1 & Jorge Chalit, OMS3

Contributor: Travis Barlock MD

Educational Pearls:

• Assessment of head and neck vascular injury due to blunt trauma

• • Symptomatic patients require screening head and neck CT angiography

• EAST guidelines include the following criteria for a screening CT angiography in blunt head trauma:

• • Unexplained neurological deficits

  • Arterial nosebleed

  • GCS < 6

  • Petrous bone fracture

  • Cervical spine fracture

  • Any size fracture through the transverse foramen

  • LeFort fractures type II or type III

• EAST guidelines include a grading scale for vascular injury:

• • Grade I: Luminal irregularity or dissection with <25% luminal narrowing

  • Grade II: Dissection or intramural hematoma with >25% luminal narrowing, intraluminal thrombus, or raised intimal flap

  • Grade III: Pseudoaneurysm

  • Grade IV: Occlusion

  • Grade V: Transection with free extravasation

References

1. Bensch FV, Varjonen EA, Pyhältö TT, Koskinen SK. Augmenting Denver criteria yields increased BCVI detection, with screening showing markedly increased risk for subsequent ischemic stroke. Emerg Radiol. 2019;26(4):365-372. doi:10.1007/s10140-019-01677-0

2. Biffl WL, Moore EE, Offner PJ, et al. Optimizing screening for blunt cerebrovascular injuries. Am J Surg. 1999;178(6):517-522. doi:10.1016/s0002-9610(99)00245-7

3. Kim DY, Biffl W, Bokhari F, et al. Evaluation and management of blunt cerebrovascular injury: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2020;88(6):875-887. doi:10.1097/TA.0000000000002668

Summarized & Edited by Jorge Chalit, OMS3

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Contributor: Aaron Lessen, MD

Educational Pearls:

• Hemothorax: blood in the pleural cavity, most commonly due to chest trauma

• Treatment: thoracostomy tube for blood drainage

• • helps to avoid clotting, scarring, and infection

• A recent study looked at patients with hemothorax who either received or did not receive thoracic irrigation with saline

• • Evaluated incidence of secondary intervention, such as video-assisted thoracoscopic surgery (VATS), for persistent hemothorax

  • Patients who received irrigation had a slight decrease in secondary intervention frequency

  • Multi-center study - all patients who had the irrigation procedure were at two centers

  • • Study limitation: variability in approaches at each location could be a confounder

• Technique that could potentially prevent future complications

References

1. Carver TW, Berndtson AE, McNickle AG, et al. Thoracic irrigation for prevention of secondary intervention after thoracostomy tube drainage for hemothorax: A Western Trauma Association multi-center study. J Trauma Acute Care Surg. Published online May 20, 2024. doi:10.1097/TA.0000000000004364

2. Yi JH, Liu HB, Zhang M, et al. Management of traumatic hemothorax by closed thoracic drainage using a central venous catheter. J Zhejiang Univ Sci B. 2012;13(1):43-48. doi:10.1631/jzus.B1100161

Summarized by Meg Joyce, MS | Edited by Meg Joyce & Jorge Chalit, OMS3

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