Evidence-Based Tools

From: Tom Fadial. Seizure. ddxof. 2015. Differential Diagnosis of Seizure (ddxof.com)

Adapted from:  Tom Fadial. Seizure. ddxof. 2015. Differential Diagnosis of Seizure (ddxof.com)

Seizure DDx

Differential diagnosis is broad, but consider these conditions which may mimic epileptic seizures:

• Possible Seizures in Stroke Patients: The elderly population that is at the highest risk of stroke and TIA is also at risk for many of the conditions that can mimic seizures (see below)¹
• Syncope: Is often confused with seizures, due to the presentation of a stiff backward fall and short tonic and clinic manifestations. Syncope is most often distinguishable from epilepsy by examining the history immediately preceding the seizure. Syncope can be accompanied by lightheadedness, vertigo, warmth, nausea, diaphoresis, or prolonged sitting/standing. Often, syncope will occur from an upright position. It can also be accompanied by chest pain, palpitations, or be exercise-related - as well as micturition/defacation or pain^1,2. 
• Migraine: Migraines can be distinguished from seizures by their more gradual, often visual, warning and longer duration. Can be confused with potential seizures due to auras at onset and potential loss of consciousness¹
• TIAs: Some have remarked that seizures can be differentiated from TIAs because they produce "positive" symptoms (shaking, stiffening, hallucinations) while TIAs produce "negative" symptoms (weakness, sensory loss). That being said, there are "limb-shaking" TIAs that can be confused with seizures. They can be differentiated from seizures by their postural character (usually occurring on promptly on standing), and their involvement of arm, leg, or both - sparing facial muscles and cognition¹
• Sleep Disorders (Narcolepsy/cataplexy/parasomnias/REM Behavior Disorder): Differentiated from seizures in that eyes are usually closed, and that subject can be awakened with stimulation. However, parasomnias are often difficult to differentiate from nocturnal seizures - that being said, the onset of these is rare during adulthood and so it can be valuable to evaluate the patient's history. REM Behavior Disorder is distinguished from seizures by its often purposeful actions and facial actions¹.
• Psychogenic Nonepileptic Seizures: Most common in young adults - especially women. Typically longer, more waxing and waning, display less stereotypy, and have nonphysiologic progression. Eyes tend more often to be closed during unresponsive periods, and environmental precipitants are more likely. Those with psychiatric history are at higher risk³
• Intracranial Pressure: Can result in temporary alteration in awareness and focal neurologic dysfunction, like seizures. Very often associated with headaches, and are associated with cranial masses masses or injuries¹
• Also consider hyperventilation syndrome and post-hypoxic myoclonus

References 

1. Steven Schater. Differential Diagnosis. Epilepsy Foundation. 2004. Differential Diagnosis | Epilepsy Foundation

2. Tom Fadial. Seizure. ddxof. 2015. Differential Diagnosis of Seizure (ddxof.com)

3. Steven Schater. Wrong Diagnosis. Epilepsy Foundation. 2008. Wrong Diagnosis | Epilepsy Foundation

From:  Tom Fadial. Seizure. ddxof. 2015. Differential Diagnosis of Seizure (ddxof.com

This ultrasound shows a normal lung with sliding.

• You can observe freer lung movement, as well as the two pleural lines shimmering just under the subcutaneous tissue. There is also an "ants marching" shimmering effect, which is indicative of normal sliding movement. On the pneumothorax US, there was no shimmering and highly restricted movement.
• B-lines are present in this ultrasound (vertical shimmering lines beneath pleura), whereas they were absent in the pneumothorax US. In pneumothorax, B-lines are obstructed by the highly reflective surface created by the gas interface. 
• There is decreased clarity of A-lines (horizontal lines deep to the pleural surface) in this ultrasound. In pneumothorax US, the clarity of these lines is accentuated

Source: Pulmonary — TPA (thepocusatlas.com)

*Hypoglycemia is not officially one of the H’s and T’s for adults, but it still can be an important cause of PEA, especially in children. If another reversible cause has not been discovered or if the patient is known to be susceptible to hypoglycemia (e.g., brittle diabetes, past surreptitious use of insulin) then this potential cause of PEA should be considered.

Source: Hs and Ts - ACLS Medical Training

Source: HCMC_RSI_Checklist.jpg (816×1056) (resusreview.com)

Rapid Sequence Intubation

Rapid Sequence Intubation (RSI) is an airway management technique that creates the optimal conditions for intubation. It induces immediate unresponsiveness through an induction agent and muscular relaxation through a neuromuscular blocking agent^1-3. It is generally seen as the fastest and most effective means of controlling the emergency airway.

Indications for Intubation

• Airway protection and patency¹
• Respiratory failure, increased FRC, decreased WOB, secretion management/pulmonary toilet, facilitate bronchoscopy, decreased LOC¹
• Minimize oxygen consumption and optimize oxygen delivery (e.g. sepsis)¹
• Unresponsive to pain, terminate seizure, prevent secondary brain injury¹
• Temperature control¹
• Humanitarian reasons (e.g. procedures) and safety during transport (e.g. psychosis)¹

In this scenario, RSI was indicated by decreased LOC (which increases the risk for airway deterioration) and by the upcoming patient transfer, where it would enhance safety during transport. 

Indications and Contraindications for RSI¹

Administer

Administer RSI: The 9 (or 10) Ps

1.  Plan​​​​​​: Share your plan A and plan B (for potential difficult intubation) with your team⁴
2. Preparation: Prepare oxygen, medications, suction, monitors, equipment, IV access, personnel⁴
3. Protect the cervical spine: Maintain C-Spine immobilization throughout the entire intubation process⁴
4. Positioning: Ear above the sternum (head flexion and neck extension). In some cases, hyperelevation may be beneficial (ramped position is preferred in obese)4
5. Preoxygenation: Tight-fitting NRB mask to deliver 10-15L/min for at least 3 mins⁵
6. Pretreatment: First medications should reduce patient's adverse response to subsequent meds and laryngoscopy - Atropine, Lidocaine, Fentanyl, Defasiculating agents⁴
7. Paralysis and Induction: Administer induction agent to render patient unconscious and unresponsive, paralytic to eliminate muscle tone and prevent vomiting and aspiration⁴
8. Placement with proof: Pass the tube and confirm with end-tidal CO₂⁴
9. Post-intubation management: Secure tube, administer sedation and analgesia, place patient on ventilator⁴
10. Pressure on cricoid: This is seen by many as optional¹. Pressure is used to prevent air insufflation during positive pressure ventilation and passive regurgitation. Overcompressing can have severe consequences and should be avoided.⁴  

Planning for RSI - Equipment and Roles

Roles: Should be a minimum of 3 people - Airway proceduralist, Airway assistant, Drug administrator (Team leader can perform one of the above, but ideally should be in a separate standalone role)¹

Other Roles: Person to perform MILS if indicated, Person to perform cricoid pressure (if necessary), Scribe¹

Preparation requires control over: Self, Patient, Others, Environment

Mnemonics to assist with preparation¹

Drugs: Premedication, Induction, Neuromuscular Blockers 

Premedication - Note: There is little evidence that these are beneficial clinically, outside of atropine in children. 

• Lidocaine: 1mg/kg. Suppresses cough response, protects from increased ICP, attenuates hypertensive and tachycardia response to intubation⁶
• Atropine: Minimum dose 0.1mg, dose 0.01mg/kg. Important in children to prevent reflex bradycardia. Dries secretions. Can worsen tachycardia.⁶
• Fentanyl: 3mcg/kg.¹
• Defasiculating Agent: Use 1/10th the paralyzing dose of any paralytic. Use in patients who are at risk of adverse effects of succinylcholine.⁶

Induction¹

• Ketamine: 1.5-2mg/kg IV. Onset 60-90s, 10-20min Duration. Use in any RSI, especially if hemodynamically unstable or if reactive airways disease. Drawbacks are increased secretions, laryngospasm (rare), raised intra-ocular pressure, caution if cardiovascular disease.
• Thiopentone: 3-5mg/kg IV. Onset 30-45s. 5-10min Duration. Use in any RSI if hemodynamically stable, status epilepticus. Drawbacks are histamine release, myocardial depression, vasodilation, hypotension. Must NOT inject intra-arterially due to risk of distal ischemia. 
• Propofol: 1-2.5mg/kg IBW + (0.4TBW). Onset 15-45s. Duration 5-10min. Use in hemodynamically stable patients, reactive airways disease, status epilepticus. Drawbacks are hypotension, myocardial depression, reduced cerebral perfusion, pain on injection, variable response, very short-acting.
• Fentanyl: 2-10mcg/kg TBW. Onset <60s. Duration dose-dependent. May used in a ’modified’ RSI approach in low doses or titrated to effect in cardiogenic shock and other hemodynamically unstable conditions. Drawbacks are respiratory depression, apnea, hypotension, slow onset, nausea and vomiting, muscular rigidity in high induction doses, bradycardia, tissue saturation at high doses.
• Midazolam: 0.3mg/kg TBW. Onset 60-90s. Duraton 15-30min. Use not usually recommended for RSI, some practitioners use low doses of midazolam and fentanyl for RSI of shocked patients. Drawbacks are respiratory depression, apnea, hypotension, paradoxical agitation, slow onset, variable responses. 
• Etomidate: 0.3mg/kg. Onset 10-15s. Suitable for most situations including haemodynamically unstable, other than sepsis or seizures. Drawbacks are adrenal suppression, myoclonus, pain on injection.

Paralytic Agents¹

• Succinylcholine/Suxamethonium: 1.5mg/kg IV and 4mg/kg IM (in extremist). Onset 45-60s. 6-10min duration. Widely used unless contra-indicated, ideal if need to extubate rapidly following an elective procedure or to assess neurology in an intubated patient. Drawbacks are that there are numerous contra-indications (hyperkalemia, malignant hyperthermia, >5d after burns/ crush injury/ neuromuscular disorder), bradycardia (esp after repeat doses), hyperkalemia, fasciculations, elevated intra-ocular pressure, will not wear off fast enough to prevent harm in CICV situations. 
• Rocuronium: 1.2mg/kg IV IBW. Onset 60s. Can be used for any RSI unless contra-indication or require rapid recovery for extubation after elective procedure or neurological assessment; ensures persistent ideal conditions in CICV situation (i.e. immobile patient for cricothyroidotomy) – can be reversed by sugammadex. Some are allergic, though this is rare. 
• Vecuronium: 0.15mg/kg IV. Onset 120-180s. Duration 45-60min. Generally not recommended for RSI, unless no suxamethonium or rocuronium cannot be used – can be reversed by sugammadex. Drawbacks are the possibility for allergic reactions, slow onset, and a long duration. 

References

1. Nickson C (2020). Rapid Sequence Intubation (RSI). Life in The Fast Lane. Rapid Sequence Intubation (RSI) • LITFL • CCC Airway
2. Rapid Sequence Intubation (RSI). Westchester Medical Centre Health Network. RSI Information Margaretville only 2.28.17.pdf (hahv.org)
3. Smith C (2001). Rapid Sequence Intubation in Adults: Indications and Concerns. Clinical Pulmonary Medicine. 8(3) pp147-165. http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=ovfte&NEWS=N&AN=00045413-200105000-00004.
4. Braude D (2007). Ten Ps of Rapid Sequence Intubation. Emergency Medicine News. 29(1) pp8,12. doi: 10.1097/01.EEM.0000264634.15897.25
5. Szyld D (2010). Paucis Verbis card: Rapid Sequence Intubation. ALiEM. Paucis Verbis card: Rapid Sequence Intubation (aliem.com)
6. Vafier J (2008). Rapid Sequence Intubation. Virginia Department of Health. Microsoft PowerPoint - RSI.ppt (virginia.gov)

References: 

1. Pinson & Tang. Acute Respiratory Failure - All there is to Know. Pinson and Tang. September 2017. Acute Respiratory Failure - All There Is To Know | Pinson & Tang (pinsonandtang.com)

*Hypoglycemia is not officially one of the H’s and T’s for adults, but it still can be an important cause of PEA, especially in children. If another reversible cause has not been discovered or if the patient is known to be susceptible to hypoglycemia (e.g., brittle diabetes, past surreptitious use of insulin) then this potential cause of PEA should be considered.

Source: Hs and Ts - ACLS Medical Training

Cushing's Triad: Cushing's Triad is a set of three primary signs that often indicate an increased ICP. They are: a change in respirations - often irregular and deep, a widening pulse pressure, and bradycardia. 

Clinical Findings Indicating Elevated ICP in Children:

• Headache
• Vomiting
• Altered Mental Status
• Papilledema
• Hypertension w/ bradycardia or tachycardia
• Transtentorial herniation: Headache, Pupillary Changes, Altered LOC, Abnormal breathing, Localization of Noxious Stimuli
• Foramen Magnum Herniation: Downbeat Nystagmus, Bradycardia, Bradypnea, Hypertension - May worsen with neck flexion and improve with extension
• Subalcine Herniation: Uni- or Bilateral Weakness, Loss of Bladder Control, Coma
• Other Findings (Less Common): Natural preference for knee-Chest position, Seizures, Spontaneous upper eyelid closing when an abrupt increase in CVP is transmitted, Transient (5-15min) epidermal flushing involving upper chest, face, or arms during deterioration

Reference

1. Robert C Tasker. Elevated Intracranial Pressure (ICP) in Children: Clinical Manifestations and Diagnosis. UpToDate. 13 Feb 2020. Elevated intracranial pressure (ICP) in children: Clinical manifestations and diagnosis - UpToDate

 References

1. Robert Tasker. Elevated Intracranial Pressure (ICP) in Children: Management. UpToDate. 4 January 2021. Elevated intracranial pressure (ICP) in children: Management - UpToDate

Source: HCMC_RSI_Checklist.jpg (816×1056) (resusreview.com)

Indications for Intubation¹

This is a clinical decision, there is no lab value that will define a need to intubate

1.  Progressive exhaustion/fatigue with altered mental status
2. Severe VQ mismatch
3. Acute Asphyxial Asthma
4. Need for transport to another centre 

Initial Ventilator Settings¹

Hypercapnia is preferable to hyperinflation, and is tolerable in many cases to avoid more serious lung/airway trauma and complications.

• Mode: No evidence for one over another. Many start with Volume-Control
• Tidal Volume: 6-10ml/kg ideal BW
• Expiratoy Time: 4-5s, want long I:E (from 1:4 to 1:8) to avoid stacking breaths with barotrauma
• RR: Below physiologic rate for age. Controlled hypoventilation has been shown to be safe
• PEEP: 0 in acute phase
• FiO2: Start at 100%, titrate to keep SATs >90%
• Keep Child adequately sedated
  • Avoid patient-ventilator asynchrony
  • Decrease CO2 production
  • Consider Ketamine
  • Avoid prolonged neuromuscular paralysis if possible
• Keep Plateau Pressures <30 cmH20
  • Increased risk of barotrauma above this
  • Measured by end-inspiratory pause of several seconds in system w/o leaks

References 

1. Sean M Fox. Mechanical Ventilation for Severe Asthma. Pediatric EM Morsels. 7 November 2014. Mechanical Ventilation for Severe Asthma in Pediatrics (pedemmorsels.com)

1. Disconnect from Ventilator and allow chest to recoil

• If hemodynamics improve, restart ventilator at lower tidal volume and RR
• If hemodynamics don't improve, consider other complications

2. Consider Typical complications

• Dislodged ETT Tube: Verify with End-Tidal CO2 Monitoring, videoscopic laryngoscope, or ultrasound
• Obstructed ETT Tube: Suction the tube
• Pneumothorax: Consider x-ray or ultrasound. If confirmed, proceed with needle thoracostomy/chest tube
• Equipment Failure

3. Other Complications

• Hypoxemia
  • Exclude right mainstem intubation
  • Exclude pneumothorax and place pleural drain
  • Determine cause - check tube obstruction (kinking, biting of tube, plugging), check settings, reassess frequently, check for bronchospasm
• Hypotension
  • Exclude other causes like myocardial infarction and sepsis
  • Trial apnea or hypopnea to decrease intrathoracic pressure unless there is unequivocal evidence of pneumothorax (this can be both diagnostic and therapeutic for lung hyperinflation)
  • Decrease RR and adjust to allow for short inspiration and longer expiration
  • Administer fluids
  • Critical hypotension with no identifiable reversible cause is indication for epinephrine
• Cardiac Arrest
  • Consider pneumothorax early
  • Trial apnea or hypopnea for no more than 30-60s with external compressions and volume challenge. This is therapeutic for lung hyperinflation as a cause of cardiac arrest
  • Consider external chest compressions, volume challenge, and epinephrine

References 

1. Sean M Fox. Mechanical Ventilation for Severe Asthma. Pediatric EM Morsels. 7 November 2014. Mechanical Ventilation for Severe Asthma in Pediatrics (pedemmorsels.com)

2. Barry Brenner, Thomas Corbridge, Antoine Kazzi. Intubation and Mechanical Ventilation of the Asthmatic Patient in Respiratory Failure. Proceedings of the American Thoracic Society. 2009. 6(4) pp371-379. Intubation and Mechanical Ventilation of the Asthmatic Patient in Respiratory Failure | Proceedings of the American Thoracic Society (atsjournals.org)

Source: algorithmpals_bradycardia_200707.pdf (heart.org)

Source: Heartify Algorithms | Pediatric Management of Shock After ROSC Algorithm

Adapted From: Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist 2000;5(4):302-311.

Source: Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist 2000;5(4):302-311.

Source: Rapid Code Status Conversation Guide (aliem.com)

Recognizing an Inferior STEMI on an ECG^1,2

• ST elevation in leads II, III, and aVF 
• Progressive development of Q waves in II, III, and aVF
• Reciprocal ST depression in aVL (+ lead I)
• Hyperacute T waves may precede these changes
• Associated features:
  • Concommitant right ventricular infarction (40% of patients) 
  • Significant bradycardia due to second or third-degree AV block (20%)
  • Posterior infarction due to extension of infarct area
  • ST elevation in lead III > lead II

Determining which artery is the culprit¹

• 98% of STEMIs are in the right coronary artery (RCA) or left circumflex artery (LCx)
  • RCA - 80%
  • LCx - 18% 
• The remaining 2% occur in the left anterior descending artery (LAD), producing concomitant inferior and anterior ST elevation

References

1. Ed Burns and Robert Buttner. Inferior STEMI. Life in the Fast Lane. 8 February 2021. Inferior STEMI • LITFL • ECG Library Diagnosis

2. Cardiac Care Network. STEMI Education for Emergency Department. CorHealth Ontario. ND. PowerPoint Presentation (corhealthontario.ca)

3. Huang et al. New ST-segment algorithms to determine culprit artery location in acutre inferior myocardial infarction. The American Journal of Family Medicine. Sep 2016. 34(9). pp1772-1778. https://doi.org/10.1016/j.ajem.2016.06.005

*For particularly vulnerable patients like young children or in resource-limited settings, these thresholds may be raised to heighten sensitivity

References

1. Nicole Glaiser. Diabetic Ketoacidosis in Children: Clinical Features and Diagnosis. UpToDate. 30 October 2020. UpToDate

2018 Canadian Diabetes Association DKA Guidelines treatment algorithm, adapted from https://guidelines.diabetes.ca/docs/CPG-2018-full-EN.pdf

Source: DKA Recognition and ED Management | Emergency Medicine Cases

Generally, you should avoid intubating a DKA patient, for several reasons:

• Respiratory dynamics of hyperpnea to correct their metabolic acidosis means that the ventilator must match their large tidal volume and RR. This puts them at risk for ventilator-induced lung injury and development of ARDS¹
• Patients with profound metabolic acidosis are at risk of circulatory collapse peri-intubation as periods of apnea during intubation will cause PCO₂ to rise rapidly¹
• DKA patients are often compensating for low bicarb with respiratory alkalosis. Difficulties intubating puts patient at risk for extremely high PaCO₂ and very low pH²
• DKA patients may develop gastroparesis and are at risk for aspiration²
• It is generally impossible/very difficult to generate the same level of respiratory alkalosis on ventilator that a strong non-intubated patient can generate²

Intubate if²:

• Decision to intubate is a clinical decision
• Prolonged changes in mental status
• They are no longer able to protect their airway
• If close observation and serial evaluation indicate it

When Intubating¹:

• Resuscitate before you intubate
• Consider ketamine +/- paralytic; continue bagging if paralytic used to avoid any period of apnea
• Consider antiemetic
• Consider giving IV bolus bicarb, esp. if serum bicarb <10
• High tidal volume (8cc/kg) and RR (24-28) to hyperventilate/match pre-intubation RR
• Consider asking for additional help/anesthesiology consult

References

1. Helman, A. Baimel, M. Sommer, L. Tillmann, B. Episode 146 – DKA Recognition and ED Management. Emergency Medicine Cases. September, 2020. https://emergencymedicinecases.com/dka-recognition-ed-management. 

2. Josh Farkas. PulmCrit - Four DKA Pearls. PulmCrit (EMCrit). May 2014. PulmCrit - Four DKA Pearls (emcrit.org)

Source: PALS.pdf (cpr4uflorida.com)

*Hypoglycemia is not officially one of the H’s and T’s for adults, but it still can be an important cause of PEA, especially in children. If another reversible cause has not been discovered or if the patient is known to be susceptible to hypoglycemia (e.g., brittle diabetes, past surreptitious use of insulin) then this potential cause of PEA should be considered.

Source: Hs and Ts - ACLS Medical Training

Source: Heartify Algorithms | Pediatric Management of Shock After ROSC Algorithm

Source: HCMC_RSI_Checklist.jpg (816×1056) (resusreview.com)

Adapted From: Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist 2000;5(4):302-311.

Source: Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist 2000;5(4):302-311.

Adapted From: Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist 2000;5(4):302-311.

Adapted From: Walker CA, McGregor L, Taylor C, Robinson S. STOP5: a hot debrief model for resuscitation cases in the emergency department. Clin Exp Emerg Med. 2020;7(4):259-266. doi:10.15441/ceem.19.086

Open in new tab

This algorithm can be found in CPS' position statement online here: https://cps.ca/documents/position/emergency-management-of-the-paediatric-patient-with-convulsive-status-epilepticus

Source: HCMC_RSI_Checklist.jpg (816×1056) (resusreview.com)

The following are indicators of Opioid Overdose:

• Altered mental status ranging from mild euphoria or lethargy to coma
• Miotic pupils
• Decreased bowel sounds
• Low-to-normal heart rate and blood pressure
• Hypoventilation
• Possible clonus

Reference: A Stolbach. 2022. Acute Opioid Intoxication in Adults. UpToDate. 

Reference: Opioid Misuse, Overdose and Withdrawal | Emergency Medicine Cases

1.  Reviewing the tracheostomy tube and its pieces

It is important to collect laryngectomy and tracheostomy history from this patient because:

Laryngectomy History: If the patient has had their larynx removed, the upper airway is not connected to the trachea. Oral ventilation and oral intubation would thus be impossible. They would need to be ventilated and intubated through the stoma. 

Tracheostomy History: If the tracheostomy is less than 7 days old, and the airway is patent (no laryngectomy), then oral intubation of the patient is preferred

Image source: NTSP_GREEN_Tracheostomy_Algorithm.pdf

Short Video: https://youtu.be/wmEwuc7Vs0w

Longer video: https://youtu.be/khS56oyBVFc

Armed Overdose – EM Sim Cases

1. Total breech extraction should not be performed to deliver singleton breech.
2. Delivery of the breech wit hthe woman in the upright position, or in the all fours position, may reduce the need for intervention
3. Necessity of pushing in second stage of labour should be explained to the woman
4. Provide adequate analgesia. Be aware that dense epidural analgesia will hamper maternal pushing efforts
5. Spontaneous descent and expulsion to the umbilicus should occur with maternal pushing only: DO NOT PULL ON BREECH
6. Episiotomy may be considered once anterior buttock and anus are crowning
7. Spontaneous delivery of enture breech fetus is desirable. Delivery of aftercoming head may be facilitated by adequate maternal pushing efforts, oxytocin augmentation after delivery of fetal body or uterin fundal pressure. Assisted deivery is acceptable if there is delay in delivery. Following manoeuvres may be required:
    a. Pinard's manoeuvre to deliver the fetal legs may be considered once popliteal fossae visible
    b. Lovset's manoeuvre to deliver nuchal arms 
8. Support baby to maintain head in a flexed position and body in a horizontal position. Delivery of the aftercoming head may be achieved with maternal pushing efforts alone. Oxytocin augmentation or uterin fundal pressure can be used to treat expulsive delay after the breech has crowned.
9. Failing these, the Mauriceau-Smellie-Viet manoeuvre, or Piper forceps, may be required to deliver head in flexion

Source:
Society of Obstetricians and Gynecologists of Canada. ALARM Manual, 28th Ed. 2022.

1. Insert two fingers along one leg to the knee 
2. Abduct knee away from midline while flexing the leg at the hip
3. This will cause spontaneous flexion of the knee and delivery of the foot
4. Knees of frank breech are hyperextended, and it is important to correctly identify popliteal fossae to avoid further hyperextension

Source:
Society of Obstetricians and Gynecologists of Canada. ALARM Manual, 28th Ed. 2022. 

A1. Grasp fetus by bony pelvis with 2 hands and raise towards maternal pubic symphisis
A2. Turn fetal torso while lowering it to bring shoulder underneath pubic symphisis
B1.  Sweep humerus of posterior arm across chest to release 
A3. Rotate fetal trunk back through a sacrum-anterior position to the other side
B2. Sweep humerus of remaining arm across chest to release 

Source:
Society of Obstetricians and Gynecologists of Canada. ALARM Manual, 28th Ed. 2022.

 

1. Place one hand underneath fetus and palpate the fetal maxilla. Have assistant maintain suprapubic pressure.
2. Apply pressure to fetal maxilla to flex head
3. Grasp fetal shoulders with other hand to apply gentle traction
4. Maintain flexion of head and suprapubic pressure while applying traction to aid delivery

Source
Society of Obstetricians and Gynecologists of Canada. ALARM Manual, 28th Ed. 2022. 

1. Elevate fetal body using warm towel
2. Apply left blade of forceps to aftercoming head
3. Apply right blade of forceps with body still elevated
4. With body still elevated, use forceps to deliver head

Source:
Society of Obstetricians and Gynecologists of Canada. ALARM Manual, 28th Ed. 2022.

Created using information from: Simon LV, Hashmi MF, Bragg BN. APGAR Score. StatPearls. 2022 Feb. https://www.ncbi.nlm.nih.gov/books/NBK470569/

There are two equations that can be used to calculate the anion gap. It is common practice to use the second one, but the first is more accurate:

1. Na⁺ + K⁺ - Cl^- - HCO3^-
2. Na⁺- Cl^- - HCO3^-

Normal anion gap when including K+ is 12-20meEQ/L¹
When not including K+, normal anion gap is 12 + 4¹

DDx of Elevated Anion Gap - MUDPILES Mnemonic¹

M - Methanol, Metformin
U- Uremia
D - DKA
P - Paraldehyde, phenformin
I - Iron, INH, Ibuprofen (large ingestions)
L - Lactic Acidosis
E - Ethylene Glycol
S - Salicylates

Other possibilities: Starvation/ETOH ketoacidosis, Carbon monoxide, CN poisoning, Colchicine, Toluene, Chronic acetaminophen use

References:

1. Fields A, Iacomini P, Cunningham R, Miller CM, Ross J, Lu K, Davey M, Young N, Ostermayer D, Donaldson R. Anion Gap. WikEM. Feb 2021. wikem.org/wiki/Anion_gap

Inclusion Criteria - Only apply to patients with GCS 13-15 and at least one of the following:

• Loss of consciousness on injury
• Amnesia to the head injury event
• Witnessed disorientation

Exclusion Criteria - If any of the following are true, Canadian CT Head Rules do not apply:

• Age < 16 years
• Patient on blood thinners
• Seizure after injury

Medium Risk Criteria - Presence of one or more indicate medium risk for brain injury on CT

• Retrograde amnesia to the event > 30 minutes
• Dangerous Mechanism - e.g. pedestrian struck by motor vehicle, occupant ejected from motor vehicle, or fall from >3 feet or >5 stairs

High Risk - Presence of one or more indicate high risk for brain injury on CT and possible need for neurological

• GCS <15 at 2 hours after injury
• Suspected open or depressed skull fracture
• Signs of basilar skull fracture (hemotympanum, "racoon" eyes, CSF otorrhea/rhinorrhea, battle's sign)
• Age > 65 years
• > 2 vomiting episodes

Source: MD Calc

Retrieved July 2, 2023 from: https://www.parents.com/pregnancy/giving-birth/labor-and-delivery/cervix-dilation-chart-pictures-that-explain-the-stages-of-labor/

Retrieved July 27, 2023 from: https://www.instagram.com/p/CHJCbAhgdIu/?utm_source=ig_web_button_share_sheet

Retrieved July 27, 2023 from: https://www.youtube.com/watch?v=x17vY7_3M2M

Adapted September 12, 2023 from https://www.medicalnewstoday.com/articles/326380

Reference(s): 
Society of Obstetricians and Gynecologists of Canada. ALARM Manual, 28th Ed. 2022.

Reference(s): 
Argani, A. H., & Satin, A. J. (2022). Occiput Posteror Position. In Barss V  (Ed.), UpToDate. Retrieved Aug 20, 2023, from https://www.uptodate.com/contents/occiput-posterior-position?search=occiput%20posterior%20position&source=search_result&selectedTitle=1~13&usage_type=default&display_rank=1#references

Reference(s): 
Retrieved July 5, 2023 from https://www.amboss.com/us/knowledge/postpartum-hemorrhage/

Reference(s): 
Society of Obstetricians and Gynecologists of Canada. ALARM Manual, 28th Ed. 2022.

Reference(s): 
Retrieved January 4, 2024 from https://www.doctorstock.com/image/I0000pff4Hvr0dFc
Society of Obstetricians and Gynecologists of Canada. ALARM Manual, 28th Ed. 2022.

Reference(s): 
Retrieved July 5, 2023 from https://www.amboss.com/us/knowledge/postpartum-hemorrhage/
Society of Obstetricians and Gynecologists of Canada. ALARM Manual, 28th Ed. 2022.

Retrieved July 2, 2023 from: https://www.parents.com/pregnancy/giving-birth/labor-and-delivery/cervix-dilation-chart-pictures-that-explain-the-stages-of-labor/

Retrieved July 27, 2023 from: https://www.instagram.com/p/CHJCbAhgdIu/?utm_source=ig_web_button_share_sheet

Retrieved July 27, 2023 from: https://www.youtube.com/watch?v=x17vY7_3M2M

Adapted September 12, 2023 from https://www.medicalnewstoday.com/articles/326380

Reference(s):
Society of Obstetricians and Gynecologists of Canada. ALARM Manual, 28th Ed. 2022.

Classification of Placental Abruption:

Retrieved July 5, 2023 from https://www.amboss.com/us/knowledge/antepartum-hemorrhage

Reference(s): 
Society of Obstetricians and Gynecologists of Canada. ALARM Manual, 28th Ed. 2022.

Retrieved July 2, 2023 from: https://www.parents.com/pregnancy/giving-birth/labor-and-delivery/cervix-dilation-chart-pictures-that-explain-the-stages-of-labor/

Retrieved July 27, 2023 from: https://www.instagram.com/p/CHJCbAhgdIu/?utm_source=ig_web_button_share_sheet

Retrieved July 27, 2023 from: https://www.youtube.com/watch?v=x17vY7_3M2M

Adapted September 12, 2023 from https://www.medicalnewstoday.com/articles/326380

Videos: 
Shoulder Dystocia & ALARMER Mnemonic (8.5 min.): https://youtu.be/BvkKMwDaryg
ALARMER Mnemonic (8.5 min.): https://youtu.be/jNmSJDbTARw

Reference(s): 
Society of Obstetricians and Gynecologists of Canada. ALARM Manual, 28th Ed. 2022.

Retrieved July 2, 2023 from: https://www.parents.com/pregnancy/giving-birth/labor-and-delivery/cervix-dilation-chart-pictures-that-explain-the-stages-of-labor/

Retrieved July 27, 2023 from: https://www.instagram.com/p/CHJCbAhgdIu/?utm_source=ig_web_button_share_sheet

Retrieved July 27, 2023 from: https://www.youtube.com/watch?v=x17vY7_3M2M

Adapted September 12, 2023 from https://www.medicalnewstoday.com/articles/326380

Created using information from: Simon LV, Hashmi MF, Bragg BN. APGAR Score. StatPearls. 2022 Feb. https://www.ncbi.nlm.nih.gov/books/NBK470569/

Reference(s): 
Society of Obstetricians and Gynecologists of Canada. ALARM Manual, 28th Ed. 2022.

Videos: 
Breech Delivery Technique (4 min): https://youtu.be/d9pU_6LDVUM
In-depth Technique Explanations (12 min) – Includes Piper Forceps Delivery: https://youtu.be/xOqWT06qVS8

Reference(s): 
Society of Obstetricians and Gynecologists of Canada. ALARM Manual, 28th Ed. 2022.

Retrieved July 17, 2023, from Melbourne University Obstetrics and Gynecology Society (Facebook)

Norwitz E. R. (2022). Eclampsia. In Barss V (Ed.), UpToDate. Retrieved July 4, 2023, from https://www.uptodate.com/contents/eclampsia

Brandt-Andrews Maneuver (preferred): an abdominal hand secures the uterine fundus to hold it in a fixed position and prevent uterine inversion while the other hand exerts sustained downward traction on the clamped umbilical cord.

Reference(s): 
Anderson, Janice M, and Duncan Etches. 2007. Prevention and Management of Postpartum Hemorrhage. www.aafp.org/afp. (October 12, 2023).

Retrieved July 17, 2023, from Melbourne University Obstetrics and Gynecology Society (Facebook)

Important Notes Regarding Pharmacological use in Labour: 

• Sedative and hypnotic drugs do not provide pain relief and may increase respiratory depression when given with opioids.
• No pharmacological method is devoid of maternal or fetal side effects - with almost all pharmaceutical therapies, some amount of the drug gets access to the fetus. 
• Anticholinergic side effects may occur with opioids and care should be directed at recognizing and addressing these discomforts.
• A pregnant person can receive opioids just before birth without significant respiratory depression in the newborn.
• When any opioid is used, opioid antagonists (e.g., naloxone) and resuscitation capabilities should be available. Before a pregnant person is sent home following opioid administration, she needs to be assessed to determine the effects and side effects of the medication.
• Action should be taken to prevent toxicity with all local anesthetics.
• Epidural analgesia provides the most efficacious pharmacological analgesia, with limited side effects to the mother and fetus.

Options for Pharmacological Pain Management in Labour (see dosing information below):

• Opioids 
  • Fentanyl preferred as it has a shorter half-life (use of meperidine, which has a longer half-life, is discouraged) 
  • Remifentanil patient controlled analgesia (PCA) may offer some benefits over traditional intramuscular (IM) opioids for labour analgesia 
    • Limitation: remifentanil requires constant nursing presence and oxygen saturation monitoring due to the narrow therapeutic window, as well as the increased risk of respiratory complications 
  • Opioids may be combined with an antiemetic as side effects of opioids include nausea and vomiting

Suggested Opioid use in labour:

• Nitrous Oxide 
  • Has been shown to provide mild analgesia, but high patient satisfaction.
    • Often useful for the pregnant person who has coped well until transition and then requires pain relief for a short time. 
  • Deep inhalation should begin as soon as the pregnant person is aware of the onset of a contraction to allow for maximal benefit. 
  • Non-analgesic benefits include relaxation, distraction from pain, anxiolysis, and an improved sense of being able to cope with the pain. 
  • Common side-effects: dizziness, nausea, altered cognition, dysphoria, and a feeling of claustrophobia.
  • It must be self-administered for safety reasons via a demand-valve.
  • Should be used in a well-ventilated room for workplace safety.
    • Nitrous oxide is destructive to the ozone layer - shorter use decreases environmental exposure. 
  • May also be used as an adjunct during other procedures such as the placement of a pudendal block or perineal repair. 
• Peripheral Nerve Blocks 
  • A pudendal block can be used for analgesia of the perineum in the second stage of labour. 
  • Useful for the sacral nerves and should be considered when other regional analgesia is not available or provides insufficient sacral spread. 
  • Important to recognize that local anaesthetic toxicity is additive. Toxic limits of each local anaesthetic should be known to ensure maximum cumulative dosing is not exceeded.
• Neuraxial Anesthesia 
  • Catheter in the epidural space (i.e., labour epidural analgesia (LEA))
  • Quite common in Canada and remains the most effective form of labour analgesia
  • Epidural analgesia can provide effective pain relief throughout all stages of labour and delivery, with limited side effects to the mother and fetus 
  • This option is often not available in rural 1A labour and delivery units, therefore will not be discussed in detail in this resource.

Reference(s): 

Grant G. (2022). Pharmacologic management of pain during labor and delivery. In Crowley M (Ed.), UpToDate. Retrieved Jul 2, 2023, from https://www.uptodate.com/contents/pharmacologic-management-of-pain-during-labor-and-delivery

Society of Obstetricians and Gynecologists of Canada. ALARM Manual, 28th Ed. 2022.

Important Notes Regarding Pharmacological use in Labour: 

• Sedative and hypnotic drugs do not provide pain relief and may increase respiratory depression when given with opioids.
• No pharmacological method is devoid of maternal or fetal side effects - with almost all pharmaceutical therapies, some amount of the drug gets access to the fetus. 
• Anticholinergic side effects may occur with opioids and care should be directed at recognizing and addressing these discomforts.
• A pregnant person can receive opioids just before birth without significant respiratory depression in the newborn.
• When any opioid is used, opioid antagonists (e.g., naloxone) and resuscitation capabilities should be available. Before a pregnant person is sent home following opioid administration, she needs to be assessed to determine the effects and side effects of the medication.
• Action should be taken to prevent toxicity with all local anesthetics.
• Epidural analgesia provides the most efficacious pharmacological analgesia, with limited side effects to the mother and fetus.

Options for Pharmacological Pain Management in Labour (see dosing information below):

• Opioids 
  • Fentanyl preferred as it has a shorter half-life (use of meperidine, which has a longer half-life, is discouraged) 
  • Remifentanil patient controlled analgesia (PCA) may offer some benefits over traditional intramuscular (IM) opioids for labour analgesia 
    • Limitation: remifentanil requires constant nursing presence and oxygen saturation monitoring due to the narrow therapeutic window, as well as the increased risk of respiratory complications 
  • Opioids may be combined with an antiemetic as side effects of opioids include nausea and vomiting

Suggested Opioid use in labour:

• Nitrous Oxide 
  • Has been shown to provide mild analgesia, but high patient satisfaction.
    • Often useful for the pregnant person who has coped well until transition and then requires pain relief for a short time. 
  • Deep inhalation should begin as soon as the pregnant person is aware of the onset of a contraction to allow for maximal benefit. 
  • Non-analgesic benefits include relaxation, distraction from pain, anxiolysis, and an improved sense of being able to cope with the pain. 
  • Common side-effects: dizziness, nausea, altered cognition, dysphoria, and a feeling of claustrophobia.
  • It must be self-administered for safety reasons via a demand-valve.
  • Should be used in a well-ventilated room for workplace safety.
    • Nitrous oxide is destructive to the ozone layer - shorter use decreases environmental exposure. 
  • May also be used as an adjunct during other procedures such as the placement of a pudendal block or perineal repair. 
• Peripheral Nerve Blocks 
  • A pudendal block can be used for analgesia of the perineum in the second stage of labour. 
  • Useful for the sacral nerves and should be considered when other regional analgesia is not available or provides insufficient sacral spread. 
  • Important to recognize that local anaesthetic toxicity is additive. Toxic limits of each local anaesthetic should be known to ensure maximum cumulative dosing is not exceeded.
• Neuraxial Anesthesia 
  • Catheter in the epidural space (i.e., labour epidural analgesia (LEA))
  • Quite common in Canada and remains the most effective form of labour analgesia
  • Epidural analgesia can provide effective pain relief throughout all stages of labour and delivery, with limited side effects to the mother and fetus 
  • This option is often not available in rural 1A labour and delivery units, therefore will not be discussed in detail in this resource.

Reference(s):