Patient Name; Age€¦ · Web viewUltrasound exam showing placenta previa CBC with Hgb = 5.9 gm/dL Distractors – distraught husband Actors Roles – nurse, husband, consultant (on

Janet Smith; 37 1/2/73

Author: Thomas Cook, MD

Reviewers: Michelle Sergel, MD, Sharon Griswold, MD

Case Title: Painless Vaginal Bleeding in Late Pregnancy

Target Audience: Residents and Medical Students

Primary Learning Objectives:

1. Provides a differential diagnosis for the patient with vaginal bleeding in the 2nd and 3rd trimester of pregnancy

2. Manages the patient with significant 3rd trimester bleeding 3. Appropriately refers patient with vaginal bleeding in the late stages of pregnancy

Secondary Learning Objectives:

1. Avoids digital or speculum vaginal exam in the patient with 2nd or 3rd trimester pregnancy before location and status of the placenta is determined

2. Immediately refers to labor and delivery of the patient with 2nd or 3rd trimester bleeding3. Provides fluid resuscitation in late pregnancy with massive vaginal bleeding

Critical actions checklist:

1. Initiates fluid resuscitation2. Identifies viability of pregnancy3. Identifies location and status of placenta BEFORE digital and speculum exam (NOTE: If

digital exam is performed, the patient’s bleeding should increase significantly)4. Orders and administers blood transfusion after minimal response to IV fluids 5. Consults obstetrics quickly (notifies them of the need for emergent C-section)6. Prepares for transportation to Labor and Delivery

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Environment for Simulation Medicine Case:

1. Room Set Up – Emergency Department Suite

2. Manikin Set Up – 3rd trimester pregnancy with vaginal bleeding

3. Propso Monitor with sinus tachycardia and SBP at 80 mm/Hgo Ultrasound exam showing placenta previao CBC with Hgb = 5.9 gm/dL

4. Distractors – distraught husband

5. Actorso Roles – nurse, husband, consultant (on phone)o Played by other residents, other students, actors

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Author: Thomas Cook, MD

Reviewer: Michelle Sergel, MD, Sharon Griswold, MD

Case Title: Painless Vaginal Bleeding in Late Pregnancy

CORE CONTENT AREA

Obstetrics, Resuscitation

SYNOPSIS OF HISTORY/ Scenario Background

This case is about a woman from a rural area without prenatal care who shows up with painless vaginal bleeding in late 3rd trimester pregnancy. The candidate should immediately recognize the need for fluid resuscitation, determine the viability of the pregnancy, establish the location of the placenta (if possible), immediately consult obstetrics, and prepare the patient for transport.

SYNOPSIS OF PHYSICAL

The patient is an obviously gravid female who appears pale and in distress.

Vital Signs: T = 98.7; HR = 115; RR = 16; BP = 80/60; SaO2 = 96% on room air

HEENT: Mucous membranes are dry

Abdomen: Distended abdomen consistent with late 3rd trimester pregnancy. Soft and non-tender.

Extremities: Distal extremities cold and clammy. Decreased to absent distal pulses. Mild edema to the distal lower extremities.

Pelvic: Examination of external genitalia shows blood coming rapidly from the vaginal os. If the candidate does a digital or speculum exam, the bleeding increases dramatically and patient becomes unconscious. A digital exam will show the cervical os to be 3 cms dilated.

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For Examiner Only

CRITICAL ACTIONSSCENARIO BRANCH POINTS/ PLAY OF CASE GUIDELINES

Key teaching points or branch points that result in changes in patient’s condition

1. Critical Action – Initiation of Fluid Resuscitation

This should be done very early in the patient interaction. She is tachycardic and hypotensive with an active source of bleeding. Two large bore intravenous catheters should be inserted and two liters of crystalloid fluid should be given as quickly as possible. Failure to do this will result in the patient becoming unconscious with a drop in blood pressure.

2. Critical Action – Identify Viability of Pregnancy

The patient is obviously pregnant. The candidate should determine the viability of the pregnancy as soon as possible after beginning the fluid resuscitation. The fetus will appear to be late stage 3rd trimester pregnancy with good fetal heart motion.

3. Critical Action – Identify the status and location of the placenta

Although placental abruption is often hard to diagnose by ultrasound (particularly in inexperienced hands), the location of the placenta is often pretty straightforward. The candidate should make an effort to determine if the placenta is low-lying or over the cervix. If the candidate attempts to perform a vaginal exam of any kind, the patient should begin to bleed more heavily and become unconscious.

4. Critical Action – Administer blood when initial fluid bolus does not adequately stabilize the blood pressure.

The patient should be type and crossed early in the scenario. Once the initial fluid resuscitation does not improve the cardiovascular status of the patient, emergency release blood (O negative) should be transfused.

5. Critical Action – Immediate consultation of obstetrics for emergency C-section.

This should be done early in the scenario after fluid resuscitation and determination of the viability of the pregnancy by ultrasound. Anesthesia and Labor and Delivery should be notified of the need for emergent C-section as well.

6. Critical Action – Prepare the patient for transport to Labor and Delivery

Once the candidate determines the need for emergent C-section, the patient needs to be prepared for immediate transport to Labor and Delivery.

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SCORING GUIDELINES

Successful management of the case includes the following actions:

Appropriate resuscitation of the patient includes immediate initiation of crystalloid fluid

resuscitation and administration of blood after minimal response to crystalloid IVF.

The candidate must correctly identify pregnancy viability and the location/ status of

placenta

Appropriate management of the patient to include an emergent obstetric consult and

preparation for transfer to Labor & Delivery

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For Examiner Only

HISTORY

Chief Complaint: Syncope

Past Medical Hx: G3P2 without complication. Children are 6 and 3 years old.

Mode of Arrival: Personally owned vehicle

Regular physician: none

History of Present Illness: The patient is a G3P2 female in the 3rd trimester of pregnancy. She is unsure of her exact dates, but she is obviously pregnant. She is from a rural area and has delivered all her previous children at home without prenatal care and only a midwife in attendance. She noted some vaginal spotting a few days prior. This has progressed to soaking a pad each hour for the past six hours. She passed out about two hours ago, and her husband brought her to the emergency department. She denies any pain. She has never had this problem before. She had some vaginal spotting a week ago, but this went away. No previous syncope in the past. No dysruria, chest pain, shortness of breath, vaginal bleeding, fever, vaginal discharge. There is no recent or remote history of trauma.

Medication: Takes acetaminophen on occasion.

Allergies: none

Social history: Husband is a farmer. She is a homemaker. No tobacco, alcohol, illicit drugs. Lives with husband and two children. All are healthy.

ROS: Negative

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For Examiner Only

PHYSICAL EXAM

Patient Name: Janet Smith Age & Sex: 37 yo female

General Appearance: Well-formed, well-nourished white female in apparent distress

Vital Signs: T = 98.7; HR = 115; RR = 16; BP = 80/60; SaO2 = 96% on room air

HEENT: Pupils equally round and reactive, mucous membranes are dry, throat is normal, Atraumatic scalp.

Neck: No thyromegaly, JVD, or lymphadenopathy

Skin: Normal

Chest: Normal

Lungs: Clear

Heart: Rapid regular rhythm. No murmurs.

Back: Normal

Abdomen: Distended abdomen consistent with late 3rd trimester pregnancy. Soft and non-tender.

Extremities: Distal extremities cold and clammy. Decreased to absent distal pulses. Mild edema to the distal lower extremities.

Rectal: No gross bleeding. Normal sphincter tone.

Pelvic: Examination of external genitalia shows blood coming rapidly from the vaginal os. If the candidate does a digital or speculum exam, the bleeding increases dramatically and patient becomes unconscious. A digital exam will show the cervical os to be 3 cms dilated.

Musculoskeletal: Normal

Skin: Normal

Neurological: Normal

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For Examiner Only

STIMULUS INVENTORY

#1 Emergency Admitting Form

#2 CBC

#3 BMP

#4 U/A

#5 Coagulation Labs

#6 Transabdominal Pelvic Ultrasound

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For Examiner Only

LAB DATA & IMAGING RESULTS

Stimulus #2 Stimulus #5Complete Blood Count (CBC) CoagsWBC /mm3 PT

Hgb g/dL PTTHct % INRPlatelets /mm3

DifferentialSegs % Stimulus #6Bands % Transabdominal Pelvic UltrasoundLymphs %Monos %Eos %

Stimulus #3 Basic Metabolic Profile (BMP) Na+ mEq/LK+ mEq/LCO2 mEq/LCl- mEq/LGlucose mg/dLBUN mg/dLCreatinine mg/dL

Stimulus #4 Urinalysis (U/A)Color yellowSp gravity 1.010Glucose negProtein negKetone negLeuk. Est. negNitrite negWBC 0-1RBC 0-1

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Learner Stimulus #1

ABEM GENERAL HOSPITAL

EMERGENCY ADMITTING FORM

Name: Janet Smith

Age: 37 years

Sex: Female

Method of Transportation: Private car

Person giving information: Husband

Presenting complaint: Late 3rd Trimester Bleeding

Background: Patient is a G3P2 white female in the late stages of pregnancy who began to

have painless vaginal bleeding 6 hours ago. Three hours ago she passed out when she got up

to go the bathroom.

Triage or Initial Vital Signs BP: 80/60

P: 115

R: 16

T : 98.7

SaO2: 96% on room air

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LEARNER STIMULUS #2

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Complete Blood Count (CBC)WBC 10 /mm3

Hgb 8.5 g/dLHct 26 %Platelets 120 /mm3

DifferentialSegs 75%Bands 5%Lymphs 15%Monos 4%Eos 1%


LEARNER STIMULUS #3

Basic Metabolic Profile (BMP)Na+ 140 mEq/LK+ 4.0 mEq/LCO2 16 mEq/LCl- 109 mEq/LGlucose 98 mg/dLBUN 22 mg/dLCreatinine 0.7 mg/dL

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LEARNER STIMULUS #4

UrinalysisColor YellowSpedific Gravity 1.025Glucose negProtein negKetone negLeuk. Esterase negNitrite NegWBC 0-1RBC 0-1

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LEARNER STIMULUS #5

STIMULUS #5CoagsPT 31.0 secondsPTT 13.9 secondsINR 1.0

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LEARNER STIMULUS #6

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FEEDBACK/ ASSESSMENT FORM

VAGINAL BLEEDING IN LATE PREGNANCY

Candidate ________________________ Examiner _________________________

Critical Actions:

Critical Action #1 – Initiates fluid resuscitation

Critical Action #2 – Identifies viability of pregnancy

Critical Action #3 – Identifies location and status of placenta

Critical Action #4 – Administers blood after minimal response to crystalloid IVF

Critical Action #5 – Consults obstetrics

Critical Action #6 – Prepares for transfer to Labor & Delivery

Dangerous Actions: (Performance of one dangerous action results in failure of the case)

Dangerous Action #1 – Fails to initiate fluid resuscitation in timely manner

Dangerous Action #1 – Performs a digital and/or speculum exam of vagina

Dangerous Action #1 – Fails to administer blood if patient becomes unstable

Dangerous Action #1 - Fails to consult obstetrics in a timely manner

Overall Score:

Pass

Fail

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ADDENDUM 2:CORE COMPETENCY ASSESSMENT


Candidate ________________________ Examiner _________________________

Does Not Meet Expectations

Meets Expectations

Exceeds Expectations

Patient Care

Medical Knowledge

Interpersonal Skills and

Communication

Professionalism

Practice-based Learning and Improvement

Systems-basedPractice

CORE COMPETENCY ASSESSMENT

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Date: Examiner: Examinee(s):

Scoring: In accordance with the Standardized Direct Observational Tool (SDOT)

The learner should be scored (based on level of training) for each item above with one of the following:

NI = Needs ImprovementME = Meets ExpectationsAE = Above ExpectationsNA= Not Assessed

Critical Actions NI ME AE NA CategoryRecognizes shock and initiate fluid resuscitation

PC, MK, PBL

Identifies viability of pregnancy PC, MKDetermines location and status of placenta

PC, MK

Type and Cross blood and begins transfusion with O-negative blood

PC, MK, PBL

Consults obstetrics in a timely manner PC, MK, SBPPrepares for transportation to labor and delivery

PC, MK, SBP

Demonstrates / utilizes effective communication techniques such as specifying order details and closed loop communication

MK, ICS

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Category: One or more of the ACGME Core Competencies as defined in the SDOT

PC= Patient CareCompassionate, appropriate, and effective for the treatment of health problems and the promotion of health

MK= Medical KnowledgeResidents are expected to formulate an appropriate differential diagnosis with special attention to life-threatening conditions, demonstrate the ability to utilize available medical resources effectively, and apply this knowledge to clinical decision making

PBL= Practice Based Learning & ImprovementInvolves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care

ICS= Interpersonal Communication SkillsResults in effective information exchange and teaming with patients, their families, and other health professionals

P= ProfessionalismManifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population

SBP= Systems Based PracticeManifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value

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CASE DEBRIEFING


The differential diagnosis of vaginal bleeding in late pregnancy

Placenta previa- usually painless bleeding Placental abruption- usually painful bleeding Bloody show associated with onset of labor or cervical incompetency Uterine rupture Vasa previa- refers to vessels that traverse the membranes located in the lower uterine

segment in advance of the fetal presenting part. Rupture of these vessels can occur with or without rupture of the membranes and result in fetal exsanguination1.

Maternal monitoring —OB consultation should be initiated promptly upon patients’ arrival to the ED. Maternal cardiac, maternal contractions, BP and maternal urine output should all be monitored during an acute vaginal bleed in patients with placenta previa. 2

Indications for maternal transfusion- Transfusion should be considered if resuscitation with 2 liters of crystalloid does not resolve hemodynamic instability.

Indications for delivery — Delivery (C-Section delivery is the delivery route of choice) is indicated if any of the following occur: A non-reassuring fetal heart rate tracing unresponsive to maternal oxygen therapy, left-sided positioning, and intravascular volume replacement Life-threatening refractory maternal hemorrhage Significant vaginal bleeding after 34 weeks of gestation3

1 Lockwood, CJ, Russo-Stieglitz, K; Vasa previa and velamentous umbilical cord; UpToDate; Last literature review version 18.2: May 2010 | This topic last updated: June 1, 2010. www.uptodate.com; Retrieved October 25, 2010.2 Lockwood, CJ, Russo-Stieglitz, Management of placenta previa; UpToDate; Last literature review version 18.2: May 2010 | This topic last updated: June 14, 2010. www.uptodate.com; Retrieved October 25, 2010.3 Lockwood, CJ, Russo-Stieglitz, Management of placenta previa; UpToDate; Last literature review version 18.2: May 2010 | This topic last updated: June 14, 2010. www.uptodate.com; Retrieved October 25, 2010.

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Figure: 18 week gestation with complete placenta previa. Marked as PLC. Retrieved from Google images, October 25, 2010. http://www.google.com/imgres?imgurl=http://1.bp.blogspot.com/_WnNkrYwZkW8/SdDd2gVU6pI/AAAAAAAAB-g/adNMFtqHlFw/s400/KAMARIAH_0000%2BP%2Bprevia.jpg&imgrefurl=http://nexradiology.blogspot.com/2009/03/complete-placenta-previa.html&usg=__drrNNRzaz7xhQbKckQuKXCkGGXs=&h=300&w=400&sz=20&hl=en&start=31&sig2=elUFWY-c-siEjqx3icUSwg&zoom=1&itbs=1&tbnid=NHKEvXhib02m4M:&tbnh=93&tbnw=124&prev=/images%3Fq%3Dplacenta%2Bprevia%26start%3D18%26hl%3Den%26sa%3DN%26gbv%3D2%26ndsp%3D18%26tbs%3Disch:1&ei=a9bFTPaOPMSqlAeGg6TlCQ

http://www.google.com/imgres?imgurl=http://1.bp.blogspot.com/_WnNkrYwZkW8/SdDd2gVU6pI/AAAAAAAAB-g/adNMFtqHlFw/s400/KAMARIAH_0000%2BP%2Bprevia.jpg&imgrefurl=http://nexradiology.blogspot.com/2009/03/complete-placenta-previa.html&usg=__drrNNRzaz7xhQbKckQuKXCkGGXs=&h=300&w=400&sz=20&hl=en&start=31&sig2=elUFWY-c-siEjqx3icUSwg&zoom=1&itbs=1&tbnid=NHKEvXhib02m4M:&tbnh=93&tbnw=124&prev=/images%3Fq%3Dplacenta%2Bprevia%26start%3D18%26hl%3Den%26sa%3DN%26gbv%3D2%26ndsp%3D18%26tbs%3Disch:1&ei=a9bFTPaOPMSqlAeGg6TlCQ



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REFERENCES


Keadey M, Houry D. Complications in Pregnancy Part 2: Hypertensive Disorders of Pregnancy and Vaginal Bleeding. Emergency Medicine Practice. 2009; 11 (5):1-19.

Arkbarnia H, Marco C. Complications of Pregnancy - Part 2: Emergency Medicine Reports. 2008; 29(4):37-48.

Lockwood, CJ, Russo-Stieglitz, K; Vasa previa and velamentous umbilical cord; UpToDate; Last literature review version 18.2: May 2010 | This topic last updated: June 1, 2010. www.uptodate.com; Retrieved October 25, 2010.

Lockwood, CJ, Russo-Stieglitz, Management of placenta previa; UpToDate; Last literature review version 18.2: May 2010 | This topic last updated: June 14, 2010. www.uptodate.com; Retrieved October 25, 2010.

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Documents

Patient Name; Age€¦ · Web viewUltrasound exam showing placenta previa CBC with Hgb = 5.9 gm/dL Distractors – distraught husband Actors Roles – nurse, husband, consultant (on