POTD: Trauma Tuesday! RhIG in the Pregnant Trauma Patient

Clinical Scenario:  26 yo F G1P0 at 33 weeks pregnancy presents via ambulance after a MVC.  She was a seatbelted driver with airbags deployed, no intrusion into her compartment.  She’s complaining of abdominal pain.  On exam, she has a seatbelt sign and very mild vaginal bleeding.  While placing your orders, you wonder if there are any lab tests that you should order specifically in a pregnant trauma patient.  You also wonder if you should go ahead and order her RhIG while you’re on the computer…  

Question:  Who do you give RhIG to?  How much do you give?  How much time do you have from injury to give it?  What labs do you order?

Rho(D) immune globulin (RhIG, aka Rhogam) is given to Rh negative females for concerns of isoimmunization during fetomaternal hemorrhage (there’s a break in placental barrier and fetal Rh positive blood enters maternal circulation).   As little as 0.01-0.03mL of fetal blood can cause isoimmunization.

A type and screen is needed initially to determine the Rh status of the patient.  A Rh negative female should receive an initial prophylactic RhIG dose of 300mcg IM within 72 hours of injury.  This dose protects against 30mL of fetal blood.  However, depending on the amount of fetomaternal hemorrhage, the patient may need more RhIG. To determine this, a Kleihauer Betke test should be ordered to quantify the degree of fetomaternal hemorrhage (A blood sample from the female is drawn and placed in an acid-elution assay and stained.  The fetal RBCs are left on the smear as rose pink while the maternal cells turn “ghost-like”).  The percent fetal cells is resulted and the additional number of vials of RhIG needed can be further calculated (check out this link for an example). The Kleihauer Betke test has a threshold of 5mL to be positive, so even if it is negative, it does not mean there was no fetomaternal hemorrhage.  **Do not underdose RhIG**

Want to read more?

https://www.acep.org/Clinical---Practice-Management/Trauma-in-the-Obstetric-Patient--A-Bedside-Tool/#sm.00019l0wujcacfjxrjy2901y3szy0

http://www.emdocs.net/trauma-management-of-the-3rd-trimester-pregnant-patient-pearls-pitfalls/

https://lifeinthefastlane.com/trauma-tribulation-006/

https://www.ncbi.nlm.nih.gov/books/NBK430876/

http://www.trauma.org/archive/resus/pregnancytrauma.html

https://www.uptodate.com/contents/prevention-of-rhesus-d-alloimmunization-in-pregnancy

POTD: Asymptomatic Hypertension in the ED

Clinical Scenario: 58 yo F with no significant PMH presents to the ED for high blood pressure.  She reports having a BP of 190/110 at the pharmacy and came right to the ED.  She denies HA, vision changes, chest pain, dyspnea, and oliguria.  She last saw her PMD for her annual checkup many months ago, noted her BP was mildly elevated at that time, no medications were started then, and she is not currently taking any medications other than her vitamins.  

Question: What is your workup for her?  Should you go beyond an H&P?  Do you start her on medications?

As per ACEP Clinical Policy from 2013, the term asymptomatic markedly elevated blood pressure includes the frequently used terms of asymptomatic hypertension and hypertensive urgency, which described markedly elevated high blood pressure without clinical evidence of acute end organ injury.

Under their 2013 policy, Level C recommendation is that: asymptomatic markedly elevated blood pressure in ED patients do not require routine screening for acute target organ injury (such as serum Cr, UA, EKG). Though in select patients, like those with poor follow-up, a screening for elevated Cr may identify kidney injury that changes disposition like admission.

Another Level C recommendation is that routine ED medical intervention is not required in these asymptomatic markedly elevated blood pressure patients.  Consensus recommendation is that in select patients, like those with poor follow up, the ED physician may treat the BP in the ED and/or start long term therapy for BP control.  Consensus recommendation is that patients with asymptomatic markedly elevated blood pressure should be referred for outpatient follow-up.

**So when do you treat the number acutely?  Treat the clinical picture, not the elevated BP reading**

Want to read more?

https://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=429&inittopicdload=1

http://www.emdocs.net/em3am-asymptomatic-hypertension/

http://epmonthly.com/article/dont-let-hypertension-stress/

https://www.mdedge.com/emed-journal/article/114826/hematology/hypertension-ed

Wolf SJ, Lo B, Shih RD, Smith MD, Fesmire FM. Clinical policy: Critical issues in the evaluation and management of adult patients in the emergency department with asymptomatic elevated blood pressure. Ann Emerg Med 2013;62(1):59–68.  https://www.ncbi.nlm.nih.gov/pubmed/23842053

POTD: Euglycemic DKA

Today’s POTD comes from Dr. Buckingham.  Her clinical question: Can a patient present as a first time diabetic with euglycemic DKA? Hmmm... Let’s break question down.  

How do you diagnose diabetes in a patient?

• Symptomatic hyperglycemia with classic symptoms of thirst, polyuria, weight loss with a random BGM≥200mg/dL
• Fasting plasma glucose ≥126 mg/dL
• Oral glucose tolerance test with two hour plasma glucose ≥200 mg/dL
• HbA1C values ≥6.5%

What is euglycemic DKA?

Just as the name states, euglycemic DKA is diabetic ketoacidosis without the hyperglycemia.  Patients will have the serum/urine ketones and anion gap metabolic acidosis of DKA while glucose levels are normal/mildly elevated (<200mg/dL).  Patients that present with euglycemic DKA are usually those with poor carbohydrate intake, adequate hydration, use of insulin, alcohol intake, or use of sodium-glucose co-transporter 2 (SGLT2) inhibitors [Canagliflozin (Invokana), Dapagliflozin (Farxiga), Empagliflozin (Jardiance)].  Euglycemic DKA occurs more often in type 1 but can also occur in type 2 diabetes, and the most common symptom is vomiting.

**Check labs for patients with concerning story of DM, poor carbohydrate intake and/or taking SGLT2 inhibitor, c/o nausea/vomiting/fatigue/SOB**

So can someone present with no prior hx of diabetes and have euglycemic DKA?

Maybe, if they have been having poor carbohydrate intake but tolerating fluids.  However, also consider a broader differential diagnosis such as starvation ketoacidosis, alcoholic ketoacidosis, lactic acidosis, and drug toxicity.

Want to read more?

http://care.diabetesjournals.org/content/38/9/1638

https://emergencymedicinecases.com/euglycemic-dka/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4488998/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5592704/

http://rebelem.com/euglycemic-dka-not-myth/

https://www.uptodate.com/contents/clinical-presentation-and-diagnosis-of-diabetes-mellitus-in-adults