Care of the Critically Ill Pregnant Patient and Perimortem Cesarean Delivery in the Emergency Department.

BACKGROUND: Maternal resuscitation in the emergency department requires planning and special consideration of the physiologic changes of pregnancy. Perimortem cesarean delivery (PMCD) is a rare but potentially life-saving procedure for both mother and fetus. Emergency physicians should be aware of the procedure's indications and steps because it needs to be performed rapidly for the best possible outcomes. OBJECTIVE: We sought to review the approach to the critically ill pregnant patient in light of new expert guidelines, including indications for PMCD and procedural techniques. DISCUSSION: The prevalence of maternal cardiac arrest and survival outcomes of PMCD in the emergency department setting are difficult to estimate. Advanced cardiovascular life support protocols should be followed in maternal arrest with special considerations made based on the physiologic changes of pregnancy. The latest recommendations for maternal resuscitation are reviewed, including advance planning, rapid determination of gestational age, emergent delivery, and postprocedure considerations for PMCD. CONCLUSIONS: Maternal resuscitation requires knowledge of physiologic changes and evidence-based recommendations. PMCD outcomes are best for both mother and fetus when the procedure is performed rapidly and efficiently in the appropriate setting. Emergency physicians should be familiar with this unique clinical scenario so they are adequately prepared to intervene in order to improve maternal and fetal morbidity and mortality.

Emergency department management of shoulder dystocia.

BACKGROUND: Precipitous obstetric deliveries can occur outside of the labor and delivery suite, often in the emergency department (ED). Shoulder dystocia is an obstetric emergency with significant risk of adverse outcome. OBJECTIVE: To review multiple techniques for managing a shoulder dystocia in the ED. DISCUSSION: We review various techniques and approaches for achieving delivery in the setting of shoulder dystocia. These include common maneuvers, controversial interventions, and interventions of last resort. CONCLUSIONS: Emergency physicians should be familiar with multiple techniques for managing a shoulder dystocia to reduce the chances of fetal and maternal morbidity and mortality.

Appendicitis, diverticulitis, and colitis.

Appendicitis, diverticulitis, and colitis are common gastrointestinal conditions presenting to the emergency department (ED). Although it is a common condition, the diagnosis of appendicitis remains challenging, and the approach to this disease continues to evolve. The diagnostic approach to diverticulitis is more straightforward, and treatment and the decision whether to hospitalize varies with disease severity. Colitis may be caused by inflammatory bowel disease, ischemia, or infection. This article details an ED-based approach to each of these disease entities.