EM Quick Hits 53 Postpartum Hemorrhage, Serotonin Syndrome, TBI Herniation Syndromes, Ulcerative Colitis, Pediatric C-Spine Immobilization, Global EM

Topics in this EM Quick Hits podcast

Anand Swaminathan on update to ED management of postpartum hemorrhage (1:11)

Nour Khatib on serotonin syndrome and its mimics (6:09)

Katie Lin on an approach to recognition and management of severe TBI and brain herniation syndromes (15:28)

Hans Rosenberg on ED recognition and management of ulcerative colitis  (24:35)

Heather Cary on pediatric c-spine immobilization controversies and techniques (30:00)

Navpreet Sahsi on the difference between humanitarian and development work (38:03)



Podcast production, editing and sound design by Anton Helman

Written summary & blog post by Shaila Gunn, edited by Anton Helman

Cite this podcast as: Helman, A. Swaminathan, A. Khatib, A. Rosenberg, H. Cary, H. Sashsi, N. EM Quick Hits 53 - Postpartum Hemorrhage, Serotonin Syndrome, TBI Herniation Syndromes, Ulcerative Colitis, Pediatric C-Spine Immobilization, Global EM. Emergency Medicine Cases. November, 2023. https://emergencymedicinecases.com/em-quick-hits-november-2023/. Accessed September 14, 2025.

An Update to ED management of postpartum hemorrhage and the 4 Ts DDx



* Recognition of postpartum hemorrhage is by gestalt



* Defined as more bleeding than expected after vaginal delivery or abortion (classically defined and >500 mL blood loss but difficult to measure accurately - if it looks bad/blood filling the vaginal vault, start resuscitation).





* As soon as postpartum hemorrhage is identified, activate the team



* Call OBGYN but if unavailable, call general surgery





* Identify the cause(s) of the hemorrhage: 4 Ts differential diagnosis of postpartum hemorrhage



* Tone (uterine atony) *most common cause post-delivery

* Tissue (retained placenta or clots) *most common cause post-abortion

* Trauma (large vaginal or cervical tears, uterine rupture)

* Thrombin (pre-existing or acquired coagulopathy i.e. DIC)





* Blood products (RBC +/- platelets, FFP, fibrinogen); consider massive hemorrhage protocol



* Postpartum patients who are hemorrhaging tend to have low fibrinogen with an increased risk for DIC, so have a low threshold to give fibrinogen





* If atony, give 4 uterotonics (oxytocin, misoprostol, methergine, and carboprost)



* If the pregnancy was 38C + ocular or inducible clonus



Consider a broad differential diagnosis for serotonin syndrome



* Mild cases are often mistaken for psychiatric presentations and severe cases may be mistaken for neuroleptic malignant syndrome.

* Rule out infections including meningitis or sepsis and drug overdoses including cocaine, ecstasy, lithium, and anticholinergics.



The treatment of serotonin syndrome is largely supportive



* Recognize and discontinue all serotonergic agents

* Supportive care:



* IV fluid hydration

* Benzodiazepines (act as a non-specific serotonin antagonists); may improve myoclonus, hyperreflexia, and seizures

* Aggressive cooling if hyperthermic (antipyretics are not effective as it is due to increased muscle tone and not central thermoregulation)





* Cyproheptadine is an H1 antihistamine that blocks serotonin receptors and can be considered as a second line agent in mod...