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+DX
2’
≥100 compressions/min
≥ 2 INCHES DEEPALLOW COMPLETE CHEST RECOIL
Assign timer/documenter ROTATE COMPRESSORS Q2 MIN MONITOR CPR QUALITY
CP
R T
IPS
manual LUD
Identify the team leader
ROSC = RETURN OF SPONTANEOUS CIRCULATION
PREPARE FOR IMMEDIATE C-SECTION AT SITE OF ARREST. IF NO ROSC WITHIN 4 MINS OF ARREST, PROCEED TO IMMEDIATE C-SECTION!
5
GET SCALPEL!
ST
ART TIMING EVENTS
≥100
minimize BREAKS IN CPR
IMPROVE CPR!
IF...DBP <20 mmHg orETCO2 <10 mmHg
Place in 30° Lateral Tilt
HANDS HIGHER
Who’s the Leader? ≥2”
Continuedon
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CALL FOR HELP!IMPORTANT PHONE NUMBERS:
NO PULSE
CALL FOR CODE CARTSTART CPR IMMEDIATELY!2
1
4
3
CARDIAC ARRESTLARRY F. CHU, MD, MS, ANDREA J. FULLER, MD, STEVE LIPMAN, MD AND KYLE HARRISON, MD
OBSTETRIC PREGNANT
NEONATAL TEAM#:
ADULT CODE TEAM #:
PUSH HARD!
PUSH FAST!OR
on pt’s LEFT-side
no tilt &LUD
30° TiltBEG
IN C
PR
place HANDS HIGHER on sternum DURING CPR
PREGNANT
≥2”
CARDIAC ARRESTLARRY F. CHU, MD, MS, ANDREA J. FULLER, MD, STEVE LIPMAN, MD AND KYLE HARRISON, MD
OBSTETRIC PREGNANTContinuedfrom
Prior Page
IMM
EDIA
TE
ASSESS & PERFORM
ADEQUATE IV ACCESS? IF NOT-> consider humeral io lineplace AED pads and assess AIRWAY & VENTILATION?
ADEQUATEVENTILATION?
IO LINE
ANTICIPATE DIFFICULTAIRWAY
6
IV LINE
PLACE ABOVE DIAPHRAGM
Continuedon
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PLACE AED
SHO
CK
7
DEFIBRILLATE200 JOULES(BIPHASIC ENERGY)
OR
DR
UG
S
IF POSSIBLE ASSIGN PERSON TO TIME & ADMINISTER DOSES VASOPRESSIN DOSE COULD REPLACE ONE EPINEPHRINE DOSE
CONSIDER VASOPRESSIN
40 UNITS IVONCE
8 EPINEPHRINE 1MG IVEVERY 3-5 MIN
ASSESS RHYTHM
IO LINE
ASSESS FOR SHOCKABLE RYHTHM. IF VT/VF SHOCK!
AIM
.STA
NFO
RD.E
DU
| O
B A
CLS
V 0
.1 3.
2013
US
2.20
.20
13
1
CA
RD
IAC
AR
RES
T
CARDIAC ARRESTLARRY F. CHU, MD, MS, ANDREA J. FULLER, MD, STEVE LIPMAN, MD AND KYLE HARRISON, MD
OBSTETRIC PREGNANTContinuedfrom
Prior Page
IMM
EDIA
TE
ASSESS & PERFORM
ADEQUATE IV ACCESS? IF NOT-> consider humeral io lineplace AED pads and assess AIRWAY & VENTILATION?
ADEQUATEVENTILATION?
IO LINE
ANTICIPATE DIFFICULTAIRWAY
6
IV LINE
PLACE ABOVE DIAPHRAGM
Continuedon
Next Page
PLACE AED
SHO
CK
7
DEFIBRILLATE200 JOULES(BIPHASIC ENERGY)
OR
DR
UG
S
IF POSSIBLE ASSIGN PERSON TO TIME & ADMINISTER DOSES VASOPRESSIN DOSE COULD REPLACE ONE EPINEPHRINE DOSE
CONSIDER VASOPRESSIN
40 UNITS IVONCE
8 EPINEPHRINE 1MG IVEVERY 3-5 MIN
ASSESS RHYTHM
IO LINE
ASSESS FOR SHOCKABLE RYHTHM. IF VT/VF SHOCK!
AIM
.STA
NFO
RD.E
DU
| O
B A
CLS
V 0
.1 3.
2013
US
2.20
.20
13
1
CA
RD
IAC
AR
RES
T
Reference: 1) Part 12: Cardiac Arrest in Special Situations : 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Vanden Hoek et al., Circulation. 2010;122:S829-S861. 2) Maternal CPR illustrations by Ms. Janet Fong, WWW.AIC.CUHK.EDU.HK/WEB8
Continuedfrom
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LARRY F. CHU, MD, MS, ANDREA J. FULLER, MD, STEVE LIPMAN, MD AND KYLE HARRISON, MD
TX
10
CARDIAC ARRESTOBSTETRIC PREGNANT
REPEAT CYCLE UNTIL RESUSCITATED8
BEG
IN C
PR
≥100 compressions/minCON
T. C
PR
≥100
REPEAT CYCLE UNTIL RESUSCITATEDCPR + DEFIBRILLATE (IF VT/VF) EVERY 2 MINS + DRUGS
9
OT
HER
IF running, STOP MaG INFUSION, give 10% CaCl2 10CC IV VENTilate 10 BREATHS/MIN Deliver 100% Oxygen
10/min
Mg
Give Ca2+Stop Mg
2+
100% O211
Ca2+
2’
MINIMIZE BREAKS IN CPR ROTATE COMPRESSORS Q2 MIN MONITOR CPR QUALITY
MI
NIMIZE BREAKS IN CPR
IF...DBP <20 mmHg orETCO2 <10 mmHg
≥2”
IMPROVE CPR!
PEA/ASYSTOLE1) Bleeding2) Drug Toxicity Local Anesthetic, Mg, Oxytocin3) High Spinal4) Hypoventilation5) Embolism pulmonary, afe, vae
VF/VT1) Hyperkalemia2) Coronary Thrombosis3) HypoMg or Torsades
TX: Consider Antiarrythmics amiodarone 300 mg iv or lidocaine 100 mg iv
OTHER CAUSESContinue to #13 to rule out other causes & TREATMENT GUIDELINES.
Continue to #14 for VF/VT treatment guidelines
FIRST RULE OUT COMMON TREATABLE CAUSES
R/O
CA
USE
S
12
Continuedon
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13 14 13
AIM
.STA
NFO
RD.E
DU
| O
B A
CLS
V 0
.1 3.
2013
US
2.20
.20
13
CA
RD
IAC
AR
RES
T
1
Continuedfrom
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LARRY F. CHU, MD, MS, ANDREA J. FULLER, MD, STEVE LIPMAN, MD AND KYLE HARRISON, MD
TX
10
CARDIAC ARRESTOBSTETRIC PREGNANT
REPEAT CYCLE UNTIL RESUSCITATED8
BEG
IN C
PR
≥100 compressions/minCON
T. C
PR
≥100
REPEAT CYCLE UNTIL RESUSCITATEDCPR + DEFIBRILLATE (IF VT/VF) EVERY 2 MINS + DRUGS
9
OT
HER
IF running, STOP MaG INFUSION, give 10% CaCl2 10CC IV VENTilate 10 BREATHS/MIN Deliver 100% Oxygen
10/min
Mg
Give Ca2+Stop Mg
2+
100% O211
Ca2+
2’
MINIMIZE BREAKS IN CPR ROTATE COMPRESSORS Q2 MIN MONITOR CPR QUALITY
MI
NIMIZE BREAKS IN CPR
IF...DBP <20 mmHg orETCO2 <10 mmHg
≥2”
IMPROVE CPR!
PEA/ASYSTOLE1) Bleeding2) Drug Toxicity Local Anesthetic, Mg, Oxytocin3) High Spinal4) Hypoventilation5) Embolism pulmonary, afe, vae
VF/VT1) Hyperkalemia2) Coronary Thrombosis3) HypoMg or Torsades
TX: Consider Antiarrythmics amiodarone 300 mg iv or lidocaine 100 mg iv
OTHER CAUSESContinue to #13 to rule out other causes & TREATMENT GUIDELINES.
Continue to #14 for VF/VT treatment guidelines
FIRST RULE OUT COMMON TREATABLE CAUSES
R/O
CA
USE
S
12
Continuedon
Next Page
13 14 13
CARDIAC ARRESTLARRY F. CHU, MD, MS, ANDREA J. FULLER, MD, STEVE LIPMAN, MD AND KYLE HARRISON, MD
OBSTETRICContinued
fromPrior Page
FIN
D T
REA
TAB
LE C
AU
SES
– B
EAU
-CH
OP
S
Continuedon
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IF SUSPECTED THEN:1) Rapid bolus IV Fluids.2) Activate MTG.3) Consider transfusion of blood products.4) Consider placement of
arterial line.5) See Tab #14 - MTG
BLEEDING/DIC ANESTHETICS UTERINE ATONY
HYPERTENSION PLACENTA SEPSIS
IF PULMONARY EMBOLISM:1) Consider TEE/TTE to rule out RV failure.2) Consider thrombolytic therapy- discuss risk/ bene�ts with team.IF AMNIOTIC FLUID EMBOLISM:1) See Tab #24 - AFE
CROSS-CHECK POSSIBLE CAUSES WITH TEAM FOR DIAGNOSIS
ANESTHETIC COMPLICATIONS INCLUDE:1) Spinal shock from regional anesthesia - Tab #232) Local anesthetic toxicity Tab #113) Loss of airway or ventilation - Tabs #5,10
IF SUSPECTED CONSIDER:1) Oxytocin2) Misoprostol3) Methylergonovine4) Carboprost 5) Bimanual fundal massage6) See Tab #27 - Uterine Atony
IF SUSPECTED CONSIDER:1) Myocardial infarction -
consider percutaneous coronary intervention.
2) Aortic dissection - Consider cardiac surgery consult3) Congenital heart disease - Consider cards consult4) Pulmonary hypertension
- Consider NO.5) Magnesium toxicity - Consider CaC12 1gmIV
IF SUSPECTED CONSIDER:1) Pre-eclampsia2) Eclampsia3) See Tab #12 - Hypertension
IF SUSPECTED CONSIDER:1) Placenta abruptio - Tab #252) Placenta accreta - Tab #26
IF SUSPECTED CONSIDER:1) Goals: CVP ≥8-12mmHg, MAP≥65mmHg, Urine output≥0.5ml/kg/h, MVO2 Sat≥65%.2) Fluid therapy3) Antimicrobial therapy4) Removing source of sepsis6) See Tab #32 - Sepsis
13
EMBOLISM
CARDIAC DISEASEAIM
.STA
NFO
RD.E
DU
| O
B A
CLS
V 0
.1 3.
2013
US
2.20
.20
13
1
CA
RD
IAC
AR
RES
T
Continuedon
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Continuedfrom
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FIN
D T
REA
TAB
LE C
AU
SES
– B
EAU
-CH
OP
S
SUSPECT IF: Unilateral breath sounds, hneck veins, [trachea
IF SUSPECTED: Perform needle decompression (Mid-
clavicular line 2nd intercostal space) and chest tube.
HYPO/HYPERTHERMIA TOXINS POISON
RULE OUT:1) Hyperkalemia2) Hypocalcemia3) Acidosis4) Hypoglycemia5) Hypokalemia
CROSS-CHECK POSSIBLE CAUSES WITH TEAM FOR DIAGNOSIS
IF SUSPECTED THEN:1) Consider TEE 2) Consider emergent revascularization or cath lab.3) Consider intra aortic balloon pump
IF SUSPECTED THEN:1) 100% FiO2. In OR: rule out switched gas lines. Use separate O2 tank.2) Check connections Re-con�rm ET tube placement. 3) Con�rm bilateral breath sounds.4) Suction ET tube. 5) Rule out other causes with TTE/TEE.
SUSPECT IF:1) hCVP, equalization of right & left- sided pressures.2) Consider TEE/TTE to rule out pericardial e�usion.3) If present, perform pericardiocentisis.
IF SUSPECTED CONSIDER:1) Rapid Re-warming Warm IV �uids, peritoneal lavage, ECMO or CPBIF >40°C THEN:1) Rule out malignant hyperthermia and treat if found.
CONSIDER ALL MEDS RECEIVED INCLUDING:1) Existing infusions2) Prescribed medications3) Ilicit drug use4) Syringe swaps or drug errors5) PoisoningIF SUSPECTED THEN:1) Contact poison control/ pharmacy2) Administer appropriate therapy/antidote
FOR A POISON EMERGENCY IN THE UNITED STATES:1) Call 1-800-222-1222
CARDIAC ARRESTLARRY F. CHU, MD, MS, ANDREA J. FULLER, MD, STEVE LIPMAN, MD AND KYLE HARRISON, MD
OBSTETRIC PREGNANT
PNEUMOTHORAX CORONARY THROMBOSIS
SpO2
79
HYPOXIA
13
ABG TO RULE OUT
CARDIAC TAMPONADE
AIM
.STA
NFO
RD.E
DU
| O
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CLS
V 0
.1 3.
2013
US
2.20
.20
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1
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RD
IAC
AR
RES
T
VT/
VFI
B C
ON
SID
ERA
TIO
NS
CONSIDER ANTIARRYTHMICS
AMIODARONE 300 MG IV ORLIDOCAINE 100 MG IV
iMG OR TORSADES?
CONSIDER MgSO4 2GM IV
HYPERKALEMIA?
CONSIDER: INSULIN 10 UNITS IV WITHGLUCOSE 40-60GM IV1
CONSIDER: 20 ML 10% CALCIUM-GLUCONATE IV
(OVER 5-10 MIN*, REPEAT IF NEEDED)2
ALSO CONSIDER: SALBUMETOL 0.5 MG IV1
IF PH<7.20 CONSIDER: BICARBONATE 1-2 AMPS IV1
*INFUSE OVER 20-30 MIN IF PATIENT ON DIGOXIN
1 Ahee P. and Crowe A.V. The management of hyperkalemia in the emergency department. J Accid Emerg Med 2000;17:188-1912Allon M. Treatment and prevention of hyperkalemia in end-stage renal disease. Kidney Int. 1993;43:1197–209.
CORONARY THROMBOSIS?
CHECK ABG:
>7.0 MMOL/LLIFE THREATENING
6.1-6.9 MMOL/LMODERATE
1) CONSIDER TTE.2) CONSIDER EMERGENT REVASCULARIZATION/CATH LAB.3) CONSIDER INTRA AORTIC BALLOON PUMP.
IF SUSPECTED THEN:
14
Continuedfrom
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OBSTETRICA
IM.S
TAN
FORD
.ED
U |
OB
AC
LS V
0.1
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13 U
S 2.
20.2
013
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