cardiac arrest in pregnancy
TRANSCRIPT
Paleerat Jariyakanjana, MDEmergency physician
19 Oct 2015
The Critically Ill Pregnant Patient
Severity of Illness and Early Warning Scores
obstetric early warning score (Class I; Level of Evidence C)
Management of the Unstable Pregnant Patient
full left lateral decubitus position (Class I; Level of Evidence C)
100% oxygen by face mask (≥15 L/min) (Class I; Level of Evidence C)
Intravenous access: above the diaphragm (Class I; Level of Evidence C)
Cardiac Arrest Management
Chest Compressions in Pregnancy
placed supine for chest compressions(Class I; Level of Evidence C)
mechanical chest compressions: not advised
Factors Affecting Chest Compressionsin the Pregnant Patient
Continuous manual LUD: uterus ≥ umbilicus (Class I; Level of Evidence C)
Factors Affecting Chest Compressionsin the Pregnant Patient
Advanced Cardiovascular Life Support
Advanced Cardiovascular Life Support
Special Equipment Required for a Maternal Cardiac Arrest
Special Equipment Required for a Maternal Cardiac Arrest
Breathing and Airway Management in Pregnancy
Management of Hypoxia Airway Management
Management of Hypoxia
early ventilatory support (Class I; Level of Evidence C)
Airway Management
Endotracheal intubation should be performed by an experienced laryngoscopist (Class I; Level of Evidence C).A. ETT with a 6.0-7.0 mm ID (Class I; Level of
Evidence C)B. ≤2 laryngoscopy attempts (Class IIa; Level of
Evidence C)C. Supraglottic airway placement: failed intubation
(Class I; Level of Evidence C)D. airway control fail and mask ventilation is not
possible → emergency invasive airway access
Airway Management
Cricoid pressure: not routinely recommended (Class III; Level of Evidence C)
Delivery
PMCD: after ≈4 minutes of resuscitative efforts (Class IIa; Level of Evidence C)
When PMCD is performedA. not be transported to OR (Class IIa; Level of
Evidence B)B. not wait for surgical equipment; only a scalpel is
required (Class IIa; Level of Evidence C)C. not spend time on lengthy antiseptic procedures
(Class IIa; Level of Evidence C)D. Continuous manual LUD until the fetus is
delivered (Class IIa; Level of Evidence C)
EMS Considerations
If available, transport should be directed toward a center that is prepared to perform PMCD, but transport should not be prolonged by >10 minutes to reach a center with more capabilities (Class IIb; Level of Evidence C).
Cause of the Cardiac Arrest
Table 5. Most Common Etiologies of Maternal Arrest and Mortality
Letter Cause Etiology
A Anesthetic complications High neuraxial blockHypotensionLoss of airwayAspirationRespiratory depressionLocal anesthetic systemic toxicity
Accidents/trauma TraumaSuicide
B Bleeding CoagulopathyUterine atonyPlacenta accretaPlacental abruptionPlacenta previaRetained products of conceptionUterine ruptureSurgicalTransfusion reaction
C Cardiovascular causes Myocardial infarctionAortic dissectionCardiomyopathyArrhythmiasValve diseaseCongenital heart disease
Table 5. Most Common Etiologies of Maternal Arrest and Mortality
Letter Cause Etiology
D Drugs OxytocinMagnesiumDrug errorIllicit drugsOpioidsInsulinAnaphylaxis
E Embolic causes Amniotic fluid embolusPulmonary embolusCerebrovascular eventVenous air embolism
F Fever SepsisInfection
G General H’s and T’s
H Hypertension PreeclampsiaEclampsiaHELLP syndrome, intracranialbleed
Point-of-Care Instruments
point-of-care checklists (Class I; Level of Evidence B)
Immediate Postarrest Care
still pregnant: full left lateral decubitus position not in full left lateral tilt: manual LUD (Class I;
Level of Evidence C)