+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”

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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

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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

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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

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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

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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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CARDIAC ARRESTLARRY F. CHU, MD, MS, ANDREA J. FULLER, MD, STEVE LIPMAN, MD AND KYLE HARRISON, MD

OBSTETRICContinued

fromPrior Page

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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

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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

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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

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