Cardiac arrest in pregnancy: Difference between revisions
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*Occurs in ~1 in 30,000 pregnancies<ref>McDonnell, NJ. Cardiopulmonary arrest in pregnancy: two case reports of successful outcomes in association with perimortem Caesarean delivery. Br J Anaesth. (2009)103(3):406-409.</ref> | *Occurs in ~1 in 30,000 pregnancies<ref>McDonnell, NJ. Cardiopulmonary arrest in pregnancy: two case reports of successful outcomes in association with perimortem Caesarean delivery. Br J Anaesth. (2009)103(3):406-409.</ref> | ||
*Key differences from non-pregnant cardiac arrest<ref>Engels PT, Caddy SC, Jiwa G, Douglas Matheson J. Cardiac arrest in pregnancy and perimortem cesarean delivery: case report and discussion. CJEM. 2011 Nov;13(6):399-403.</ref>: | *Key differences from non-pregnant cardiac arrest<ref>Engels PT, Caddy SC, Jiwa G, Douglas Matheson J. Cardiac arrest in pregnancy and perimortem cesarean delivery: case report and discussion. CJEM. 2011 Nov;13(6):399-403.</ref>: | ||
**Need to remove uterus from IVC (by rolling | **Need to remove uterus from IVC (by rolling patient to side or manual lifting of uterus) | ||
***Do not obtain venous access below the diaphragm | ***Do not obtain venous access below the diaphragm | ||
**Secure airway immediately | **Secure airway immediately | ||
| Line 41: | Line 41: | ||
**May be of concern even if < 20 wks | **May be of concern even if < 20 wks | ||
**Put hands on right side of gravid abdomen, and '''pull upwards towards ceiling''' and '''leftwards''' | **Put hands on right side of gravid abdomen, and '''pull upwards towards ceiling''' and '''leftwards''' | ||
**OR tilt | **OR tilt patient 15–30° to left<ref>Campbell TA and Sanson TG. Cardiac arrest and pregnancy. J Emerg Trauma Shock. 2009 Jan-Apr; 2(1): 34–42.</ref> | ||
**Downward force will worse IVC compression | **Downward force will worse IVC compression | ||
*IVs above diaphragm - avoids IVC which may be compressed | *IVs above diaphragm - avoids IVC which may be compressed | ||
*Administer fluids and blood products | *Administer fluids and blood products | ||
*Anticipate difficult airway with high risk of aspiration | *Anticipate difficult airway with high risk of aspiration | ||
*If | *If patient receiving IV magnesium prearrest, stop mag and give arrest dose calcium | ||
*Continue [[CPR]], positioning, de-fib, drugs, and fluids during and after C-section | *Continue [[CPR]], positioning, de-fib, drugs, and fluids during and after C-section | ||
*[[Therapeutic hypothermia]] contraindicated if | *[[Therapeutic hypothermia]] contraindicated if patient still intrapartum, but may be safe for postpartum cardiac arrest<ref>Song et al. Safely completed therapeutic hypothermia in postpartum cardiac arrest survivors. Am Jour Emer Med. June 2015. Volume 33, Issue 6, Pages 861.e5–861.e6.</ref> | ||
==Disposition== | ==Disposition== | ||
Revision as of 08:22, 2 July 2016
Background
- Occurs in ~1 in 30,000 pregnancies[1]
- Key differences from non-pregnant cardiac arrest[2]:
- Need to remove uterus from IVC (by rolling patient to side or manual lifting of uterus)
- Do not obtain venous access below the diaphragm
- Secure airway immediately
- Non-cardiac cause of arrest is more likely
- Perimortem C-section should be performed rapidly, and may save both fetus and mother
- Need to remove uterus from IVC (by rolling patient to side or manual lifting of uterus)
Clinical Features
- Cardiopulmonary arrest in gravid female.
Differential Diagnosis
BEAT CHOPS
- Bleeding / DIC
- Embolism - coronary, pulmonary, amniotic fluid
- Anesthetic complications
- Tone (uTerine aTony)
- Cardiac disease - MI, aortic dissection, cardiomyopathy
- HTN, preeclampsia, eclampsia
- Other - all typical H's and T's
- Placental abruption, placental previa
- Sepsis
Diagnosis
- Clinical
Management
- Standard ACLS management
- Early defibrillation - use standard energy levels (safe for fetus in maternal arrest)
- Anterior/Posterior pad placement is preferred
- May use AP pads to pace as well
- Give typical adult ACLS drugs/dosages
- Aiway management / Ventilate with 100% FiO2
- Monitor EtCO2
- Ensure post-cardiac arrest care
- Early defibrillation - use standard energy levels (safe for fetus in maternal arrest)
Maternal Modifications
- Manual left uterine displacement
- Displaces uterus to patient's left, relieving aortocaval compression
- May be of concern even if < 20 wks
- Put hands on right side of gravid abdomen, and pull upwards towards ceiling and leftwards
- OR tilt patient 15–30° to left[3]
- Downward force will worse IVC compression
- IVs above diaphragm - avoids IVC which may be compressed
- Administer fluids and blood products
- Anticipate difficult airway with high risk of aspiration
- If patient receiving IV magnesium prearrest, stop mag and give arrest dose calcium
- Continue CPR, positioning, de-fib, drugs, and fluids during and after C-section
- Therapeutic hypothermia contraindicated if patient still intrapartum, but may be safe for postpartum cardiac arrest[4]
Disposition
- Admit (if ROSC obtained)
See Also
References
- ↑ McDonnell, NJ. Cardiopulmonary arrest in pregnancy: two case reports of successful outcomes in association with perimortem Caesarean delivery. Br J Anaesth. (2009)103(3):406-409.
- ↑ Engels PT, Caddy SC, Jiwa G, Douglas Matheson J. Cardiac arrest in pregnancy and perimortem cesarean delivery: case report and discussion. CJEM. 2011 Nov;13(6):399-403.
- ↑ Campbell TA and Sanson TG. Cardiac arrest and pregnancy. J Emerg Trauma Shock. 2009 Jan-Apr; 2(1): 34–42.
- ↑ Song et al. Safely completed therapeutic hypothermia in postpartum cardiac arrest survivors. Am Jour Emer Med. June 2015. Volume 33, Issue 6, Pages 861.e5–861.e6.