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 | ||
**Non-cardiac cause of arrest is more likely | **Non-cardiac cause of arrest is more likely | ||
** | **[[Resuscitative hysterotomy]] should be performed rapidly (within 4 minutes), and may save both fetus and mother | ||
==Clinical Features== | ==Clinical Features== | ||
*Cardiopulmonary arrest in gravid female. | *[[Cardiac arrest|Cardiopulmonary arrest]] in gravid female. | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
===Cardiac Arrest in Pregnancy=== | |||
''BEAT CHOPS'' | ''BEAT CHOPS'' | ||
* | *[[hemorrhage|'''B'''leeding]] / [[DIC]] | ||
* | *'''E'''mbolism - coronary, [[PE|pulmonary]], [[amniotic fluid embolus|amniotic fluid]] | ||
* | *'''A'''nesthetic complications | ||
* | *'''T'''one (uTerine aTony) | ||
* | *'''C'''ardiac disease - [[MI]], [[aortic dissection]], [[peripartum cardiomyopathy|cardiomyopathy]] | ||
* | *[[hypertensive emergency|'''H'''ypertension]], [[preeclampsia]], [[eclampsia]] | ||
* | *'''O'''ther - all typical H's and T's | ||
*Placental abruption, | **[[Hypovolemia]] | ||
*Sepsis | **[[Hypoxemia]] | ||
**Hydrogen ion (i.e. [[acidosis|acidemia]]) | |||
**[[Hypokalemia|Hypo]]/[[hyperkalemia]] | |||
**[[Hypothermia]] | |||
**[[Tension Pneumothorax]] | |||
**[[Pericardial effusion and tamponade|Cardiac tamponade]] | |||
**[[Toxicology (main)|Toxins]] | |||
**[[Pulmonary embolism|Thrombosis, pulmonary]] | |||
**[[Acute coronary syndrome (main)|Thrombosis, coronary]] | |||
*[[Placental abruption|'''P'''lacental abruption]], [[placenta previa]] | |||
*[[Sepsis|'''S'''epsis]] | |||
== | ==Evaluation== | ||
[[File:Bumm 123 lg - Copy.jpg|thumb|Estimated gestational age based on physical exam.]] | |||
*Clinical | *Clinical | ||
{{Fundal height in pregnancy}} | |||
==Management== | ==Management== | ||
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***May use AP pads to pace as well | ***May use AP pads to pace as well | ||
**Give typical adult [[ACLS]] drugs/dosages | **Give typical adult [[ACLS]] drugs/dosages | ||
** | **Airway management / Ventilate with 100% FiO2 | ||
**Monitor EtCO2 | **Monitor EtCO2 | ||
**Ensure post | **Ensure [[post cardiac arrest]] care | ||
===Maternal Modifications=== | ===Maternal Modifications=== | ||
*[[Resuscitative hysterotomy]] (aka perimortem c-section) if estimated gestational age >24wks (fundus >~4cm above umbilicus) | |||
**Must make decision early, <4min without ROSC | |||
*Manual left uterine displacement | *Manual left uterine displacement | ||
**Displaces uterus to patient's left, relieving aortocaval compression | **Displaces uterus to patient's left, relieving aortocaval compression | ||
**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 [[IVF|fluids]] and [[pRBCs|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== | ||
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*[[Pregnancy (main)]] | *[[Pregnancy (main)]] | ||
*[[Perimortem cesarean delivery]] | *[[Perimortem cesarean delivery]] | ||
==External Links== | |||
*https://first10em.com/cardiac-arrest-in-pregnancy-the-perimortem-cesarean-section/ | |||
==References== | ==References== | ||
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[[Category:Critical Care]] | [[Category:Critical Care]] | ||
[[Category: | [[Category:OBGYN]] |
Latest revision as of 20:30, 3 August 2022
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
- Resuscitative hysterotomy should be performed rapidly (within 4 minutes), 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
Cardiac Arrest in Pregnancy
BEAT CHOPS
- Bleeding / DIC
- Embolism - coronary, pulmonary, amniotic fluid
- Anesthetic complications
- Tone (uTerine aTony)
- Cardiac disease - MI, aortic dissection, cardiomyopathy
- Hypertension, preeclampsia, eclampsia
- Other - all typical H's and T's
- Placental abruption, placenta previa
- Sepsis
Evaluation
- Clinical
Estimated Gestational Age by Fundal Height[3]
Weeks | Fundal Height / Finding |
12 | Pubic symphysis |
20 | Umbilicus |
20-32 | Height (cm) above symphysis = gestational age (weeks) |
36 | Xiphoid process |
>37 | Regression |
Post delivery | Umbilicus |
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
- Airway 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
- Resuscitative hysterotomy (aka perimortem c-section) if estimated gestational age >24wks (fundus >~4cm above umbilicus)
- Must make decision early, <4min without ROSC
- 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[4]
- 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[5]
Disposition
- Admit (if ROSC obtained)
See Also
External Links
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.
- ↑ Vasquez V, Desai S. Labor and delivery and their complications. In: Walls RM, Hockberger RS, Gausche-Hill M, et al., eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed. Philadelphia, PA: Elsevier Saunders; 2018:2296–2312.
- ↑ 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.