Cardiac arrest in pregnancy

Background

• Key differences from AHA ACLS for non-maternal cardiac arrest
  • If no ROSC by 4 min of resuscitation, perform immediate perimortem cesarean delivery
  • Goal of delivery within 5 min of starting resuscitation (1 minute to deliver)
• DDx - 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

Interventions

• In keeping with regular ACLS algorithms
  • Early defibrillation, same energy dosages; safe for fetus in maternal arrest
  • Give typical adult ACLS drugs/dosages
  • Ventilate with 100% FiO2
  • Monitor EtCO2
  • Ensure post-cardiac arrest care

Maternal Modifications

• Manual left uterine displacement
  • Displaces uterus to pt's left, relieving aortocaval compression
  • May be of concern even if < 20 wks
  • Put hands on left side of gravid abdomen, and pull upwards towards ceiling and leftwards
  • 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 pt receiving IV magnesium prearrest, stop mag and give arrest dose calcium
• Continue CPR, positioning, de-fib, drugs, and fluids during and after C-section

References

• Lipman et Al. The Society for Obstetric Anesthesia and Perinatology Consensus Statement on the Management of Cardiac Arrest in Pregnancy. Anesth Analg 2014;118:1003–16.