This is an obstetric case presentation

1. case presentation and
discussion on
principles of
resuscitation in
cardiac arrest
Padibe health centre team

2. Case presentation
Demographics
• Name; HS
• Sex; f
• Age; 27yrs
• Address; apyeta c, apyeta, ogilli
• Nationality; Ugandan
• Occupation; businesswoman
• Education level; secondary
• Religion; Muslim
• Referral status; referral from Paluda
HCIII
• Date of admission; 20/12/2023
• LNMP: unsure.
• EDD:

3. Presenting complaint
• Headache for 1 week
• Epigastric pain for 5 days
• Lower abdominal pain for 1 day

4. HPC
• Presenting a G2p1+0 at?? WoA who was well until a week prior to
admission when she developed headache of gradual onset, throbbing
in nature, frontal, on most times of the day mildly relieved by
analgesics and lying in quiet places she had occasional visual blurring
but no h/o fever, Loss of consciousness, focal weakness, and
convulsions.
• She progressed to have epigastric pain of gradual onset, burning in
nature, on for most of the day, radiating to the right side of the
abdomen below the ribcage, no known relieving and exacerbating
factors, however she had no history of vomiting, no hematemesis, no
passing bloody stool.

5. Cont.
• A day prior to admission she developed lower abdominal pain of
gradual onset, increasing in frequency and intensity, radiating to the
lower part of the back, h/o draining of clear colourless fluid P/v.
however, no h/o abnormal P/v discharge, bleeding, itching or rash.
• She reports to have had good fetal play, about 5 times a day, attended
ANC 5times with booking visit at 20/40 received most of the ANC
packages.
• When she developed this symptom, she sought treatment at Paluda
HCIII where she was diagnosed with PET, received treatment, and
referred for further management in Padibe HC IV.

6. Review of other systems: unremarkable
Past Obsgyn History
• G2P1+0 at term 1st preg in 2009 delivered live baby boy by SVD.
• Sexual debut at 17years, menstrual cycle 28 days, this is a new
partner.
• Has not had any OBSGYN procedure.
Past medical
• Unremarkable
Past surgical
• Had exlap done in 2015 for acute abdomen.
Family social
• Married, doesn’t live with husband, doesn’t smoke tobacco or drink
alcohol. No familial illness.

7. Summary
Presented HS G2P1+0 at?? WOG referral from paluda HCIII who
presented with headache, epigastric pain, visual blurring, and
progressive lower abdominal pain increasing in frequency and intensity.
She also reports h/o changing sexual partner. However, no h/o LOC,
convulsions, DIB, focal weakness, and fever.

8. Differentials
G2P1+0 at term
In labour in view of lower abdominal pain, increasing in nature, h/o
draining liquor, lower back ache.
PET with severe features in view of headache, visual blurring,
epigastric pain.
Exacerbation of PUD in view of epigastric pain
False labour 2nd to UTI, malaria in view of headache, lower abdominal
pain.
Prelabour rupture of membranes. In view of draining liquor.

9. Examination
• General exam: mother restless, in pain, pacing and sweating, IV
cannulas gauge 16 in situ on both forearms, a febrile, not pale, not
jaundiced, oedema grade 1.
• Abdominal exam; epigastric and right hypochondriac tenderness,
distended abdomen, linear nigra, FH 38/40, right longitudinal lie,
FHHR=132bpm, cephalad at lowest pole, descent 3/5.
• V/E; pelvis adequate, vulva and vagina hot, cervix thick, posterior,
33% effaced, os 7cm, cephalic presentation station -1, membranes
ruptured.

10. Cont.
• CVS; warm extremities, pulse 98bpm normal volume synchronous, bp
150/100mmhg, non-distended jugular veins, HS1 and 2, no added
sounds, negative hepatojugular reflux.
• CNS; alert, oriented, GCS 15/15, cranial nerves intact, normal tone,
bulk and reflexes on all muscle groups and limbs, PEARL, no signs of
meningism.
• R/S; RR23 breaths/min, Spo2 98% in room air, chest clear.

11. Impression
G2P1+0 in active labour with
• PET severe features
• ?? OBL.
Investigations
• CBC Hb 12g/dl, platelets 109x 10^9
• Blood grouping and crossmatching, o rh +ve, blood booked.
• HCT- TR
• HBsag- neg
• Urinalysis- Proteins ++

12. Management
Prevent /control seizures.
• magnesium sulfate loading dose 14g (4g of 20% IV and 5g of 50% with
1ml of lignocaine in each buttock im)
Control BP
• Sublingual nifedipine 20mg start then bd-
Delivery plan
• Emergency c/s
• Consent patient.
• Preload with 1.5 ltrs of normal saline.

13. Cont.
• Insert urinary catheter.
• Preop antibiotics; iv cef Ig start
• Metoclopramide 10mg
• Iv tranexamic 500mg 30 mins preop
• Anaesthetic assessment
• Inform theatre.

14. Intraoperative management
• Mother given spinal anaesthesia(bupivacaine)
• Mother draped aseptically and Pfannenstiel incision made, LUSCI
made delivered live baby APGAR 9/10 at 1 min, 10/10 at 5min, birth
weight. placenta delivered and uterus exteriorized for repair.
• Mother became restless, agitated, disoriented, and then suddenly
went unresponsive.
Did rapid primary survey.
• Airway collapsed, straightened airway through chin lift and jaw
thrust.
• Breathing mother not breathing spo2 25%

15. Cont.
• Called for help and started chest compressions at a ratio of 30
compressions to 2 breaths by ambu bag.
• Circulation: bps undetectable, no radial pulse, no cardiac impulse.
• Continued compressions until there was a detectable at 2 cycles. Iv
adrenaline 1 mg given.
• Assessed and treated reversible causes; gave D10% 100mls, give bolus
iv NS 2l, gave warm fluids to prevent hypothermia.
• Cause; Cardiac arrest 2nd total spinal
• Mother still on steady rehabilitation

16. Post Resuscitation care.
After 2 compression cycles there was return of spontaneous
circulation, progressed to an advanced airway, Rapid sequence
induction intubation with 2 failed intubations due to Oedematous
airway.
• Continued ventilating using a vent, SpO2 returned progressively to 45
%, 65 %,85% to 98% on ventilation.
• PR returned progressively to 30bpm,60bpm, 90bpm, 100bpm.
• Patient ETT kept in place while closure of the abdomen was
completed.

17. • Patient kept sedated with midazolam and transfer to St Mary’s hospital Lacor
done.
• GCS V T E 3 M 3.
Transfer done with ambulance with oxygen source.
• 1 referral nurse and midwife.
• Maintenance dose of mgso4 enroute at Atanga HC III.
Follow-up
• Patient admitted and transferred to ICU and kept on mechanical ventilation for 5
days.
• Baby admitted in NICU for management.
• On day 6 mother had tracheostomy done
• Day 10 mother transferred to ward with neurological impairment.
• Mother discharged last week, on NGTube and physiotherapy.

18. CASE DISCUSSION
PRINCIPLES OF RESUSCITATION IN CARDIAC
ARREST

19. Definition and background
• Cardiac arrest is a condition where the heart
suddenly and unexpectedly stops pumping dues to
abnormal electrical activity.
• A meta-analysis of 141 eligible studies
revealed ROSC at 29.7%(95% CI 27.6-31.7%)
(shijiao yan et al, 2020)
• A study in Mulago national referral deduced
that 2.3% (190) of the 8131 patients admitted
in the study period got cardiac arrest and only
35 (18.4%) received CPR and 14(7.4%) got ROSC
(Ocen Davidson et al).
• The common clinical presentation cardiac arrest

21. Principles
Non-technical skills in resuscitation
• Cooperation of team members focusing on the interpersonal skills of
leadership and team membership.
• They include cognitive and functional skills of
Teamwork: collaboration between two health care professionals of
different backgrounds and complementing skills to achieve a common
goal.
Task management: the process of handling the entire resuscitation
cycle right from planning to execution carried out by the team.

22. Cont.
Leadership: the art of guiding and motivating a group of health care
professionals to act toward achieving a common objective.
• Situational awareness
• Decision making
Communication; briefing and debriefing.
• 3 phases; initial team brief, communication during resuscitation and final
team debrief.
• Communication in resuscitation should involve clear instructions and
feedback.
In this case one of the doctors became the leader and assigned roles and
motivated team members to carry out their tasks

23. Chain of prevention
This is very valuable and if implemented effectively it prevents most of
the incidences of cardiac arrest and its adverse outcomes. It includes.
• Staff education
• Monitoring of patients
• Recognition of deteriorating patient
 Decline in CVS, R/S and CNS
 Decline in ABCDE
 Early warning scores and calling criteria.

24. Cont.
• Call for help.
The above tool was
used to call for help
from the receiving
ICU.
• Response.
Should always be prompt
and organized.

25. Chain of survival
Early recognition and call for help.
• Use of track and trigger systems e.g. early warning score system
(EWS) to be able to identify and recognize patients promptly.
• Responder ensures the surrounding is safe, shake the patient at the
shoulders and ask if they are ok.
• Airway chin lift, head tilt. Look for chest expansion, feel- check for
breathing, listen- for breathing.
• If absent proceed to CPR.
Early cardiopulmonary resuscitation
• Chest compressions and ventilation slow down the rate of
deterioration of the brain and heart.

26. Cont.
CPR algorithm
Approach safely.
Check for response.
Call for help.
Open airway head tilt, chin lift with 2 fingers and left hand on forehead.
Check for normal breathing (10seconds)
If unresponsive and not breathing commence CPR (30:2) for adults (3:1)
children approximate rate 100-120/min, depth of about 5-6cm.
o Do not interrupt CPR unless AED arrives, your environment is not safe,
you become tired. Get more people to alternate Compressions.
o High quality CPR
The team member not actively doing the C/S identified and did the
initial assessment and promptly started CPR intra-op and assigned the
other team members specific roles.

27. Early defibrillation
• In case you have the device.
• This plus the above are the cornerstone of CPR. Defibrillation should
happen in less than 3 minutes of recognition of cardiac arrest.
In shockable rhythms we give IV adrenalin 1mg alternate between
cycles and IV Amiodarone 150mg in the 5th cycle.
In non-shockable rhythms give 1 mg IV adrenaline alternate with the
compressions

28. Cont.
Reversible causes of cardiac arrest
Identify the reversible causes of cardiopulmonary arrest is ongoing in
the process of CPR.
• 4 Hs: hypoxia, hypovolemia, hyperkaleamia, hypothermia
• 4 Ts: tension pneumothorax, tamponade, toxins, thrombosis.
The identifiable reversible causes in our patient were, hypoxia,
hypovoleamia and thrombosis.

29. Post resuscitation care.
Return of spontaneous circulation (ROSC) is an important phase in the
continuum of CPR.
The goal is to return patient to normal cerebral function, stable cardiac
rhythm, and normal hemodynamic function.
Signs of ROSC, pulse, patient breathing independently
Immediate care.
• Do ABCDE
• advanced airway spo2 94-98%
• 12 lead ECG, IV access sBP target 100mmhg.
• Control temperature.
In our client advanced airway was instituted ETT with warm iv fluids.

30. Post cardiac arrest syndrome
• Post cardiac arrest brain Injury
• Post cardiac arrest myoclonic dysfunction.
• Systemic ischeamic/ reperfusion response
• Persistent preciptatory pathology
Our patient suffered post cardiac arrest brain injury she presented
with neurocognitive dysfunction.
Clinical presentation
• Coma, seizures, myoclonus, varying degrees of neurocognitive
dysfunction, brain death

31. Missed opportunities and way-
forward
s/n Missed opportunity Recommendation
1 Inappropriate monitoring of
patient intra-op
Lobby for a patient monitor for
theatre and maternity
2 Limited knowledge in
cardiopulmonary resuscitation
CMEs and drills on basic life support
Lobby to enroll more cohorts of staff
for ALS training
Cross cutting issues
1 Inability to defibrillate
patient promptly
Lobby for AEDs
2 Ambulances without oxygen
source fitted in
Ongoing paperwork with health manager

32. References
• ALS ERC guidelines 2021
• Uganda Maternal and Newborn Care Guidelines
• Uganda clinical guidelines
• Medscape
• Padibe health centre IV patient files

33. • Thankyou for listening