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Maternal cardiac arrest (english)
- 1. WHEN A WOMAN CODES DURING PREGNANCY
- 2. Maternal Mortality rate in the USA is rising……
- 3. Why? CA Pregnancy-Associated Mortality Review Published May 2018 Key themes • Cardiovascular disease is the leading cause of pregnancy-related deaths • Racial disparities persist (3x!) • In most cases, multiple patient, facility, and health care provider factors contributed to the pregnancy-related deaths Forty-one percent of the pregnancy-related deaths had a good-to-strong chance of preventability!
- 4. Management principles of cardiac arrest in pregnancy • What are the most common reasons for a maternal cardiac arrest? • What do we need to do differently when resuscitating a pregnant woman? • What does the evidence show?
- 5. OBLS (Obstetrical life support) •CABD •Circulation •Airway •Breathing •Defibrillation/Delivery
- 6. C (Circulation) • CPR started immediately • PUSH HARD PUSH FAST* • Change compressors q1- 2 min •Place back board when possible *Compressions rate of a least 100 per minute at a depth of 5 cm
- 8. Circulation(left uterine displacement) • Confirm left uterine displacement when the uterus is palpated at or above the umbilicus *Manual displacement preferred over lateral tilt Fetal monitoring is not required during maternal arrest. Either spontaneous circulation is restored or delivery occurs within 5 minutes of confirmed maternal pulselessness.
- 9. A (Airway) • Chin lift • Oral airway if indicated
- 10. B (Breathing) • Airway = intubation if anesthesiologist available •Bag/Mask if intubation not possible • Breath ratios Intubate breath = q 6 seconds Bag mask = 30 compressions 2 breaths
- 11. D (Defibrillation) • Prompt evaluation for possible defibrillation (use AED mode if needed) • Use same energy requirements as in nonpregnancy •120-200 J with escalation of energy output if first shock is not effective
- 12. D (Defibrillation) • Resume compressions immediately after delivery of electrical shock • Do NOT check pulse after shock • Do check for a pulse if AED does not advise shock • Continue CPR if pulse is absent • Rhythm is PEA or Asystole • Immediately reversible causes of cardiac arrest should be ruled out. (i.e. stop intravenous medications like magnesium)
- 13. Causes of maternal cardiac arrest Conditions Examples A Accident (trauma) Anesthesia Related Blunt trauma, fall, gunshot wound, motor vehicle collision, self-inflicted injury Aspiration, loss of airway, respiratory arrest or depression, hypotension, high (or total) spinal/epidural block, local anesthetic systemic toxicity B Bleeding (Hemorrhage) Uterine issue (atony, retained placenta, rupture), coagulation disorder, placental issue (abruption, previa, invasive), reaction to blood products, surgical trauma C Cardiovascular Acute myocardial infarction, acquired or congenital heart disease, dissecting aortic aneurysm, cardiomyopathy, dysrhythmias D Drugs Anaphylaxis, error (oxytocin, magnesium sulfate, insulin, opioids), recreational drug use E Embolism Air, amnioitic fluid, venous thromboembolism, pulmonary F Fever Infection, sepsis G General From ACLS: H’s; hypoxia, hypovolemia, hyper/hypokalemia, hypo/hyperthermia, hydrogen ions (acidosis), hypoglycemia and T’s; trauma, toxins, tamponade, tension pneumothorax, thromboembolism, thrombosis H Hypertension Preeclampsia, HELLP, eclampsia, intracranial bleed Adapted from: Cardiac arrest in pregnancy: a scientific statement from the American Heart Association. (2015)
- 14. Medications • In the setting of cardiac arrest NO medications should be withheld because of concerns for fetal teratogenicity • Medication doses do not require alteration • 1 mg of epinephrine IV q 3-5 minutes during cardiac arrest should be considered
- 15. D (Delivery) •When the gravid uterus is large enough to cause maternal hemodynamic changes due to aortocaval compression, delivery/emergency cesarean section should be considered, regardless of fetal viability •The goal is for delivery within 5 minutes of maternal arrest
- 16. Why perform an emergency cesarean section in cardiac arrest? What the evidence shows….. Several case reports of emergency cesarean section in maternal cardiac arrest indicate a return of spontaneous circulation, or improvement in maternal hemodynamic status only *after the uterus has been emptied.* Ref: Circulation, Vanden Hoek et al, Part 12, 2010
- 17. What the evidence shows….. In a case series of 38 cases of perimortem cesarean section, 12 of 20 women (60%) for whom maternal outcome was recorded had return of spontaneous circulation immediately after delivery. No cases of worsened maternal status after cesarean section were reported.
- 18. Maternal CardiacArrest and Perimortem Ceasarean Delivery: Evidence or expert-based? EinavS,etal. Resuscitation(2012) PMCD was determined to have been beneficial to the mother in 31.7% of cases and was not harmful in any case.
- 19. Bottom line "No pregnant woman should die undelivered” (yet one-third of these patients remain undelivered at the time of death) Ref: Reidy Jr, Russell R, CMACE 2006-2008, Int J Obstet Anesth 2011;20:208-12.
- 22. Thank you for your attention Image by Rick Gomez/Corbis
- 24. Additional References • The Society for Obstetric Anesthesia and Perinatology Consensus Statement on the Management of Cardiac Arrest in Pregnancy • Anesth Analg 2014;118:1003–16 • AWHONN Position Statement: Advanced Cardiac Life Support in Obstetric Settings • JOGNN, 39, 606–607; 2010.DOI: 10.1111/j.1552-6909.2010.01176.x
Editor's Notes
- We are going to review the principles for the management of cardiac arrest in pregnancy
- Immediate use of chest compressions has been associated with a better outcome in witnessed arrests thus beginning all codes with chest compressions has been adopted High quality chest compressions are essential to maximize the patient’s chance of survival. Compressions are best done with the patient supine on a hard surface with minimal interruptions. Because hospital beds are typically not firm thus decreasing the strength of the compressions it is recommended to use a backboard when possible. Pushing hard and fast is vital
- Uterine displacement should be used to relieve aortocaval compression during resuscitation. Studies have shown that with a tilt the heart may also shift laterally making chest compressions less effective.
- Hypoxemia develops more rapidly in the pregnant patient compared with nonpregnant therefore effective airway and breathing interventions are essential First steps include treatment for possible obstruction - chin lift and placement of oral airway
- Hypoxemia should always be considered as a cause of cardiac arrest, Oxygen reserves are lower in pregnant women thus early ventilatory support may be necessary- either intubation or bag mask Intubation is difficult in a pregnant woman and should be attempted only by an experienced medical provider The rates of compressions to respirations are listed here
- Identifying a rhythm that can be defibrillated is vital to maximize survival and should be done as soon as possible. However many providers in OB are not well versed in evaluation of cardiac arrhythmias. Use of an AED is an excellent alternative while awaiting a provide who can read ECG If defibrillation is needed such as in v fib or ventricular tachycardia he energy required in pregnancy is the same as in nonpregnancy no modifications are needed and should be performed without hesitation or delay. There is no difference in the pregnant patient – the same energy required is the same and passage of the current to the fetus is considered safe
- There should be minimal interruption of chest compressions- no longer than 10 seconds. Consider possible reversible causes of arrest
- It is important for the OB to beaware and inform the medical code team that any medications that are normally used CAN be used in a pregnant woman who is experiencing a cardiac arrest. And that the dosages remain the same
- Perimortum delivery should be strongly considered for every mother in in who resuscitation efforts has not been achieved after 4 minutes and if the uterus is large enough to cause aortocaval compression. In general this occurs when the uterine fundus is at the level of the umbilicus The 5 minute time was chosen to minimize neurologic damage which begins to occurs after 4-6 minutes of anoxia
- MORRIE
- In review Assess for pulse , if pulse present begin respiratory support but if no pulse present immediately begin chest compressions and left uterine displacement. Mange airway Check for a rhythm for defibrillation Minimize CPR interruptions
- Think of reversible causes like magnesium overload When the cardiac team arrives remind thme that all resuscitation treatments remain the same Begin to prepare for delivery if there is evidence of aortocaval compression with the uterus at the umbilicus-
- JULIE
- JULIE