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Cardiac arrest in pregnancy
From WikEM
Contents
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
- hypertension, preeclampsia, eclampsia
- Other - all typical H's and T's
- Placental abruption, placental previa
- Sepsis
Evaluation
- 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.
Authors
Kevin Lu, Michael Holtz, Ross Donaldson, Neil Young, Daniel Ostermayer
