You Want Me to do What!? Pearls for Resuscitating the Pregnant

Patient

Rebecca A. Bavolek, MDAssistant Program Director

Washington University School of MedicineBarnes Jewish Hospital/St. Louis Children’s Hospital

http://en.wikipedia.org/wiki/User:Aleister_Wilson/ethereal_being

Pager 0430: 23yo pregnant female from homeless shelter, unresponsive,

agonal respirations, unable to obtain pulse or BP. ETA

10 min

http://www.flickr.com/photos/emtgin/8143846230/

http://www.picardyproject.com/2011_07_01_archive.html

Caesarian_section_-_Pull_out.jpg

2298925061_b56af27dab_z.jpg start_photo.jpg

ERTraumaRoomGhostsPict_lg04.jpgGather Your Resources

?

Start with your basic mantra...

6a00d83483b8fc53ef013488a2189e970c-800wi

About those A’s and B’s

http://crashingpatient.com/resuscitation/airway/airway.htm/

About those A’s and B’sTiny,

Squished Stomach

About those A’s and B’s

About those A’s and B’s

http://en.wikipedia.org/wiki/Reinke's_edema

Moving on to C...

Hypotension in Pregnancy

Is it normal, or is it shock?

HR by5-15 bpm

MAP by10-15 mmHg

Blood vol by 1L

Hgb by1-3 mg/dL

Patient Positioning

Does Pelvic Position Matter?

Where is the Max IVC diameter?

Supine 24%LLT 48% RLT 28%

No correlation to patient age, BMI, EGA

Hypovolemia:

Pump Failure: Obstruction:

http://stumander1989.deviantart.com/art/Film-Review-The-Sixth-Sense-206478746

Should we consider a “P-RUSH” in the hypotensive pregnant patient?

H Heart

I IVC

MMorrison’s

Pouch

A Aorta

P Pneumo

H Heart

I IVC

MMorrison’s

Pouch

F Fetus

P Pneumo

If time allows, perform a full FAST

If time allows, perform a full FAST

May need to switch to intercostal window, could help determine optimal positioning?

May need to switch to intercostal window, could help determine optimal positioning?

What now?

You already know what to do!

PEA/Arrhythmia

Same ACLS Drugs/Protocols

TraumaControl

Hemorrhage/ATLS

STEMI PCI

Massive PE Lytics

Other H’s&T’s

Carry On

What about BEAU-CHOPS?

B Bleeding/DIC

E Embolism

A Anesthetic Complication

U Uterine Atony

C Cardiac Disease

HHTN/Pre-eclampsia/

Eclampsia

O Other (ACLS Ddx)

P Placental Abruption/Previa

S Sepsis

Amniotic Embolus, ECMO?

IV Magnesium

Control hemorrhage,Consider MTP, oxytocin

Control hemorrhage, Consider MTP, delivery

Control hemorrhageConsider MTP, delivery

If your patient arrests, time is ticking...

Cardiac Arrest in Gravid Female

Cardiac Arrest in Gravid Female

Optimal PositioningET Intubation

IV Access (Upper Torso)ACLS

Prepare for Perimortem C-Section

Optimal PositioningET Intubation

IV Access (Upper Torso)ACLS

Prepare for Perimortem C-Section

GA > 20 wks?

GA > 20 wks? Yes

YesNoNo

Continue Maternal Resuscitation

Continue Maternal ResuscitationContinue Maternal

Resuscitation

Continue Maternal Resuscitation Fetal

Resuscitation

Fetal Resuscitation

Obstetrics NICU

Adult ICUInfant WarmerInstruments

Obstetrics NICU

Adult ICUInfant WarmerInstruments

Perform C-SectionPerform C-Section

0 Min

4 Min

The Perimortem C-SectionThe Perimortem C-Section

Summary

• Stay Calm (at least on the outside!)

• Mobilize your resources, assign roles

• Proceed with ABCs and consider modifications

• Consider using ultrasound to help guide therapy

• Most treatments are the same as the non-pregnant patient!

• Be ready to perform perimortem c-section within 4 minutes in appropriate patients

http://memegenerator.net/instance/37652575

References1. Fields JM, Catallo K, Au AK, Rotte M, Leventhal D, Weiner S, Ku BS. “Resuscitation of the pregnant patient: What is

the effect of patient positioning on inferior vena cava diameter?” Resuscitation 84 (2013) 304-8.

2. Sommerkamp SK, Gibson A. “Cardiovascular Disasters in Pregnancy.” Emerg Med Clin N Am 30 (2012) 949-59.

3. Brown S, Mozurkewich E. “Trauma During Pregnancy.” Obstet Gynecol Clin N Am 40 (2013) 47-57.

4. Gabbot DA. “Editorial: Uterine displacement during CPR in the pregnant patient -- Why bother?” Resuscitation 84 (2013) 267-8.

5. Engels PT, Caddy SC, Jiwa G, Matheson JD. “Cardiac arrest in pregnancy and perimortem c-section delivery: A case report and discussion.” CJEM 2011; 13(6): 399-403.

6. Vanden Hoek TL, Morrison LJ, Shuster M, Donnino M, Sinz E, Lavonas EJ, JeejeebhoyFM, Gabrielli A. “Part 12: Cardiac Arrest in Special Situations: 2010 American Heart Association Guidelines for Cardiopulmonary Care and Emergency Cardiovascular Care.” Circulation 2010; 122:S829-S861.

7. Weingart SW, Duque DD, Nelson BN. ACEP-EMED home; 3 April 2009. Available from: http://www.webcitation.org/5vyzOaPYU.

8. Wagner JC, Sampson C, Bausano B, Renz N. “Perimortem C-Section Simulation Model.” http://vimeo.com/32749876

9. The Crashing Patient: A Webtext of ED Critical Care. http://crashingpatient.com/resuscitation/physiology-oxygenation-ventilation.htm/, accessed October 2013.

10. Tanoubi I, Drolet P, Donati F. “Optimizing PreOxygenation in Adults.” Can J of Anesth (2009) 56:449-66.

11. Lange Anethesiology, Section IV. Physiology, Pathophysiology, & Anesthetic Management, Chapter 22: Respiratory Physiology: The effects of anesthesia.