Part 10.8: Cardiac Arrest Associated with Pregnancy Iv-151 Primary and Secondary ABCD Surveys: Modifications for Pregnant Women ACLS Modifications to bls and acls guidelines Primary ABCD Surve Airway ● No modifications. Breathing Place the woman on her left side with her back angled 15 to 30 back from the left lateral position. Then start chest Place a wedge under the woman' s right side(so that she tilts toward her left side e Have one rescuer kneel next to the woman' s left side and pull the gravid uterus laterally. This maneuver will relieve pressure the inferior vena cava Defibrillation No modifications in dose or pad position. Defibrillation shocks transfer no significant current to the fetus. e Remove any fetal or uterine monitors before shock delivery Secondary ABCD Survey Airway e Insert an advanced airway earty in resuscitation to reduce the risk of regurgitation and aspiration Airway edema and swelling may reduce the diameter of the trachea. Be prepared to use a tracheal tube that is slightly smaller than the one you would use for a nonpregnant woman of similar siz Monitor for excessive bleeding following insertion of any tube into the oropharynx or nasopharynx. No modifications to intubation techniques. a provider experienced in intubation should insert the tracheal tube Effective preoxygenation is critical because hypoxia can develop quickly Rapid sequence intubation with continuous cricoid pressure is the preferred technique. Agents for anesthesia or deep sedation should be selected to minimize hypotension e No modifications of confirmation of tube placement Note that the esophageal detector device may suggest esophageal placement despite correct tracheal tube placement The gravid uterus elevates the diaphragm: -Patients can develop hypoxemia if either oxygen demand or pulmonary function is compromised. They have less reserve because functional residual capacity and functional residual volume are decreased. minute ventilation and tidal volume are increased -Tailor ventilatory support to produce effective oxygenation and ventilation Follow standard acls recommendations for administration of all resuscitation medications Do not use the femoral vein or other lower extremity sites for venous access. Drugs administered through these sites may not reach the maternal heart unless or until the fetus is delivered Dififerential Decide whether to perform emergency hysterotomy e Identify and treat reversible causes of the arrest. Consider causes related to pregnancy and causes considered for all ACLS patients(see the 6 H's and 6 Ts, in Part 7.2: "Management of Cardiac Arrest"). pregnancy-specific diseases and procedural complications the treatment of choice for magnesium toxicity. Empiric Providers should try to identify these common and revers- calcium administration may be lifesaving 8.9 ible causes of cardiac arrest in pregnancy during resusci- Acute coronary syndromes. Pregnant women may expe ation attempts. The use of abdominal ultrasound by a rience acute coronary syndromes, typically in association skilled operator should be considered in detecting preg with other medical conditions. Because fibrinolytics an nancy and possible causes of the cardiac arrest, but this relatively contraindicated in pregnancy, percutaneous should not delay other treatments. oronary intervention is the reperfusion strategy of Excess magnesium sulfate. latrogenic overdose is possi- hoice for ST-elevation myocardial infarction. 10 ble in women with eclampsia who receive magnesium Pre-eclampsia/eclampsia. Pre-eclampsia/eclampsia de sulfate, particularly if the woman becomes oliguric velops after the 20th week of gestation and can produce Administration of calcium gluconate(I ampule or 1 g)is severe hypertension and ultimate diffuse organ systempregnancy-specific diseases and procedural complications. Providers should try to identify these common and revers￾ible causes of cardiac arrest in pregnancy during resusci￾tation attempts.7 The use of abdominal ultrasound by a skilled operator should be considered in detecting preg￾nancy and possible causes of the cardiac arrest, but this should not delay other treatments. – Excess magnesium sulfate. Iatrogenic overdose is possi￾ble in women with eclampsia who receive magnesium sulfate, particularly if the woman becomes oliguric. Administration of calcium gluconate (1 ampule or 1 g) is the treatment of choice for magnesium toxicity. Empiric calcium administration may be lifesaving.8,9 – Acute coronary syndromes. Pregnant women may expe￾rience acute coronary syndromes, typically in association with other medical conditions. Because fibrinolytics are relatively contraindicated in pregnancy, percutaneous coronary intervention is the reperfusion strategy of choice for ST-elevation myocardial infarction.10 – Pre-eclampsia/eclampsia. Pre-eclampsia/eclampsia de￾velops after the 20th week of gestation and can produce severe hypertension and ultimate diffuse organ system Primary and Secondary ABCD Surveys: Modifications for Pregnant Women ACLS Approach Modifications to BLS and ACLS Guidelines Primary ABCD Survey Airway ● No modifications. Breathing ● No modifications. Circulation ● Place the woman on her left side with her back angled 15° to 30° back from the left lateral position. Then start chest compressions. or ● Place a wedge under the woman’s right side (so that she tilts toward her left side). or ● Have one rescuer kneel next to the woman’s left side and pull the gravid uterus laterally. This maneuver will relieve pressure on the inferior vena cava. Defibrillation ● No modifications in dose or pad position. ● Defibrillation shocks transfer no significant current to the fetus. ● Remove any fetal or uterine monitors before shock delivery. Secondary ABCD Survey Airway ● Insert an advanced airway early in resuscitation to reduce the risk of regurgitation and aspiration. ● Airway edema and swelling may reduce the diameter of the trachea. Be prepared to use a tracheal tube that is slightly smaller than the one you would use for a nonpregnant woman of similar size. ● Monitor for excessive bleeding following insertion of any tube into the oropharynx or nasopharynx. ● No modifications to intubation techniques. A provider experienced in intubation should insert the tracheal tube. ● Effective preoxygenation is critical because hypoxia can develop quickly. ● Rapid sequence intubation with continuous cricoid pressure is the preferred technique. ● Agents for anesthesia or deep sedation should be selected to minimize hypotension. Breathing ● No modifications of confirmation of tube placement. Note that the esophageal detector device may suggest esophageal placement despite correct tracheal tube placement. ● The gravid uterus elevates the diaphragm: —Patients can develop hypoxemia if either oxygen demand or pulmonary function is compromised. They have less reserve because functional residual capacity and functional residual volume are decreased. Minute ventilation and tidal volume are increased. —Tailor ventilatory support to produce effective oxygenation and ventilation. Circulation ● Follow standard ACLS recommendations for administration of all resuscitation medications. ● Do not use the femoral vein or other lower extremity sites for venous access. Drugs administered through these sites may not reach the maternal heart unless or until the fetus is delivered. Differential Diagnosis and Decisions ● Decide whether to perform emergency hysterotomy. ● Identify and treat reversible causes of the arrest. Consider causes related to pregnancy and causes considered for all ACLS patients (see the 6 H’s and 6 T’s, in Part 7.2: “Management of Cardiac Arrest”). Part 10.8: Cardiac Arrest Associated With Pregnancy IV-151