Part 10.8: Cardiac Arrest Associated With Pregnancy D urovidertemapve es usfeation aiea p rege m r and Defibrillation Defibrillate using standard ACls defibrillation doses the fetus. The best hope of fetal survival is maternal survival. Class Ila).5 Review the ACLS Pulseless Arrest Algo- For the critically ill patient who is pregnant, rescuers must rithm(see Part 7.2: "Management of Cardiac Arrest") provide appropriate resuscitation, with consideration of the There is no evidence that shocks from a direct current physiologic changes due to pregnancy defibrillator have adverse effects on the heart of the fetus Key Interventions to Prevent arrest If fetal or uterine monitors are in place, remove them To treat the critically ill pregnant patient: before delivering shocks Place the patient in the left lateral position(see below) Modifications of Advanced Cardiovascular e Give 100% Establish intravenous(IV) access and give a fluid bolus. Life Support The treatments listed in the standard ACLs Pulseless arrest Consider reversible causes of cardiac arrest and identify any preexisting medical conditions that may be complicat Algorithm, including recommendations and doses for defi- brillation, medications, and intubation, apply to cardiac arrest in the pregnant woman(see the Table). There are important Resuscitation of the Pregnant Woman in considerations to keep in mind, however, about airway, Cardiac arrest breathing, circulation, and the differential diagnosi Modifications of Basic Life Support Airway Several modifications to standard BLS approaches are appro- Secure the air resuscitation. Because of the priate for the pregnant woman in cardiac arrest (Table). At potential for gastroesophageal sphincter insufficiency gestational age of 20 weeks and beyond, the pregnant uterus with an increased risk of regurgitation, use continuous can press against the inferior vena cava and the aorta, cricoid pressure before and during attempted endotra- impeding venous return and cardiac output. Uterine obstruc- cheal intubation tion of venous return can produce prearrest hypotension or Be prepared to use an endotracheal tube 0.5 to I mm shock and in the critically ill patient may precipitate arrest. 2 maller in internal diameter than that used for a nonpreg In cardiac arrest the compromise in venous return and cardiac nant woman of similar size because the airway may be output by the gravid uterus limits the effectiveness of chest narrowed from edema.6 compressions. The gravid uterus may be shifted away from Breathing the inferior vena cava and the aorta by placing the patient 15 Pregnant patients can develop hypoxemia rapidly be- to 30 back from the left lateral position( Class Ila) or by cause they have decreased functional residual capacity pulling the gravid uterus to the side. This may be accom- and increased oxygen demand, so rescuers should be plished manually or by placement of a rolled blanket or other prepared to support oxygenation and ventilation. object under the right hip and lumbar area. Other modifica- Verify correct endotracheal tube placement usin tions are discussed below cal assessment and a device such as an exhal Airway and breathing detector. In late pregnancy the esophageal Hormonal changes promote insufficiency of the gastro- device is more likely to suggest esophageal placement esophageal sphincter, increasing the risk of regurgita- the aspirating bulb does not reinflate after compression tion Apply continuous cricoid pressure during positive- when the tube is actually in the trachea. This could lead pressure ventilation for any unconscious pregnant to the removal of a properly placed endotracheal tube Ventilation volumes may need to be reduced because the mother's diaphragm is elevated Circulation Circulation Perform chest compressions higher on the sternum, Follow the ACLs guidelines for resuscitation slightly above the center of the sternum. This will adjust medications for the elevation of the diaphragm and abdominal con- Vasopressor agents such as epinephrine, vasopressin tents caused by the gravid uterus.4 d dopamine will decrease blood flow to the uterus. There are no alternatives, however to using all indicated (Circulation. 2005: 112: IV-150-IV-153) medications in recommended doses. The mother must be o 2005 American Heart Association resuscitated or the chances of fetal resuscitation vanish This special supplement to Circulation is freely available at http://www.circulationaha.org Differential diagnoses. The same reversible causes of cardiac arrest that occur in nonpregnant women can occur DOI: 10.1161/CIRCULATIONAHA. 105.166570 during pregnancy. But providers should be familiar with ⅣV150Part 10.8: Cardiac Arrest Associated With Pregnancy During attempted resuscitation of a pregnant woman, providers have two potential patients, the mother and the fetus. The best hope of fetal survival is maternal survival. For the critically ill patient who is pregnant, rescuers must provide appropriate resuscitation, with consideration of the physiologic changes due to pregnancy. Key Interventions to Prevent Arrest To treat the critically ill pregnant patient: ● Place the patient in the left lateral position (see below). ● Give 100% oxygen. ● Establish intravenous (IV) access and give a fluid bolus. ● Consider reversible causes of cardiac arrest and identify any preexisting medical conditions that may be complicat￾ing the resuscitation. Resuscitation of the Pregnant Woman in Cardiac Arrest Modifications of Basic Life Support Several modifications to standard BLS approaches are appro￾priate for the pregnant woman in cardiac arrest (Table). At a gestational age of 20 weeks and beyond, the pregnant uterus can press against the inferior vena cava and the aorta, impeding venous return and cardiac output. Uterine obstruc￾tion of venous return can produce prearrest hypotension or shock and in the critically ill patient may precipitate arrest.1,2 In cardiac arrest the compromise in venous return and cardiac output by the gravid uterus limits the effectiveness of chest compressions. The gravid uterus may be shifted away from the inferior vena cava and the aorta by placing the patient 15° to 30° back from the left lateral position (Class IIa) or by pulling the gravid uterus to the side.3 This may be accom￾plished manually or by placement of a rolled blanket or other object under the right hip and lumbar area. Other modifica￾tions are discussed below. ● Airway and breathing – Hormonal changes promote insufficiency of the gastro￾esophageal sphincter, increasing the risk of regurgita￾tion. Apply continuous cricoid pressure during positive￾pressure ventilation for any unconscious pregnant woman. ● Circulation – Perform chest compressions higher on the sternum, slightly above the center of the sternum. This will adjust for the elevation of the diaphragm and abdominal con￾tents caused by the gravid uterus.4 ● Defibrillation – Defibrillate using standard ACLS defibrillation doses (Class IIa).5 Review the ACLS Pulseless Arrest Algo￾rithm (see Part 7.2: “Management of Cardiac Arrest”). There is no evidence that shocks from a direct current defibrillator have adverse effects on the heart of the fetus. – If fetal or uterine monitors are in place, remove them before delivering shocks. Modifications of Advanced Cardiovascular Life Support The treatments listed in the standard ACLS Pulseless Arrest Algorithm, including recommendations and doses for defi￾brillation, medications, and intubation, apply to cardiac arrest in the pregnant woman (see the Table). There are important considerations to keep in mind, however, about airway, breathing, circulation, and the differential diagnosis. ● Airway – Secure the airway early in resuscitation. Because of the potential for gastroesophageal sphincter insufficiency with an increased risk of regurgitation, use continuous cricoid pressure before and during attempted endotra￾cheal intubation. – Be prepared to use an endotracheal tube 0.5 to 1 mm smaller in internal diameter than that used for a nonpreg￾nant woman of similar size because the airway may be narrowed from edema.6 ● Breathing – Pregnant patients can develop hypoxemia rapidly be￾cause they have decreased functional residual capacity and increased oxygen demand, so rescuers should be prepared to support oxygenation and ventilation. – Verify correct endotracheal tube placement using clini￾cal assessment and a device such as an exhaled CO2 detector. In late pregnancy the esophageal detector device is more likely to suggest esophageal placement (the aspirating bulb does not reinflate after compression) when the tube is actually in the trachea. This could lead to the removal of a properly placed endotracheal tube. – Ventilation volumes may need to be reduced because the mother’s diaphragm is elevated. ● Circulation – Follow the ACLS guidelines for resuscitation medications. – Vasopressor agents such as epinephrine, vasopressin, and dopamine will decrease blood flow to the uterus. There are no alternatives, however, to using all indicated medications in recommended doses. The mother must be resuscitated or the chances of fetal resuscitation vanish. ● Differential diagnoses. The same reversible causes of cardiac arrest that occur in nonpregnant women can occur during pregnancy. But providers should be familiar with (Circulation. 2005;112:IV-150-IV-153.) © 2005 American Heart Association. This special supplement to Circulation is freely available at http://www.circulationaha.org DOI: 10.1161/CIRCULATIONAHA.105.166570 IV-150