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Management of maternal cardiac arrest

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Presentation on theme: "Management of maternal cardiac arrest"— Presentation transcript:

1 Management of maternal cardiac arrest
Dr A Hards, Dr S Davies, Dr A Salman, Dr M Balki Mount Sinai Hospital 2010

2 Aim To enable you to competently manage a case of maternal cardiac arrest

3 Objectives To review relevant maternal physiology
To review standard ACLS guidelines To review ACLS modifications for pregnancy

4 Physiology of pregnancy
Respiratory System 1. 60% increase in oxygen consumption & decreased FRC Implications – rapid desaturation & hypoxemia 2. increased minute ventilation and hypoxic ventilatory response Implications - chronic respiratory alkalosis, difficult determining benign vs. sinister causes of dyspnea 3. increased capillary engorgement & mucosal edema Implications – airway bleeding, nasal congestion, difficult airway, failed intubation 1. Oxygen consumption increases as the pregnancy progresses FRC begins to fall by the 5th month and is decreased to 80% of pre-pregnancy capacity by term < closing capacity in 50% supine pregnant women 2. Mainly due to increased TV

5 Physiology of pregnancy
Cardiovascular System cardiac output increases by 50% (due to increased HR & SV). Increased contractility and LVEF. SVR and PVR fall by up to 35%. SBP, DBP, MAP decrease during mid preganancy, return to baseline near term Aorto-caval compression occurs from weeks Implications - supine hypotension - higher femoral/IVC pressures Pregnancy causes cardiac hypertrophy by 12/40 with 50% increase in muscle mass at term. Blood flow to uterus, kidneys and extremities increases; brain and liver stays the same.

6 Physiology of Pregnancy
Gastrointestinal System 1. Anatomical changes 2. Reduced lower esophageal sphincter pressure 3. Increased intra-gastric pressure 4. Delayed gastric emptying in labour but probably normal at other times Implications  - High incidence of gastro-oesophageal reflux - Increased risk of aspiration from ~ weeks gestation 1. Stomach displaced up, axis rotated 45 degrees to R2. Due to progesterone 3. due to gravid uterus, intra abdominal esophagus into thorax Around 30-50% women And it’s potentially fatal consequences

7 Physiology of Pregnancy
Hematological System 50% increase in plasma volume 30% increase in red cell volume Increased platelet turnover, clotting and fibrinolysis Implications   - delayed presentation of hypovolaemia - physiological anemia of pregnancy - pro-coagulopathic state

8 ACLS in pregnancy Essentially follows same guidelines as for non-pregnant patients AHA recommend some modifications based on physiology Need to review general adult ACLS first i.e. drug doses/defib energy

9 ACLS Cardiac Arrest Algorithm 2010
Go through changes of 2010, i.e. -continuous qualitative waveform capnography for confirmation and monitoring of endotracheal tube placement - importance of high-quality CPR - removal of atropine from algorithm - emphasis on monitoring of CPR quality and ROSC NB intro after study started so leniency in scoring to include either system

10 AHA Modifications for pregnancy
Ventilate with cricoid pressure (remove if impeding ventilation, oxygenation or intubation) Early intubation with a smaller diameter ETT (such as 6.5 cm) Left Uterine Displacement Position hands 1-2cm higher on sternum for chest compressions Remove fetal monitoring for defibrillation Do not use femoral or leg veins for IV access Consider emergency cesarean section - to reduce aspiration risk - usually a 6.5; higher incidence of airway bleeding and difficult intubation - to minimize aorto-caval compression..can use wedge, tilt or manual displacement - to reduce risk of trauma to abdominal organs - theoretical risk of arcing or transfer of shock to fetus - distance to heart increased, lower limb blood flow predominantly collaterals - only definitive way to improve venous return

11 Emergency cesarean section
Rationale for early CS - Provides effective maternal resuscitation (improves venous return & cardiac output) - If fetus > weeks may save the life of the baby Management Do not move patient to OR prior to CS Continue maternal resuscitation during CS Aim for skin incision by 4 minutes Aim for delivery by 5 minutes - primary reason is maternal - good outcome reports for mother and fetus even after prolonged resuscitation

12 Cause of arrest Always consider the “Hs and Ts”
Hypovolemia Tension PTX Hypoxia Tamponade Hydrogen ions Toxins Hypo/erkalemia Thrombosis, cardiac Hypothermia Thrombosis, coronary Pregnancy-specific causes mnemonic “BEAU-CHOPS”

13 Maternal cardiac arrest algorithm
Vanden Hoek T L et al. Circulation 2010;122:S829-S861 Copyright © American Heart Association

14 Any questions?

15 Summary Reviewed relevant maternal physiology
Reviewed standard ACLS guidelines Reviewed modifications for pregnancy

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