Paleerat Jariyakanjana, MDEmergency physician

19 Oct 2015

The Critically Ill Pregnant Patient

Severity of Illness and Early Warning Scores

obstetric early warning score (Class I; Level of Evidence C)

Management of the Unstable Pregnant Patient

full left lateral decubitus position (Class I; Level of Evidence C)

100% oxygen by face mask (≥15 L/min) (Class I; Level of Evidence C)

Intravenous access: above the diaphragm (Class I; Level of Evidence C)

Cardiac Arrest Management

Chest Compressions in Pregnancy

placed supine for chest compressions(Class I; Level of Evidence C)

mechanical chest compressions: not advised

Factors Affecting Chest Compressionsin the Pregnant Patient

Continuous manual LUD: uterus ≥ umbilicus (Class I; Level of Evidence C)

Factors Affecting Chest Compressionsin the Pregnant Patient

Advanced Cardiovascular Life Support

Advanced Cardiovascular Life Support

Special Equipment Required for a Maternal Cardiac Arrest

Special Equipment Required for a Maternal Cardiac Arrest

Breathing and Airway Management in Pregnancy

Management of Hypoxia Airway Management

Management of Hypoxia

early ventilatory support (Class I; Level of Evidence C)

Airway Management

Endotracheal intubation should be performed by an experienced laryngoscopist (Class I; Level of Evidence C).A. ETT with a 6.0-7.0 mm ID (Class I; Level of

Evidence C)B. ≤2 laryngoscopy attempts (Class IIa; Level of

Evidence C)C. Supraglottic airway placement: failed intubation

(Class I; Level of Evidence C)D. airway control fail and mask ventilation is not

possible → emergency invasive airway access

Airway Management

Cricoid pressure: not routinely recommended (Class III; Level of Evidence C)

Delivery

PMCD: after ≈4 minutes of resuscitative efforts (Class IIa; Level of Evidence C)

When PMCD is performedA. not be transported to OR (Class IIa; Level of

Evidence B)B. not wait for surgical equipment; only a scalpel is

required (Class IIa; Level of Evidence C)C. not spend time on lengthy antiseptic procedures

(Class IIa; Level of Evidence C)D. Continuous manual LUD until the fetus is

delivered (Class IIa; Level of Evidence C)

EMS Considerations

If available, transport should be directed toward a center that is prepared to perform PMCD, but transport should not be prolonged by >10 minutes to reach a center with more capabilities (Class IIb; Level of Evidence C).

Cause of the Cardiac Arrest

Table 5. Most Common Etiologies of Maternal Arrest and Mortality

Letter Cause Etiology

A Anesthetic complications High neuraxial blockHypotensionLoss of airwayAspirationRespiratory depressionLocal anesthetic systemic toxicity

Accidents/trauma TraumaSuicide

B Bleeding CoagulopathyUterine atonyPlacenta accretaPlacental abruptionPlacenta previaRetained products of conceptionUterine ruptureSurgicalTransfusion reaction

C Cardiovascular causes Myocardial infarctionAortic dissectionCardiomyopathyArrhythmiasValve diseaseCongenital heart disease

Table 5. Most Common Etiologies of Maternal Arrest and Mortality

Letter Cause Etiology

D Drugs OxytocinMagnesiumDrug errorIllicit drugsOpioidsInsulinAnaphylaxis

E Embolic causes Amniotic fluid embolusPulmonary embolusCerebrovascular eventVenous air embolism

F Fever SepsisInfection

G General H’s and T’s

H Hypertension PreeclampsiaEclampsiaHELLP syndrome, intracranialbleed

Point-of-Care Instruments

point-of-care checklists (Class I; Level of Evidence B)

Immediate Postarrest Care

still pregnant: full left lateral decubitus position not in full left lateral tilt: manual LUD (Class I;

Level of Evidence C)