Dr A Hards, Dr S Davies, Dr A Salman, Dr M Balki Mount Sinai Hospital 2010.
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Transcript of Dr A Hards, Dr S Davies, Dr A Salman, Dr M Balki Mount Sinai Hospital 2010.
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Dr A Hards, Dr S Davies, Dr A Salman, Dr M Balki Mount Sinai Hospital 2010
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Aim
To enable you to competently manage a case of maternal cardiac arrest
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Objectives
To review relevant maternal physiology
To review standard ACLS guidelines
To review ACLS modifications for pregnancy
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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
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Physiology of pregnancy
Cardiovascular System1. cardiac output increases by 50% (due to increased HR & SV). Increased
contractility and LVEF.
2. SVR and PVR fall by up to 35%. SBP, DBP, MAP decrease during mid preganancy, return to baseline near term
3. Aorto-caval compression occurs from 13-16 weeks
Implications
- supine hypotension
- higher femoral/IVC pressures
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Physiology of Pregnancy
Gastrointestinal System1. 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 ~ 16-20 weeks gestation
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Physiology of Pregnancy
Hematological System
1. 50% increase in plasma volume
2. 30% increase in red cell volume
3. Increased platelet turnover, clotting and fibrinolysis
Implications
- delayed presentation of hypovolaemia
- physiological anemia of pregnancy
- pro-coagulopathic state
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ACLS in pregnancy
Essentially follows same guidelines as for non-pregnant patients
AHA recommend some modifications based on physiology
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ACLS Cardiac Arrest Algorithm 2010
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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
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Emergency cesarean sectionRationale for early CS
- Provides effective maternal resuscitation (improves venous return
& cardiac output)
- If fetus > 24-25 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
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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”
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Maternal cardiac arrest algorithm
Vanden Hoek T L et al. Circulation 2010;122:S829-S861Copyright © American Heart Association
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Any questions?
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Summary
Reviewed relevant maternal physiology
Reviewed standard ACLS guidelines
Reviewed modifications for pregnancy