OB Resuscitation - Dr. Rebecca Bavolek
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Transcript of OB Resuscitation - Dr. Rebecca Bavolek
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You Want Me to do What!? Pearls for Resuscitating the Pregnant
Patient
Rebecca A. Bavolek, MDAssistant Program Director
Washington University School of MedicineBarnes Jewish Hospital/St. Louis Children’s Hospital
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http://en.wikipedia.org/wiki/User:Aleister_Wilson/ethereal_being
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Pager 0430: 23yo pregnant female from homeless shelter, unresponsive,
agonal respirations, unable to obtain pulse or BP. ETA
10 min
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http://www.flickr.com/photos/emtgin/8143846230/
http://www.picardyproject.com/2011_07_01_archive.html
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Caesarian_section_-_Pull_out.jpg
2298925061_b56af27dab_z.jpg start_photo.jpg
ERTraumaRoomGhostsPict_lg04.jpgGather Your Resources
?
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Start with your basic mantra...
6a00d83483b8fc53ef013488a2189e970c-800wi
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About those A’s and B’s
http://crashingpatient.com/resuscitation/airway/airway.htm/
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About those A’s and B’sTiny,
Squished Stomach
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About those A’s and B’s
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About those A’s and B’s
http://en.wikipedia.org/wiki/Reinke's_edema
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Moving on to C...
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Hypotension in Pregnancy
Is it normal, or is it shock?
HR by5-15 bpm
MAP by10-15 mmHg
Blood vol by 1L
Hgb by1-3 mg/dL
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Patient Positioning
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Does Pelvic Position Matter?
Where is the Max IVC diameter?
Supine 24%LLT 48% RLT 28%
No correlation to patient age, BMI, EGA
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Hypovolemia:
Pump Failure: Obstruction:
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http://stumander1989.deviantart.com/art/Film-Review-The-Sixth-Sense-206478746
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Should we consider a “P-RUSH” in the hypotensive pregnant patient?
H Heart
I IVC
MMorrison’s
Pouch
A Aorta
P Pneumo
H Heart
I IVC
MMorrison’s
Pouch
F Fetus
P Pneumo
If time allows, perform a full FAST
If time allows, perform a full FAST
May need to switch to intercostal window, could help determine optimal positioning?
May need to switch to intercostal window, could help determine optimal positioning?
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What now?
You already know what to do!
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PEA/Arrhythmia
Same ACLS Drugs/Protocols
TraumaControl
Hemorrhage/ATLS
STEMI PCI
Massive PE Lytics
Other H’s&T’s
Carry On
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What about BEAU-CHOPS?
B Bleeding/DIC
E Embolism
A Anesthetic Complication
U Uterine Atony
C Cardiac Disease
HHTN/Pre-eclampsia/
Eclampsia
O Other (ACLS Ddx)
P Placental Abruption/Previa
S Sepsis
Amniotic Embolus, ECMO?
IV Magnesium
Control hemorrhage,Consider MTP, oxytocin
Control hemorrhage, Consider MTP, delivery
Control hemorrhageConsider MTP, delivery
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If your patient arrests, time is ticking...
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Cardiac Arrest in Gravid Female
Cardiac Arrest in Gravid Female
Optimal PositioningET Intubation
IV Access (Upper Torso)ACLS
Prepare for Perimortem C-Section
Optimal PositioningET Intubation
IV Access (Upper Torso)ACLS
Prepare for Perimortem C-Section
GA > 20 wks?
GA > 20 wks? Yes
YesNoNo
Continue Maternal Resuscitation
Continue Maternal ResuscitationContinue Maternal
Resuscitation
Continue Maternal Resuscitation Fetal
Resuscitation
Fetal Resuscitation
Obstetrics NICU
Adult ICUInfant WarmerInstruments
Obstetrics NICU
Adult ICUInfant WarmerInstruments
Perform C-SectionPerform C-Section
0 Min
4 Min
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The Perimortem C-SectionThe Perimortem C-Section
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Summary
• Stay Calm (at least on the outside!)
• Mobilize your resources, assign roles
• Proceed with ABCs and consider modifications
• Consider using ultrasound to help guide therapy
• Most treatments are the same as the non-pregnant patient!
• Be ready to perform perimortem c-section within 4 minutes in appropriate patients
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http://memegenerator.net/instance/37652575
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References1. Fields JM, Catallo K, Au AK, Rotte M, Leventhal D, Weiner S, Ku BS. “Resuscitation of the pregnant patient: What is
the effect of patient positioning on inferior vena cava diameter?” Resuscitation 84 (2013) 304-8.
2. Sommerkamp SK, Gibson A. “Cardiovascular Disasters in Pregnancy.” Emerg Med Clin N Am 30 (2012) 949-59.
3. Brown S, Mozurkewich E. “Trauma During Pregnancy.” Obstet Gynecol Clin N Am 40 (2013) 47-57.
4. Gabbot DA. “Editorial: Uterine displacement during CPR in the pregnant patient -- Why bother?” Resuscitation 84 (2013) 267-8.
5. Engels PT, Caddy SC, Jiwa G, Matheson JD. “Cardiac arrest in pregnancy and perimortem c-section delivery: A case report and discussion.” CJEM 2011; 13(6): 399-403.
6. Vanden Hoek TL, Morrison LJ, Shuster M, Donnino M, Sinz E, Lavonas EJ, JeejeebhoyFM, Gabrielli A. “Part 12: Cardiac Arrest in Special Situations: 2010 American Heart Association Guidelines for Cardiopulmonary Care and Emergency Cardiovascular Care.” Circulation 2010; 122:S829-S861.
7. Weingart SW, Duque DD, Nelson BN. ACEP-EMED home; 3 April 2009. Available from: http://www.webcitation.org/5vyzOaPYU.
8. Wagner JC, Sampson C, Bausano B, Renz N. “Perimortem C-Section Simulation Model.” http://vimeo.com/32749876
9. The Crashing Patient: A Webtext of ED Critical Care. http://crashingpatient.com/resuscitation/physiology-oxygenation-ventilation.htm/, accessed October 2013.
10. Tanoubi I, Drolet P, Donati F. “Optimizing PreOxygenation in Adults.” Can J of Anesth (2009) 56:449-66.
11. Lange Anethesiology, Section IV. Physiology, Pathophysiology, & Anesthetic Management, Chapter 22: Respiratory Physiology: The effects of anesthesia.