Paleerat Jariyakanjana, MD Emergency physician 19 Oct 2015
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)