a practical step by step approach of how to address a pregnant lady in imminent cardiac arrest

1. HOW I DO IT

2. Arrest scenario ???
RULE 1 -- NEVER PANIC
Always easier said than done
RULE 2— ALWAYS CALL FOR HELP
There are always more people to help than we
actually assume always…
Rule 3— AVOID CONFLICTS. DELEGATE ROLES &
RESPONSIBILITIES
Team wins-always

3.  Case 1 : A 50 yr old lady with IHD for TAH under spinal
anaesthesia devolops severe bradycardia and arrest 15 minutes
after anaesthesia.
 Case 2: A 26 yr old primi after prolonged labour delivers a
term baby. 20 minutes later, she collapse in labour room table
after drinking horlicks. Pale and cyanosed.
 Case 3 : A 30 yr old young lady undergoing HSG suddenly
complains of giddiness and fatiguie ,collapses and becomes
pulseless.
 Case 4: A 32 yr primi concieved after infertility LSCS 4
days back,suddenly c/o breathlessness in ward and
collapses. She was due for discharge next day.

4.  In general, an assessment of the peri-arrest patient
closely resembles what you do when encountered with a
bleeding uterus, "find the bleeding, fix the bleeding"
approach to immediately life threatening problems.
 As one progresses from airway to breathing to
circulation, one addressess the immediately life
threatening issues first, and only then moves on with
the survey
 ABCD holds good even now right from montessori/KG

5. 1) Confirm cardiac arrest
2) Call for help
3) Commence BLS (CPR) as a sole responder until help
arrives
 100 compressions per minute
 Compression to a depth of 1/3rd of the anterior-posterior
chest diameter
 If airway is unprotected, 30:2 ratio of compressions to
breaths
 If intubated, asynchronous ventilation of 8-10 breaths per
minute
 Ensure the ETT is not malpositioned (chest examination,
end tidal CO2 )

6. 4) Once help arrives, commence ALS arrest algorithm
 Apply defibrillator pads and charge defibrillator with
CPR in progress
 Perform a rhythm check, minimising interruption of
compressions
 If shockable rhythm, administer shock : choose max
energy
 Then, Adrenaline every 2nd rhythm check
 Amiodarone after the 3rd shock (300mg)
 If non-shockable rhythm, administer adrenaline 1 mg
every 3 minutes.
5) Exclude treatable causes of cardiac arrest
(4 Hs and 4 Ts).

7. Causes of cardiac arrest
For the majority of situations, BEING,able to reason in
terms of Hs and Ts is enough.
 These are the reversible causes.
 Hypoxia
 Hypovolemia
 Hyper/hypokalemia
 Hyper/hypothermia
 Tension pneumothorax
 Tamponade
 Toxins
 Thrombus (CORONARY,PULMONARY)

8.  Modifications to diagnostic thinking in obstetrics
Though pregnant women may die of the same causes as non-
pregnant non-women (i.e. the four Hs and four Ts), one needs
to keep in mind the following alternative causes of arrest:
 Amniotic fluid embolism
 Hypertensive disorder of pregnancy (with ensuing cardiac
failure)
 Seizures (with ensuing hypoxia and arrest)
 Haemorrhage from liver rupture
 Haemorrhage from uterine rupture

9. Issues which complicate the pregnant arrest and
peri-arrest scenario
 Difficult intubation
 Increased risk of aspiration (Stomach just doesnt't empty)
 Venous return is impaired by the gravid uterus
 Systemic oxygen consumption is increased
 Cardiac output and circulating volume are greater
 Decompensation occurs faster.

10.  Manually displace the uterus to the left (off the aorta and
vena cava)
 Add a left lateral tilt (the ideal angle is unknown, and is
thought to be between 15° and 30°)
 From the first paper of 2010 offers a weirdly specific 27° pelvis tilt is recommended. The 27°
figure comes from Rees and Willis (1998), who got physicians to perform CPR on specially
modified mannequins at different degrees of tilt. The authors found that the 27 degrees was
the angle at which safe positioning and compression efficacy were at optimal
compromise. Chest compression force was not too badly affected (80% of the force of
compressions with the patient in a supine position), and the patient was unlikely to roll off the
bed at this angle.
Modifications to Basic life support

11.  Biaxillary defibrillator pad placement
 PREFERABLY DEFEBRILLATOR BOARD.
 Prepare for an emergency perimortem caesarean.
Rationale for peri-mortem Caesarean
 The practice is recommended for pregnancies later than the 23rd week
(fundal height more than 2 finger breadths above the umbilicus),
 A foetus beyond the 23rd week has a chance of extrauterine survival
 A gravid uterus beyond the 23rd week is large enough to cause aortocaval
compression
 In the case of pregnant cardiac arrest, relief of aortocaval compression is
the major modification to BLS/ALS algorithms because aortocaval
compression by the gravid uterus is the most significant barrier to
successful resuscitation

12. Arguments for peri-mortem Caesarean
 Improved venous return to the heart
 Improved efficiency of external cardiac compressions (in the absence
of pelvic tilt)
 In the presence of truly unsalvageable maternal pathology, it offers a
chance for foetal survival
 Delivery of the foetus and placenta allows ample space in the abdomen for
transabdominal direct cardiac massage to take place.
Arguments against peri-mortem Caesarean
 Strong evidence in support of perimortem caesarian is lacking.
 The procedure must occur within 4 minutes of maternal arrest, or the
benefit to either mother or foetus is lost. This sort of slick obstetric speed
is relatively rare: Katz et al (1986) report on a case series where only 48% of
the infants were delivered within this timeframe.
 The average time from arrest to delivery was 16 minutes in a recent case
series of non-trauma arrests (Einav et al, 2012).
 Of the infants delivered "late", many will have persisting severe
neurological sequelae. Katz et al (1986) report that only 66% were
neurologicall normal 18 months after delivery.

13. Theoretical risks of perimortem Caesarean
 Foetal injury during the rushed procedure
 Maternal complications consistent with survival, but resulting in
disability (eg. ranging from loss of fertility to bowel perforation,
infection, paraplegia etc)
 Medicolegal risks, eg. years later an angry father of a disabled child
turns up, "why did you do this to my family" etc.; this is particularly
concerning in the vacuum of evidence and with only weak support
from major society recommendations.
 Medicolegal risks work in both ways (i.e.one may be determined
negligent for not performing this potentially lifesaving
procedure).

14. Evidence regarding the efficacy and safety
of peri-mortem Caesarean
 An old study (Morris, 1996) reports satisfactory outcomes for both mothers and infants in non-arrest trauma
setting (75% survived)
 In a more modern non-trauma series of perimortem caesarian neonatal survival rate was 62% and a "good"
outcome was achieved in half of the survivors.
 Perimortem caesarian may lead to improved maternal survival and increased rates of ROSC. Beckett et al
(2015) found that in all survivors, the median time from arrest to caesarian was shorter than in non-survivors,
suggesting that perimortem caesarian has a significant survival benefit.
 It is true that the recommendations to perform
caesarian within 4 minutes of arrest are rarely met,
but this does not mean that we should stop trying to
meet them.
 A rapid and successful perimortem caesarean it is
most likely to happen in a large tertiary hospital.
Thus, in-hospital arrest is the most important
predictor of maternal and foetal survival.

15. “Tailored approach"
 Patient meeting criteria for perimortem caesarian
 Less than 4-5 minutes from arrest
 Without a prolonged period of unwitnessed collapse
 At or after 23 weeks of gestation
 If the delivery is being performed with foetal survival as the
rationale, further criteria apply:
 Without a prolonged period of maternal haemorrhage or hypoxia
 With foetal heart beat confirmed as present
 Without a prolonged period of maternal haemorrhage or
hypoxia
 With foetal heart beat confirmed as present

16.  If there is ample warning to staff (eg. advanced notice to the ED),
then following should take place:
 Neonatologist available on site
 O&G team scrubbed and ready to meet the patient
 Brief ABC assessment in the ED to confirm the above listed criteria are met
 Transfer straight to the operating theatre, where the resuscitation may
continue
 If there is no maternal ROSC within 5 minutes, go ahead with the caesarean
 The caesarean is carried out through a laparotomy midline incision (Elkady
et al)
 If ROSC occurs during the caesarian, one has the option of stopping the
delivery and going ahead with normal resuscitation
 The priority is maternal survival. If maternal survival is
impossible, there should be no delay in ensuring foetal survival.
 "There is no requirement for transfer to an operating theatre,
obstetric/surgical expertise, and equipment beyond a scalpel or
lengthy antiseptic procedures"

17. A stereotyped approach to the peri-arrest patient
 1) Ensure personal safety
 2) Perform a basic peri-arrest primary survey
 Immediate assessment to diagnose cardiac arrest
 Are they awake?
 If they appear unconscious, shake them and ask "Are you
alright?"
 If they are unresponsive, look ,listen and feel for respiratory
effort.
 If the patient is unconscious, unresponsive, and is not
breathing, call for help and start CPR.
 Otherwise, move on with the structured approach to prevent
cardiac arrest

18. Airway:
 Assess patency: Best done by interrogating the patient. If she provides coherent
answers to your questions, his ABCs are unlikely to be desperately compromised.
 If she does not, one should secure her airway - initially using unsophisticated
techniques (jaw thrust, chin lift), progressing through airway adjuncts to
intubation as needed.
 Look for presence of vomit or foreign body
 Prepare to progress to intubation
 Get trained in SGA
 CALL FOR EXPERT HELP
 MASK VENTILATE TILL THEN
 DON’T PANIC

19. Breathing
 Observe respiratory rate
 Maintain oxygenation intially with high flow oxygen via tight-fitting
reservoir mask.
 Progress to bag-mask ventilation if respiratory arrest occurs
 Auscultate the chest, percuss it, palpate for surgical emphysema
 Investigate with ABG and urgent CXR
 Specific differentials to consider before moving on with the survey:
 Massive PE (distended neck veins, cyanosis, tachycardia and
hypotension)
 Acute severe asthma (silent hyperexpanded chest, the hint of
wheeze)
 Tension pneumothorax (unequal air entry, deviated trachea,
hyper-resonant chest)
 Massive haemothorax or effusion (unequal air entry, deviated
trachea, dull percussion note over the hemithorax)
 Pulmonary oedema (pink frothy sputum, coarse gurling creps)

20. Circulation
 Ensure large-bore IV access
 Go for intra osseous early.
 Measure the blood pressure non-invasively and attach ECG leads
for monitoring
 Administer IV fluids as bolus – one litre crystalloid.
 Administer readily available vasopressors, eg.
MEPHENTERMINE in order to maintain cerebral
perfusion,assess for sources of bleeding
 ABG or CBC to assess Hb and need for transfusion,rapid bedside
echo to assess cardiac chamber volume and contractility

21.  Specific differentials to consider before moving on with
the survey:
 Extremes of hypovolemia (collapsed veins, empty chambers,
slow capillary refill, dry mucosae, cool extremities, weak rapid
pulse)
 Haemorrhagic shock ( exactly as above but also deathly pallor)
 Cardiac tamponade (distended neck veins, muffled heart
sounds, electrical alternans on ECG)
 Peri-arrest arrhythmia (eg. VT or SVT)
 Severe sepsis (mottled skin, fever, hyperdynamic circulation
with hypotension)
 A fluid bolus is appropriate reaction in any case.
 A hand-operated pump giving set with a litre of crystalloid
should be set up. Ideally, one should prepare for invasive
arterial blood pressure monitoring.

22. Disability (neuro) & Exposure(examination)
 Assess for sources of bleeding
 Examine for features of anaphylaxis
 Check blood sugars always
 Look for seizures,focal signs,pupils
 Check temperature; ensure normothermia
Immediate investigations for the peri-arrest patient
 ABG
 ECG
 CXR
 CBC, LFT, group and screen, blood cultures (as well as any other relevant body fluid)
Investigations in the short-medium term
 CTPA
 CT of any specific suspicious cavity (abdomen, chest, brain)
 TTE-2d echo
 Random cortisol level, TFTs, etc (to exclude exotic causes of haemodynamic
instability)

23. Bedside Echo
Causes of peri-arrest deterioration which can be identified by rapid bedside TTE
 Hypovolaemia
 Tamponade (pericardial)
 Tension pneumothorax
 Thrombosis – pulmonary (thromboembolism)
 Thrombosis – coronary (regional or global wall motion abnormalities,
including lack of cardiac motion)
 Pacemaker capture
 Unexpected VF
 Acute valvular insufficiency (e.g. papillary muscle rupture)
 Ventricular rupture
 Aortic dissection
 Massive pleural effusion