ob resuscitation - dr. rebecca bavolek
TRANSCRIPT
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
http://en.wikipedia.org/wiki/User:Aleister_Wilson/ethereal_being
Pager 0430: 23yo pregnant female from homeless shelter, unresponsive,
agonal respirations, unable to obtain pulse or BP. ETA
10 min
http://www.flickr.com/photos/emtgin/8143846230/
http://www.picardyproject.com/2011_07_01_archive.html
Caesarian_section_-_Pull_out.jpg
2298925061_b56af27dab_z.jpg start_photo.jpg
ERTraumaRoomGhostsPict_lg04.jpgGather Your Resources
?
Start with your basic mantra...
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About those A’s and B’s
http://crashingpatient.com/resuscitation/airway/airway.htm/
About those A’s and B’sTiny,
Squished Stomach
About those A’s and B’s
About those A’s and B’s
http://en.wikipedia.org/wiki/Reinke's_edema
Moving on to C...
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
Patient Positioning
Does Pelvic Position Matter?
Where is the Max IVC diameter?
Supine 24%LLT 48% RLT 28%
No correlation to patient age, BMI, EGA
Hypovolemia:
Pump Failure: Obstruction:
http://stumander1989.deviantart.com/art/Film-Review-The-Sixth-Sense-206478746
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?
What now?
You already know what to do!
PEA/Arrhythmia
Same ACLS Drugs/Protocols
TraumaControl
Hemorrhage/ATLS
STEMI PCI
Massive PE Lytics
Other H’s&T’s
Carry On
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
If your patient arrests, time is ticking...
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
The Perimortem C-SectionThe Perimortem C-Section
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
http://memegenerator.net/instance/37652575
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.