European Resuscitation Council Guidelines for Resuscitation 2010 ...
European Resuscitation Council Guidelines for Resuscitation 2010 ...
European Resuscitation Council Guidelines for Resuscitation 2010 ...
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1258 J.P. Nolan et al. / <strong>Resuscitation</strong> 81 (<strong>2010</strong>) 1219–1276<br />
Cardiac arrest associated with pregnancy<br />
Mortality related to pregnancy in developed countries is rare,<br />
occurring in an estimated 1:30,000 deliveries. 667 The fetus must<br />
always be considered when an adverse cardiovascular event occurs<br />
in a pregnant woman. <strong>Resuscitation</strong> guidelines <strong>for</strong> pregnancy are<br />
based largely on case series, extrapolation from non-pregnant<br />
arrests, manikin studies and expert opinion based on the physiology<br />
of pregnancy and changes that occur in normal labour.<br />
Studies tend to address causes in developed countries, whereas<br />
the most pregnancy-related deaths occur in developing countries.<br />
There were an estimated 342,900 maternal deaths (death during<br />
pregnancy, childbirth, or in the 42 days after delivery) worldwide<br />
in 2008. 668<br />
Causes of cardiac arrest in pregnant women include: cardiac<br />
disease; pulmonary embolism; psychiatric disorders; hypertensive<br />
disorders of pregnancy; sepsis; haemorrhage; amniotic fluid<br />
embolism; and ectopic pregancy. 669 Pregnant women can also sustain<br />
cardiac arrest from the same causes as women of the same age<br />
group.<br />
Modifications to BLS guidelines <strong>for</strong> cardiac arrest during<br />
pregnancy<br />
After 20 weeks’ gestation, the pregnant woman’s uterus can<br />
press down against the inferior vena cava and the aorta, impeding<br />
venous return and cardiac output. Uterine obstruction of venous<br />
return can cause pre-arrest hypotension or shock and, in the critically<br />
ill patient, may precipitate arrest. 670,671 After cardiac arrest,<br />
the compromise in venous return and cardiac output by the gravid<br />
uterus limits the effectiveness of chest compressions.<br />
The key steps <strong>for</strong> BLS in a pregnant patient are:<br />
• Call <strong>for</strong> expert help early (including an obstetrician and neonatologist).<br />
• Start basic life support according to standard guidelines. Ensure<br />
good quality chest compressions with minimal interruptions.<br />
• Manually displace the uterus to the left to remove caval compression.<br />
• Add left lateral tilt if this is feasible—the optimal angle of tilt is<br />
unknown. Aim <strong>for</strong> between 15 and 30 ◦ . The angle of tilt needs<br />
to allow good quality chest compressions and if needed allow<br />
caesarean delivery of the fetus (see below).<br />
Modifications to advanced life support<br />
There is a greater potential <strong>for</strong> gastro-oesophageal sphincter<br />
insufficiency and risk of pulmonary aspiration of gastric contents.<br />
Early tracheal intubation with correctly applied cricoid pressure<br />
decreases this risk. Tracheal intubation will make ventilation of<br />
the lungs easier in the presence of increased intra-abdominal<br />
pressure. A tracheal tube 0.5–1 mm internal diameter (ID) smaller<br />
than that used <strong>for</strong> a non-pregnant woman of similar size may be<br />
necessary because of maternal airway narrowing from oedema<br />
and swelling. 672 There is no change in transthoracic impedance<br />
during pregnancy, suggesting that standard shock energies <strong>for</strong><br />
defibrillation attempts should be used in pregnant patients. 673<br />
Rescuers should attempt to identify common and reversible<br />
causes of cardiac arrest in pregnancy during resuscitation attempts.<br />
The 4Hs and 4Ts approach helps identify all the common causes<br />
of cardiac arrest in pregnancy. Pregnant patients are at risk of all<br />
the other causes of cardiac arrest <strong>for</strong> their age group (e.g., anaphylaxis,<br />
drug overdose, trauma). Consider the use of abdominal<br />
ultrasound by a skilled operator to detect pregnancy and possible<br />
causes during cardiac arrest in pregnancy; however, do not delay<br />
other treatments.<br />
If immediate resuscitation attempts fail<br />
Consider the need <strong>for</strong> an emergency hysterotomy or caesarean<br />
section as soon as a pregnant woman goes into cardiac arrest. In<br />
some circumstances immediate resuscitation attempts will restore<br />
a perfusing rhythm; in early pregnancy this may enable the pregnancy<br />
to proceed to term. When initial resuscitation attempts fail,<br />
delivery of the fetus may improve the chances of successful resuscitation<br />
of the mother and fetus. 674–676<br />
• At gestational age