Cardiac Arrest in the Pregnant Patient (and Indian Food)

Our excellent Critical Care Medicine Mini-Fellowship met last week for our monthly meeting where we actually had an inter-departmental and inter-disciplinary presence to discuss cardiac arrest in the pregnant patient.

We reviewed three articles which I have summarized for you below:

1. Management of Cardiac Arrest in Pregnancy: A Systematic Review

Turns out there aren’t so many randomized control trials on this topic. Reviewed were case series about peri-mortem C sections – turns out they are only done in the recommended initial 5 minutes of arrest <20% of the time. Amazingly, numerous case reports show women had immediate hemodynamic improvement after the procedure. One review reported 12/22! They found higher rates of baby and maternal recovery when the procedure was done within 5 minutes.

Secondly, there is no difference in impedence in the pregnant patient, and the recommendation is to shock at the same Joules as a nonpregnant patient.

Thirdly, they reviewed an interesting complication in pregnant arrest. We all know that the uterus can put pressure on the IVC, decreasing venous return to the heart. So how do you do compressions on a pregnant patient? Too tilted and they slide off, not tilted enough and you worry about IVC compression. And the strength of compressions decreases with the patient tilted! One possible solution is manual displacement of the uterus.left displacement


2. Management of Cardiac Arrest in Pregnancy

Besides covering some information in the last paper, this one made a few key interesting points. They recommend each hospital set up a “Maternal Arrest Team” to call to the ED in an organized and efficient manner when needed. A good differential for maternal arrest is BEAUCHOPSBleeding/DIC Embolism  Anesthesia complications Uterine atony Cardiac disease Hypertension(eclampsia) Other (see acls) Placenta abruption/previa Sepsis


3. Resuscitation of the pregnant patient: What is the effect of patient positioning on inferior vena cava diameter?

Prospective, observational study in ultrasounding the IVC in healthy, 3rd trimester volunteers in right lateral decub, left lateral decub, and supine. Conclusions: Left lat increased the IVC in 75% of the patients versus supine. Right lat was less effective than left. Oddly, 24%had larger IVC’s in the supine position. They did not test the manual displacement of the uterine


Random Fun

The discussion eventually evolved into discussing APRV, a very hip new method of ventilation. Curious? Check it out here and here




By Dr. Andrew Grock

Special thanks to Dr. Ashika Jain as usual for cooking, hosting, and teaching


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