Chapter 7 Airway Head tilt/chin lift unless trauma then use jaw thrust Rescue breathing without chest compressions 10 – 12 breaths/min Rescue breaths with advanced airway 8 – 10 brea
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Trang 5Critical Care Obstetrics, 5th edition Edited by M Belfort, G Saade,
M Foley, J Phelan and G Dildy © 2010 Blackwell Publishing Ltd
Andrea Shields 1 & M Bardett Fausett 2
1 Antenatal Diagnostic Center, San Antonio Military Medical Center, Lackland Airforce Base, Texas, USA
2 Obstetrics and Maternal - Fetal Medicine, San Antonio Military Medical Center and Department of Obstetrics and Gynecology,
Wilford Hall Medical Center, Lackland Airforce Base, Texas, USA
Introduction
Sudden cardiac arrest (SCA) is a leading cause of death in the
United States and Canada An estimated 330 000 people die
annu-ally in the United States from SCA in out - of - hospital and
emer-gency department settings [1] This translates to 0.55 per thousand
people in the US, and 1 in 30 000 gravid women who will suffer
SCA each year Overall maternal mortality is signifi cantly higher
in developing countries including mortality from SCA Women
of childbearing age are commonly healthy and the overall risk of
death is low in developed nations These facts, along with the
additional life involved, make SCA in pregnancy unexpected and
particularly devastating
Women are most likely to survive cardiopulmonary arrest
when attended by providers skilled in basic and advanced
cardio-pulmonary resuscitative techniques The mechanical and
physi-ologic changes of pregnancy impact every phase of the resuscitation
process In this chapter, we review the most recent American
Heart Association (AHA) cardiopulmonary resuscitation (CPR)
guidelines and emphasize pregnancy - specifi c modifi cations We
do not address infant and child resuscitation in this chapter but
the practicing obstetrician should likewise be expert with
neona-tal resuscitation In this chapter, we will consider other relevant
pregnancy - related issues such as perimortem cesarean section
and the ethical dilemma of prolonged maternal life support for
fetal maturation
The initial objective of CPR and emergency cardiac care (ECC)
is to maintain adequate oxygenation and vital organ perfusion
patients; however, prolonged survival is lower with underlying
illness [2] Overall outcome, particularly full neurologic recovery,
is improved by early initiation of CPR and defi brillation Most
victims of SCA demonstrate ventricular fi brillation at some point
leading to full arrest Ventricular fi brillation is best treated by
electrical cardioversion performed within the fi rst 5 minutes after collapse [3] Since the majority of SCA occurs outside of the hospital setting, it is uncommon for emergency medical service personnel to be contacted and arrive at the victim ’ s side within these critical 5 minutes [4] Thus, achieving a high survival rate depends upon public training in CPR and well - organized public access defi brillation programs Considering all victims, out of -hospital survival rates for SCA victims are only 6% but can improve to 75% when victims are given high - quality CPR [4] Outside of the hospital, SCA is usually associated with cata-strophic trauma and is rarely a survivable event for pregnant women even in developed countries
In the hospital, SCA in pregnancy is usually associated with
high - quality CPR is likely to have a signifi cant impact on survival rates Thus, hospital personnel involved in the care of pregnant women should be expertly trained and facile in techniques of cardiopulmonary resuscitation Obstetrical units should have proper resuscitative equipment readily available and staff members be engaged in ongoing programs to train and maintain CPR competency In one recent evaluation of obstetric training programs, the authors concluded that even basic life support knowledge and skills are inadequate and ongoing training is necessary [6]
Current c ardiac c are r ecommendations
In December 2005, the American Heart Association published an update to the guidelines for lay and professional Basic and Advanced Cardiac Life Support (BLS/ACLS) A summary of the ABCDs of lay and provider rescuer BLS is shown in Table 7.1 The primary changes to the 2005 resuscitation guidelines were meant to simplify algorithms and promote their early application
to SCA victims The new guidelines include four major changes relevant to women of reproductive age and are applicable to both lay and provider rescuer CPR [7] These general changes are sum-marized in Table 7.2
Trang 6Chapter 7
Airway Head tilt/chin lift unless trauma then use jaw thrust
Rescue breathing without chest compressions 10 – 12 breaths/min
Rescue breaths with advanced airway 8 – 10 breaths/min
Foreign body obstruction Abdominal thrusts
Compression method Heel of one hand with the other on top; push hard and fast
and allow complete recoil
Compression : ventilation ratio 30 : 2 (either one or two rescuers)
Table 7.1 Summary of CPR ABCD s (modifi ed from
“ Summary of BLS ABCD maneuvers for infants, children and adults ” ) [68]
Table 7.2 Summary of key changes in 2005 CPR guidelines [4]
Deliver more effective chest
compressions
Early, consistent, fast, hard Single compression : ventilation
ratio for all but neonates
30 : 2 Rescue breaths Given over 1 second; 500 – 600 mL for adults
Defi brillation After fi rst shock go directly to
compression : ventilations × 2 min
First, there is signifi cant emphasis on, and recommendations
to improve, delivery of effective chest compressions The key
words are early, consistent, fast and hard This emphasis is made
because half of chest compressions (even by healthcare providers)
are too shallow The chest is often not allowed to recoil
ade-quately between compressions and interruptions are too common
Complete chest wall recoil increases cardiac fi lling by increasing
negative pressure, promoting venous return and maximizing
cardiac output with the subsequent compression The fi rst few
compressions after interruption are not as effective as those that
follow Thus, inadequate compressions, incomplete chest recoil
and frequent interruptions all signifi cantly decrease circulation
and oxygen delivery and decrease survival [7]
The second new recommendation is for a single 30 : 2
compres-sion to ventilation ratio for all victims except newborns The
guideline authors note most cases of cardiac arrest in adults are
not hypoxia - induced Consequently, circulation is more critical
than ventilation in the fi rst minute of CPR Since the blood fl ow
to the lungs is diminished (25 – 33%) during arrest/CPR, victims
need less ventilation than normal In contrast, newborn cardiac
arrest is commonly related to hypoxia so more ventilations (5:1)
to compressions are indicated and remain part of the new
guide-lines [7]
The third recommendation is that each rescue breath should
be given over 1 second (rather than 1 – 2 seconds) and produces
a visible chest rise The visible chest rise ensures effi cacy and the
1 - second breath provides adequate tidal volume (500 – 600 mL) while avoiding hyperinfl ation Rescuers are to take a normal breath before giving the rescue breath Frequent rescue breathing interrupts and delays chest compressions Hyperinfl ation increases intrathoracic pressure leading to decreased blood return
to the chest This results in diminished effi cacy of the next several compressions and increases the risk of gastric insuffl ation The fi nal new major recommendation is that during ventricu-lar fi brillation (VF) cardiac arrest, a single shock should be given followed by immediate CPR CPR is to begin even before the fi rst rhythm check 2 minutes later Historically, rhythm analysis by automated defi brillators available before 2005 resulted in delays
of more than 30 seconds before giving the fi rst post - shock com-pressions Current defi brillators eliminate VF more than 85% of the time Thus, in a case where the fi rst shock fails, CPR is likely
to convey greater value than a second shock Even when a shock eliminates VF, it usually takes several minutes for a normal effec-tive rhythm to return A brief period of CPR can increase energy and oxygen to the heart, increasing the likelihood that the heart will be able to continue effective blood fl ow There is no evidence that postdefi brillation chest compressions provoke recurrent VF For similar reasons, lay rescuer CPR recommendations now eliminate the initial check for pulse after giving the initial two rescue breaths [7]
Key changes to recommendations for provider - level and hos-pital - based adult BLS include use of the 30 : 2 ventilation to com-pression ratio (even with two rescuers) until an advanced airway
is in place As noted in the general guidelines above, before an advanced airway is in place, rescuers should perform 5 cycles of CPR after shock before the next rhythm check Even once the advanced airway is in place, rescuers should perform 2 minutes
Trang 7of CPR after shock before the next rhythm check With two
or more rescuers and an advanced airway in place, rescuers
no longer provide cycles of compressions with pauses for
ventila-tion One rescuer provides 8 – 10 breaths per minute (1 every 6 – 8
seconds) while the other rescuer provides continuous
compres-sions Where possible, rescuers should rotate the compressor role
every 2 minutes, taking no more than 5 seconds to do so After
2 – 3 minutes of CPR, rescuers typically perform chest
compres-sions less effectively [7] The general provider BLS algorithm is
shown in Figure 7.1 and the pulseless arrest ACLS algorithm in
Figure 7.2 Algorithms for tachycardia and bradycardia are not
included here but are usually available on all “ code carts ”
Patient p opulation and e tiologies of SCA
in p regnancy
Of women who suffer SCA during pregnancy, most have
throm-boembolic - , followed by hemorrhage - , related events [8] The
most common causes of SCA during pregnancy are listed in Table
7.3 Victims of SCA in pregnancy are younger and have fewer
underlying medical conditions than non - pregnant victims [8]
However, maternal age and underlying medical problems
con-tinue to increase in developed countries due to elective delayed
childbearing and advanced reproductive technologies
Pregnancy increases the risk of venous thromboembolic disease
(VTE) due to hormonally stimulated increases of virtually all of
the procoagulant proteins The risk of VTE is amplifi ed by
condi-tions necessitating bed rest such as gestational hypertensive
dis-orders and preterm labor The risk is highest in the immediate
postpartum period, [9] probably due to the tissue trauma and
decreased physical activity associated with delivery
Lipo - oxidative injury to the coronary vessels is the most
common cause of SCA in non - pregnant individuals but is an
uncommon cause of SCA in pregnancy However, the added
physiologic stress of pregnancy can unveil underlying congenital
or acquired valve disease Pregnancy does increase the risk of
myocardial infarction 3 – 4 fold over otherwise comparable non
pregnant women The pregnancy - related MI risk is signifi cantly
greater in women older than 30 years [10] Additionally, pregnant
women have a relatively increased risk of coronary artery and
aortic dissections compared to non - pregnant women with
other-wise similar demographic characteristics [11] This may be due
to progesterone - mediated relaxation of smooth muscle
Pregnancy - s pecifi c c onditions a ssociated
with SCA
Turning now to pregnancy - specifi c conditions associated with
SCA, we fi rst highlight the anaphylactoid syndrome of pregnancy
also called amniotic fl uid embolus (AFE) This disorder is
char-acterized by an anaphylaxis - like syndrome that is associated with
cardiac depression, cardiopulmonary collapse and coagulopathy
The disorder is highly lethal with a 50 – 65% risk of cardiac arrest and maternal death [12 – 15] This catastrophic condition is discussed in detail in Chapter 35 but the reader is encouraged
to remember that this disorder is associated with profound vascular leak, and over - resuscitation with crystalloid fl uids can result in massive pulmonary edema Therapy targeted to support the cardiovascular system and correct the coagulopathy while avoiding over - resuscitation with crystalloid fl uid may be helpful [16]
Gestational hypertensive disorders occur more frequently than thromboembolic disorders and both occur more commonly than anaphylactoid syndrome of pregnancy [14] Women with hyper-tensive disorders of pregnancy are at increased risk of SCA for several reasons including the associated underlying endothelial injury and infl ammatory response Hypertension may necessitate medical therapy and magnesium is often used for seizure prophy-laxis Both may be associated with cardiac compromise leading
to SCA [17 – 20] Profound hypotension and SCA can occur in women with pre - eclampsia treated concurrently with calcium channel antagonists and magnesium sulfate In cases of cardio-pulmonary compromise due to magnesium sulfate toxicity, resuscitation must include calcium rescue The typical dose is 1 g
of intravenous calcium carbonate
ABCD s in p regnancy
If breathing stops fi rst, then the heart often continues to pump for several minutes usually providing enough oxygen in the lungs and bloodstream to support life for up to 6 minutes [21] In contrast, when the heart stops fi rst, oxygen in the lungs and bloodstream cannot be circulated to vital organs The patient whose heart and respirations have stopped for less than 4 minutes has an excellent chance of recovery if CPR is administered imme-diately and is followed by ACLS within 4 minutes [22] By 4 – 6 minutes, brain damage may occur, and after 6 minutes, brain damage will almost always occur Therefore, the initial goals of CPR are to deliver oxygen to the lungs and provide a means of circulation to the vital organs Initially circulation is provided via closed - chest compression followed by ACLS, with restoration of the heart as the mechanism of circulation These goals are achieved by remembering the “ ABCDs ” of the primary and sec-ondary survey (Table 7.1 ) The primary survey consists of airway management using non - invasive techniques, breathing with pos-itive - pressure ventilations, and performing CPR until equipment for external defi brillation arrives Out - of - hospital and BLS tools required include gloved hands, a barrier device for CPR, and an automated external defi brillator (AED) for defi brillation A sec-ondary survey requires the use of advanced, invasive techniques
as the rescuer attempts to resuscitate, stabilize, and transfer the patient to a higher level of care if indicated (i.e hospital or inten-sive care setting) Potentially reversible causes of cardiopulmo-nary arrest should also be considered and addressed at this stage (Table 7.4 )
Trang 8Chapter 7
If not breathing, give 2 BREATHS that make chest rise
Definite Pulse
If no response, check pulse:
Do you DEFINITELY feel pulse within 10 seconds?
No movement or response
PHONE 911 or emergency number
Get AED
or send second rescuer (if available) to do this
Open AIR WAY, check BREATHING
Resume CPR immediately
for 5 cycles Check rhythm every
5 cycles; continue until ALS providers take over or victim starts to move
Give cycles of 30 COMPRESSIONS and 2 BREATHS
until AED/defibrillator arrives, ALS providers take over, or
victim starts to move
Push hard and fast (100/min) and release completely Minimize interruptions in compressions AED/defibrillator ARRIVES
Check Rhythm Shockable rhythm?
Give 1 shock Resume CPR immediately
for 5 cycles
-Give 1 breath every
5 to 6 seconds -Recheck pulse every
2 minutes 5A
1 2 3 4
5 6
7 8
No Pulse
Figure 7.1 ACLS Adult BLS Provider Algorithm Modifi ed from Circulation 2005; 112: IV - 58 – IV - 66
Trang 9Figure 7.2 ACLS Adult Pulseless Arrest Algorithm Modifi ed from Circulation 2005; 112: IV - 58 – IV - 66
Shockable Not Shockable
Shockable Give 5 cycles of CPR*
Give 5 cycles of CPR*
Shockable
Give 5 cycles of CPR*
Not Shockable Shockable
Check rhythm
Shockable rhythm?
PULSELESS ARREST
• BLS Algorithm: Call for help, five CPR
• Give oxygen when available
• Attach monitor/defibrillator when available
Continue CPR while defibrillator is charging
Give 1 shock
• Manual biphasic: device specific (typically 120 to 200 J)
• AED: device specific
• Monophasic: 360 J
Resume CPR immediately after the shock
When IV/IO available, give vasopressor during CPR (before
or after the shock)
• Epinephrine 1 mg IV/IO
Repeat every 3 to 5 minutes
or
• May give 1 dose of vasopressin 40 U IV/IO to replace
first or second dose of ephinephrine
Give 1 shock
• Manual biphasic: device specific
(typically 120 to 200 J)
• AED: device specific
• Monophasic: 360 J
Resume CPR immediately
Check rhythm
Shockable rhythm?
Continue CPR while defibrillator is charging
Give 1 shock
• Manual biphasic: device specific (typically 120 to 200 J)
• AED: device specific
• Monophasic: 360 J
Resume CPR immediately after the shock
Consider antiarrhythmics; give during CPR
(before or after the shock)
amiodarone (300 mg IV/IO once, then
consider additional 150 mg IV/IO once) or
lidocaine (1 to 1.5 mg/kg first dose, then 0.5 to 0.75 mg/
kg IV/IO, maximum 3 doses or 3 mg/kg)
Consider magnesium, loading dose 1 to 2 g IV/IO for
torsades de pointes
After 5 cycles of CPR,* go to Box 5 above
Check rhythm
Shockable rhythm?
• If asystole, go to Box 10
• If elecrical activity, check pulse, If no pulse, got to Box 10
• If pulse present, begin postresuscitation care
Resume CPR immediately for 5 cycles
When IV/IO available, give vasopressor
• Epinephrine 1 mg IV/IO
Repeat every 3 to 5 minutes or
• May give 1 dose of vasopressin 40 U IV/IO to replace first or second dose of ephinephrine Consider atropine 1 mg IV/IO
for asystole or slow PEA rate Repeat every 3 to 5 min (up to 3 doses)
Check rhythm
Shockable rhythm?
Go to Box 4
During CPR
• Push hard and fast (100/min)
• Ensure full chest recoil
• Minimize interruptions in chest compressions
• One cycle of CPR; 30 compressions then 2 breaths; 5 cycles takes about
2 min
•Avoid hyperventilation
• Secure airway and confirm placement After an advanced airway is placed, rescuers no longer deliver “cycles”
of CPR, Give continuous chest pressions with pauses for breaths.
Give 8 to 10 breaths/minute Check rhythm every 2 minutes
• Rotate compressors every 2 minutes with rhythm checks
• Search for and treat possible contributing factors:
•Hypovolemia •Hypoxia •Hydogen ion (acidosis) •Hypo-/hyperkalemia •Hypoglycemia •Hypothermia •Toxins •Tamponade, cardiac •Tension pneumothorax •Thrombosis (coronary or pulmonary)
•Trauma
No No
1
2 3
4
5
6
7
8
9
10
11
12
13
Airway
Delivery of oxygen is achieved by positioning the patient,
opening the airway, and delivering rescue breaths In the absence
of muscle tone, the tongue and epiglottis frequently obstruct the
airway The head tilt with the chin - lift maneuver (Figure 7.3 ) or
the jaw thrust maneuver (Figure 7.4 ) facilitates airway access If
foreign material appears in the mouth, it should be removed If
air does not enter the lungs with rescue breathing, reposition the
head and repeat the attempt at rescue breathing Persistent
obstruction may require the Heimlich maneuver
(subdiaphrag-matic abdominal thrusts), chest thrusts, removal of foreign body
if now visualized, and rescue breathing The Heimlich maneuver
cannot be used in the late stages of pregnancy or in the obese
choking victim Airway obstruction may occur in a choking
victim as well as the patient experiencing a cardiopulmonary
arrest The conscious women with only partial airway obstruction should be allowed to attempt to clear the obstruction herself Rescuers should avoid the fi nger sweep in a conscious patient
In the fi rst half of pregnancy, airway obstruction can be relieved with the Heimlich maneuver or abdominal thrusts From a stand-ing position the rescuer wraps his arms around the victim ’ s waist, making a fi st with one hand and placing the thumb side of the
fi st against the victim ’ s abdomen in the midline slightly above the umbilicus and well below the top of the xiphoid process The rescuer grasps the fi st with the other hand and presses the fi st into the victim ’ s abdomen with quick, distinct, upward thrusts The thrusts are continued until the object is expelled or the victim is unconscious The unconscious victim is placed supine, the heel
of one hand remains against the victim ’ s abdomen, in the midline slightly above the umbilicus but below the top of the xiphoid The
Trang 10Chapter 7
second hand lies directly on top of the fi rst, and quick upward
thrusts are administered
In the latter half of pregnancy, the gravid uterus or maternal
habitus may necessitate the use of chest thrusts instead of
abdom-inal thrusts Chest thrusts in a conscious sitting or standing victim
require placing the thumb side of the fi st on the middle of the
sternum, avoiding the xiphoid and the ribs The rescuer then
grabs his or her own fi st with the other hand and performs chest
thrusts until either the foreign object is dislodged or the patient
loses consciousness The unconscious patient is placed supine
The rescuer ’ s hand closest to the patient ’ s head is placed 2 fi
nger-breadths above the xiphoid The long axis of the heel of the
provider ’ s hand rests on the long axis of the sternum and the
other hand lies over the fi rst, with the fi ngers either extended or
interlaced The elbows are extended and the chest is compressed
1.5 – 2 inches Up to 5 abdominal or chest thrusts are given
fol-lowed by repetition of the jaw - lift, foreign body visualization, and
attempted ventilation These steps are repeated until effective or
until a surgical airway can be obtained by emergency
cricothy-rotomy or jet - needle insuffl ation
If, after clearing any obstruction, the patient is unresponsive but breathing spontaneously, she is placed in the recovery posi-tion to keep the airway open The pregnant victim is placed on her left side The left arm is placed at a right angle to the victim ’ s torso, while the right arm is placed across her chest with the back
of her hand under the lower cheek The victim ’ s right thigh is
fl exed at a right angle to the torso, across the left leg, with the right knee resting on the surface The victim ’ s head is tilted back
to maintain the airway, using the right hand to maintain the head tilt Fetal monitoring should begin as soon as possible and breath-ing is monitored regularly If breathbreath-ing does not resume after clearing the airway or if it stops, the emergency medical system
is activated and the BCDs of CPR continued
Table 7.3 Causes of cardiac arrest during pregnancy [69]
Venous thromboembolism
Pregnancy - induced hypertension
Sepsis
Amniotic fl uid embolism
Hemorrhage
Placental abruption
Placenta previa
Uterine atony
Disseminated intravascular coagulation
Trauma
Iatrogenic
Medication errors or allergy
Anesthetic complications
Hypermagnesemia
Pre - existing heart disease
Congenital
Acquired
Table 7.4 Potentially reversible causes of cardiac arrest
Hypovolemia
Hypoxia
Hydrogen ion acidosis
Hyper - or hypokalemia, other metabolic
Hypothermia
Tablets (drug overdose)
Trauma
Tamponade, cardiac
Tension pneumothorax
Thrombosis, coronary
Thrombosis, pulmonary
Toxins (e.g amniotic fl uid)
Figure 7.3 Head tilt, chin lift
Figure 7.4 Jaw thrust