Learning Station 3 Environmental Emergency 7 No Pulse; Not Breathing and Pregnant

1999 American Heart Association

Case 1. 17-Year-Old With Gunshot Wound to Head

Situation Report

You: chief resident on duty in ED Info: receive Medic 1 dispatchers call: 17-year-old female shot in the head in a drive-by shooting MS: unconscious, minimally responsive to deep pain Vital signs: HR = 145 bpm, BP = 90/55 mm Hg, Resp = 12/min Therapy: cervical collar; immobilize; short-board extrication; long-board stabilization; oropharyngeal (no gag); oxygenIVmonitorfluid; transport ETA: 12 minutes

What are your immediate thoughts?

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Case 1. Conditions Change During Transport

EMT-Ps call back; condition changes Gunshot wound: bleeding controlled Vital signs: BP drops to 40 mm Hg/palpable Heart rate: monitor shows sinus tachycardia = 180 bpm Doc, now that we have a better look, she looks like she is about 8 to 9 months pregnant!
A dramatic drop in BP why? How does term pregnancy change things? What do you do now?

Primary ABCD Survey

Modifications for Term Pregnancy

Third trimester: avoid placing woman flat on her back Gravid uterus can occlude inferior vena cava Prevents blood return to heart Hypotension; shock Tilt 30 to 45 toward left side Do CPR against wedge, knees, chairs
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Another Status Change

Medics call back Backboard tilted to left at 30 EMT pushes uterus toward left Good response: increased BP, decreased HR But 5 minutes later: BP = 200/90 mm Hg, Resp = 6/min, HR = 35 to 40 bpm
What is going on now? What should you be thinking about?
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Advance Planning

Neurologic response: Cushings triadominous Cardiovascular status: close to cardiac arrest What about the second patient? Is a perimortem cesarean section indicated? Stat call to OB Stat call to pediatrics and neonatology
If she arrests with no pulse, no respirations, unresponsive, how would you approach the Secondary ABCD Survey?
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One Minute From Arrival in ED

Cardiac arrest; no breathing; no pulse

Primary ABCD modify in pregnancy Primary: do CPR at tilt Shock VF/VT same energies and intervals Secondary ABCD A: Orotracheal intubation in-line stabilization (due to trauma, not pregnancy) B: Ventilation volumes more problematic C: Give all ACLS meds same drugs, doses, intervals What if she remains in full cardiac arrest? What factors now enter into decision making?
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Cardiac Arrest Continues

No Response to ACLS Care

Transferred: EMS care to ED care Ongoing CPR Intubated IV medications given

What can you do next?

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Perimortem C-Section?

Empty the uterus if no response to wellexecuted resuscitation in 5 minutes! Minimal chance of successful survival mother or child if arrest continues more than 5 minutes Important: preceding resuscitation MUST have been well-executed: intubation correct, IV in place, drugs appropriate
What other factors should be considered before performing cesarean section?
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Mother/Child Factors
Consider Before the C-Section Decision

Mother/child factors to consider: Is fetus old enough to have a good chance for meaningful survival outside the uterus? What if the infant is too small to play occlusive role noted above? Is arrest duration too great for mothers meaningful survival?
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Setting / Personnel Factors

Consider Before the C-Section Decision

Setting and personnel Is appropriate equipment available? Is C-section within skill comfort zone of rescuers? Is there skilled pediatric support to care for infant? What if infant is not full term? Is immediate obstetric support available for mother after C-section? Regardless of emergency setting, is there staff support and approval?
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