European Resuscitation Council Guidelines for Resuscitation ... - CPR

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18 de 0ctubre de 2010 www.elsuapdetodos.com1422 J. Soar et al. / Resuscitation 81 (2010) 1400–1433• psychiatric disorders;• hypertensive disorders of pregnancy;• sepsis;• haemorrhage;• amniotic-fluid embolism;• ectopic pregnancy.Pregnant women can also sustain cardiac arrest from the samecauses as women of the same age group.Key interventions to prevent cardiac arrest• Start basic life support according to standard guidelines. Ensuregood quality chest compressions with minimal interruptions.• Manually displace the uterus to the left to remove caval compression.• Add left lateral tilt if this is feasible – the optimal angle of tilt isunknown. Aim for between 15 ◦ and 30 ◦ . Even a small amount oftilt may be better than no tilt. The angle of tilt used needs to allowgood quality chest compressions and if needed allow Caesareandelivery of the fetus.• Start preparing for emergency Caesarean section (see below) –the fetus will need to be delivered if initial resuscitation effortsfail.In an emergency, use an ABCDE approach. Many cardiovascularproblems associated with pregnancy are caused by aortocavalcompression. Treat a distressed or compromised pregnant patientas follows:• Place the patient in the left lateral position or manually and gentlydisplace the uterus to the left.• Give high-flow oxygen guided by pulse oximetry.• Give a fluid bolus if there is hypotension or evidence of hyovolaemia.• Immediately re-evaluate the need for any drugs being given.• Seek expert help early. Obstetric and neonatal specialists shouldbe involved early in the resuscitation.• Identify and treat the underlying cause.Modifications to BLS guidelines for cardiac arrestAfter 20 weeks gestation, the pregnant woman’s uterus canpress down against the inferior vena cava and the aorta, impedingvenous return and cardiac output. Uterine obstruction of venousreturn can cause pre-arrest hypotension or shock and, in the criticallyill patient, may precipitate arrest. 481,482 After cardiac arrest,the compromise in venous return and cardiac output by the graviduterus limits the effectiveness of chest compressions.Non-arrest studies show that left lateral tilt improves maternalblood pressure, cardiac output and stroke volume 483–485 andimproves fetal oxygenation and heart rate. 486–488 Two studiesfound no improvement in maternal or fetal variables with 10–20 ◦left lateral tilt. 489,490 One study found more aortic compression at15 ◦ left lateral tilt when compared with a full left lateral tilt. 484Aortic compression has been found to persist at over 30 ◦ of tilt. 491Two non-arrest studies show that manual left uterine displacementwith the patient supine is as good as or better than left lateral tiltin relieving aortocaval compression, as assessed by the incidenceof hypotension and ephedrine use. 492,493 Non-cardiac arrest datashow that the gravid uterus can be shifted away from the cavain most cases by placing the patient in 15 ◦ of left lateral decubitusposition. 494 The value of relieving aortic or caval compressionduring CPR is, however, unknown.Unless the pregnant victim is on a tilting operating table, leftlateral tilt is not easy to perform whilst maintaining good qualitychest compressions. A variety of methods to achieve a left lateral tilthave been described including placing the victim on the rescuersknees 495 , pillows or blankets, and the Cardiff wedge 496 althoughtheir efficacy in actual cardiac arrests is unknown. Even when atilting table is used, the angle of tilt is often overestimated. 497 In amanikin study, the ability to provide effective chest compressionsdecreased as the angle of left lateral tilt increased and that at anangle of greater than 30 ◦ the manikin tended to roll. 496The key steps for BLS in a pregnant patient are:• Call for expert help early (including an obstetrician and neonatologist).Modifications to advanced life supportThere is a greater potential for gastro-oesophageal sphincterinsufficiency and risk of pulmonary aspiration of gastric contents.Early tracheal intubation with correctly applied cricoid pressuredecreases this risk. Tracheal intubation will make ventilation of thelungs easier in the presence of increased intra-abdominal pressure.A tracheal tube 0.5–1 mm internal diameter (ID) smaller thanthat used for a non-pregnant woman of similar size may be necessarybecause of maternal airway narrowing from oedema andswelling. 498 One study documented that the upper airways in thethird trimester of pregnancy are narrower compared with theirpostpartum state and to non-pregnant controls. 499 Tracheal intubationmay be more difficult in the pregnant patient. 500 Expert help,a failed intubation drill and the use of alternative airway devicesmay be needed (see Section 4). 24a,501There is no change in transthoracic impedance during pregnancy,suggesting that standard shock energies for defibrillationattempts should be used in pregnant patients. 502 There is no evidencethat shocks from a direct current defibrillator have adverseeffects on the fetal heart. Left lateral tilt and large breasts willmake it difficult to place an apical defibrillator paddle. Adhesivedefibrillator pads are preferable to paddles in pregnancy.Reversible causesRescuers should attempt to identify common and reversiblecauses of cardiac arrest in pregnancy during resuscitation attempts.The 4 Hs and 4 Ts approach helps identify all the common causes ofcardiac arrest in pregnancy. Pregnant patients are at risk of all theother causes of cardiac arrest for their age group (e.g., anaphylaxis,drug overdose, trauma). Consider the use of abdominal ultrasoundby a skilled operator to detect pregnancy and possible causes duringcardiac arrest in pregnancy; however, do not delay other treatments.Specific causes of cardiac arrest in pregnancy include thefollowing.www.elsuapdetodos.comHaemorrhageLife-threatening haemorrhage can occur both antenatally andpostnatally. Postpartum haemorrhage is the commonest singlecause of maternal death worldwide and is estimated to cause onematernal death every 7 min. 503 Associations include ectopic pregnancy,placental abruption, placenta praevia, placenta accreta, anduterine rupture. 480 A massive haemorrhage protocol must be availablein all units and should be updated and rehearsed regularly inconjunction with the blood bank. Women at high risk of bleedingshould be delivered in centres with facilities for blood transfusion,intensive care and other interventions, and plans should bemade in advance for their management. Treatment is based on anABCDE approach. The key step is to stop the bleeding. Consider thefollowing:
• fluid resuscitation including use of rapid transfusion system andcell salvage 504 ;• oxytocin and prostaglandin analogues to correct uterineatony 505 ;• massaging the uterus 506 ;• correction of coagulopathy including use of tranexamic acid orrecombinant activated factor VII 507–509 ;• uterine balloon tamponade 510,511 ;• uterine compression sutures 512 ;• angiography and endovascular embolization 513 ;• hysterectomy 514,515 ;• aortic cross-clamping in catastrophic haemorrhage. 516Cardiovascular diseaseMyocardial infarction and aneurysm or dissection of the aortaor its branches, and peripartum cardiomyopathy cause most deathsfrom acquired cardiac disease. 517,518 Patients with known cardiacdisease need to be managed in a specialist unit. Pregnant womenmay develop an acute coronary syndrome, typically in associationwith risk factors such as obesity, older age, higher parity, smoking,diabetes, pre-existing hypertension and a family history ofischaemic heart disease. 480,519 Pregnant patients can have atypicalfeatures such as epigastric pain and vomiting. Percutaneouscoronary intervention (PCI) is the reperfusion strategy of choicefor ST-elevation myocardial infarction in pregnancy. Thrombolysisshould be considered if urgent PCI is unavailable. A review of 200cases of thrombolysis for massive pulmonary embolism in pregnancyreported a maternal death rate of 1% and concluded thatthrombolytic therapy is reasonably safe in pregnancy. 520Increasing numbers of women with congenital heart disease arebecoming pregnant. 521 Heart failure and arrhythmias are the commonestproblems, especially in those with cyanotic heart disease.Pregnant women with known congenital heart disease should bemanaged in specialist centres.Pre-eclampsia and eclampsiaEclampsia is defined as the development of convulsions and/orunexplained coma during pregnancy or postpartum in patientswith signs and symptoms of pre-eclampsia. 522,523 Magnesium sulphateis effective in preventing approximately half of the casesof eclampsia developing in labour or immediately postpartum inwomen with pre-eclampsia. 524–526Pulmonary embolismThe estimated incidence of pulmonary embolism is 1–1.5 per10,000 pregnancies, with a case fatality of 3.5% (95% CI 1.1–8.0%). 527Risk factors include obesity, increased age, and immobility. Successfuluse of fibrinolytics for massive, life-threatening pulmonaryembolism in pregnant women has been reported. 520,528–531Amniotic-fluid embolismAmniotic-fluid embolism usually presents around the timeof delivery with sudden cardiovascular collapse, breathlessness,cyanosis, arrhythmias, hypotension and haemorrhage associatedwith disseminated intravascular coagulopathy. 532 Patients mayhave warning signs preceding collapse including breathlessness,chest pain, feeling cold, light-headedness, distress, panic, a feelingof pins and needles in the fingers, nausea, and vomiting.The UK Obstetric Surveillance System identified 60 cases ofamniotic-fluid embolism between 2005 and 2009. The reportedincidence was 2.0 per 100,000 deliveries (95% CI 1.5–2.5%) 533The case fatality is 13–30% and perinatal mortality is 9–44%. 53218 de 0ctubre de 2010 www.elsuapdetodos.comJ. Soar et al. / Resuscitation 81 (2010) 1400–1433 1423Amniotic-fluid embolism was associated with induction of labour,multiple pregnancy, older, and ethnic-minority women. Caesareandelivery was associated with postnatal amniotic-fluid embolism.Treatment is supportive, as there is no specific therapy based onan ABCDE approach and correction of coagulopathy. Successful useof extracorporeal life support techniques for women suffering lifethreateningamniotic-fluid embolism during labour and delivery isreported. 534If immediate resuscitation attempts failConsider the need for an emergency hysterotomy or Caesareansection as soon as a pregnant woman goes into cardiac arrest. Insome circumstances immediate resuscitation attempts will restorea perfusing rhythm; in early pregnancy this may enable the pregnancyto proceed to term. When initial resuscitation attempts fail,delivery of the fetus may improve the chances of successful resuscitationof the mother and fetus. 535–537 One systematic reviewdocumented 38 cases of Caesarean section during CPR, with 34 survivinginfants and 13 maternal survivors at discharge, suggestingthat Caesarean section may have improved maternal and neonataloutcomes. 538 The best survival rate for infants over 24–25 weeksgestation occurs when delivery of the infant is achieved within5 min after the mother’s cardiac arrest. 535,539–541 This requires thatthe provider commence the hysterotomy at about 4 min after cardiacarrest. At older gestational ages (30–38 weeks), infant survivalis possible even when delivery was after 5 min from the onset ofmaternal cardiac arrest. 538 A case-series suggests increased use ofCaesarean section during CPR with team training 542 ; in this seriesno deliveries were achieved within 5 min after starting resuscitation.Eight of the twelve women had ROSC after delivery, with twomaternal and five newborn survivors. Maternal case fatality ratewas 83%. Neonatal case fatality rate was 58%. 542Delivery will relieve caval compression and may improvechances of maternal resuscitation. The Caesarean delivery alsoenables access to the infant so that newborn resuscitation canbegin.Decision-making for emergency hysterotomy (Caesarean section)The gravid uterus reaches a size that will begin to compromiseaortocaval blood flow at approximately 20 weeks gestation;however, fetal viability begins at approximately 24–25 weeks. 543Portable ultrasound is available in some emergency departmentsand may aid in determination of gestational age (in experiencedhands) and positioning, provided its use does not delay the decisionto perform emergency hysterotomy. 544 Aim for delivery within5 min of onset of cardiac arrest. This will mean that Caesareansection needs to ideally take place where the cardiac arrest hasoccurred to avoid delays.www.elsuapdetodos.com• At gestational age less than 20 weeks, urgent Caesarean deliveryneed not be considered, because a gravid uterus of this size isunlikely to significantly compromise maternal cardiac output.• At gestational age approximately 20–23 weeks, initiate emergencyhysterotomy to enable successful resuscitation of themother, not survival of the delivered infant, which is unlikely atthis gestational age.• At gestational age approximately ≥24–25 weeks, initiate emergencyhysterotomy to save the life of both the mother and theinfant.Post-resuscitation carePost-resuscitation care should follow standard guidelines. Therapeutichypothermia has been used safely and effectively in early
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European Resuscitation Council Guidelines for Resuscitation ... - CPR

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