AHA/acc Resuscitation Guidelines

Answer 1

Code team members with responsibility for pregnant women should be familiar with the physiological changes of pregnancy that affect resuscitation technique and potential complications (Class I; Level of Evidence C).

Answer 2

Pregnant women who become ill should be risk stratified by the use of a validated obstetric early warning score (Class I; Level of Evidence C).

Answer 3

Hospital units with a pregnant woman in their care should ensure that proper pre-event planning has been instituted, including preparation for maternal cardiac arrest and neonatal resuscitation (Class I; Level of Evidence C).

Answer 4

The patient should be placed in a full left lateral decubitus position to relieve aortocaval compression (Class I; Level of Evidence C).

Answer 5

Administration of 100% oxygen by face mask to treat or prevent hypoxemia is recommended (Class I; Level of Evidence C).

Answer 6

Intravenous access should be established above the diaphragm to ensure that the intravenously administered therapy is not obstructed by the

Answer 7

Precipitating factors should be investigated and treated (Class I; Level of Evidence C).

Answer 8

Chest compressions should be performed at a rate of at least 100 per minute at a depth of at least 2 in (5 cm), allowing full recoil before the next compression, with minimal interruptions, and at a compression-ventilation ratio 30:2

Answer 9

Interruptions should be minimized and limited to 10 seconds except for specific interventions such as insertion of an advanced airway or use of a defibrillator51 (Class IIa; Level of Evidence C

Answer 10

The patient should be placed supine for chest compressions (Class I; Level of Evidence C).

Answer 11

There is no literature examining the use of mechanical chest compressions in pregnancy, and this is not advised at this time.

Answer 12

Continuous manual LUD should be performed on all pregnant women who are in cardiac arrest in which the uterus is palpated at or above the umbilicus to relieve aortocaval compression during resuscitation (Class I; Level of Evidence C

Answer 13

If the uterus is difficult to assess (eg, in the morbidly obese), attempts should be made to perform manual LUD if technicallfeasible (Class IIb; Level of Evidence C).

Answer 14

The rescuer should place the heel of 1 hand on the center (middle) of the victim’s chest (the lower half of the sternum) and the heel of the other hand on top of the first so that the hands overlap and are parallel (Class IIa; Level of Evidence C).

Answer 15

Because an immediate cesarean delivery may be the best way to optimize the condition of the mother and fetus (see section on “PMCD”), this operation should optimally occur at the site of the arrest. A pregnant patient with in-hospital cardiac arrest should not be transported for cesarean delivery. Management should occur at the site of the arrest (Class I; Level of Evidence C). Transport to a facility that can perform a cesarean delivery may be required when indicated (eg, for out-of-hospital cardiac arrest or cardiac

Answer 16

The same currently recommended defibrillation protocol should be used in the pregnant patient as in the nonpregnant patient. There is no modification of the recommended application of electric shock during pregnancy29 (Class I; Level of Evidence C).

Answer 17

Compressions should be resumed immediately delivery of the electric shock58 (Class IIa; Level of Evidence C).

Answer 18

For in-hospital settings where staff have no ECG rhythm recognition skills or where defibrillators are used infrequently such as in an obstetric unit, the use of an automated external defibrillator may be considered58 (Class IIb; Level of Evidence C).

Answer 19

Anterolateral defibrillator pad placement is recommended as a reasonable default (Class IIa; Level of Evidence C). The lateral pad/paddle should be placed under the breast tissue, an important consideration in the pregnant patient.

Answer 20

The use of adhesive shock electrodes is recommended to allow consistent electrode placement (Class IIa; Level of Evidence C).

Answer 21

Rapid notification should be provided to the maternal cardiac arrest response team29,63–65 (Class I; Level of Evidence C).

Answer 22

The time when pulselessness was confirmed should be documented66 (Class I; Level of Evidence C).

Answer 23

High-quality CPR should be paired with uterine displacement, and a firm backboard should be used42-45 (Class I; Level of Evidence C).

Answer 24

Rapid automated defibrillation should be provided whenever it is indicated as appropriate by rhythm analysis63,65 (Class I; Level of Evidence C).

Answer 25

Appropriate BLS airway management should be initiated. a. A member of the first responder team should perform bag-mask ventilation with 100% oxygen flowing to the bag at a rate of at least 15 L/ min (Class IIb; Level of Evidence C). b. Two-handed bag-mask ventilation is preferred (Class IIa; Level of Evidence C).

Answer 26

Hospitals need to establish first-responder roles that satisfy all of the requirements for BLS, including modifications recommended during pregnancy. A minimum of 4 staff members should respond for BLS resuscitation of the pregnant patient. All hospital staff should be able to fulfill first-responder roles (Class I; Level of Evidence C).

Answer 27

There should be 1 call to action that activates the maternal cardiac arrest team, notifies all members, and ensures that specialized equipment is brought to the scene without delay (Class I; Level of Evidence C).

Answer 28

The maternal cardiac arrest team would ideally be composed of the following26 (Class I; Level of Evidence C): a. An adult resuscitation team (potentially composed of critical care physicians and nurses, and/or emergency physicians and nurses, and/ or internal medicine physicians and nurses, or other service lines such as general surgery and trauma, with respiratory therapy or equivalent [ie, nurse or physician] and pharmacy representatives according to institutional policy, etc) b. Obstetrics: 1 obstetric nurse, 1 obstetrician c. Anesthesia care providers: obstetric anesthesiologist if available or staff anesthesiologist; anesthesia assistant or certified nurse anesthetist if available d. Neonatology team: 1 nurse, 1 physician, 1 neonatal respiratory therapist or equivalent (ie, nurse or physician) e. In centers without obstetric/neonatology services, it is suggested that the cardiac arrest committee and hospital emergency services discuss contingency plans in the event of maternal cardiac arrest.

Answer 29

Leadership during a maternal cardiac arrest is complicated, given the multiple teams involved. Leadership will depend on where the arrest occurs and may be specific to institutional practices. In general, there should be a team leader for adult resuscitation, a team leader for obstetric care, and a team leader for neonatal/fetal care. One approach to deal with multiple subspecialties is for the usual cardiac arrest team leader to delegate leadership for obstetric care, fetal/neonatal care, and airway/ventilatory management. All team leaders must communicate effectively together to make decisions about code manage

Answer 30

Hypoxemia should always be considered as a cause of cardiac arrest. Oxygen reserves are lower and the metabolic demands are higher in the pregnant patient compared with the nonpregnant patient; thus, early ventilatory support may be necessary (Class I; Level of Evidence C).

Answer 31

Endotracheal intubation should be performed by an experienced laryngoscopist (Class I; Level of Evidence C). a. Starting with an ETT with a 6.0- to 7.0-mm inner diameter is recommended (Class I; Level of Evidence C). b. Optimally no more than 2 laryngoscopy attempts should be made (Class IIa; Level of Evidence C). c. Supraglottic airway placement is the preferred rescue strategy for failed intubation (Class I; Level of Evidence C). d. If attempts at airway control fail and mask ventilation is not possible, current guidelines for emergency invasive airway access should be followed (call for help, obtain equipment).

Answer 32

Prolonged intubation attempts should be avoided to prevent deoxygenation, prolonged interruption in chest compressions, airway trauma, and bleeding (Class I; Level of Evidence C

Answer 33

Cricoid pressure is not routinely recommended (Class III; Level of Evidence C).

Answer 34

Continuous waveform capnography, in addition to clinical assessment, is recommended as the most reliable method of confirming and monitoring correct placement of the ETT (Class I; Level of Evidence C) and is reasonable to consider in intubated patients to monitor CPR quality, to optimize chest compressions, and to detect ROSC (Class IIb; Level of Evidence C). Findings consistent with adequate chest compressions or ROSC include arising Petco2 level or levels >10 mm Hg (Class IIa; Level of Evidence C).

Answer 35

Interruptions in chest compressions should be minimized during advanced airway placement (Class I; Level of Evidence C).

Answer 36

For refractory (shock-resistant) ventricular fibrillation and tachycardia, amiodarone 300 mg rapid infusion should be administered with 150-mg doses repeated as needed (Class IIb; Level of Evidence C).

Answer 37

Medication doses do not require alteration to accommodate the physiological changes of pregnancy. Although there are changes in the volume of distribution and clearance of medication during pregnancy, there are very few data to guide changes in current recommendations (Class IIb; Level of Evidence C).

Answer 38

Evidence C). 3. In the setting of cardiac arrest, no medication should be withheld because of concerns about fetal teratogenicity83 (Class IIb; Level of Evidence C).

Answer 39

Physiological changes in pregnancy may affect the pharmacology of medications, but there is no scientific evidence to guide a change in current recommendations. Therefore, the usual drugs and doses are recommended during ACLS (Class IIb; Level of Evidence C).

Answer 40

Administering 1 mg epinephrine IV/IO every 3 to 5 minutes during adult cardiac arrest should be considered. In view of the effects of vasopressin on the uterus and because both agents are considered equivalent, epinephrine should be the preferred agent (Class IIb; Level of Evidence C).

Answer 41

It is recommended that current ACLS drugs at recommended doses be used without modifications29 (Class IIa; Level of Evidence C).

Answer 42

Fetal assessment should not be performed during resuscitation (Class I; Level of Evidence C).

Answer 43

Fetal monitors should be removed or detached as soon as possible to facilitate PMCD without delay or hindrance (Class I; Level of Evidence C).

Answer 44

If maternal viability is not possible (through either fatal injury or prolonged pulselessness), the procedure should be started immediately; the team does not have to wait to begin the PMCD (Class I; Level of Evidence C).

Answer 45

When PMCD is performed, the following are recommended: a. The woman should not be transported to an operating room for PMCD during the management of an in-hospital maternal cardiac arrest (Class IIa; Level of Evidence B). b. The team should not wait for surgical equipment to begin the procedure; only a scalpel is required (Class IIa; Level of Evidence C). c. The team should not spend time on lengthy antiseptic procedures. Either a very abbreviated antiseptic pour should be performed, or the step should be eliminated entirely (Class IIa; Level of Evidence C). d. Continuous manual LUD should be performed throughout the PMCD until the fetus is delivered (Class IIa; Level of Evidence C). Care should be taken to avoid injury to the rescue

Answer 46

If the uterus is difficult to assess (eg, in the morbidly obese), then determining the size of the uterus may prove difficult. In this situation, PMCD should be considered at the discretion of the obstetrician by using his or her best assessment of the uterus. In these patients, bedside ultrasound may help guide decision making (Class IIa; Level of Evidence C).

Answer 47

During cardiac arrest, if the pregnant woman (with a fundus height at or above the umbilicus) has not achieved ROSC with usual resuscitation measures with manual uterine displacement, it is advisable to prepare to evacuate the uterus while resuscitation continues (Class I; Level of Evidence C).

Answer 48

Decisions on the optimal timing of a PMCD for both the infant and mother are complex and require consideration of factors such as the cause of the arrest, maternal pathology and cardiac function, fetal gestational age, and resources (ie, may be delayed until qualified staff is available to perform this procedure). Shorter arrest-to-delivery time is associated with better outcome (Class I; Level of Evidence B).

Answer 49

PMCD should be strongly considered for every mother in whom ROSC has not been achieved after ≈4 minutes of resuscitative efforts (Class IIa; Level of Evidence C).

Answer 50

If maternal viability is not possible (through either fatal injury or prolonged pulselessness), the procedure should be started immediately; the team does not have to wait to begin the PMCD (Class I; Level of Evidence C).

Answer 51

When PMCD is performed, the following are recommended: a. The woman should not be transported to an operating room for PMCD during the management of an in-hospital maternal cardiac arrest (Class IIa; Level of Evidence B). b. The team should not wait for surgical equipment to begin the procedure; only a scalpel is required (Class IIa; Level of Evidence C). c. The team should not spend time on lengthy antiseptic procedures. Either a very abbreviated antiseptic pour should be performed, or the step should be eliminated entirely (Class IIa; Level of Evidence C).Continuous manual LUD should be performed throughout the PMCD until the fetus is delivered (Class IIa; Level of Evidence C). Care should be taken to avoid injury to the rescuer performing the manual LUD during PMCD.

Answer 52

If the uterus is difficult to assess (eg, in the morbidly obese), then determining the size of the uterus may prove difficult. In this situation, PMCD should be considered at the discretion of the obstetrician by using his or her best assessment of the uterus. In these patients, bedside ultrasound may help guide decision making (Class IIa; Level of Evidence C).

Answer 53

Assisted vaginal delivery should be considered when the cervix is dilated and the fetal head is at an appropriately low station (Class IIb; Level of Evidence C).