Best Practice & Research Clinical Obstetrics and Gynaecology 24 (2010) 383e400

Contents lists a ailable at !cience"irect

Best Practice & Research Clinical Obstetrics and Gynaecology

#o$rnal ho%e&age' ((()else ier)co%*locate*b&obgyn

10

Cardio&$l%onary res$scitation and the &art$rient

+aya !) !$resh, +)", Pro-essor and .nteri% Chair a, Cha(la /a0oya +ason, +)", 1ssistant Pro-essor 2, 3%a +$nn$r, +)", 1ssociate Pro-essor a
"e&art%ent o- 1nesthesiology, Baylor College o- +edicine, 1405 "ryden, !$ite 1400, 6o$ston, 07 44030, 3!1

8ey(ords' &hysiologic changes o- &regnancy cardio&$l%onary res$scitation ad anced cardiac li-e s$&&ort g$idelines anaesthesia9related %aternal %ortality &eri9%orte% caesarean section &ost9cardiac arrest hy&other%ia i%&ro ing &ost9res$scitation o$tco%es

Cardio&$l%onary arrest occ$rs in 1' 30 000 &regnancies) 1ltho$gh rare, o&ti%al o$tco%es are de&endent on the ca$se o- the arrest, the ra&id res&onse tea%:s $nderstanding o- the &hysiological e--ects o- &regnancy on the res$scitati e e--orts and a&&lication othe latest &rinci&les o- ad anced cardiac li-e s$&&ort (1C/!)) 1naesthesia9related co%&lications, secondary to di-;c$lt or -ailed int$bation, and inability to o;ygenate and entilate can res$lt in ad erse o$tco%es -or %other and baby) <;&erience in ad anced air(ay %anage%ent has been sho(n to decrease the incidence obrain death and %aternal %ortality) 1(areness o- li&id res$scita9 tion o- local anaesthetic to;icity is i%&ortant) 0he e--ects o- li&id res$scitation and its inter-erence (ith 1C/! %edications are also i%&ortant) Peri9%orte% caesarean deli ery o- the -oet$s greater than 24 (ee=s: gestational age %$st be considered) Caesarean deli ery sho$ld be &er-or%ed no later than 4 %in a-ter initial %aternal cardiac arrest) 1 -oet$s deli ered (ithin > %in has the best chance o- s$r i al) "eli ery o- the baby hel&s in the %aternal res$scitation e--orts and reco ery o- circ$lation) ?inally, the 2003 .nternational /iaison Co%%ittee on Res$scitation (./COR) and the 200> 1%erican 6eart 1ssociation (161) ad ocate the &ro ision o%ild thera&e$tic hy&other%ia to the s$r i ors o- cardiac arrest) 0his (ill i%&ro e the ne$rological o$tco%es by decreasing cere9 bral o;ygen cons$%&tion, s$&&ression o- the radical reactions and red$ction o- intracell$lar acidosis and inhibition o- e;citatory ne$rotrans%itters) @ 2010 P$blished by <lse ier /td)

2 Corres&onding a$thor) 0el)' A1 413 458 1884B ?a;' A1 413 458 C344) <9%ail addresses' %s$reshDbc%)ed$ (+)!) !$resh), c%asonDbc%)ed$ (C) /a0oya +ason), $%$nn$rDbc%)ed$ (3) +$nn$r)) a0el)' A1 413 458 1884B ?a;' A1 413 458 C344)

1>219C534*E e see -ront %atter @ 2010 P$blished by <lse ier /td) doi'10)101C*#)b&obgyn)2010)01)002

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Ca$ses o- cardio&$l%onary arrest Cardio&$l%onary arrest in &regnant &atients is rare) 0he esti%ated incidence is a&&ro;i%ately 1'30 000 &regnancies and al%ost 10F o- %aternal deaths res$lt -ro% cardio&$l%onary arrest) 1,2 O&ti%al %aternal and -oetal o$tco%es are de&endent on (1) the $nderlying ca$se o- the arrestB (2) the s&eed o- inter ention by the res&onse tea%B (3) an $nderstanding o- the &rinci&les o- res$scitation d$ring &regnancyB and (4) the s&eci;c challenges o- dealing (ith t(o &otential li es, that is, %other and baby) Cardiac arrest (ith (ides&read cerebral ischae%ia leads to se ere ne$rological i%&air%ent) 6ae%odyna%ic instability and de astating ne$rological in#$ry contrib$te to %ortality, des&ite the restoration o- circ$lation)3 ?$nctional s$r i al to discharge a-ter cardiac arrest in all icti%s is esti9 %ated at C)4F)4 !$ccess is also de&endent on addressing thera&e$tic inter entions to o&ti%ise ne$rological o$tco%es) 3ntil recently, there (as no thera&y (ith doc$%ented e-;cacy in &re enting brain da%age a-ter cardiac arrest) On the basis o- the &$blished e idence to date, the 1d anced /i-e !$&&ort (1/!) 0as= ?orce o- the .nternational /iaison Co%%ittee on Res$scitation (./COR) has %ade a s&eci;c reco%%endation -or the instit$tion o- thera&e$tic hy&other%ia a-ter ret$rn o- s&ontaneo$s circ$lation (RO!C))> 0hera&e$tic hy&other%ia a-ter cardiac arrest has been de%onstrated to i%&ro e -$nctional reco ery and increase the li=elihood o- a ne$rologically intact s$r i al in &atients) C,4 0here is a recent case re&ort o- s$ccess-$l o$tco%e $sing hy&other%ia in &regnancy) 8 .nd$ction o- %oderate hy&other%ia a-ter RO!C -ollo(ing cardiac arrest has been associated (ith i%&ro ed -$nctional reco ery and red$ced cerebral histological de;cits in ario$s ani%al %odels o- cardiac arrest) 5e11 0here are %any ca$ses o- cardiac arrest in the general &o&$lationB ho(e er, the ca$ses o- cardiac arrest d$ring &regnancy incl$de direct ca$ses o- &regnancy as (ell as &re9e;isting disease states) 12 +a#or ca$ses o- cardiac arrest are listed in 0able 1) 0he a ailable e&ide%iological data on %aternal %ortality in the 3nited !tates o- 1%erica and the 3nited 8ingdo% are sho(n in ?ig$res 1 and 2) 0he ca$ses and %anage%ent o- cardio9res&iratory %aternal arrest incl$de eno$s thro%bo9 e%bolis%, &re9ecla%&sia, se&sis, a%niotic ;$id e%bolis%, hae%orrhage, tra$%a, cardio%yo&athy and congenital or acG$ired cardiac disease) .atrogenic ca$ses incl$de anaesthesia9related co%&lica9 tions, s$ch as -ailed or di-;c$lt int$bation and local anaesthetic to;icity) ?ollo(ing a%niotic ;$id e%bolis% (1?<), &atients o-ten either die or s$--er &er%anent ne$rologic da%age) Chani%o et al), in disc$ssing 1?<, %a=e a &lea -or better brain &rotection in s$r i ors o- 1?<) 13,14 0his article also deals (ith &ost9res$scitation %anage%ent and brain &rotection) !e eral o- the ca$sati e -actors o- %aternal cardio9res&iratory arrest are disc$ssed in detail in other articles)

1naesthesia9related ca$ses o- cardio9&$l%onary arrest 1naesthesia 9related co%&lications are the se enth leading ca$se o- %aternal death in the 3nited !tates and 3nited 8ingdo%)1>e14 !$ch co%&lications are %ainly related to di-;c$lt or -ailed int$bation and inability to entilate or o;ygenate) 0he ;rst national st$dy o- anaesthesia9related %aternal %ortality in the 3nited !tates (as &resented in 1554) 0he %a#ority o- the anaesthesia9related deaths (82F) too= &lace d$ring caesarean section (C*!)) "eath rates d$ring C*! increased -ro% 20 &er %illion to 32)3 &er %illion -or general anaesthesia (G1)) Con ersely, the death rate -or regional anaesthesia (R1)

0able 1 Obstetric and nonobstetric ca$ses o- cardiac arrest in &regnancy) Obstetric ca$ses 6e%orrhage (14F) Pregnancy ind$ced hy&ertension (2)8F) .dio&athic &eri&art$% cardio%yo&athy (8F) 1nesthetic co%&lications (2F) 9 1ir(ay9related catastro&hes 9 /ocal anesthetic to;icity Honobstetric ca$ses P$l%onary e%bolis% (25F) .n-ection*se&sis (13F) !tro=e (>F) +yocardial in-arction Cardiac disease 9 Congenital 9 1cG$ired 9 Cardio%yo&athy 0ra$%a

1%niotic ;$id e%bolis%

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?ig) 1) +odi;ed -ro% Coo&er G+, +cCl$re I6 +aternal deaths -ro% anaesthesia) 18

declined -ro% 8)C to 1)5 &er %illion) 0he ris= ratio -or G1 increased to 1C)4 ti%es -ro% 158> to 1550, des&ite the (ide $se o- &$lse o;i%etry and end9tidal CO2 %onitoring) 0he ris= ratio o- G1 %ortality (as 2)3 ti%es that o- regional anaesthesia)1> .n the 3nited 8ingdo%, in the Con;dential <nG$iry into +aternal and Child 6ealth (C<+1C6) 2000e2002 st$dy, there (ere si; direct deaths, all related to G1) 18 +aternal deaths -ro% co%&lications o- G1 incl$ded a ris= o- one %aternal death in 20 000) 0hese cardio&$l%onary arrests and deaths (ere related to di-;c$lt or -ailed int$bation, di-;c$lt &$l%onary entilation res$lting in -ail$re to o;ygenate, &$l%onary as&iration and ac$te res&iratory distress syndro%e (1R"!)) .n all o- these cases, the anaesthesia care that (as rendered (as considered s$bstandard) 18 !ince di-;c$lt or -ailed int$bation d$ring &regnancy can lead to hy&o;ic cardio &$l%onary arrest and co%&licate the sit$ation, it is i%&ortant to be s=illed in the $se o- ario$s ad anced air(ay de ices) 0he recent Closed Clai%s !t$dy, &$blished in the 3!1, re ealed that obstetric anaesthesia clai%s -or in#$ries -ro% 1550 to 2003 had declined co%&ared (ith obstetric clai%s -or in#$ries be-ore 1550) .n case o- the obstetric clai%s -ro% 1550 to 2003, the &ro&ortion o- %aternal death*brain da%age and ne(born death*brain da%age decreased) Res&iratory ca$ses o- in#$ries also decreased -ro% 24F to 4F in clai%s -ro% 1550 or later) Clai%s related to inadeG$ate o;ygenation* entilation and as&iration also decreased) 6o(e er, the clai%s related to di-;c$lt int$bation did not change) 15 0he i%&ro e%ent in the statistics and decline in anaesthesia9related %aternal %ortality in the &ast -e( years is d$e to the in ention and $se o- ario$s s$&raglottic de ices in these di-;c$lt sit$ations) Recently, other ne(er air(ay ad#$ncts s$ch as ideolaryngosco&es ha e been introd$ced) 0here is also a heightened a(areness o- di-;c$lt obstetric air(ay a%ongst all anaesthesia &ractitioners) 0he laryngeal %as= air(ays (Classic, .nt$bating, and Pro!eal) ha e been sho(n to be li-e9sa ing resc$e de ices d$ring -ailed int$bation in obstetrical &atients) 20e24

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?ig) 2) +odi;ed -ro% Coo&er G+, +cCl$re I6) +aternal deaths -ro% anaesthesia) 18

0he Co%bit$be(J), (hich is incl$ded in the ad anced cardiac li-e s$&&ort (1C/!) res$scitation and laryngeal t$be de ices ha e also been sho(n to be $se-$l in establishing entilation and o;ygenation in a di-;c$lt or -ailed int$bation sit$ation in obstetrics) 28,25 Kideolaryngosco&y (K/) is the latest -rontier in air(ay %anage%ent) C$rrently a ailable ideo9 laryngosco&es incl$de Glidesco&e, !torL C9+1C, 1irtraG, +cGrath and Penta; 1M!9!9100) !e eral st$dies ha e sho(n that ideolaryngosco&es can &ro ide better laryngeal e;&os$re than con entional laryn9 gosco&y30 in ro$tine and in di-;c$lt int$bation)31 .n obstetric &atients, K/ has also been sho(n to &ro ide enhanced glottic ie( and decrease the ris= o- -ailed int$bation) 32 0he 1irtraG (as sho(n to be $se-$l in establishing entilation and o;ygenation in %orbidly obese &art$rients d$ring e%ergency C*!) 1d antages o- K/ incl$de a high9ill$%ination, high9resol$tion ie( o- the glottis and an i%&ro e%ent in ie(ing angle as the line o- sight is di--erent) 1lign%ent o- oral, &haryngeal and laryngeal a;es is not reG$ired)

1naesthetic9related ca$ses o- arrest d$e to syste%ic to;icity res$lting -ro% local anaesthetic ad%inistration Both the incidence o- local anaesthetic to;icity and the occ$rrence o- death d$e to local anaesthetic to;icity ha e declined in recent years) "ata esti%ates the incidence o- e&id$ral anaesthesia9associated local anaesthetic to;icity to be 1 to 1)3 &er 10 000 e&id$ral anaesthetics) 0his decline %ay be attrib$ted to se eral -actors, (hich incl$de the $se o- lo( concentration anaesthetics in &art$rients, an increased a(areness o- to;icity by anaesthesia &ro iders, and the $se o- i%&ro ed sa-ety %eas$res d$ring ne$ra;ial anaesthetic techniG$es)33,34 1lbeit a rare entity, the e--ects o- local anaesthetic syste%ic to;icity can be G$ite deleterio$s i- they do occ$r) 0here-ore, it is &r$dent that anaesthesia &ro iders $nderstand its &re ention and a&&ro&riate treat%ent) !yste%ic to;icity %ay res$lt -ro% high circ$lating &las%a le els o- local anaesthetics as a res$lt o$nintentional intra eno$s in#ection or -ro% absor&tion a-ter ne$ral bloc=ade) .n &artic$lar, &art$rients are at increased ris=) 0his is beca$se &regnancy re&resents one o- se eral clinical settings in (hich local anaesthetic to;icity %ay be &otentiated) 3> 1t higher doses, local anaesthetic to;icity %ay ca$se hy&o;ia leading to res&iratory arrest as (ell as cardio asc$lar de&ression) Cardio asc$lar %ani-estations o- local anaesthetic to;icity %ay incl$de hy&otension, bradycardia, contractile dys-$nction and entric$lar

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dysrhyth%ias) Perha&s the %ost de astating %ani-estation o- local anaesthetic o erdose is co%&lete cardio asc$lar colla&se)3C /ocal anaesthetic to;icity has the &otential to be G$ite catastro&hic i- it occ$rs) .t has been asserted that creation o- a de;niti e &lan to %anage this clinically signi;cant e ent is necessary) 0he estab9 lish%ent o- $ni-or% g$idelines in this area is greatly needed b$t contin$es to be a challenge to de elo&) 1 recently cond$cted s$r ey o- acade%ic anaesthesiology de&art%ents de%onstrated (ide ariability in &re&aredness -or local anaesthetic to;icity and lac= o- consens$s -or treat%ent) 0he creation oa $ni ersally acce&ted &rotocol -or treating syste%ic local anaesthetic to;icity (o$ld red$ce treat%ent ariance and i%&ro e &hysician &re&aredness and o erall &atient sa-ety) 34 1t the earliest sign o- to;icity, i%%ediate inter ention %$st be e;ec$ted to i%&ro e the chances othe %ost -a o$rable &atient o$tco%es)38 Partic$larly in the setting o- obstetric anaesthesia, ra&id res$scitation o- the &art$rient &ro ides the best chance o- s$r i al -or both %other and -oet$s) 35 Con entional treat%ents %$st -ollo( (itho$t delay) Clinicians %$st i%%ediately discontin$e the $se o- the inciting agent) <--ecti e air(ay %anage%ent that incl$des the &ro ision o- adeG$ate o;ygenation and entilation %$st be ens$red) .nt$bation (ith a tracheal t$be %ay be necessary) 1deG$ate l$ng entilation and deli ery o- 100F o;ygen is ital beca$se hy&o;ae%ia and res$lting acidosis enhance the ne$rologic and cardiac to;icities o- local anaesthetics) 40 !ec$ring o- a de;niti e air(ay also ser es to &rotect against as&iration o- gastric contents in &art$rients, (ho are at increased ris= -or this e ent) 0he establish%ent or con;r%ation o- a&&ro&riate intra eno$s access is also a =ey thera&e$tic inter ention) .t %ay be necessary to s$&&ress seiL$re acti ity ia intra eno$s ad%inistration o- anti9 con $lsants and other &har%acologic agents (benLodiaLe&ines, barbit$rates and &ro&o-ol) in s%all incre%ental doses) .t is also i%&ortant to assess cardio asc$lar stat$s thro$gho$t) .n the setting o- cardiac arrest, 1C/! &rotocols sho$ld be initiated i%%ediately) 0his incl$des cardiac co%&ression, de;brillation, cardio ersion and &ressor s$&&ort as dee%ed necessary) < idence -a o$rs the $se o- sy%&atho%i%etics to restore hae%odyna%ic stability) !&eci;cally, N1C/! g$idelines reco%%end the $se o- aso&ressin (40 $nits intra eno$s, once) in &lace o-, or in addition to, e&ine&hrine) 0his a&&ears logical in the setting o- b$&i9 acaine to;icity beca$se e&ine&hrine %ay e;acerbate local anaesthetic9ind$ced arrhyth%iasO) C$rrent data s$&&ort the $se o- a%iodarone to treat b$&i acaine9ind$ced se ere entric$lar dysrhyth%ias) 38,41 .t has been de%onstrated that cardiac to;icity ca$sed by local anaesthetics (na%ely b$&i acaine) is e;tre%ely resistant to %ost con entional res$scitati e techniG$es and dr$gs) 3ntil recently, the instit$tion o- cardio&$l%onary by&ass (as the only =no(n treat%ent sho(n to be e--ecti e in treating the re-ractory cardiac arrest that occ$rred as a res$lt o- local anaesthetic o erdose) 42 0here-ore, its &ossible role %$st be serio$sly considered early in this clinical setting) 0he release o- recent data &ro ides e idence that li&id in-$sion thera&y %ay ha e a &ro%ising role in the treat%ent o- to;icity -ro% local anaesthetics) 43e4> 0here no( e;ist a gro(ing n$%ber o- case re&orts that doc$%ent s$ccess-$l res$scitation -ro% local anaesthetic to;icity ia li&id e%$lsions) 4Ce48 .t is &$r&orted that instit$tion o- li&id in-$sion thera&y (ill atten$ate &rogression o- the local anaesthetic to;icity syndro%e) Gi en this in-or%ation, it see%s reasonable to stoc= li&id e%$lsion resc$e =its in obstetric $nits, o&erating roo%s, and other &erio&erati e areas (here local anaesthetic o erdoses %ay occ$r) 48,45 0he e;act %echanis% o- li&id e%$lsion re ersal o- local anaesthetic to;icity is $nclear b$t recent data &ro&ose the theory o- a Pli&id sin=:) 0his theory is based on the &redo%inant ie( that Ne;ogeno$s li&id &ro ides an alternati e so$rce -or binding o- li&id sol$ble local anaestheticsO) .t has also been &ro&osed that the li&id %ay a--ect the heart in a P%etabolically ad antageo$s: (ay) 4>,>0,>1 0his co%%entary does in no (ay ad ocate the $se o- li&id thera&y as a s$bstit$tion or alternati e -or standard res$scitati e techniG$es) .nstead, it reco%%ends its role as an ad#$nct thera&y -or a to;icity that is o-ten ti%es resistant to traditional res$scitati e %eas$res) 45 1naesthesia &ro iders %$st be cogniLant o- so%e o- the li%iting -actors associated (ith the instit$tion o- li&id thera&y in this setting) 0he a&&ro&riate dose, d$ration and o&ti%al ti%ing o- li&id thera&y -or res$scitation re%ain $n=no(n) ?$rther, e;cess li&id %ay i%&air the action o- li&o&hilic 1C/! dr$gs) Possible co%&lications or ad erse e--ects o- li&id in-$sion %$st also be considered)>2,>3 "es&ite these concerns, res&ondents -ro% 50 acade%ic anaesthesiology de&art%ents re ealed that 2CF (o$ld consider $sing li&id resc$e in the setting o- local anaesthetic to;icity)>4

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1n e;a%&le &rotocol -or the $se o- li&id e%$lsions as a treat%ent -or local anaesthetic to;icity as &ro&osed by Meinberg is described belo()>>,>C Mith ac=no(ledge%ent o- the li%itations noted &re io$sly, this &rotocol sho$ld be considered along (ith standard res$scitation %ethods to re9 establish s$-;cient circ$latory stability (hen local aesthetic to;icity is s$s&ected)

(1) 1d%inister 1)> %l =gQ1o- .ntrali&id 20F as an initial bol$s) 0he bol$s can be re&eated 1e2 ti%es i&ersists) (2) !tart an intra eno$s in-$sion o- .ntrali&id 20F at 0)2> %l =gQ1 %inQ1 -or 30eC0 %in) .ncrease the in-$sion rate $& to 0)> %l =gQ1 %inQ1 -or re-ractory hy&otension) (3) 0he in-$sion sho$ld be contin$ed $ntil a stable and adeG$ate circ$lation has been restored)

.n concl$sion, the &ri%ary thera&y -or local anaesthetic to;icity sho$ld adhere to standard %eas$res) 0hat is, e%&hasis sho$ld re%ain on se eral -actors' (1) a&&ro&riate &atient %onitoring, (2) &ro&er dosing and $se o- local anaesthetic agents, (3) e;tre%e igilance by anaesthesia &ro iders, (4) i%%ediate %eans to s$&&ort entilation, (>) &ro&er cardiac res$scitati e e--orts and (C) a&&ro&riate a&&lication o- &ro en 1/! techniG$es) Once these con entional %eas$res ha e been -ollo(ed, the $se o- li&id in-$sion sho$ld be considered as an ad#$nct to the thera&e$tic algorith%)

+aternal anato%y and &hysiology Changes in %aternal anato%y and &hysiology that occ$r thro$gho$t &regnancy a--ect the incidence and &resentation o- certain diseases as (ell as their %anage%ent) Physicians dealing (ith obstetric &atients sho$ld ha e a thoro$gh =no(ledge o- these &hysiologic changes to deter%ine the se erity o- the illness, instit$te ti%ely inter ention, and &ro ide a&&ro&riate res$scitation inter entions (hen needed) 0he cardio asc$lar and res&iratory changes that occ$r d$ring &regnancy are disc$ssed in detail else9 (here in this &$blication, b$t they are s$%%arised here to disc$ss in the conte;t o- a&&ro&riate res$s9 citation -ollo(ing cardiac arrest) One o- the %ost i%&ortant inter entions d$ring cardiac arrest incl$des sec$ring the air(ay, and a thoro$gh =no(ledge o- the anato%ic and &hysiological changes d$ring &reg9 nancy is i%&ortant) 1nato%ic and &hysiologic -actors alter the air(ay d$ring &regnancy, &lacing the &art$rient at ris= -or di-;c$lt int$bation) 1n e--ect o- oestrogen on the gro$nd s$bstance o- connecti e tiss$e leads to an increase in interstitial (ater res$lting in oede%a o- the res&iratory tract, incl$ding the oral and nasal &haryn;, laryn; and trachea) 1n increase in nasal %$cosal congestion &redis&oses the &atient to e&ista;is (ith the &assage o- a nasogastric or nasotracheal t$be) Pharyngolaryngeal and ocal cord oede%a %ay hinder the &assage o- an <00 that (o$ld &ass easily in a non9&regnant -e%ale) ?$rther%ore, tong$e enlarge%ent and i%%obility o- the ;oor o- %o$th can res$lt in di-;c$lt laryngos9 co&y) 1 &regnant &atient (ith &re9ecla%&sia*ecla%&sia (ho s$stains a cardio&$l%onary arrest %ay also be at high ris= -or di-;c$lt int$bation beca$se o- red$ced &las%a &roteins and %ar=ed ;$id retention, es&ecially in the head and nec= region) Oede%a %a=es the tong$e larger and less %obile, %a=ing iden9 ti;cation o- land%ar=s %ore di-;c$lt) 1n e;&ert in air(ay %anage%ent is &re-erable to sec$re the air(ay) 0he heart rate increases thro$gho$t &regnancy) By the end o- &regnancy, it is 1>e20F higher than in the non9&regnant state)1>,>4 Progesterone9ind$ced s%ooth %$scle rela;ation res$lts in decreased asc$lar resistance leading to a decrease in systolic and diastolic blood &ress$res d$ring the ;rst t(o tri%esters) 0he blood &ress$re ret$rns to &re&regnancy al$es d$ring the third tri%ester) >4e>5 .n addition, &regnant &atients ha e a dil$tional anae%ia d$e to a >0F increase in &las%a ol$%e acco%&anied by a 30F increase in red blood cell %assB this leads to a 3>e40F e;&ansion o- blood ol$%e) "e&ending on the &atient:s &re&regnancy al$es, all o- these changes ha e the &otential to %i%ic shoc= in an other(ise stable &atient) 1t ter%, the &lacenta alone recei es a&&ro;i%ately 13F o- the circ$lating blood ol$%e) 0he increase in circ$lating ol$%e %eans that a s$bstantial a%o$nt o- hae%orrhage can ta=e &lace be-ore signs o%aternal hy&o olae%ia beco%e a&&arent) C0 1t the end o- the second tri%ester, cardiac o$t&$t increases by 30e>0F in res&onse to the increasing de%ands o- the gro(ing $ter$s) 1,2 (0able 2) 0here is a 109-old increase in the blood ;o( to the &regnant $ter$s)1,>8,C0 0he %other:s total blood ol$%e ;o(s thro$gh the $ter$s e ery 8e11 %in$tes) 0h$s, &lacental disr$&tion or tra$%a to the $ter$s or &el is can res$lt in e;tensi e %aternal hae%orrhage)C0

+)!) !$resh et al) * Best Practice & Research Clinical Obstetrics and Gynaecology 24 (2010) 383e400 0able 2 +ean al$es -or he%odyna%ic changes seen thro$gho$t &regnancy) Pre9&regnancy 6eart rate (beats*%in) !ystolic blood &ress$re (%%*6g) "iastolic blood &ress$re (%%*6g) Central Keno$s &ress$re (%%*6g) ?e%oral eno$s &ress$re (%%*6g) Cardiac o$t&$t (/*%in) Blood ol$%e (%/) 3terine blood ;o( (%/*%in) 6e%atocrit (F) 40 12> 40 5)0 C 4)> 4000 C0 40 1st tri%ester 48 112 C0 4)> C 4)> 4200 C00 3C 2nd tri%ester 82 122 C3 4)0 18 C)0 >000 C00 34 3rd tri%ester 8> 11> 40 3)8 18 C)0 >C00 C00 3CC00

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By 20 (ee=s: gestation, the gra id $ter$s has reached the le el o- the in-erior ena ca a) .n the s$&ine &osition, the gra id $ter$s can ca$se co%&ression o- the ena ca a res$lting in decreased eno$s ret$rn and hy&otension)2,C0,C1 0he co%&ression o- &el ic eins by the enlarging $ter$s can ca$se an increase in eno$s &ress$re belo( the $ter$s) .ncreased eno$s &ress$re can res$lt in ra&id blood loss -ro% in#$ries to the &el is or lo(er e;tre%ities) "$e to the increased &ress$re and &oor eno$s ret$rn to the heart, intra eno$s lines in the lo(er e;tre%ities sho$ld be a oided beca$se any %edication ad%inistered thro$gh that ro$te (ill ha e a li%ited ret$rn to the heart and arterial circ$lation) C0 .n addition to the hae%odyna%ic changes, there are also alterations in the res&iratory syste%, (hich can a--ect the &atient:s ability to co%&ensate -or res&iratory distress) 0he enlarging gra id $ter$s &$shes the dia&hrag% %ore ce&halad) 0his decreases the -$nctional resid$al ca&acity and %a=es the &art$rient %ore $lnerable to the e--ects o- hy&o;ia) 0here is a 1>e20F increase in %aternal o;ygen reG$ire%ents) 1 0he co%bination o- these changes ca$ses a 40F increase in tidal ol$%e (ith a res$ltant 3>F decrease in resid$al ol$%e and -$nctional resid$al ca&acity) 1,>,>4,C2 0here-ore, hy&o;ia can occ$r G$ic=ly (ith res&iratory arrest)2 0he increase in tidal ol$%e and %in$te entilation res$lt in res&iratory al=alosis) >,>5 Mhile renal co%&ensation $s$ally %aintains a near9nor%al &6, arterial blood gas al$es %ay re;ect an increase in PaO2 and a decrease in both PaCO2 and bicarbonate) ConseG$ently, the &art$rient is less able to b$--er &6 changes or to co%&ensate -or res&iratory co%&ro%ise, thereby increasing the ris= o%aternal hy&o;ae%ia and acidae%ia) > Gastrointestinal %otility decreases and the gastric s&hincter res&onse is red$ced, res$lting in an increased li=elihood o- as&iration (ith an altered le el o- conscio$sness d$ring res$scitati e e--orts) > +oreo er, increased gastric acid &rod$ction d$ring &regnancy increases the &$l%onary da%age -ollo(ing as&iration) Beca$se o- the ris=s o- ra&id de elo&%ent o- hy&o;ae%ia and as&iration, sec$ring the air(ay d$ring %aternal cardio&$l%onary arrest is critical) Changes in %aternal &hysiology i%&act so%e laboratory al$es and this has to be ta=en into acco$nt (hen inter&reting the res$lts (see 0able 3)) /aboratory al$es can be nor%al, -alsely ele ated, or -alsely decreased indicating the &resence o- a disease &rocess) 6ae%oglobin and hae%atocrit (ill be decreased d$e to hae%odil$tion) Platelets %ay also be decreased d$e to hae%odil$tion, increased cons$%&tion, or &re9ecla%&sia*6<//P (hae%olytic anae%ia, ele ated li er enLy%es, lo( &latelet co$nt) syndro%e) Mhite blood cells, erythrocyte sedi%entation rate and ;brinogen le els %ay all be increased in &regnancy) 1rterial blood gas al$es &ro ide al$able in-or%ation abo$t a &atient:s res&iratory stat$s) 1 PaCO 2 o40 %%6g is nor%al -or a non9&regnant &atient) 6o(e er, it is a ca$se -or concern in a &regnant &atient (here it %ay indicate &oor entilation and &ossible res&iratory acidosis e both o- (hich %ay lead to -oetal co%&ro%ise)>,C

Cardio&$l%onary res$scitation (CPR) .- the &regnant &atient is in a health9care -acility, a ra&id res&onse by the 6ealth Care 0ea% is reG$ired to %ini%ise the inter al bet(een the cardiac arrest and the s$bseG$ent deli ery so as to allo( -or the best %aternal and -oetal o$tco%e) .nitial ste&s incl$de beginning CPR, calling -or assistance and establishing o;ygenation, entilation and intra eno$s access to o&ti%ise circ$lation) /astly, an i%&or9 tant -actor to consider &rior to an e%ergent caesarean deli ery is the gestational age o- the -oet$s)

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0he &rinci&les o- CPR -or the late9ter% &regnant (o%an are based on the 1%erican 6eart 1sso9 ciation (161) 1C/! reco%%endations) 0he 161 CPR g$idelines %ade ; e %a#or e idence9based changes to &ro%ote %ore e--ecti e CPR) 0hese changes incl$de e%&hasising the deli ery o- e--ecti e chest co%&ressions, creating a $ni ersal co%&ression9to9 entilation ratio -or lone resc$ers, reco%9 %ending one9second breaths d$ring CPR, restr$ct$ring the de;brillation %ethods and endorsing a$to%ated e;ternal de;brillator (1<") $sage) > "$ring CPR in &regnancy, the tea% needs to -ollo( the re ised 200> 161 g$idelines (ith %odi;cations to co%&ensate -or the altered anato%y and &hysi9 ology o- &regnancy as delineated abo e) 0he %a#or %odi;cations incl$de' (1) &ro%&t air(ay %anage%ent, (2) %etic$lo$s attention to lateral dis&lace%ent o- $ter$s and a oidance o- aortoca al co%&ression, (3) o&ti%al &er-or%ance o- chest co%&ressions in the lateral dec$bit$s &osition, (4) ca$tion in the $se o- sodi$% bicarbonate and (>) early consideration o- &eri9%orte% caesarean deli ery so as to o&ti%ise CPR and s$r i al o- %other and baby)

1ir(ay %anage%ent "$ring CPR, &ro%&t int$bation o- the trachea and sec$ring o- the air(ay is i%&erati e to %a;i%ise o;ygenation, &rotect the air(ay and &re ent as&iration) !$&&le%ental o;ygen at a concentration o100F (ith ra&id control o- the air(ay sho$ld be the goal early in the res$scitation e--ort) Cricoid &ress$re sho$ld al(ays be %aintained in the &art$rient $ntil the air(ay is sec$red to &re ent as&i9 ration o- gastric contents) .ntragastric &ress$re steadily increases d$ring &regnancy as a res$lt o- the enlarged gra id $ter$s) 0he lo(er oeso&hageal s&hincter tone is decreased d$e to the high le els ocirc$lating &rogesterone increasing the tendency to re;$;) Ra&id seG$ence ind$ction (ith cricoid &ress$re is $sed to int$bate a &regnant (o%an) Mhen the ;rst atte%&t at int$bation -ails, a di--erent blade %ay be $sed and a %ore e;&erienced anaesthesia &ractitioner sho$ld atte%&t int$bation) 0he &regnant (o%an is at increased ris= -or de elo&ing hy&o;ae%ia %ore than a non9&regnant &atient d$e to the decreased -$nctional resid$al ca&acity and increased o;ygen cons$%&tionB there-ore, i- int$bation is $ns$ccess-$l, %as= entilation sho$ld be atte%&ted along (ith cricoid &ress$re to &re ent hy&o;ae%ia and as&iration) <;&ert air(ay %anage%ent hel& sho$ld be so$ght i%%ediately) 12,C3 0he ris= o- as&iration can be -$rther e;acerbated by gastric distention d$ring &rolonged %as= entilation) 1lternati e air(ay de ices s$ch as s$&raglottic air(ay de ices (e)g), laryngeal %as= air(ay (/+1), laryngeal t$be), Co%bit$be, lighted o&tical stylet or ideolaryngosco&y sho$ld be G$ic=ly $sed to entilate and o;ygenate the &atient) 0he iss$es and &roble%s (ith air(ay %anage%ent ha e been detailed in the section on air(ay9 related catastro&hes)

/ateral dis&lace%ent o- the $ter$s 0he 2000 .nternational G$idelines -or CPR and 200> <%ergency Cardiac Care (<CC) G$idelines C4 state that it is not ad isable to res$scitate a &regnant &atient in the s$&ine &osition, beca$se the (eight o- the gra id $ter$s obstr$cts the eno$s ret$rn ia the in-erior ena ca a) C4 ?or chest co%&ressions to be %ore e--ecti e d$ring the second hal- o- &regnancy, st$dies ha e con;r%ed that a&&lying a &artial le-t lateral tilt to the &atient (ill relie e the aortoca al co%&ression) C> Rees and Millis concl$ded that the best co%&ro%ise -or cardio&$l%onary res$scitation is achie ed by (edging

0able 3 /aboratory al$es in &regnancy co%&ared to nor%al) Pregnancy al$es 6e%atocrit (F) Mhite blood cell co$nt (+*%/) <!R (%%*hr) 1rterial &6 Bicarbonate (%<G*/) PCO (%%6g) ?ibrinogen (%g*d/) Prothro%bin ti%e (sec) Platelets (; 103 %/) 32e42 >,000e32,000 48 4)40e4)4> 14e22 2>e30 R400 11)2 Ho change or decreased Hor%al al$es 3>e44 4,>00e22,000 S20 4)3>e4)44 22e28 3>e4> 200e400 23)> 130e400

+)!) !$resh et al) * Best Practice & Research Clinical Obstetrics and Gynaecology 24 (2010) 383e400

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the &atient 24 )CC 0his led to the de elo&%ent o- the Cardi-- Res$scitation (edge e a (ooden -ra%e inclined at a 24 angle and s&eci;cally designed -or &er-or%ing CPR on &regnant &atients) C4 6o(e er, at this angle, there is a disad antage in that the resc$er can &ro ide only 80F o- the trans%itted e;ternal -orce) Beca$se the trans%ission -orces d$ring e;ternal CPR in this &osition are not &er&en9 dic$lar to the thora; and a &art o- the trans%itted -orce is lost, le-t lateral &ositioning -or CPR is not ideal) O ert$rned chairs, h$%an (edge (ith the =nee, -$ll lateral &osition and the Cardi-- (edge %a=e e;ternal co%&ressions and CPR ine--ecti e)CC 0he best co%&ro%ise -or CPR and o&ti%al eno$s ret$rn is in Pthe s$&ine &osition (ith %an$al dis&lace%ent o- the $ter$s to the le-t:) C>

<--ecti e chest co%&ressions Cardiac o$t&$t d$ring o&ti%al CPR has been esti%ated to be only 30F o- nor%al) 0here-ore, the $tero&lacental &er-$sion is %ar=edly co%&ro%ised) 0his %a=es the -oet$s hy&o;ic and acidotic d$ring chest co%&ressions $nless the rhyth% and circ$lation are restored ra&idly) Recent st$dies ha e sho(n that hal- o- the chest co%&ressions ad%inistered by &ro-essional resc$ers d$ring CPR (ere too shallo( and (ere interr$&ted too o-ten)C4 Cardiac arrest ca$ses cessation o- blood ;o( thro$gho$t the body) Mhen a li-e9threatening e ent occ$rs d$ring &regnancy, the blood ;o( is di erted to ital organs s$ch as %yocardi$% and brain and a(ay -ro% non9 ital organs incl$ding the $ter$s) 0his se erely co%&ro%ises the $tero&lacental &er-$sion leading to -oetal distress, as&hy;ia and $lti%ately death) .the co%&ressions are e--ecti e, then blood ;o( and &er-$sion to the ital organs is (ell &reser ed) ?ollo(ing the interr$&tion in chest co%&ressions, the blood ;o( ceases) 3&on res$%&tion o- the co%&ressions, the initial co%&ressions are not as e--ecti e as the latter co%&ressions) 0here-ore, the e idence9based 200> re ised 161 g$idelines e%&hasise e--ecti e co%&ressions (itho$t interr$&tion) 0he r$le o- th$%b is to N&$sh hard and -astO -or an ideal co%&ression rate o- 100 &er %in -or all icti%s) 0he chest %$st be allo(ed to recoil co%&letely d$ring each co%&ression cycle to %a;i%ise the a%o$nt o- blood that ;lls the heart) (0able 4)

3ni ersal co%&ression9to9 entilation ratio 0he 200> 161 re ised g$idelines s$ggest that, in %ost icti%s, entilation is not as i%&ortant as co%&ressions d$ring the ;rst -e( %in$tes o- CPR -or cardiac arrest) 6o(e er, entilation and o;ygenation are critical in &regnant &atients &artic$larly -ollo(ing a hy&o;ic e ent to ens$re o&ti%al o$tco%es o- both %other and baby) 0he &ractice o- chest co%&ressions only d$ring CPR (itho$t entilation has been abandoned) 0he ne( g$ideline, (hich is a co%&ression9to9 entilation ratio o30'2, gi es resc$ers a chance to assist icti%s and increase their chance o- s$r i al) 0he reco%%endation regarding all lone resc$ers: initial res&onse to CPR has also changed) 0he lone resc$er sho$ld ;rst call -or hel& and an 1<" be-ore initiating CPR) 0hese reco%%endations &ro ide the best o$tco%e -or all icti%s incl$ding &regnant &atients)

One9!econd breaths d$ring CPR "$ring the ;rst -e( %in$tes o- CPR, the o;ygen content in the bloodstrea% re%ains adeG$ate) 1s the cardiac o$t&$t decreases, the o;ygen s$&&ly to the ital organs incl$ding the l$ngs is only 2>e30F o- nor%al ;o() Beca$se less blood ;o( is being circ$lated than &re io$sly belie ed, resc$ers can $se shorter entilation e--orts than &re io$sly reco%%ended and still &ro ide adeG$ate o;ygenation and e--ecti e carbon dio;ide eli%ination d$ring cardiac arrest) 0he ne( g$idelines reco%%end one9second breaths d$ring all CPR e--orts (ith the e%&hasis being on e--ecti e chest co%&ressions) ?ollo(ing int$bation, 161 e idence indicates that hy&er entilation d$ring CPR is not indicated and %ay indeed be &artic$larly har%-$l in &regnant &atients) Positi e &ress$re and hy&erin;ated l$ngs %ay increase intrathoracic &ress$re, li%it le-t entric$lar ;lling and, $lti%ately, red$ce cardiac o$t&$t d$ring res$scitation) 0h$s, the 161 ne( g$idelines reco%%end one9second resc$e breaths) >

"e;brillation 3&on arri al at the resc$e scene, the 161 g$ideline %andates that resc$ers deli er one shoc= by 1<", to be i%%ediately -ollo(ed by CPR and initiation o- chest co%&ressions) 0he re ised g$ideline is

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0able 4 1d anced Cardiac /i-e !$&&ort G$idelines) 0o&ic Chest co%&ression e--ecti eness He( Reco%%endations 200> P$sh hard and -ast at a rate o100 ti%es &er %in$te Rationale <--ecti e chest co%&ressions %$st &ro ide adeG$ate blood ;o( to the heart9coronary artery blood ;o( and to the brain9cerebral blood ;o(, st$dies o- CPR &er-or%ers sho(ed %at hal- o- the chest co%&ressions (ere to shallo( .- not -$lly allo(ed to recoil, there (ill be less eno$s ret$rn to %e heart) 0his red$ction in ol$%e res$lts in decreased cardiac o$t&$t (ith s$bseG$ent chest co%&ressions !t$dies o- CPR &er-or%ers sho(ed %at no co%&ressions (ere &ro ided d$ring 24Fe45F o- %e act$al CPR t$ne

1llo( -$ll chest recoil a-ter each co%&ression

Co%&ression9to9 entilation ratio

+ini%iLed interr$&tions o- co%&ressions9 ideally less than 10 s, e;ce&t -or inter entions s$ch as insertion o- an air(ay or $se o- the de;brillator 0he chest co%&ressions9to9 entilation ratio is 30'2

0his (ill allo( %ore e--ecti e co%&ressions $sing %e hard and -ast techniG$e, (ith less interr$&tion than 0he -or%er ration (1>'2)

"eli er resc$e breath o er 1 second Kentilate eno$gh to see the chest rise $sing a nor%al breath, not a -orce-$l breath

/one &ro iders

3nres&onsi e ad$ltsB call -or hel& ;rstT

"e;brillation changes

1ny age icti% that is a li=ely hy&o;ic in#$ry, &ro ide CPR -or > cycles or 2 %in be-ore calling -or hel& "o not interr$&t chest co%&ressions to chec= circ$lation .%%ediate de;brillation -ollo(ed by chest co%&ressions

Pro ides adeG$ate entilation and red$ces carbon %ono;ide b$ild $& d$ring the res$scitation e--ort) Mill need assistance, so acti ate that e%ergency %edical syste% ;rstB locate 1<" i- a ailable 0he red$ction in ti%e -ro% 192 to 1 s, red$ces %e chance o- hy&er entilation, ine--ecti e chest co%&ressions, and gastric in;ation "ecreases blood ;o(

Kicti%s e;&eriencing K? or K0 (ill bene;t -ro% both shoc= and chest co%&ressions Re%o e internal -etal %onitoring de ices

Hote) 1<" U a$to%ated e;ternal de;brillatorB CPR U cardio&$l%onary res$scitationB K? U entric$lar ;brillationB K0 U en9 tric$lar tachycardia) 1%erican 6eart 1ssociation) 1098 Cardiac arrest associated (ith &regnancy) Circ$lation' I 1% 6eart 1ssoc) 200>B112 (1K)' 1>0e1>3)

based on three -acts' (1) 3sing the c$rrent 1<", (aiting -or cardiac rhyth% analysis a-ter 1<" shoc= &rod$ces a T349s delay) "$ring the interi%, instit$tion o- chest co%&ressions can enhance deli ery oo;ygen and %$ch9needed &er-$sion and energy to the heart %a=ing it %ore e--ecti e -or the heart to &$%& blood %ore e--ecti ely a-ter the 1<" shoc=) (2) .n sit$ations (here the 1<" is not e--ecti e initially in correcting the entric$lar ;brillation, res$%&tion o- CPR is %ore al$able than rendering a second shoc=) ?ollo(ing 2 %in, a-ter > cycles o- CPR, resc$ers sho$ld chec= the rhyth%) (3) < en i- the 1<" eli%inates the entric$lar ;brillation, it still ta=es a -e( %in$tes -or the nor%al heart rhyth% to ret$rn and -or the heart to res$%e nor%al blood ;o( to the organs) 0here is a &a$city o- e idence9based data to sho( (hether the de;brillation reG$ire%ents change d$ring &regnancy) Hanson et al)C8 %eas$red the transthoracic i%&edance (00.) registered by a de;bril9 lator in 4> (o%en at ter% &regnancy) 0hey re&eated the %eas$re%ents at Ce8 (ee=s &ost&art$% in 42 o$t o- the 4> (o%en, a-ter the &hysiological changes o- &regnancy had resol ed) 0he 00. at ter% (as 51)3 and &ost9deli ery, the 00. (as 51)C) 0here (as no statistical di--erence) 0he concl$sion (as that the c$rrent energy reG$ire%ents -or ad$lt de;brillation are a&&ro&riate -or $se d$ring &regnancy) C8

.n9hos&ital %aternal arrest and treat%ent o- s&eci;c dysrhyth%ias P$lseless entric$lar tachycardia (K0) or entric$lar ;brillation (K?) "e;brillation is the treat%ent o- choice -or these dysrhyth%ias and is not contraindicated in &regnancy)C5 6o(e er, i- de;brillation is reG$ired, it is i%&ortant to re%e%ber to re%o e any internal -oetal %onitoring eG$i&%ent that %ight cond$ct electricity to the -oet$s) C5

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0he ne;t ste& d$ring res$scitation o- a &atient (ith &$lseless K0 or K? is to ad%inister a&&ro&riate %edications that (ill %a=e the heart res&onsi e to de;brillation) Kaso&ressin has been added to the 1C/! g$idelines as an alternati e to e&ine&hrine) 0he e--ect o- aso&ressors on $tero&lacental &er-$sion in a cardiac arrest sit$ation is $n=no(nB ho(e er, the 1C/! g$idelines %$st be -ollo(ed and the $se o- these aso&ressors %$st not be (ithheld)40 0he $se o- e&ine&hrine can enhance &lacental blood ;o( and i%&ro e -oetal o$tco%e)41 Circ$late the %edication (ith 30eC0 s o- CPR) 0hen, de;brillate at 3C0 I) .- &$lseless K0 or K? re%ains, contin$e CPR and ad%inister an anti9arrhyth%ic) /idocaine 1e1)> %g =gQ1 .K bol$s is indicated) 1%iodarone 300 %g .K bol$s %ay also be $sed) 0here is li%ited or no data on the e--ect o- anti9arrhyth%ics d$ring &regnancy) .n &atients (ith hy&o%agnesae%ia, %agnesi$% s$l&hate (1e2 g) %ay be the anti9arrhyth%ic o- choice) 41

P$lseless electrical acti ity P$lseless electrical acti ity (P<1) is de;ned as the &resence o- an electrical cardiac rhyth% (hen there is no detectable &$lse) <&ine&hrine is the dr$g o- choice and %ay be ad%inistered e ery 3e> %in) .- the rhyth% is slo(, atro&ine 1 %g .K bol$s can be ad%inistered e ery 3e> %in -or a %a;i%$% dose o- 0)04 %g =gQ1) 1tro&ine does cross the &lacenta) .t is also i%&ortant to deter%ine the ca$se o- P<1 e s&eci;cally, the P; e 6s: and P; e 0s: associated (ith P<1) (0able >)

1systole 1systole is the lac= o- detectable electrical cardiac acti ity) .t is &r$dent to chec= a second lead to con;r% that the &atient is in asystole and not ;ne K?) 6y&o;ia and hy&o olae%ia are associated (ith asystole) !ec$ring the air(ay, establishing intra eno$s access and &er-or%ing e--ecti e CPR are the &ri%ary &riorities) 1d%inister e&ine&hrine 1 %g) Contin$e cardiac co%&ressions) 0he e&ine&hrine dosage can be re&eated e ery 3e> %in) .- e&ine&hrine is not e--ecti e in generating an electrical cardiac acti ity, atro&ine %g .K bol$s %ay be ad%inistered) 0he dosage can be re&eated e ery 3e> %in to a %a;i%$% dose o- 0)04 %g =gQ1) 0hro$gho$t res$scitation, ;$id ad%inistration sho$ld be aggressi e) .n general, the sa%e &rotocols -or 1C/! &har%acological inter entions %$st be i%&le%ented in &regnant &atients as in non 9&regnant &atients) 1ltho$gh, theoretically, the $se o- a9adrenergic %edications can red$ce the $tero&lacental blood ;o(, the sa%e &rinci&les -or 1C/! dr$g thera&y is a&&licable in the CPR o- &regnant &atients) 0he best chance o- s$r i al -or the %other and -oet$s de&ends on ra&id res$scitation o- the %other)

0able > P$lseless <lectrical 1cti ity) Ca$ses 6y&o ole%ia 6y&o;ia 6ydrogen ions 6y&o*hy&er=ale%ia 6y&o*hy&erther%ia 1ctions 1d%inister ;$ids and blood &rod$cts as needed) Pro ide entilation and o;ygenation) .n the case o- acidosis, &ro ide entilation) Correct electrolyte i%balance) Correct te%&erat$re abnor%alities)

0ension &ne$%othora; 0a%&onade (cardiac) 0hro%bosis (&$l%onary) 0hro%bosis (coronary) 0ablets (dr$g o erdose)

1$sc$ltate breath so$nds) Per-or% e%ergency needle as&iration .- needed) Per-or% &ericardiocentesis i- needed) Pro ide s$&&orti e thera&y) /oo= -or a history o- cardiac disease or &reter% labor) Consider dr$gs that %ay be $sed to treat conditions o&regnancy s$ch as &reter% labor or &regnancy9ind$ced hy&ertension) 0he $se o- a tocolytic s$ch as terb$taline s$l-ate to s$&&ress $terine contractions can ca$se cardiac ische%ia)

!o$rce' C$%%ins, R (<d) 2001) 1./! &ro ider %an$al, "allas' 1%erican 6eart 1ssociation

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Peri9%orte% caesarean deli ery and o$tco%es Peri9%orte% caesarean deli eries (ere reco%%ended in 158C) 42 8atL et al) reco%%ended a P49 %in$te r$le: -ro% the %aternal arrest to the initiation o- the caesarean deli ery, (ith the -oet$s being deli ered (ithin > %in) 0his a&&roach (as &ro%oted &rinci&ally on -oetal gro$nds to allo( the &otential sal age o- a iable -oet$s) 0he ti%ing o- deli ery (as based on theoretical considerations s$ch as o;ygen cons$%&tion and &re ention o- ne$rological in#$ry) 43 !ince the initial descri&tion, n$%ero$s case re&orts ha e described o-ten dra%atic re ersal o- the %aternal hae%odyna%ic colla&se, e en in re-ractory sit$ations)42 .- initial res$scitation is not e--ecti e d$ring cardiac arrest in &regnancy, deli ering the -oet$s (ithin > %in %ay -acilitate %aternal and -oetal s$r i al) 0he P>9%in$te r$le: -ro% arrest to deli ery is no( reco%%ended by the 161 (hen the intra$terine gestation is longer than 24 (ee=s) 0he &er-or%ance o- a &eri9%orte% caesarean deli ery is a challenging as&ect o- %aternal res$s9 citation) 1dherence to a P4 %in$te r$le: %eans that the ra&id res&onse tea% %$st ra&idly assess the &atient, instit$te a&&ro&riate res$scitation and &re&are -or deli ery) >,44 0he ra&id res&onse %$ltidis9 ci&linary tea% %$st not only be trained in a&&ro&riate CPR techniG$es, b$t also, the res$scitation tea% leader sho$ld consider the need -or an e%ergency hysteroto%y (caesarean deli ery) &rotocol as soon as a &regnant (o%an de elo&s a cardiac arrest) 44 !&eed is o- the essence once the decision is %ade to $nderta=e deli ery) 0he &roced$re sho$ld be &er-or%ed by an a ailable &ro ider (ho is %ost s=illed in caesarean deli ery)4>e44 0he best s$r i al -or in-ants greater than 24e2> (ee=s in gestation res$lts (hen deli ery occ$rs no %ore than > %in a-ter the %other:s heart sto&s beating) 42,48,45 0here is also an ongoing debate regarding (hether to %o e the &atient to the o&erating roo% or &er-or% a &eri9%orte% caesarean section in the labo$r and deli ery s$ite in the case o- a %aternal cardiac arrest)80 1 recent si%$lation st$dy s$ggests that e en in an o&ti%al setting, deli ery (ithin > %in cannot be achie ed i- the &atient is %o ed to the o&erating roo%) 0his st$dy s$ggests that deli ery %$st be &er-or%ed in the &atient:s roo% i- one ho&es to achie e the best o$tco%e) 80 <%ergency hysteroto%y see%s co$nterint$iti e, gi en that the =ey to sal age o- a &otentially iable -oet$s in ol es %aternal res$scitation) <--ecti e %aternal res$scitation is not &ossible $ntil eno$s ret$rn and o&ti%al cardiac o$t&$t are restored) "eli ery o- the baby hel&s acco%&lish the ob#ecti e o- e%&tying the $ter$s and relie ing aortoca al obstr$ction) 0he critical &oint is that delay in deli ery can res$lt in ad erse %aternal and -oetal o$tco%es) !&eci;cally, delay in deli ery can res$lt in either 200F %orbidity or %ortality) ?$rther%ore, the &roced$re sho$ld not be delayed to obtain in-or%ed consent) <;&erts agree that the doctrine o- e%ergency and i%&lied consent is a&&licable in a %aternal cardiac9arrest sit$ation and the best interest o- the -oet$s ta=es &rece9 dence)42 0here is no e idence in the literat$re -or liability against &hysicians in the 3nited !tates -or &er-or%ing a &eri9%orte% caesarean deli ery -ollo(ing a %aternal cardiac arrest) 42B81 <;&edited deli ery o- the baby also allo(s -or e--ecti e ne(born res$scitation) 42 Consideration %$st be gi en to the a ailability o- a&&ro&riate sta-- and -acilities -or neonatal care as the neonate (es&ecially i&re%at$re) %ay reG$ire e;tensi e res$scitation) CPR %$st contin$e d$ring and a-ter deli ery $ntil the ret$rn o- s&ontaneo$s circ$lation) .- cardiac arrest occ$rs earlier in &regnancy, it is not =no(n (hether &er-or%ance o- a hysteroto%y to &rod$ce a &re9 iable -oet$s a--ects %aternal o$tco%e) 0he hae%odyna%ic e--ects -ro% a %$ch s%aller -oetale&lacental %ass are not signi;cant) 0here-ore, in general, a &eri9%orte% caesarean deli ery is not ad ocated in sit$ations o- %aternal arrest (ith less than 24 (ee=s: gestation) 0he e--orts sho$ld -oc$s on all as&ects o- best &ractices o- 1C/! res$scitation to ens$re the best o$tco%es -or %other and -oet$s) 1 case re&ort o- %aternal and -oetal s$r i al occ$rred a-ter &rolonged %aternal cardiac arrest at 1> (ee=s: gestation secondary to accidental lidocaine o erdose and to;icity) CPR (as &er-or%ed -or 22 %in be-ore ret$rn o- s&ontaneo$s circ$lation) 0he &atient reco ered and deli ered a ne$rologically intact nor%al in-ant at 409(ee=s: gestation) 82

Post9res$scitation %anage%ent ?e( rando%ised controlled clinical trials deal s&eci;cally (ith s$&&orti e care -ollo(ing cardio9 &$l%onaryecerebral res$scitation (CPCR) -ro% cardiac arrest)

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.nitial ob#ecti es o- &ost9res$scitation care are to' O&ti%ise cardio&$l%onary -$nction and syste%ic &er-$sion, es&ecially &er-$sion to the brain .denti-y the &reci&itating ca$se(s) o- the arrest .nstit$te %eas$res to &re ent rec$rrence .nstit$te %eas$res that %ay i%&ro e long9ter%, ne$rologically intact s$r i al

.%&ro ing &ostres$scitation o$tco%es Postres$scitation care is a critical co%&onent o- ad anced li-e s$&&ort) Patient %ortality re%ains high a-ter RO!C and initial stabilisation) 3lti%ate &rognosis in the ;rst 42 h %ay be di-;c$lt to deter%ine,83 yet s$r i ors o- cardiac arrest ha e the &otential to lead nor%al li es) 84e8C "$ring &ostres$scitation care, &ro iders sho$ld' (1) o&ti%ise hae%odyna%ic, res&iratory and ne$rologic s$&&ortB (2) identi-y and treat re ersible ca$ses o- arrestB and (3) %onitor te%&erat$re and consider treat%ent -or dist$rbances o- te%&erat$re reg$lation and %etabolis%) 0hera&e$tic hy&other%ia a-ter cardiac arrest has been de%onstrated to abate the ne$rologic in#$ry and increase the li=elihood o- a ne$rologically intact s$r i al) 4,84 Rittenberger et al) describe the ;rst case o- thera&e$tic hy&other%ia a&&lied to the &ost9arrest care o- a &regnant (o%an -ollo(ed by a s$ccess-$l deli ery and good o$tco%e thera&y) 0hey reco%%end that thera&e$tic hy&other%ia sho$ld be considered in &regnant &atients: stat$s &ost9 cardiac arrest and RO!C)8 0hera&e$tic hy&other%ia is the %ost e--ecti e thera&y -or cerebral &rotection &resently a ailable to clinical &ro iders) 0here are large trials that describe the bene;ts o- this thera&yB ho(e er, these trials ha e e;cl$ded &regnant &atients)4,84 0he 200> <CC G$idelines granted hy&other%ia an ..a reco%9 %endation in entric$lar ;brillation and entric$lar tachycardia cardiac arrest) 84 6o(e er, they do not co%%ent on its $se in &regnancy) 0he s$ccess-$l res$scitation o- a &regnant &atient is %$lti-actorial) 6y&other%ia re%ains one lin= in the chain o- s$r i al -or cardiac arrest icti%s d$ring &regnancy)

+echanis%s o- action 0here are se eral &ossible %echanis%s by (hich %ild hy&other%ia %ight i%&ro e ne$rological o$tco%e (hen $sed a-ter re&er-$sion) 6y&other%ia red$ces the cerebral %etabolic rate o- o;ygen (C+RO2) in the nor%al brain) !&eci;cally, C+RO2 red$ces by CF -or e ery 1)8 red$ction (hen brain te%&erat$re is less than 28)8 C)88 !o%e o- this e--ect is d$e to red$ced nor%al brain electrical acti ity)88 +ild hy&other%ia is tho$ght to s$&&ress %any o- the che%ical reactions associated (ith re&er-$sion in#$ry) 0hese reactions incl$de -ree radical &rod$ction, e;citatory a%ino acid release, and calci$% shi-ts, (hich can in t$rn lead to %itochondrial da%age and a&o&tosis (&rogra%%ed cell death)) 85e51 "es&ite these &otential ad antages, hy&other%ia can also &rod$ce ad erse e--ects incl$ding arrhyth%ias, in-ection and coag$lo&athy)

0i%ing o- cooling Cooling sho$ld &robably be initiated as soon as &ossible a-ter RO!CB ho(e er, it a&&ears to be s$ccess-$l e en (hen delayed (e)g), 4eC h)) .n the <$ro&ean st$dy, the inter al bet(een RO!C and attain%ent o- a core te%&erat$re o- 32 *34)8 C had an interG$artile range o- 4eC h)84

Cooling techniG$es and %onitoring 1 ariety o- cooling techniG$es ha e been described) <;ternal cooling %ethods are si%&le to $se b$t slo( in red$cing core te%&erat$re) 0hese techniG$es incl$de the $se o- cooling blan=etsB a&&lication o- ice &ac=s to the groin, a;illae and nec=B $se o- (et to(els and -anningB and $se oa cooling hel%et)52 .n a recent st$dy, intra eno$s in-$sion o- 30 %l =gQ1 o- crystalloid at 34 C o er

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30 %in red$ced core te%&erat$re signi;cantly and did not ca$se &$l%onary oede%a) 8> 1n intra9 asc$lar heat e;change de ice de elo&ed by the 1rctic !$n gro$& that enables ra&id cooling and &recise te%&erat$re control has recently beco%e a ailable) !hi ering d$ring cooling leads to (ar%ing and an increase in o erall o;ygen cons$%&tion) !hi ering sho$ld be &re ented by $se oa ne$ro%$sc$lar bloc=er and sedation) Care-$l %onitoring o- te%&erat$re is i%&ortant d$ring $se othera&e$tic hy&other%ia) 0he incidence o- co%&lications s$ch as arrhyth%ias, in-ection and coa9 g$lo&athy is li=ely to increase i- the core te%&erat$re -alls considerably belo( 32)8 C) Contin$o$s %onitoring o- te%&erat$re can be acco%&lished by $se o- a bladder te%&erat$re &robe or a &$l%onary artery catheter i- one is in sit$)

!$%%ary' ./COR reco%%endations On the basis o- the &$blished e idence to date, the ./COR 1/! tas= -orce has %ade the -ollo(ing reco%%endations 3nconscio$s ad$lt &atients (ith s&ontaneo$s circ$lation sho$ld be cooled to 32e34)8 C -or 12e24 h (hen the initial rhyth% (as entric$lar ;brillation) !$ch cooling %ay also be bene;cial -or other rhyth%s or in9hos&ital cardiac arrest) Post9res$scitation care is a critical co%&onent o- 1/!) Patient %ortality re%ains high a-ter RO!Cand initial stabilisation) 0hera&e$tic hy&other%ia is the %ost e--ecti e thera&y -or cerebral &rotection &resently a ailable to care &ro iders)

0raining in res$scitation o- &regnant &atients Recent research has sho(n a signi;cant lac= o- =no(ledge a%ong obstetric care &ro iders abo$t di--erences in the res$scitation o- the &regnant &atient) 53,54 Cohen and colleag$es53 -o$nd that 2>e40F o- res&ondents (ere $na(are o- a n$%ber o- cr$cial di--erences bet(een the res$scitation o- &regnant &atients -ro% non9&regnant &atients) Mith the change in the obstetric &o&$lation, ad anced %aternal age, %orbid obesity and signi;cant co9%orbidities d$ring &regnancy,18 the n$%ber o- (o%en (ho beco%e serio$sly ill (hile &regnant is li=ely to increase) .t has been (idely reco%%ended that instit$tions sho$ld $nderta=e reg$lar %$ltidisci&linary training, (hich in ol es all le els o- sta--) Practice o- %aternal cardiac arrest drills sho$ld be $nderta=en to ens$re that a&&ro&riate care is &ro ided in a ti%ely -ashion)14,18,44,5>e54 Recent C<+1C6 re&orts ha e s$ggested that care (as s$bstandard in %ore than >0F o- %aternal deaths and that res$scitation s=ills (ere Nconsidered &oor in an $nacce&tably high n$%ber ocasesO)14,18 0he Royal College o- Obstetricians and Gynaecologists ha e no( reco%%ended that =no(ledge o- res$scitation in &regnancy be an a$ditable standard) 0he 1d anced /i-e !$&&ort in Obstetrics (1/!OV) &rogra%%e hel&s &regnancy care &ro iders learn the in-or%ation and s=ills necessary to deal (ith $rgent and e%ergent conditions that arise d$ring &regnancy and deli ery by $sing %anneG$ins, %ne%onics and e idence9based a&&roaches) !ince its origin, the &rogra%%e has been disse%inated internationally) 58 ?ro% 155C to the &resent, &hysicians in 24 co$ntries o$tside the 3nited !tates ha e disco ered and s$ccess-$lly i%&le%ented 1/!O) 0he o$tco%e s$r ey that is no( &art o- 1/!OV i%&le%entation in ne( co$ntries, &artic$larly de elo&ing co$ntries, is designed to loo= -or changes in &regnancy care &ractices and o$tco%es as (ell as changes in &ro ider con;dence) CPR is rarely needed in the labo$r and deli ery s$ite) .t (o$ld be bene;cial to de elo& si%$lation scenarios to i%&ro e tea%(or= bet(een n$rses, obstetricians and anaesthesiologistsB this (o$ld also i%&ro e the res&onse ti%es (hen enco$ntered (ith s$ch &roble%s d$e to the rarity o- s$ch sit$ations) Partici&ating in the si%$lation9based &rogra%%es gi es the &ro iders the o&&ort$nity to incor&orate the necessary s=ills as %e%bers o- a %$ltidisci&linary tea%) < ery %e%ber o- the tea% sho$ld also be $&dated (ith their 1C/! certi;cation)

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!$%%ary Cardiac arrest d$ring &regnancy is an $nco%%on e ent in (hich s&eed o- the res&onse to the arrest and attention to a n$%ber o- &regnancy9s&eci;c inter entions is cr$cial to the o$tco%e) 0o ha e the best o$tco%e -or %other and baby, ra&id res&onse %$ltidisci&linary tea% training in res$scitation othe &regnant &atient is %andatory) .t is i%&ortant -or the res&onse tea% to be cogniLant o- the ca$ses o- %aternal arrest and the -act that CPR is a--ected or i%&aired by the anato%ic and &hysiologic changes o- &regnancy) !$ccess-$l o$tco%e is de&endent on sec$ring the %aternal air(ay ra&idly by int$bation to &re ent hy&o;ia and as&hy;ia) +an$al dis&lace%ent o- the $ter$s and adeG$ate chest co%&ressions are critical to a oid aortoca al co%&ression and to enhance eno$s ret$rn, cardiac o$t&$t and &er-$sion to ital organs and the -oet$s) 0he ne(ly %odi;ed 1C/! &rotocols and dr$g thera&ies si%ilar to that i%&le%ented in non9&regnant &atients %$st be -ollo(ed) .- de;brillation is reG$ired, it is essential to re%o e the internal -oetal %onitor) Beyond 24 (ee=s: gestation, the standard P1BCs: o- CPR (air(ay, breathing and circ$lation) sho$ld also incl$de a P": -or deli ery) 55 ?inally, the i%&le%entation o- thera&e$tic hy&other%ia a-ter cardiac arrest has been de%onstrated to %ini%ise the ne$rologic in#$ry and increase the li=elihood o- a ne$rologically intact s$r i al) 8

Practice &oints .%&le%entation o- the re ised CPR g$idelines is cr$cial to ha e o&ti%al o$tco%es) +an$al dis&lace%ent o- the $ter$s and e--ecti e chest co%&ressions hel&s in &re enting aortoca al co%&ression, enhances eno$s ret$rn and cardiac o$t&$t and &er-$sion to ital organs incl$ding $tero&lacental &er-$sion) 1 chest co%&ression9to9 entilation ratio o- 30'2 gi es resc$ers a chance to assist icti%s and increase their chance o- s$r i al) "r$g thera&y sho$ld -ollo( standard ad anced cardiac li-e s$&&ort g$idelines) .- de;brillation is reG$ired, internal -oetal %onitoring de ices sho$ld be re%o ed) 0o a oid air(ay9related catastro&hes, ad anced air(ay s=ills in the $se o- air(ay de ices and ideolaryngosco&es are essential) .n addition to &ri%ary thera&y -or local anaesthetic to;icity, 20F intrali&id sol$tions sho$ld be considered as an ad#$nct to the thera&e$tic algorith%) Peri9%orte% caesarean deli ery %$st be considered i- the -oet$s is o- greater than 24 (ee=s: gestation and initial res$scitation is $ns$ccess-$l) 0he critical &oint is that delay in deli ery can res$lt in ad erse %aternal and -oetal o$tco%es, res$lting in either P200F: %orbidity or %ortality) .- initial res$scitation is not e--ecti e d$ring cardiac arrest in &regnancy, deli ering the -oet$s (ithin > %in %ay -acilitate %aternal and -oetal s$r i al) Patient %ortality re%ains high a-ter RO!C and initial stabilisationB thera&e$tic hy&other%ia is the %ost e--ecti e thera&y -or cerebral &rotection) ./COR reco%%endations incl$de cooling o- the $nconscio$s ad$lt &atient (ith RO!C to 32e34)8 C -or 12e24 h) Recent C<+1C6 re&orts ha e s$ggested that care (as s$bstandard in %ore than >0F o%aternal deaths and that res$scitation s=ills (ere Nconsidered &oor in an $nacce&tably high n$%ber o- casesO) 6os&itals %$st de elo& %$ltidisci&linary ra&id res&onse tea%s co%&rising o- obstetricians, anaesthetists, internists, s$rgeons and n$rsing tea%s s=illed in the care o- &regnant &atients) !i%$lation training %$st be incor&orated to i%&ro e and retain =no(ledge and s=ills)

Con;ict o- interest state%ent "r) +aya !$resh, "r) Cha(la /a0oya +ason, and "r) 3%a +$nn$r do not ha e any ;nancial rela9 tionshi&s that co$ld in;$ence (bias) the content o- this article)

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+)!) !$resh et al) * Best Practice & Research Clinical Obstetrics and Gynaecology 24 (2010) 383e400

Re-erences
1) "atner < & Pro%es !) .n' 0intinalli:s e%ergency %edicine) Res$scitation in &regnancy) 0he +cGra(96ill Co, 200C, &) 2>4) 2) He$-eld I) 0ra$%a in &regnancy) .n +ar; (ed))) RosenWs e%ergency %edicine' conce&ts and clinical &ractices) Cth ed) +osby, 200C Xcha&ter 3>Y) 3) /a er !, ?arro( C, 0$rner " et al) +ode o- death a-ter ad%ission to an intensi e care $nit -ollo(ing cardiac arrest) .ntensi e Care +ed 2004B 30(11)' 212Ce2128) 4) Hichol G, !tiell .G, /a$&acis 1 et al) 1 c$%$lati e %eta9analysis o- the e--ecti eness o- de;brillator9ca&able e%ergency %edical ser ices -or icti%s o- o$t9o-9hos&ital cardiac arrest) 1nn <%erg +ed 1555B 34(4 Pt 1)' >14e>2>) >) 1%erican 6eart 1ssociation) 1098 cardiac arrest associated (ith &regnancy) Circ$lation) I 1% 6eart 1ssoc 200>B 112(.K)' 1>0e1>3) C) +ild thera&e$tic hy&other%ia to i%&ro e the ne$rologic o$tco%e a-ter cardiac arrest) H <ngl I +ed 2002B 34C(8)' >45e>>C) 24) Bernard !1, Gray 0M, B$ist +" et al) 0reat%ent o- co%atose s$r i ors o- o$t9o-9hos&ital cardiac arrest (ith ind$ced hy&other%ia) H <ngl I +ed 2002B 34C(8)' >>4e>C3) 28) Rittenberger IC, 8elly <, Iang " et al) !$ccess-$l o$tco%e $tiliLing hy&other%ia a-ter cardiac arrest in &regnancy' a case re&ort) Crit Care +ed 2008B 3C(4)' 13>4e13>C) 5) ":Cr$L BI, ?ertig 8C, ?iliano 1I et al) 6y&other%ic re&er-$sion a-ter cardiac arrest a$g%ents brain9deri ed ne$rotro&hic -actor acti ation) I Cereb Blood ?lo( +etab 2002B 22(4)' 843e8>1) 10) 6ic=s !", "e?ranco "B & Calla(ay CM) 6y&other%ia d$ring re&er-$sion a-ter as&hy;ial cardiac arrest i%&ro es -$nctional reco ery and selecti ely alters stress9ind$ced &rotein e;&ression) I Cereb Blood ?lo( +etab 2000B 20(3)' >20e>30) 11) !terL ?, !a-ar P, 0isher%an ! et al) +ild hy&other%ic cardio&$l%onary res$scitation i%&ro es o$tco%e a-ter &rolonged cardiac arrest in dogs) Crit Care +ed 1551B 15(3)' 345e385) 12) Mali 1 & !$resh +!) +aternal %orbidity, %ortality, and ris= assess%ent) 1nesthesiol Clin 2008B 2C(1)' 154e230,) i;) 13) Chani%o +, Ben !hlo%o ., Chayen B et al) 1%niotic ;$id e%bolis%' a &lea -or better brain &rotection 1) .sr +ed 1ssoc I 2008B 10(2)' 1>4e1>>) 14) Gist R!, !ta--ord .P, /eibo(itL 1B et al) 1%niotic ;$id e%bolis%) 1nesth 1nalg 2005B 108(>)' 1>55e1C02) 1>) 6a(=ins I/, 8oonin /+, Pal%er !8 et al) 1nesthesia9related deaths d$ring obstetric deli ery in the 3nited !tates, 1545e1550) 1nesthesiology 1554B 8C(2)' 244e284) 1C) 6a(=ins I/) 1nesthesia9related %aternal %ortality) Clin Obstet Gynecol 2003B 4C(3)' C45eC84) 214) /e(is G (ed))) Con;dential enG$iry into %aternal and child health) !a ing %other:s li es' re ie( %aternal deaths to %a=e %otherhood sa-ere2003e200> 0he se enth re&ort on con;dential enG$iries into %aternal deaths in the 3nited 8ingdo%) /ondon' C<+1C6) C<+1C6, 2004) Chittern Co$rt, 188 Ba=er !treet, /ondon, HM1 >!")Re- ty&e' re&ort 218) Coo&er G+ & +cCl$re I6) +aternal deaths -ro% anaesthesia) 1n e;tract -ro% Mhy +others "ie 2000e2002, the con;9 dential enG$iries into %aternal deaths in the 3nited 8ingdo%' cha&ter 5) Br I 1naesth 200> 1&rB 54(4)' 414e423) 15) "a ies I+, Posner 8/, /ee /1 et al) /iability associated (ith obstetric anesthesia' a closed clai%s analysis) 1nesthesiology 2005B 110(1)' 131e135) 20) 1(an R, Holan IP & Coo= 0+) 3se o- a Pro!eal laryngeal %as= air(ay -or air(ay %aintenance d$ring e%ergency Caesarean section a-ter -ailed tracheal int$bation) Br I 1naesth 2004B 52(1)' 144e14C) 21) Bailey !G & 8itching 1I) 0he laryngeal %as= air(ay in -ailed obstetric tracheal int$bation) .nt I Obstet 1nesth 200>B 14(3)' 240e241) 22) B$llingha% 1) 3se o- the Pro!eal laryngeal %as= air(ay -or air(ay %aintenance d$ring e%ergency caesarean section a-ter -ailed int$bation) Br I 1naesth 2004B 52(C)' 503) 23) GonLaleL GG, +arenco de la ?$ente +/ & Berto%e$ C+) ?astrach %as= to resol e a di-;c$lt air(ay d$ring e%ergency cesarean section) Re <s& 1nestesiol Reani% 200>B >2(1)' >Ce>4) 24) 8eller C, Bri%aco%be I, /ir= P et al) ?ailed obstetric tracheal int$bation and &osto&erati e res&iratory s$&&ort (ith the Pro!eal laryngeal %as= air(ay) 1nesth 1nalg 2004B 58(>)' 14C4e1440) 2>) +in ille K, H:g$yen /, Co$stet B et al) "i-;c$lt air(ay in obstetric $sing .l%a9?astrach) 1nesth 1nalg 2004B 55(C)' 1843) 2C) !har%a B, !ahai C, !ood I et al) 0he Pro!eal laryngeal %as= air(ay in t(o -ailed obstetric tracheal int$bation scenarios) .nt I Obstet 1nesth 200CB 1>(4)' 338e335) 24) Kaida !I & Gaitini /1) 1nother case o- $se o- the Pro!eal laryngeal %as= air(ay in a di-;c$lt obstetric air(ay) Br I 1naesth 2004B 52(C)' 50>) 28) Case Re&ort) "i-;c$lt 1ir(ay) Case Re&ort 2, 48e83) 2001)Re- ty&e' case 25) Zand ? & 1%ini 1) 3se o- the laryngeal t$be9! -or air(ay %anage%ent and &re ention o- as&iration a-ter a -ailed tracheal int$bation in a &art$rient) 1nesthesiology 200>B 102(2)' 481e483) 30) !tro$%&o$lis 8, Pago$lato$ 1, Kiolari + et al) Kideolaryngosco&y in the %anage%ent o- the di-;c$lt air(ay' a co%&arison (ith the +acintosh blade) <$r I 1naesthesiol 2005B 2C(3)' 218e222) 31) 8a&lan +B & Berci G) Kideolaryngosco&y in the %anage%ent o- the di-;c$lt air(ay 1) Can I 1naesth 2004B >1(1)' 54e5C) 32) Gray 8, /$cas H, Robinson PH et al) 1 case series o- s$ccess-$l ideolaryngosco&ic int$bations in obstetric &atients) .nt I oObstetric 1nesthesia 2005B 18' !1e!C13) 33) 1$roy [, Harchi P, +essiah 1 et al) !erio$s co%&lications related to regional anesthesia' res$lts o- a &ros&ecti e s$r ey in ?rance) 1nesthesiology 1554B 84(3)' 445e48C) 34) Bro(n "/, Ranso% "+, 6all I1 et al) Regional anesthesia and local anesthetic9ind$ced syste%ic to;icity' seiL$re -reG$ency and acco%&anying cardio asc$lar changes) 1nesth 1nalg 155>B 81(2)' 321e328) 3>) !antos 1C & "e1r%as P.) !yste%ic to;icity o- le ob$&i acaine, b$&i acaine, and ro&i acaine d$ring contin$o$s intra e9 no$s in-$sion to non&regnant and &regnant e(es) 1nesthesiology 2001B 5>(>)' 12>Ce12C4) 3C) ?accenda 81 & ?in$cane B0) Co%&lications o- regional anaesthesia incidence and &re ention) "r$g !a- 2001B 24(C)' 413e442) 34) Corcoran M, B$tter(orth I, Meller R! et al) /ocal anesthetic9ind$ced cardiac to;icity' a s$r ey o- conte%&orary &ractice strategies a%ong acade%ic anesthesiology de&art%ents) 1nesth 1nalg 200CB 103(>)' 1322e132C)

+)!) !$resh et al) * Best Practice & Research Clinical Obstetrics and Gynaecology 24 (2010) 383e400 238) Meinberg G/) C$rrent conce&ts in res$scitation o- &atients (ith local anesthetic cardiac to;icity) Reg 1nesth Pain +ed 2002B 24(C)' >C8e>4>) 35) 1tta < & Gardner +) Cardio&$l%onary res$scitation in &regnancy) Obstet Gynecol Clin Horth 1% 2004B 34(3)' >8>e>54) ;iii) 40) 6ea ner I<, "ryden Ir) C?, !anghani K et al) !e ere hy&o;ia enhances central ner o$s syste% and cardio asc$lar to;icity ob$&i acaine in lightly anesthetiLed &igs) 1nesthesiology 1552B 44(1)' 142e144) 41) Groban /, "eal "", Kernon IC et al) Cardiac res$scitation a-ter incre%ental o erdosage (ith lidocaine, b$&i acaine, le 9 ob$&i acaine, and ro&i acaine in anesthetiLed dogs) 1nesth 1nalg 2001B 52(1)' 34e43) 42) /ong MB, Rosenbl$% ! & Grady .P) !$ccess-$l res$scitation o- b$&i acaine9ind$ced cardiac arrest $sing cardio&$l%onary by&ass) 1nesth 1nalg 1585B C5(3)' 403e40C) 43) Groban / & B$tter(orth I) /i&id re ersal o- b$&i acaine to;icity' has the sil er b$llet been identi;ed\ Reg 1nesth Pain +ed 2003B 28(3)' 1C4e1C5) 44) Meinberg G, Ri&&er R, ?einstein "/ et al) /i&id e%$lsion in-$sion resc$es dogs -ro% b$&i acaine9ind$ced cardiac to;icity) Reg 1nesth Pain +ed 2003B 28(3)' 158e202) 4>) Meinberg G/) /i&id in-$sion thera&y' translation to clinical &ractice) 1nesth 1nalg 2008B 10C(>)' 1340e1342) 4C) /itL RI, Roessel 0, 6eller 1R et al) Re ersal o- central ner o$s syste% and cardiac to;icity a-ter local anesthetic into;ication by li&id e%$lsion in#ection) 1nesth 1nalg 2008B 10C(>)' 1>4>e1>44) table) 44) Rosenblatt +1, 1bel +, ?ischer GM et al) !$ccess-$l $se o- a 20F li&id e%$lsion to res$scitate a &atient a-ter a &res$%ed b$&i acaine9related cardiac arrest) 1nesthesiology 200CB 10>(1)' 214e218) 48) Marren I1, 0ho%a RB, Georgesc$ 1 et al) .ntra eno$s li&id in-$sion in the s$ccess-$l res$scitation o- local anesthetic9 ind$ced cardio asc$lar colla&se a-ter s$&racla ic$lar brachial &le;$s bloc=) 1nesth 1nalg 2008B 10C(>)' 1>48e1>80) 45) Meinberg G/, Ri&&er R, +$r&hy P et al) /i&id in-$sion accelerates re%o al o- b$&i acaine and reco ery -ro% b$&i acaine to;icity in the isolated rat heart) Reg 1nesth Pain +ed 200CB 31(4)' 25Ce303) >0) Br$ll !I) /i&id e%$lsion -or the treat%ent o- local anesthetic to;icity' &atient sa-ety i%&lications) 1nesth 1nalg 2008B 10C (>)' 1334e1335) >1) Meinberg G/, KadeBonco$er 0, Ra%ara#$ G1 et al) Pretreat%ent or res$scitation (ith a li&id in-$sion shi-ts the dose9 res&onse to b$&i acaine9ind$ced asystole in rats) 1nesthesiology 1558B 88(4)' 1041e104>) >2) Cor%an !/ & !=ledar !I) 3se o- li&id e%$lsion to re erse local anesthetic9ind$ced to;icity) 1nn Phar%acother 2004B 41(11)' 1843e1844) >3) ?elice 8 & !ch$%ann 6) .ntra eno$s li&id e%$lsion -or local anesthetic to;icity' a re ie( o- the literat$re) I +ed 0o;icol 2008B 4(3)' 184e151) >4) Rosenberg P6, Keering B0 & 3r%ey M?) +a;i%$% reco%%ended doses o- local anesthetics' a %$lti-actorial conce&t) Reg 1nesth Pain +ed 2004B 25(C)' >C4e>4>) >>) !tiles P & Prieli&& RC) .ntrali&id treat%ent o- b$&ica aine to;icity) 0he O-;cial Io$rnal o- the 1nesthesia Patient !a-ety ?o$ndation 2005B 24(Ho) 1))Re- ty&e' electronic citation >C) Meinberg G/) 0reat%ent regi%ens) /i&id resc$e res$scitation -or cardiac to;icity 2004)Re- ty&e' electronic citation >4) Clar= !) Critical care obstetrics) .n' "an-orth:s obstetrics and gynecology) /i&&incott Millia%s and Mil=ins, 2003) >8) 6o$ry " & 1bbott I) 1c$te co%&lications o- &regnancy) .n' Rosen:s e%ergency %edicine' conce&ts and clinical &ractices) +ar;, 200C) >5) +atto; 8 & GoetLi /) 0ra$%a in &regnancy) Crit Care +ed 200>B 33' 38>e385) C0) Crochetiere C) Obstetric e%ergencies) 1nesthesiol Clin Horth 1%erica 2003B 21(1)' 111e12>) C1) +orrison /) General a&&roach to the &regnant &atient) .n' Conce&ts and clinical &ractices) +osby, 200C) C2) /a&ins=y !<, 8r$cLyns=i 8, !ea(ard GR et al) Critical care %anage%ent o- the obstetric &atient) Can I 1naesth 1554B 44(3)' 32>e325) 2C3) /a&ins=y !<) Cardio&$l%onary co%&lications o- &regnancy) Crit Care +ed 200>B 33(4)' 1C1Ce1C22) C4) .nternational g$idelines 2000 -or CPR and <CC) Part 8' ad anced challenges in res$scitation) !ection 3' s&ecial challenges in <CC) 3?' cardiac arrest associated (ith &regnancy) <$ro&ean Res$scitation Co$ncil) Res$scitation 2000B 4C(1e3)' 253e25> X!&ecial .ss$eY) C>) Iohnson +" & 1tta <) Cardio&$l%onary res$scitation) .n Ga%bling "R & "o$glas +I (eds))) Obstetric anesthesia and $nco%%on disorders) Philadel&hia, P1' M)B) !a$nders, 1558, &&) >1e44) 2CC) Rees G1 & Millis B1) Res$scitation in late &regnancy) 1naesthesia 1588B 43(>)' 344e345) C4) 0he .nternational /iaison Co%%ittee on Res$scitation (./COR) consens$s on science (ith treat%ent reco%%endations -or &ediatric and neonatal &atients' &ediatric basic and ad anced li-e s$&&ort) Pediatrics 200CB 114(>)' e5>>ee544) C8) Hanson I, <lcoc= ", Millia%s + et al) "o &hysiological changes in &regnancy change de;brillation energy reG$ire%ents\ Br I 1naesth 2001B 84(2)' 234e235) C5) Gilbert <!, 6ar%on I!) +an$al o- 6igh Ris= Pregnancy & "eli ery) 3rd edB 2003) 40) "i Gregoria R) Kaso&ressin $se in the H[C R<+1C &rotocols' 1 teaching re-erence) Regional <%ergency +edical !er ices Co$ncil o- He( [or=, 2001) 41) C$%%ins R) 1C/! &ro ider %an$al) "allas' 1%erican 6eart 1ssociation, 2001) 42) 8atL K/, "otters "I & "roege%$eller M) Peri%orte% cesarean deli ery) Obstet Gynecol 158CB C8(4)' >41e>4C) 43) "ePace H/, Betesh I! & 8otler +H) PPost%orte%: cesarean section (ith reco ery o- both %other and o--s&ring) I1+1 1582B 248(8)' 541e543) 44) Ban=s 1) +aternal res$scitation' &lenty o- roo% -or i%&ro e%ent) .nt I Obstet 1nesth 2008B 14(4)' 285e251) 4>) 1%erican heart association in collaboration (ith the .nternational /iason Co%%ittee on Res$scitation) G$ideliness 2000 -or cardio&$l%onary res$scitation and e%ergency cardio asc$lar Care' international Consens$s on science, Part 8' ad anced 1d ancec Challenges in Res$scitation' !ection 3' ad anced Challenges in <CC) Circ$lation 2000B 102(!$&&l) 1)' 1225e12>2) 4C) C$%%ins RO, 6aLins=i +? & Zelo& C+) Cardiac arrest associated (ith &regnancy) .n C$%%ins R, 6aLins=i + & ?ield I (eds))) 1C/! e 0he Re-erence 0e;tboo=) "allas' 1%erican 6eart 1ssociation, 2003, &&) 143e1>8) 44) +orris ! & !tacey +) Res$scitation in &regnancy) B+I 2003B 324(442C)' 1244e1245) 48) Boyd R & 0eece !) 0o(ards e idence9based e%ergency %edicine' best B<0s -ro% the +anchester Royal .n;r%ary) Peri9 %orte% caesarean section) <%erg +ed I 2002B 15(4)' 324e32>)

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45) Oates !, Millia%s G/ & Rees G1) Cardio&$l%onary res$scitation in late &regnancy) B+I 1588B 254(CC4>)' 404e40>) 280) /i&%an ! & Car alho BC!) 0he >9%in$te r$le -or &eri%orte% cesarean deli ery' sho$ld (e %o e tot he o&erating roo%\ 0he Io$rnal o- the 1%erican !ociety o- 1nesthesiology, .nc 2005B 11C12)Re- ty&e' abstract 81) !trong Ir) 06 & /o(e R1) Peri%orte% cesarean section) 1% I <%erg +ed 1585B 4(>)' 485e454) 82) !elden B! & B$r=e 0I) Co%&lete %aternal and -etal reco ery a-ter &rolonged cardiac arrest) 1nn <%erg +ed 1588B 14(4)' 34Ce345) 83) Booth C+, Boone R6, 0o%linson G et al) .s this &atient dead, egetati e, or se erely ne$rologically i%&aired\ assessing o$tco%e -or co%atose s$r i ors o- cardiac arrest) I1+1 2004B 251(4)' 840e845) 284) 0he 6y&other%ia a-ter Cardiac 1rrest !t$dy Gro$&) +ild thera&e$tic hy&other%ia to i%&ro e the ne$rologic o$tco%e a-ter cardiac arrest) H <ngl I +ed 2002B 34C(8)' >45e>>C) 8>) Bernard !, B$ist +, +onteiro O et al) .nd$ced hy&other%ia $sing large ol$%e, ice9cold intra eno$s ;$id in co%atose s$r i ors o- o$t9o-9hos&ital cardiac arrest' a &reli%inary re&ort) Res$scitation 2003B >C(1)' 5e13) 8C) B$nch 0I, Mhite R", Gersh BI et al) /ong9ter% o$tco%es o- o$t9o-9hos&ital cardiac arrest a-ter s$ccess-$l early de;bril9 lation) H <ngl I +ed 2003B 348(2C)' 2C2Ce2C33) 84) .nternational /iaison Co%%ittee on Res$scitation) Part 4)>) Postres$scitation s$&&ort) Circ$lation 200>B 112' 84e88) 88) !teen P1, He(berg /, +ilde I6 et al) 6y&other%ia and barbit$rates' indi id$al and co%bined e--ects on canine cerebral o;ygen cons$%&tion) 1nesthesiology 1583B >8(C)' >24e>32) 85) Colbo$rne ?, !$therland G & Corbett ") Postische%ic hy&other%ia) 1 critical a&&raisal (ith i%&lications -or clinical treat%ent) +ol He$robiol 1554B 14(3)' 141e201) 250) Ginsberg +", !terna$ //, Glob$s +[ et al) 0hera&e$tic %od$lation o- brain te%&erat$re' rele ance to ische%ic brain in#$ry) Cerebro asc Brain +etab Re 1552B 4(3)' 185e22>) 51) !a-ar PI & 8ochane= P+) 0hera&e$tic hy&other%ia a-ter cardiac arrest) H <ngl I +ed 2002B 34C(8)' C12eC13) 52) 6achi%i9.drissi !, Corne /, <binger G et al) +ild hy&other%ia ind$ced by a hel%et de ice' a clinical -easibility st$dy) Res$scitation 2001B >1(3)' 24>e281) 53) Cohen !<, 1ndes /C & Car alho B) 1ssess%ent o- =no(ledge regarding cardio&$l%onary res$scitation o- &regnant (o%en) .nt I Obstet 1nesth 2008B 14(1)' 20e2>) 54) <ina !, +atot ., Ber=enstadt 6 et al) 1 s$r ey o- labo$r (ard clinicians: =no(ledge o- %aternal cardiac arrest and res$scitation) .nt I Obstet 1nesth 2008B 14(3)' 238e242) 5>) Clar=e I & B$tt +) +aternal colla&se) C$rr O&in Obstet Gynecol 200>B 14(2)' 1>4e1C0) 5C) Cohen I, !inger P, 8ogan 1 et al) Co$rse and o$tco%e o- obstetric &atients in a general intensi e care $nit) 1cta Obstet Gynecol !cand 2000B 45(10)' 84Ce8>0) 54) Pandey 3, R$ssell .? & /indo( !M) 6o( co%&etent are obstetric and gynaecology trainees in %anaging %aternal cardiac arrests\ I Obstet Gynaecol 200CB 2C(C)' >04e>08) 58) "e$tch%an +, "resang / & Minslo( ") 1d anced li-e s$&&ort in obstetrics (1/!O) international de elo&%ent) ?a% +ed 2004B 35(5)' C18eC22) 55) Phenan GP) ?etal consideration) .n' Golden (+arch)) Blac=(ell !cience, 2004, &&) >53eC11)