Department of Emergency Medicine

Saiful Anwar General Hospital

Faculty of Medicine – University of Brawijaya
Malang, Indonesia
Indication
• Heart Attack
• Choking
• Near drowning
• Electric shock
• Drug overdose (amphetamine, morphine, beta blockers,
digitalis, etc)
Chain of Survival

1. Early recognition of cardiac arrest signs and prompt

access to the Emergency Medical Services
2. Early CPR, emphasis on chest compression
3. Early defibrilation if indicated
4. Rapid advanced life support
5. Integrated post cardiac arrest care
Step 1 EVALUATE RESPONSE
Step 2
ACTIVATE EMERGENCY MEDICAL SERVICES (EMS)

Please inform Ambulance 118:

 Location of victims
 What has happened (heart attack/
unconscious)
 Number of victims
 Need an ambulance immediately
 Your contact phone number
 End-up phone call upon instruction
from EMS officer
Step 3 VICTIMS POSITIONING
Step 4 EVALUATE CAROTID PULSE (5-10 seconds)
Step 5
LAND-MARKING FOR CHEST COMPRESSION
Step 6 CHEST COMPRESSION
 30 chest compression, followed
by 2 ventilations (30:2)
 Compression depth of 5 cm
 Evaluation of CPR after 5
cycles/2 minutes
High Quality CPR
 Speed at least 100 x/min
 Regular
 5 cm depth or 1/3 AP chest diameter
 Full chest recoil
 Minimal interruptions
Step 7
OPEN AIRWAY , after 30 chest compressions
Step 8 EVALUATE BREATHING

 Look at chest movement

 Listen to breath sounds
 Feel the breath on your
cheek

If no breathing,
two VENTILATION for 1-1,5 second each
Step 9 RE-EVALUATE CIRCULATORY SIGNS/PULSE

If pulse presents, stop CPR!

Step 10 RE-EVALUATE BREATHING
 If no breathing,
give rescue breathing for 8-
10 times/minute

 Re-evaluate every 1 minute

by evaluating carotid pulse
& breathing
Step 11 RECOVERY POSITION

After pulse and breathing present!

 III. Cardiac Arrest Associated
With Pregnancy
Scope of the Problem:
•

During attempted resuscitation of a pregnant woman,

•

providers have 2 potential patients: mother & fetus.

The best hope of fetal survival is maternal survival.
•

For the critically ill pregnant patient, rescuers must

•

provide appropriate resuscitation based on consideration

of the physiological changes caused by pregnancy.

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 Key Interventions to Prevent Arrest

Standard care for treating the critically ill pregnant patient

•

(Class I, LOE C):

Place patient in the full left-lateral position to relieve possible

•

compression of the inferior vena cava.

Uterine obstruction of venous return can produce hypotension

•

and may precipitate arrest in the critically ill patient.

Give 100% oxygen.

•

Establish intravenous access above the diaphragm.

•

Hypotension; maternal hypotension that warrants therapy has

•

been defined as SBP <100 mmHg.

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Key Interventions to Prevent Arrest

Maternal hypotension can result in reduced

•

placental perfusion.
In the patient who is not in arrest, both crystalloid
•

and colloid solutions have been shown to increase

preload.
Consider reversible causes of critical illness and treat
•

conditions that may contribute to clinical

deterioration as early as possible.

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Resuscitation of the Pregnant
Patient in Cardiac Arrest (Figure1)
There are no randomized controlled trials evaluating
•

the effect of specialized obstetric resuscitation versus

standard care in pregnant patients in cardiac arrest.
There are reports in the literature of patients not in
•

arrest that describe the science behind important

physiological changes that occur in pregnancy that
may influence treatment recommendations and
guidelines for resuscitation from cardiac arrest in
pregnancy.

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 BLS Modifications

Patient Positioning
•

•Patient position has emerged as an important

strategy to improve the quality of CPR and
resultant compression force and output.

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ACLS Modifications
• Airway
• Breathing
• Circulation :
• Defibrillation should be performed as indication.
• ACLS defibrillation doses (Class I, LOE C).
Use of an AED on a pregnant victim has not been
•

studied but is reasonable.

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Treatment of Reversible Causes

Cardiac Disease
•

Magnesium Sulfate Toxicity

•

Preeclampsia/Eclampsia
•

Life-Threatening Pulmonary Embolism (PE)

•

Amniotic Fluid Embolism

•

Anesthetic Complications
•

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Maternal Cardiac Arrest Not
Immediately Reversed by
BLS and ACLS

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 Institutional Preparation for
Maternal
Cardiac Arrest:
•

•Experts and organizations have emphasized the

importance of preparation.
Providers at medical centers must review whether
•

performance of an emergency hysterotomy is feasible,

and if so, they must identify the best means of
accomplishing this procedure rapidly.
•Team planning should be done in collaboration with the
obstetric, neonatal, emergency, anesthesiology,
intensive care, & cardiac arrest services (Class I, LOE C)

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Emergency Cesarean Section in
Cardiac Arrest
Resuscitation team leaders should activate the protocol
•

for an emergency cesarean delivery as soon as cardiac

arrest is identified in a pregnant woman with an obviously
gravid uterus.
•By the time the physician is ready to deliver the baby,
standard ACLS should be underway and immediately
reversible causes of cardiac arrest should be ruled out.
When the gravid uterus is large enough to cause
•

maternal hemodynamic changes due to aortocaval

compression, emergency cesarean section should be
considered, regardless of fetal viability.
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 Reasons-Problems

What Defines a Gravid Uterus With the Potential

•

to Cause Aortocaval Compression?

•Why Perform an Emergency Cesarean Section
in Cardiac Arrest?
The Importance of Timing With Emergency
•

Cesarean Section?

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 Institutional Preparation for
Maternal
Post–Cardiac Arrest Care:
•

One case report showed that post– cardiac arrest hypothermia

•

can be used safely and effectively in early pregnancy without

emergency cesarean section (with fetal heart monitoring), with
favorable maternal and fetal outcome after a term delivery.

No cases in literature have reported the use of therapeutic

•

hypothermia with perimortem cesarean section.

•Therapeutic hypothermia may be considered on an individual

basis after cardiac arrest in a comatose pregnant patient based
on current recommendations for the nonpregnant patient (Class
IIb, LOE C).

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Thank You