Page 692 - ACCCN's Critical Care Nursing

Resuscitation 669

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pneumothorax, aortic dissection or hypovolaemia. Place- airways secondary to oedema or swelling. Defibrillation
ment of the probe at the sub-xiphoid position prior to energy, drug doses and administration are in accordance
stopping for planned rhythm assessment will facilitate with ALS guidelines. 87
views within 10 sec and minimise chest compression If maternal cardiac arrest occurs in the labour ward,
20
interruptions. While the use of imaging has not been operating room or emergency department and BLS and
shown to improve outcome, absence of heart motion on ALS measures are unsuccessful, the uterus should be
sonography during resuscitation is highly predictive of emptied by surgical (scalpel) intervention within 4–5
death. 20
minutes. Maternal resuscitation may not be possible
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Special Considerations until the fetus is removed. Successful resuscitations have
occurred after prompt surgical intervention. Refer to
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Whilst not common, there are some clinical presenta- Chapter 26 for additional information about critical
tions that require special considerations in a cardiac arrest illness and pregnancy.
scenario: these include pregnancy, electrical injuries and
drowning. The principles of airway, breathing and circula- Electrical injuries
tion remain the same, although modifications must be Electrical burn injuries (EBIs) and lightning injuries are
made because of the physiological changes that occur.
similar in that they occur infrequently, commonly cause
Pregnancy widespread acute and delayed tissue damage, and can
arrest the heart and respiratory centre. Burn injuries are
In 2008, there was an estimated 342,900 maternal deaths discussed in Chapter 23. This section focuses on the
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worldwide. Precipitants included pulmonary embolism, cardiac arrest situation. High-voltage electrocution is
trauma, peripartum haemorrhage, amniotic fluid embo- associated with a high incidence of cardiac abnormalities,
lism, eclamptic seizure, congenital and aquired cardiac including arrhythmias, prolongation of the QT interval,
disease, myocardial infarction, subarachnoid haemor- ST and T wave changes, and myocardial infarction. The
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rhage and cerebral aneurysm. Regardless of the aetio- most common cause of death with lightning injury is
logy, resuscitation following cardiac arrest in late cardiac arrest due to VF or asystole or respiratory arrest.
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pregnancy is often unsuccessful. Hence, timely delivery Because of the potential for cardiac injuries, all patients
by caesarean section in the setting of maternal cardiac should be admitted for cardiac monitoring.
arrest may save both infant and mother.
A lightning strike may result in asystole followed by spon-
The principles of airway, breathing and circulation remain taneous return of circulation. If ventilation is initiated
the same, but modifications must be made because of the early and severe hypoxia does not ensue, a patient’s
physiological changes that occur with normal preg- chance of recovery should be better. Initial response of
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nancy. A number of factors may need to be considered BLS should always begin with D (danger), that is, avoid-
when resuscitating a pregnant woman. Any situation that ance of injury to the rescuer. Ensure that the environment
affects haemodynamic status will be exacerbated in a is safe for rescuers by disconnecting the electrical supply,
supine position, as autocaval compression may result in where possible, without touching the patient. Where
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a fall in cardiac output of up to 25%. The mother may high-voltage lines (power lines) are in contact with the
be placed in the left lateral tilt (15 degrees) or supine with person or the vehicle, no attempt should be made to
a pillow under the right buttock, to displace the uterus extricate the person from the vehicle until the situation
from the inferior vena cava, facilitating venous return and is deemed safe by an authorised electricity supply person.
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cardiac output. Often the angle of the tilt is overesti- Once the environment is safe, commence BLS resuscita-
mated potentially reducing the quality of the chest com- tion. The neck and spine should be protected, as there
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pressions. The uterus may also be manually and gently may be trauma.
displaced to the left to remove caval compression. 83
In lightning victims, emphasis is on the immediate resus-
While ventilation : compression ratios remain the same citation of those who appear unresponsive. Respiratory
for a pregnant woman, chest compression may be com- arrest may be prolonged due to paralysis of the medullary
plicated by flaring of the ribs, raised diaphragm, obesity respiratory centre; if not corrected, cardiac arrest second-
and breast hypertrophy. 83 ary to hypoxia ensues. Fixed, dilated pupils should not

The superior displacement of stomach contents by the be used as a poor prognosis of outcome, as victims can
gravid uterus and a relaxed cardiac sphincter contribute benefit from prolonged resuscitation without major
to an increased risk of gastric aspiration in the pregnant sequelae. 88
woman. 83,86 Because of this increased risk, cricoid pres-
sure should be applied until after the airway is protected Drowning
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by a cuffed tracheal tube. Tracheal intubation should be General issues in managing drowning presentations are
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attended to early, utilising a short-handled laryngoscope discussed in Chapter 22. This section focuses on resusci-
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or with a blade mounted at more than 90 degrees, as tation of a cardiorespiratory arrest. Hypoxia and acute
airway anatomy is altered with the larynx more anterior lung injury (ALI) from drowning results in respiratory
and superior, while pharyngeal mucosa is slightly oede- arrest which, if not corrected may proceed to a cardiac
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matous and friable. A tracheal tube a size smaller than arrest. 89,90 A patient’s emotional state, associated diseases,
one normally chosen for a similar size non-pregnant previous hypoxia and water temperature all influence this
woman may be chosen because of potential narrower progression. 83