Special Circumstances

Pregnancy and Cardiac Arrest

The patient position has emerged as an important strategy to improve the quality of CPR. After approximately 20 weeks gestation, the pregnant patient’s uterus can compress the inferior vena cava (IVC) and the aorta, impeding venous return, thereby reducing stroke volume, cardiac output and uterine perfusion. IVC compression limits the effectiveness of chest compressions. Pregnant patients in cardiac arrest with a known or suspected gestation >20 weeks should be resuscitated with a 15°-30° tilt of the patient to the left to raise their right hip if it is feasible and doesn’t interfere with high-performance CPR.

Early consult with the MedSTAR Medical Retrieval Consultant (MRC) via the EOC Clinician should occur to discuss management options.

Bariatric Patients

Morbid obesity can provide challenges during the resuscitation attempt and extra resources should be considered early. In essence, we know that performing chest compressions on these patients may be more difficult and physically exhausting. To maintain sufficient rate and depth of chest compressions, the compressor may need to change more frequently than the standard 2-minute intervals. Ventilating these patients can also be challenging, and you may require greater inspiratory pressures due to thoracic mass compression, increased intrabdominal pressure and changes to lung physiology. This can result in excessive leaks with ventilation through an i-Gel® during uninterrupted compressions. Consider pausing for ventilation even when an i-Gel® is insitu. The increased intraabdominal pressure and higher inspiratory pressures also increase the risk of aspiration. Have your suction set up and readily available. If transport under CPR is being considered, there is a need to liaise early with EOC for the potential use of bariatric ambulance or regional bariatric resources

Asthma

For the asthmatic patient in cardiac arrest, we need to be careful of ventilation rates and volumes if the patient is very difficult to ventilate. We have to stop and think about what we are doing, ensuring that we allow enough time for the patient to completely exhale before delivering the next ventilation.