ill & expectant

Some brief highlights from Dr. Haney Mallemat’s lecture titled “Pregnant & Sick: Management of the Critically Ill & Expectant” at the All NYC EM conference this past week.

Optimize Perfusion & Diffusion when treating the critically-ill pregnant patient.

If you treat mom, you’ll treat baby; just remember what you were TOLD:
Tilt (alleviates IVC compression, subsequently increasing venous return by 30%)
Oxygen (use Nasal Cannula, Non-Rebreathers, High Flow Humidified O2. BiPAP is bad – pregnant women have lower esophageal sphincter tone amongst other changes, which increases their aspiration risk.)
Lines (Obtain IV access above diaphragm. Avoid femoral veins, as the placenta is compressing them.)
Dates (24 weeks is the trigger for whether or not to perform a Perimortem C-Section)

Some more on Perfusion Physiology:
-25% goes of the circulating volumes goes to the placenta.
-During cardiac arrest, displacement of the uterus alleviate IVC compression (see Tilt). However, in this circumstance tilting the patient may impede effective CPR. Instead have an assistant manually displace the uterus while leaving the patient in the supine position.
-Perimortem C-sxn can increase the mother’s cardiac output by up to 80%.

And speaking of perimortem C-sxn…
EMCrit’s 2013 Conference’s Blast competition winner, Dr. Salil Bhandari, succinctly described 3 critical point to remember: 24, 4, Scissors.

24 weeks (increased chances of survival for mom and baby)
4 minutes (4 minutes of CPR… or 2 rounds)
Scissors (to make the midline cut)

EMCrit on PeriMortem C-Section – http://vimeo.com/59516684
ACLS on the pregnant patient – http://circ.ahajournals.org/content/122/18_suppl_3/S829.full#sec-35

And on Diffusion Physiology:
The growing placenta pushes upward into the diaphragm, decreasing the FRC (hurts apnea time while intubating)

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