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Riblett

Handling a maternal cardiac arrest situation-rural EMS

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Like Doc said, the kid needs to be out NOW. If you don't plan on making that happen, HIT THE ROAD.

Somebody's neo-natal team will be more than happy to pay the ED a visit and scoop the kid and transport, with their expertise, personnel, and equipment, back to whatever capable facility they came from. I transported such teams all the time.

But they can't do that if the baby died because you decided to play Doctor onscene for 20 minutes. This is NOT a normal code and can NOT be treated as such.

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Great points ER doc. I was hoping you and Dust both would weigh in. So you would advocate a trip to the community ED (choice #1) I assume?

Our protocols are not specific for this situation; they just say treat the mother per appropriate protocol, immediate notification to medical control, and immediate rapid tranport.

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That is a tough call Rib. Unfortunetly in the US not all ERs are staffed by EM residency trained physicians. Those of us that are would cut without a second thought (and change our underwear afterwards). You do have some ERs that use Internal Medicine and Family Medicine trained physicians that may not be as ready to do it. Putting that aside, I would go to the closest as that should give them the best chance (in theory). One ER doc should be able to manage both mother and child. If they gave you crap about bringing the pt to them I would remind them, "Hey, you're scared shitless to have them here, how do you think I feel in the field? You are a doctor working in an ER and should be able to handle this. I do not have the appropriate training or equipment to do what is needed. The mother and baby have the best chance of survival here, not in an ambulance for 30-45 minutes. Do you want to put your license on the line, doc?"

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i have a close friend who did just that, got orders from medical control to cut and deliver the baby. The mothers head was crushed under the car yet the baby still had a good heartrate.

He delivered a baby, and the kid is still alive today.

I would contact medical control and go from there.

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This patient needs a midline incision from xyphoid to pubis. Are you prepared to do that? If not, DO NOT wait on the scene, you will sentence the baby to death. The c-section needs to be done within 5-10 minutes of maternal arrest for the best possible outcome (though literature is lacking due to the inability to enroll many patients in a double-blinded study). Get your IV in and start running like hell. Push meds on the way.

In that case the fetus is already dead long before I arrive, so I might as well try to save the mother. As to the previous post about the medic who did the C-Section in the field. Lucky for him the baby lived. Had it not no doubt that medic would be penniless from all of the court cases for conducting a procedure out of his scope of practice. Not even medical control can authorize something like that. If loading and running like hell was the best practice for cardiac arrest we would be doing that every time rather than sitting on scene running a code.

I stand by my treatment

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This is not your standard cardiac arrest so the rules that you are applying go out the window. You have 2 patients to think about, not 1. The typical cardiac arrest is usually due to undelying cardiac pathology. In the case of a pregnant woman, a cardiac cause is low on the differential and there are other things that can be corrected in the ER that you cannot correct in the field. The greatest chance of survival for both mother and fetus is delivery, by delaying that you are costing your patients any chance they might have had. Standing by your statement shows your lack of understanding on the subject. Why do you say that the fetus is long dead before you get there?

I'm not a big fan of case reports but in a case like this there is no large study you take what you can get, but here is just one example of why the stay and play theory will kill your pts.

http://www.ncbi.nlm.nih.gov/pubmed/9764669...ogdbfrom=pubmed

What good is your epi and atropine going to do for a PE or amniotic fluid embolus?

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Granted, but before conducting those things in the ER that I can't do, my docs are first going to do exactly what I would do, so, why not do it sooner, rather than later? Arriving at the hospital at the time when I have exhausted those treatments so they can move on to doing what I can't do? Why delay the exact same treatment the patient would get after a 10 minute transport to option number one when I can provide that in the field, possibly getting a ROSC that will keep the fetus alive for a little longer? You already stated that after 10 minutes the fetus is dead anyways, do you really think that poor CPR alone in a moving ambulance is sufficient to perfuse the fetus after 20 minutes? If I transport this patient in this scenario, they are both dead according to your statement because the fetus will be long past viable before we're anywhere close to the hospital.

Perhaps this will be helpful...here is how I run a code....

Assess the patient

Determine Pulselessness

Start CPR, usually my BLS partner

OPA and BVM, same CPR partner

Apply defib pads and shock if advised

IV access and first round of meds

Intubate and attach ventilator

Second round of meds

I take over CPR with my med kit right beside me and my partner drives

Several scenarios occur past this point....either my second crew has arrived, we had a 3 person crew, a qualified bystander is able to assist during transport, or I am doing a code by myself in the unit, trying to push meds and do CPR.

I will not simply run any code BLS to the hospital because that is not in the best interests of my patient. Why do CPR alone when I can do so much more that has the potential for a ROSC. I have never spent more than 15 minutes on scene for a code, and by the time I arrive at the hospital the docs are able to consider treatments other than what I have done because I have covered the basics for them.

You may think it is a waste of time to run the code on scene, but it remains my contention that it is a greater waste of time to take the patient to the hospital with no ALS interventions because those will have to be completed upon our arrival at the hospital and the fetus will already be dead.

2 additional comments, per this scenario, the local ED is no better equipped to handle this patient than I am, so why delay treatment just to have them do what I could have 10 minutes or more earlier? Secondly, I am making my treatment decisions based on my experience with my facilities and staff. I've actually talked about this very thing with my local chief of staff over drinks a few years back. He made it clear to me that if the mother to be arrives in his ER with no indication of life whatsoever..ie asystole during a prolonged arrest, the fetus would not be worth attempting to extract, even if it was something he could do. My docs are GPs, our hospital doesn't even perform deliveries, the procedure you describe would have them strung up before the medical board.

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I never said to BLS the pt. I said get your IV in and push meds enroute. You are not delaying care, you are reducing the time the pt and baby have to wait for appropriate care. Isn't that what is important? I don't believe I said the baby would be dead in 10 minutes. I said your best chance of survival is opening the uterus in 5-10 minutes (the American College of Gynecology has set a 4 minutes standard from the time of maternal arrest thought evidence is lacking at this point). This is a situation you are not equipped to handle. You need to get them to the ER. I can't speak for your doctors, but the code will only be run for as long as it takes me to get the crash c-section supplies ready before the first incision is made.

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The c-section needs to be done within 5-10 minutes of maternal arrest for the best possible outcome Get your IV in and start running like hell. Push meds on the way.

Apologies, I had inferred from this that my, ideally, 10 minute response, 5 minutes on scene, the 10 minute transport, and we'll say 5 minutes to extract the fetus would likely result in the worst possible outcome for both patients. This scenario doesn't take into account that 911 has to be called, the ambulance dispatched, the enroute time to the scene, etc, etc, etc. My only option was to assume these facts. As for the BLS to the hospital...what other option would I have as the lone practitioner in the back of the ambulance? I can't start a line or sink a tube while doing CPR, how do I push meds if we load and go? At best, I might be able to defib, of course if I have an AED I can't analyze with the ambulance moving. Fortunately, I have a manual option. Before we transport I would have to start a line and drop a tube while my partner does CPR before we begin transport. Per my previous post indicating how I would treat this patient, it seems to be the only option I have to be able to "push meds and drive like hell"

BTW, I added some comments to my previous post that you might have missed when you were typing your reply.

I continue to stand by my treatment plan.

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Man, as much as I loath disagreeing with the Doc, I have to go with Kat on this one.

If 5-10 mins post arrest is your most viable time to remove the baby (I'm assuming Doc that as we have that little bit of data, that it is hospital based, with O2, airway management, and good CPR which were unlikely to be used initially with this woman I'm thinking.), and without data to show how quickly viability degrades after that, it seems the only realistic option for saving the baby is to attempt to save the mother.

2-3 mins post arrest before 911 is notified, another few minutes (In many places) while they dispatch Fire, and then the ambulance, 5 mins response (right around the corner), 5 mins for gear into house, monitor placement, IV, rhythm analysis, 2-3 mins to package and move to unit, 10 minute transport, 2-3 mins to transfer to ER.

And this is if all goes pretty peachy. I don't see her on your bed Doc in less than 30 mins with the likelihood of the first 5-10 being bystander CPR only. I have to say work her and curse the EMS Gods that this situation sucked.

On the flip side, perhaps this boils down to simple, standard triage. I can't work an ACLS code properly alone in the back of the truck, which sacrafices the mother if we move. But I can intubate and do good CPR which may keep the child viable while possibly, almost certainly sacrificing the mother, so do I choose to triage and sacrifice the mother with the child being by far the most viable patient?

I don't know. Having come upon this situation, I would have worked the code if I had limited resources. And likely, in my ignorance would have worked the code if I had resources running out my rear. But now I'm not sure I know the right answer.

Dwayne

EDIT:

What good is your epi and atropine going to do for a PE or amniotic fluid embolus?

None at all, but what good have we done if those are not in fact the issues? And regardless of what the issue might be, not only can we not beat the clock on this one, but by the time we can see the finish line with a telescope fate will have been on the other side for 15-30 (best/worst) minutes sipping brandy and signing autographs, right? Don't we take out 2% shot over our 1% shot?

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