CPR

CPR in Pregnancy: Ohio CORES Series

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Are you prepared for an OB emergency? In this special six-part podcast series, the Ohio CORES team at The Ohio State University explores the management of pregnant and postpartum women in emergency situations. Each episode focuses on a high-stakes obstetrics scenarios, including: 1) maternal morbidity and mortality, 2) postpartum hemorrhage, 3) hypertensive emergencies, 4) cardiac arrest in pregnant patients, 5) peripartum cardiomyopathy, and 6) complicated vaginal deliveries. Whether you’re in the field, ED, ICU, or on L&D, this series equips you with the knowledge to respond when seconds count.

Ohio CORES (Collaborative Obstetric Resuscitation Education and Simulation) is an interdisciplinary team of educators from The Ohio State University dedicated to improving care for pregnant and postpartum women in critical condition  through high-impact education and simulation training. Supported by funding from the Ohio Department of Children and Youth, Ohio CORES delivers obstetric emergency education to healthcare providers across the state.

In this episode of Crash Cart EM, we cover high-quality CPR in pregnancy- a rare emergency with a 7% survival rate. Learn how to adapt your resuscitation approach, avoid common pitfalls, and perform a resuscitative hysterotomy.

Guests: Jennifer Mitzman, MD; Kimberly Bambach, MD
Host: Sheryl Pfeil, MD
Editors: Rashelle Ghanem; Nicole McGarity, MHI, BSN, RN, CEN; Cynthia Shellhaas, MD, MPH; Kim Bambach, MD

1. Common Causes of Maternal Cardiac Arrest

  • Most common: Pulmonary embolism, hemorrhage (including trauma), hypertensive emergencies, infections, peripartum cardiomyopathy, and rare causes like stroke
  • Often occurs during or immediately after delivery
  • Risk factors: Advanced maternal age, African American race, high parity, and lack of prenatal care

2. What Stays the Same in CPR

  • Same compression rate (100–120/min), hand positioning and depth, defibrillation pad placement and energy levels, medication dosing (e.g., 1 mg epinephrine)

3. Key Differences in Pregnant Patients

  • Manual Lateral Uterine Displacement:
    • Displace uterus to the left to relieve IVC compression
    • Must be done manually- lateral tilt is no longer recommended
  • No LUCAS Device: LUCAS device use is not recommended for use in pregnancy due to safety concerns

4. Procedure and Airway Considerations

  • Prefer humeral IO (above diaphragm) over tibial
  • Chest tubes: Place higher (3rd–4th ICS) due to elevated diaphragm
  • Aggressive oxygenation: Avoid borderline sats—aim for 97–99%
  • High aspiration risk: Have readily suction available (two are helpful)
  • Airway edema common: Downsize ETT

5. Resuscitative Hysterotomy

  • Timing: If no ROSC by 4 minutes and >24 weeks gestation (or fundus at umbilicus), proceed
  • Purpose: Increases maternal preload and decreases afterload- improving perfusion. This is a resuscitative procedure for the pregnant patient and will also maximize chances of survival for the fetus. The procedure is still indicated in the case of fetal demise.
  • Steps:
    • Vertical midline incision
    • Dissect to the peritoneal cavity
    • Incise uterus
    • Deliver fetus, clamp/cut cord
    • Deliver placenta, pack uterus
    • Continue high-quality CPR throughout

7. Team Preparation & Simulation

  • The mental barrier is real– similar to performing a cricothyroidotomy
  • Debrief early, assign roles, and have equipment ready
  • Practice with simulation to improve readiness

Resources:

  1. Virtual Obstetric Emergency Simulation Training at The Ohio State University

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Sub Zero: Managing Hypothermia

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Hypothermia can be deadly and as the weather turns colder, we need to be ready to treat it. In this episode, Dr. Close (PGY-3 Chief Resident) and Dr. Kaide (Professor of EM) teach us how to manage the spectrum of hypothermia from mild cases to cardiac arrest.

Guest: Colin Kaide, MD. Host: Alex Close, MD. Editor: Kim Bambach, MD.

Key Take-Aways:

  1. Hypothermia= core body temp <95* F (35* C)
  2. Risk factors: environmental exposure (winter sports, lack of shelter), ethanol use, extremes of age, underlying illness with impaired thermoregulation (ex. sepsis)
  3. Hypothermia can progress to altered mental status/CNS depression and cardiac arrest due to arrhythmia 
  4. Have a high index of suspicion for trauma, concomitant injuries (ex: SDH after fall and prolonged time down, C spine injury in the submerged patient) 
  5. Loss of shivering is an ominous sign of moderate-severe hypothermia.
  6. For mild hypothermia rewarming may be passive external: warm environment, blankets. Remove any wet clothing. For moderate hypothermia: initiate active external measures like warm blankets/Bair hugger, warm IVF, heated humidified oxygen, targeted temperature management (ex. Zoll catheter). For the critically ill patient with severe hypothermia such as a post arrest patient: chest tube placement for thoracic lavage, consider ECMO. In a lower resource setting consider hemodialysis.
  7. In cardiac arrest the key to obtaining ROSC is high quality CPR and rewarming. Anti-arrhythmic medications have limited efficacy. Common arrhythmias are sinus bradycardia, atrial fibrillation with slow ventricular rate, VF, VT, systole. Look for Osbourne waves on EKG: a positive deflection at the J point in precordial and true limb leads. 
  8. While it is true that hypothermia can slow metabolism CPR should not be terminated until the patient has a core temp of 90*F (>32 *C) “warm and dead”, there are some exceptions such as hyperkalemia >10-12 mmol/L, arrest occurred prior to insult, obvious signs of irreversible death/major trauma, patient is rigid to the extent compressions are not possible.
  9. Always make sure you have a documented core temperature for a patient who is altered or bradycardic- it just might be due to hypothermia! 
  10. Editors note: It is also critical to obtain a finger stick glucose STAT- hypoglycemia and hypothermia frequently co-occur! 

References:

  1. Brown DA. Hypothermia. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill Education; 2020. Accessed September 12, 2024. https://accessemergencymedicine-mhmedical-com.proxy.lib.ohio-state.edu/content.aspx?bookid=2353&sectionid=220746470
  2. Kuhl E, Yamane D. . Accidental Hypothermia and Cardiac Arrest: Physiology, Protocol Deviations, and ECMO. ALiEM. December 12, 2018. Accessed September 12, 2024. https://www.aliem.com/accidental-hypothermia-cardiac-arrest-physiology-protocol-deviations-ecmo/
  3. Furgurson M. EM@3AM: Hypothermia. emDOCs.net – Emergency Medicine Education. December 19, 2020. Accessed September 12, 2024. https://www.emdocs.net/em3am-hypothermia-2/
  4. Hypothermia. Core EM. Accessed September 12, 2024. https://coreem.net/core/hypothermia/
  5. Hypothermia. EMCrit Project. Accessed September 12, 2024. https://emcrit.org/ibcc/hypothermia/

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