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858 l AUGUST JOGC AOT 2011

The American Heart Association 2010 Guidelines


for the Management of Cardiac Arrest in
Pregnancy: Consensus Recommendations on
Implementation Strategies
Dini Hui, MD, FRCSC,
1
Laurie J. Morrison, MD, MSc, FRCPC,
2,3
Rory Windrim, MD, FRCSC,
4

Andrea Y. Lausman, MD, FRCSC,
5
Laura Hawryluck, MSc (Bioethics), MD, FRCPC,
6

Paul Dorian, MD, FRCPC,
7
Stephen E. Lapinsky, MB BCh, MSc, FRCPC,
8

Stephen H. Halpern, MD, MSc, FRCPC,
9
Douglas M. Campbell, MD, FRCPC,
10

Paul Hawkins, MD, MCFP(EM), FACEP,
11
Randy S. Wax, MD, MEd, FRCPC, FCCM,
12

Jose C.A. Carvalho, MD, PhD, FANZCA, FRCPC,
13
Katie N. Dainty, PhD,
2

Cynthia Maxwell, MD, FRCSC,
4
Farida M. Jeejeebhoy, MD, FRCPC, FACC
14
11
Department of Obstetrics and Gynaecology, Division of Maternal Fetal Medicine, Sunnybrook Health Sciences Centre, University of Toronto,
Toronto ON
12
Rescu, Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michaels Hospital, University of Toronto, Toronto ON
13
Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto ON
14
Department of Obstetrics and Gynaecology, Division of Maternal Fetal Medicine, Mount Sinai Hospital, University of Toronto, Toronto ON
15
Department of Obstetrics and Gynaecology, St Michaels Hospital, University of Toronto, Toronto ON
16
Critical Care, Toronto General Hospital, University of Toronto, Toronto ON
17
Department of Medicine, Division of Cardiology, St Michaels Hospital, University of Toronto, Toronto ON
18
Interdepartmental Division of Critical Care, University of Toronto, Intensive Care Unit, Mount Sinai Hospital, Toronto ON
19
Obstetrics and Gynaecology, Anaesthesia, Sunnybrook Health Sciences Centre, University of Toronto, Toronto ON
10
Department of Paediatrics, Li Ka Shing Knowledge Institute, St Michaels Hospital, University of Toronto, Toronto ON
11
Department of Emergency Services, Sunnybrook Health Sciences Centre, University of Toronto, Toronto ON
12
Departments of Emergency Medicine and Critical Care, Lakeridge Health Corporation and Interdepartmental Division of Critical Care,
University of Toronto, Oshawa ON
13
Departments of Anaesthesia and Pain Management and Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto ON
14
Division of Cardiology, William Osler Health Centre, Department of Medicine, University of Toronto, Toronto ON
COMMENTARY
Key Words: Cardiac arrest, pregnancy, resuscitation,
multidisciplinary care, implementation strategy, management
Competing Interests: None declared
Received on January 27, 2011
Accepted on April 1, 2011
J Obstet Gynaecol Can 2011;33(8):858863
INTRODuCTION
C
ardiac deaths during pregnancy have increased steadily
over the past two decades.
1
According to the recently
published 20062008 Confdential Enquiries into Maternal
Deaths in the United Kingdom, the largest population-based
data set for this target population, cardiac disease in the United
Kingdom represented the most common cause of maternal
death overall, exceeding the rates of thromboembolism,
sepsis, and hemorrhage.
1
The most common causes of
maternal death from cardiac disease were sudden adult death
AUGUST JOGC AOT 2011 l 859
The American Heart Association 2010 Guidelines for the Management of Cardiac Arrest in Pregnancy
syndrome, myocardial infarction (mainly related to ischemic
heart disease), aortic dissection, and cardiomyopathy (mainly
peripartum cardiomyopathy).
1
All the women who died of
ischemic heart disease had identifable risk factors such as
older age, obesity, smoking, diabetes, and hypertension.
1
The
incidence of cardiac arrest during pregnancy also increased,
from 1:30 000 in the 20002002 Confdential Enquiries
report
2
to 1:20 000 in the 20032005 report.
3
Management of cardiac arrest in pregnant women is more
complicated than in non-pregnant patients.
4
Maternal
physiologic adaptations to pregnancy present special
challenges, and the resuscitation team must consider the
needs of both the mother and the fetus. In comparison,
cardiac arrest in young athletes is much less common
than in pregnant women, with an incidence of 1:200 000.
5

However, there have been many position statements
addressing prevention and prediction of sudden death
in the young athlete.
6
There is a need for heightened
awareness of and education about the management of
cardiac arrest during pregnancy, as illustrated in two
publications assessing knowledge regarding management
of maternal cardiac arrest among health care providers.
7,8

Both studies concluded that knowledge of important
basic concepts of cardiac arrest in pregnancy among
anaesthesiologists, obstetricians, midwives, and emergency
medicine specialists was inadequate.
In October 2010, the American Heart Association (AHA)
published new guidelines for cardiopulmonary resuscitation
and emergency cardiovascular care for maternal cardiac
arrest
9
based on the 2010 consensus on science and
treatment recommendations for maternal cardiac arrest,
published by the International Liaison Council on
Resuscitation.
1012
As these guidelines represent a signifcant
change in practice, it will be important for knowledge
translation programs to disseminate the information, to
educate and train caregivers, and to develop strategies that
will enable caregivers to adhere to the guidelines at the
point of care. The management of maternal cardiac arrest
requires a multidisciplinary team and it is important to
bring the specialties involved together to ensure that such
teams are coordinated and ready to respond.
Several publications have outlined potential strategies to
prepare for maternal cardiac arrest in accordance with
older guidelines.
1316
The 2010 guidelines, however, are
transformative, and their implementation will require
training, preparation, ongoing feedback, and support to
ensure that all maternal cardiac arrest victims are treated
optimally and consistently.
9
In order to address this
objective, a group of physicians from six different hospitals
within the Greater Toronto Area representing obstetrics,
cardiology, emergency medicine, anaesthesia, critical
care, and neonatology, met with a knowledge translation
expert to develop an implementation strategy to be used
by hospitals, resuscitation teams, and related units for
the management of maternal cardiac arrest. The group
considered available evidence leading to the new maternal
cardiac arrest guidelines.
912
We present this strategy,
providing a framework for emergency preparedness and
management of these devastating events, as a tool for
others to consult, adapt, and review to ensure that their
institution and their staff are prepared.
IMPLEMENTATION RECOMMENDATIONS
01. There should be a specifc manner in which to activate
the maternal cardiac arrest team. If a hospital does
not have a system in place, consider Code Blue
Obstetrics as the universal call to action.
02. Suggested composition for the maternal cardiac
arrest team:
(a) Adult resuscitation team
(b) Obstetrics: one obstetrical nurse, one obstetrician
(c) Anaesthesia: obstetrical anaesthesiologist if
available, or staff anaesthesiologist; anaesthesia
assistant if available
(d) Neonatology team: one nurse, one physician,
one neonatal respiratory therapist
(e) In centres without obstetrics/neonatology
services, we suggest that the Code Blue
committee and hospital emergency services
discuss contingency plans in the event of
maternal cardiac arrest.
03. The AHA ACLS (Advanced Cardiac Life Support)
maternal cardiac arrest algorithm should be used
as a template for management of cardiac arrest
in pregnancy (Figure).
9
A laminated card of the
algorithm should be available throughout hospitals
and outpatient settings in which the potential for
maternal cardiac arrest exists. The AHA ACLS
maternal cardiac arrest algorithm should be posted
in prominent locations as well as on code carts.
9

Dissemination of information in this algorithm
should be part of the education program for all
obstetrics and anaesthesia residents, obstetric nurses,
physicians and nurses working in a critical care
setting, and those who deliver care through the
Code Blue teams.
9
There should be specifc initiatives
in education regarding the potential etiologies of
maternal arrest. The acronym
860 l AUGUST JOGC AOT 2011
COMMENTARY
2010 American Heart Association
Search for and treat possible contributing factors
(BEAU-CHOPS)
Bleeding/DIC
Embolism: coronary/pulmonary/amniotic fuid embolism
Anesthetic complications
Uterine atony
Cardiac disease (MI/ischemia/aortic dissection/cardiomyopathy)
Hypertension/preeclampsia/eclampsia
Other: differential diagnosis of standard ACLS guidelines
Placenta abruptio/previa
Sepsis
Subsequent responders
Maternal interventions
Treat per BLS and ACLS algorithms
Do not delay defbrillation
Give typical ACLS drugs and doses
Ventilate with 100% oxygen
Monitor waveform capnography and CPR quality
Provide postcardiac arrest care as appropriate
Maternal modications
Start IV above the diaphragm
Assess for hypovolemia and give fuid bolus when required
Anticipate diffcult airway; experienced provider preferred for
advanced airway placement
If patient receiving IV/IO magnesium prearrest, stop magnesium
and give IV/IO calcium chloride 10 mL in 10% solution, or
calcium gluconate 30 mL in 10% solution
Continue all maternal resuscitative interventions (CPR,
positioning, defbrillation, drugs, and fuids) during and after
cesarean section
Obstetric interventions for patient with
an obviously gravid uterus*
Perform manual left uterine displacement (LUD)
displace uterus to the patients left to relieve
aortocaval compression
Remove both internal and external fetal monitors
if present
Obstetric and neonatal teams should
immediately prepare for possible emergency
cesarean section
If no ROSC by 4 minutes of resuscitative efforts,
consider performing immediate emergency
cesarean section
Aim for delivery within 5 minutes of onset of
resuscitative efforts
*An obviously gravid uterus is a uterus that is
deemed clinically to be suffciently large to cause
aortocaval compression
First responder
Activate maternal cardiac arrest team
Document time of onset of maternal cardiac arrest
Place the patient supine
Start chest compressions as per BLS algorithm;
place hands slightly higher on sternum than usual
Maternal cardiac arrest algorithm
9

Used with permission, American Heart Association
AUGUST JOGC AOT 2011 l 861
The American Heart Association 2010 Guidelines for the Management of Cardiac Arrest in Pregnancy
BEAU-CHOPS may be a helpful mnemonic
(Figure).
9
04. Ensure there is a process for a sterile emergency
Caesarean section tray to be immediately available
in the event of a maternal cardiac arrest. This can
be accomplished by having all code carts in high-
risk areas for maternal cardiac arrest equipped with
a sterile emergency Caesarean section tray; this tray
should be included in routine Code Blue cart check
lists (Table 1). Alternatively, this may be brought to the
code site by a member of the Code Blue Obstetrics
team. In nonhigh-risk areas, a regular procedural tray
and scalpel may be used for the emergency Caesarean
section in the event of maternal cardiac arrest.
Neonatal expertise in the resuscitation, stabilization,
and treatment of the preterm and term neonate is
essential. Resuscitation equipment for the preterm and
term neonate should be readily available in high-risk
areas (Table 1). We suggest that neonatal caregivers be
trained in neonatal resuscitation, including the 2010
AHA Neonatal Resuscitation Program guidelines.
17,18
05. The areas that should be considered high risk for
maternal cardiac arrest include
(a) Obstetrical units, including antepartum areas
(b) Emergency departments
(c) Intensive care units; the equipment described
should be routinely placed outside the room of
a critically ill pregnant patient, in anticipation of
sudden cardiac arrest.
06. All resuscitation staff should be familiar with the
2010 AHA ACLS guidelines for the management of
maternal cardiac arrest, with special attention to the
following
9
:
(a) Because superfuous personnel can contribute to
challenges in crisis management or crowd control,
the Code Blue Obstetrics team should include
only the necessary complement of health care
staff members to bring the required competencies
to the scene.
(b) Correct use of one- or two-hand manual left
and upward uterine displacement, as opposed to
leftward tilt, should be used to relieve aortocaval
compression.
(c) Team training should emphasize rapid decision-
making and excellent communication strategies,
especially in advance airway management and
emergency Caesarean section.
(d) Advanced airway placement should be performed
by the most experienced provider available.
Ensuring optimal positioning and expert assistance
are necessary parts of managing the maternal
airway.
07. In the patient with an obviously gravid uterus who
has not had a return of spontaneous circulation, the
team leader should pay particular attention to the time
interval between onset of cardiac arrest and decision
to initiate an emergency Caesarean section. Regular
announcements of time elapsed since collapse by
the person recording details of the resuscitation may
help the entire team focus on avoiding inappropriate
delays in delivery. When time elapsed has reached
four minutes from confrmed maternal cardiac arrest,
the decision to perform a Caesarean section must be
made in order to meet the fve-minute limit for time to
delivery of the neonate.
08. Post-arrest care after a successful resuscitation
for cardiac arrest in pregnancy requires the
coordinated effort of all services involved to provide
comprehensive care, prevent premature withdrawal
of life-sustaining therapy, and optimize survival
to discharge. Particular issues that may need to be
addressed include the use of therapeutic hypothermia
during pregnancy (which is a relative contraindication,
but one case report suggests beneft
19
) and the
management of a post-arrest, unstable patient post-
Caesarean section who may be conscious and aware.
09. We recommend development of an initial and
ongoing training program for maternal ACLS, which
should include regular and random drills to maintain
team competence.
10. All maternal cardiac arrest cases should be reviewed
by quality improvement teams within the hospital
to derive beneft from experience. This review must
be done expeditiously and the knowledge gained
disseminated widely as soon after the event as
possible.
Creating a standardized system for managing maternal
cardiac arrest is only the frst step in an active knowledge
translation (KT) strategy. This includes multi-disciplinary
involvement and a variety of ongoing dissemination
approaches, and it is crucial to ensure adoption of and
adherence to the evidence and the guidelines. Common KT
strategies for change include interdisciplinary education,
embedding the algorithm in routine care processes, reminder
systems, and audit and feedback. Specifc examples are
862 l AUGUST JOGC AOT 2011
COMMENTARY
Table 1. Recommended equipment in high risk areas
Equipment contents of the emergency
Caesarean section tray
Equipment for neonatal resuscitation and
stabilization
Scalpel with no 10 blade Over-bed warmer
Lower end of Balfour retractor Neonatal airway supplies
Pack of sponges Umbilical access
2 Kelly clamps Medications (eg, epinephrine 1:10 000)
Needle driver
Russian forceps
Sutures and suture scissors
Table 2. Knowledge-to-action model applied to implementation of the maternal cardiac arrest
algorithm
Knowledge-to-action steps Specifc strategies
Assess barriers to knowledge use Prior to implementation, work with staff from all relevant units
(eg, using focus groups) to understand current local process for
managing maternal cardiac arrest and any shortcomings to be
sure improvements are addressed properly when the algorithm is
implementated This step is often missed but is crucial to ensuring
uptake
Adapt knowledge to local use Compare the algorithm recommendations with current local
process and adapt or innovate as needed to encourage
acceptance and meet existing local requirements Ensure all
relevant disciplines are included so that there are no gaps and full
consensus is reached on all decisions
Implement with tailored strategies Use implementation/dissemination strategies that are known to
work well in the local context For example, if laminated pocket
cards are used regularly by staff, have one made for the algorithm;
if not, perhaps one copy on the crash cart is enough Because
of the uncommon and urgent nature of maternal cardiac arrest,
posters, emails, and printed educational material may be less
useful than evidence-based instructions at the point of care
Monitor knowledge use Establish measures of performance associated with steps in
the algorithm and provide timely feedback on performance to
the team involved; build in case debrief sessions with the team
to understand what went well, what didnt, and why, and how to
prepare proactively for future cases
Evaluate outcomes Using the performance data described above, compare relevant
patient outcomes (eg, survival) with performance longitudinally
over time to evaluate the impact of the new algorithm, and be
prepared to adjust the implementation strategy accordingly
Sustain knowledge use A plan for regular annual updating of the evidence and
communication of changes to the implementation strategy should
be agreed upon prior to launching Ensure that information about
decision-making processes and algorithm steps remain accessible
to all staff in various mediums (eg, electronic, hardcopy, posters)
and that input on upgrades is sought from all relevant disciplines
If maternal cardiac arrests are not frequent in any given setting,
incorporating a random mock code system to keep staff
competence high may be useful
21
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The American Heart Association 2010 Guidelines for the Management of Cardiac Arrest in Pregnancy
included in the above recommendations (steps 1 to 10
above) and in Table 2, which uses the knowledge-to-action
framework of Graham et al. to outline a tailored KT plan.
20

Information and guidelines must be kept up to date with the
evidence and must be accessible to all staff, or guidelines will
very likely fall out of use.
CONCLuSION
Maternal cardiac arrest requires an organized and
coordinated effort on the part of various specialties. We
hope that this framework will help hospitals and emergency
personnel organize and prepare for the management of
this rare but critical event.
ACKNOWLEDGEMENTS
Dr Morrison is the Robert and Dorothy Pitts Chair in Acute
Care and Emergency Medicine, Keenan Research Centre, Li
Ka Shing Knowledge Institute, St Michaels Hospital, Past
Chair of the Advance Cardiac Life Support Committee
of the American Heart Association and the Co Chair of
the Advance Life Support Task Force of the International
Liaison Committee on Resuscitation for Consensus 2010.
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