Thread by @ash_bo21

🚨Code Blue🚨 = patient in cardiac arrest. You've got your ACLS algorithms ready to go.

But…what if that patient is PREGNANT? 😳

I’ll leave ACLS pearls to my Medicine and EM colleagues. They all still apply! Here are a few notable things about running a maternal code.

Start the timer immediately. Not only will you need this for the code, but 4min after cardiac arrest, it’s time to perform a resuscitative hysterotomy. More on that later. 2/

Remember to move the bed away from the wall to make room for obtaining an airway. Maternal airways are classified as difficult right off the bat due to physiologic edema. The most experienced person available should be the one to conduct intubation. 3/

Stop all medication drips, like you do for every code. Magnesium sulfate is commonly administered for eclampsia prevention, fetal neuroprotection, tocolysis, etc.

What med do you give immediately if MgSO4 was running pre-arrest? 🧐

If MgSO4 was one of the medications stopped, give 30cc calcium gluconate in 10% solution over 2-5min. To be honest, I’ve come close to giving CaGluc once during a case of possible hypermagnesemia, but never actually done it. Dosing/administration advice is welcome! 5/

Stop fetal monitoring. I repeat: do not attempt to ultrasound, dopple, or in any other way assess fetal heart rate. It will not change your management and causes extra commotion during the code. I know, it feels wrong. 6/

Leftward uterine displacement. If the uterine fundus is above the umbilicus, it’s big enough to cause aortocaval compression. Assign someone to stand on the patient’s right and push the uterus to the left OR stand on the left and pull the uterus toward the left. See diagram. 7/

We used to tilt the patient to the left by placing a wedge under the back board, but found this led to decreased efficacy of chest compressions. 8/

Speaking of aortocaval compression, you are essentially working with functional abdominal compartment syndrome in a maternal code. Obtain IV access ABOVE the diaphragm to ensure that medications reach the heart. 💉💊 9/

OK, it’s been 4 minutes. Time for 1-2 OBs to get a spot at the bedside to do the “resuscitative hysterotomy,” i.e. a bedside Cesarean section to deliver the fetus. We don't need a whole OR tray, just gloves and a disposable scalpel. 10/

The incision should be made at 4min post-arrest, with delivery of the fetus by 5min. Why 4min? It improves maternal outcomes AND gives your best chances for intact neonatal survival. 11/

There is discussion about whether the skin incision should be vertical or Pfannenstiel. My opinion? Whichever the surgeon feels will be fastest! For those of us who do OBGYN residency, that usually means Pfannenstiel. For EM docs or general surgeons, that may be vertical. 12/

In sum for 🚨maternal Code Blue🚨:
⚡️Resuscitative hysterotomy at 4min if ROSC not yet achieved.
⚡️Most experienced person conducts intubation
⚡️Give CaGluc if MgSO4 was running
⚡️Stop fetal monitoring
⚡️Left uterine displacement
⚡️High IV access
13/

Excellent resources:
- Inspired by lecture by Dr. Ronen Dudaie, St. Mary’s Hospital ICU Critical Care Attending ⚜️
- ahajournals.org/doi/pdf/10.116…
- ahajournals.org/doi/pdf/10.116…
- soap.org/CPR-consensus-…
- Foley’s Obstetric Intensive Care Manual (Ch. 17)

This is my first tweetorial. Feedback and clarifications welcome & encouraged. Shoutout to my inspirations @CPSolvers, @thecurbsiders, & @EMCC.

@MohitHarshMD @CaraBuskmiller @gyno_mite @whitman_barbara. @SCCM #FOAMed #MedEd #CritCareMedicine #maternalcode