Key points in the management of cardiac arrest in pregnancy:
Hand location for chest compressions should be in the center of the chest as for nonpregnant patients (previous recommendations had been to shift upward to accommodate for the gravid uterus but there is no data to support this).
Chest compressions should be performed with the patient supine, using manual left uterine displacement （LUD）for aortocaval decompression. Left lateral tilt position is no longer recommended due to poorer quality of cardiac compressions, the lack of full aortocaval decompression, and further complication of other procedures such as airway management.
IV or IO access should be obtained above the diaphragm, to ensure no interference to flow to the heart by the gravid uterus.
Rate and depth of chest compressions, ACLS drugs and doses, and defibrillation all remain the same as in nonpregnant OHCA patients.
NB: As opposed to nonpregnant patients periarrest, oxygen saturation in the pregnant female should be maintained at 95% or greater, or PaO2 > 70 mmHg, to ensure appropriate oxygen delivery to the fetus. The goal PCO2 is ~28-32 mmHg, to facilitate fetal CO2 removal.
If advanced airway is pursued, the most experienced provider should perform intubation due to the higher intrinsic difficulties, more rapid decompensation, and propensity for airway trauma and bleeding in the pregnant female.
Perimortem c-section should occur within the first 5 minutes of cardiac arrest / arrival to the ED in ongoing arrest.
Two important indications of methylene blue:
【2】Refractory distributive shock
Methylene Blue for Distributive Shock: a Potential New Use of An Old Antidote. Jang DH, Nelson LS, Hoffman RS. J Med Toxicol. 2013;9(3):242-9.
Methylene blue used in treatment of refractory shock resulting from drug poisoning. Fischer J. Taori G. et al. Clin Toxicol 2014 Jan;52(1) 63-65.
Calcium channel antagonist and beta blocker overdoses: antidotes and adjunct therapies. Graudins A, Lee HM, Druda D. Br J Clin Pharmacol. 2016 Mar 81(3):453-61.
A Review of Methylene Blue Treatment for Cardiovascular Collapse. Lo A, Jean CY, et al. Journal of Emerg Med. May 2014. Vol 46 (6): 670-679.
A Systematic Analysis of methylene Blue for Drug-Induced Shock. Warrick BJ, Tataru AP, Smolinske S. Clin Toxicol 2016 Aug;54(7):547-55.
Transient Ischemic Attack (TIA)
Classic definition of TIA is neurologic dysfunction caused by focal brain or retinal ischemia lasting < 24 hrs. Recent definition has changed to 1 hr because up to 50% of classically defined TIAs are actually infarcts as shown on MRI.
Diagnosis and Treatment of Hyponatremia
The risk of tendinopathy is increased in patients taking fluoroquinolones (FQs) along with steroids. Watch out for this combination in COPD patients.
FQs should be used cautiously in patients with risk factors associated with tendinitis, such as advanced age, history of tendon rupture, corticosteroid use, and/or acute or chronic renal dysfunction. Tendinitis can be misdiagnosed as a gouty flare, infection, or venous thrombosis (leg region involvement). Since Achilles tendinitis can be debilitating and
may lead to rupture, clinicians may need to monitor changes in gait and for symptoms suggestive of tendinopathy in patients on FQ therapy.