critical care and ptc_082519_062221.pptx

This is an obstetric case presentation

1. Maternal near miss case presentation and discussion on principles of resuscitation in cardiac arrest Padibe health centre team

2. Case presentation Demographics Name; HS Sex; f Age; 27yrs Address; apyeta c, apyeta, ogilli Nationality; Ugandan Occupation; businesswoman Education level; secondary Religion; Muslim Referral status; referral from Paluda HCIII Date of admission; 20/12/2023 LNMP: unsure. EDD:

3. Presenting complaint Headache for 1 week Epigastric pain for 5 days Lower abdominal pain for 1 day

4. HPC Presenting a G2p1+0 at?? WoA who was well until a week prior to admission when she developed headache of gradual onset, throbbing in nature, frontal, on most times of the day mildly relieved by analgesics and lying in quiet places she had occasional visual blurring but no h/o fever, Loss of consciousness, focal weakness, and convulsions. She progressed to have epigastric pain of gradual onset, burning in nature, on for most of the day, radiating to the right side of the abdomen below the ribcage, no known relieving and exacerbating factors, however she had no history of vomiting, no hematemesis, no passing bloody stool.

5. Cont. A day prior to admission she developed lower abdominal pain of gradual onset, increasing in frequency and intensity, radiating to the lower part of the back, h/o draining of clear colourless fluid P/v. however, no h/o abnormal P/v discharge, bleeding, itching or rash. She reports to have had good fetal play, about 5 times a day, attended ANC 5times with booking visit at 20/40 received most of the ANC packages. When she developed this symptom, she sought treatment at Paluda HCIII where she was diagnosed with PET, received treatment, and referred for further management in Padibe HC IV.

6. Review of other systems : unremarkable Past Obsgyn History G2P1+0 at term 1 st preg in 2009 delivered live baby boy by SVD. Sexual debut at 17years, menstrual cycle 28 days, this is a new partner. Has not had any OBSGYN procedure. Past medical Unremarkable Past surgical Had exlap done in 2015 for acute abdomen. Family social Married, doesn’t live with husband, doesn’t smoke tobacco or drink alcohol. No familial illness.

7. Summary Presented HS G2P1+0 at?? WOG referral from paluda HCIII who presented with headache, epigastric pain, visual blurring, and progressive lower abdominal pain increasing in frequency and intensity. She also reports h/o changing sexual partner. However, no h/o LOC, convulsions, DIB, focal weakness, and fever.

8. Differentials G2P1+0 at term In labour in view of lower abdominal pain, increasing in nature, h/o draining liquor, lower back ache. PET with severe features in view of headache, visual blurring, epigastric pain. Exacerbation of PUD in view of epigastric pain False labour 2 nd to UTI, malaria in view of headache, lower abdominal pain. Prelabour rupture of membranes. In view of draining liquor.

9. Examination General exam : mother restless, in pain, pacing and sweating, IV cannulas gauge 16 in situ on both forearms, a febrile, not pale, not jaundiced, oedema grade 1. Abdominal exam ; epigastric and right hypochondriac tenderness, distended abdomen, linear nigra, FH 38/40, right longitudinal lie, FHHR=132bpm, cephalad at lowest pole, descent 3/5. V/E ; pelvis adequate, vulva and vagina hot, cervix thick, posterior, 33% effaced, os 7cm, cephalic presentation station -1, membranes ruptured.

10. Cont. CVS ; warm extremities, pulse 98bpm normal volume synchronous, bp 150/100mmhg, non-distended jugular veins, HS1 and 2, no added sounds, negative hepatojugular reflux. CNS ; alert, oriented, GCS 15/15, cranial nerves intact, normal tone, bulk and reflexes on all muscle groups and limbs, PEARL, no signs of meningism. R/S ; RR23 breaths/min, Spo2 98% in room air, chest clear.

11. Impression G2P1+0 in active labour with PET severe features ?? OBL. Investigations CBC Hb 12g/dl, platelets 109x 10^9 Blood grouping and crossmatching, o rh + ve , blood booked. HCT- TR HBsag- neg Urinalysis- Proteins ++

12. Management Prevent /control seizures. magnesium sulfate loading dose 14g (4g of 20% IV and 5g of 50% with 1ml of lignocaine in each buttock im) Control BP Sublingual nifedipine 20mg start then bd- Delivery plan Emergency c/s Consent patient. Preload with 1.5 ltrs of normal saline.

13. Cont. Insert urinary catheter. Preop antibiotics; iv cef Ig start Metoclopramide 10mg Iv tranexamic 500mg 30 mins preop Anaesthetic assessment Inform theatre.

14. Intraoperative management Mother given spinal anaesthesia(bupivacaine) Mother draped aseptically and Pfannenstiel incision made, LUSCI made delivered live baby APGAR 9/10 at 1 min, 10/10 at 5min, birth weight. placenta delivered and uterus exteriorized for repair. Mother became restless, agitated, disoriented, and then suddenly went unresponsive. Did rapid primary survey. Airway collapsed, straightened airway through chin lift and jaw thrust. Breathing mother not breathing spo2 25%

15. Cont. Called for help and started chest compressions at a ratio of 30 compressions to 2 breaths by ambu bag. Circulation: bps undetectable, no radial pulse, no cardiac impulse. Continued compressions until there was a detectable at 2 cycles. Iv adrenaline 1 mg given. Assessed and treated reversible causes; gave D10% 100mls, give bolus iv NS 2l, gave warm fluids to prevent hypothermia. Cause; Cardiac arrest 2 nd total spinal Mother still on steady rehabilitation

16. Post Resuscitation care. After 2 compression cycles there was return of spontaneous circulation, progressed to an advanced airway, Rapid sequence induction intubation with 2 failed intubations due to Oedematous airway. Continued ventilating using a vent, SpO2 returned progressively to 45 %, 65 %,85% to 98% on ventilation. PR returned progressively to 30bpm,60bpm, 90bpm, 100bpm. Patient ETT kept in place while closure of the abdomen was completed.

17. Patient kept sedated with midazolam and transfer to St Mary’s hospital Lacor done. GCS V T E 3 M 3. Transfer done with ambulance with oxygen source. 1 referral nurse and midwife. Maintenance dose of mgso4 enroute at Atanga HC III. Follow-up Patient admitted and transferred to ICU and kept on mechanical ventilation for 5 days. Baby admitted in NICU for management. On day 6 mother had tracheostomy done Day 10 mother transferred to ward with neurological impairment. Mother discharged last week, on NGTube and physiotherapy.

18. CASE DISCUSSION PRINCIPLES OF RESUSCITATION IN CARDIAC ARREST

19. Definition and background Cardiac arrest is a condition where the heart suddenly and unexpectedly stops pumping dues to abnormal electrical activity. A meta-analysis of 141 eligible studies revealed ROSC at 29.7%(95% CI 27.6-31.7%) ( shijiao yan et al, 2020) A study in Mulago national referral deduced that 2.3% (190) of the 8131 patients admitted in the study period got cardiac arrest and only 35 (18.4%) received CPR and 14(7.4%) got ROSC ( Ocen Davidson et al). The common clinical presentation cardiac arrest are, fatigue, dizziness, shortness of breath, chest pain and palpitations.

20. Principles Non-technical skills in resuscitation Cooperation of team members focusing on the interpersonal skills of leadership and team membership. They include cognitive and functional skills of Teamwork : collaboration between two health care professionals of different backgrounds and complementing skills to achieve a common goal. T ask management : the process of handling the entire resuscitation cycle right from planning to execution carried out by the team.

21. Cont. Leadership : the art of guiding and motivating a group of health care professionals to act toward achieving a common objective. Situational awareness Decision making Communication; briefing and debriefing. 3 phases; initial team brief, communication during resuscitation and final team debrief. Communication in resuscitation should involve clear instructions and feedback.   In this case one of the doctors became the leader and assigned roles and motivated team members to carry out their tasks

22. Chain of prevention This is very valuable and if implemented effectively it prevents most of the incidences of cardiac arrest and its adverse outcomes. It includes. Staff education Monitoring of patients Recognition of deteriorating patient Decline in CVS, R/S and CNS Decline in ABCDE Early warning scores and calling criteria.

23. Cont. Call for help. The above tool was used to call for help from the receiving ICU. Response. Should always be prompt and organized.

24. Chain of survival Early recognition and call for help. Use of track and trigger systems e.g. early warning score system (EWS) to be able to identify and recognize patients promptly. Responder ensures the surrounding is safe, shake the patient at the shoulders and ask if they are ok. Airway chin lift, head tilt. Look for chest expansion, feel- check for breathing, listen- for breathing. If absent proceed to CPR. Early cardiopulmonary resuscitation Chest compressions and ventilation slow down the rate of deterioration of the brain and heart.

25. Cont. CPR algorithm Approach safely. Check for response. Call for help. Open airway head tilt, chin lift with 2 fingers and left hand on forehead. Check for normal breathing (10seconds) If unresponsive and not breathing commence CPR (30:2) for adults (3:1) children approximate rate 100-120/min, depth of about 5-6cm. Do not interrupt CPR unless AED arrives, your environment is not safe, you become tired. Get more people to alternate Compressions. High quality CPR The team member not actively doing the C/S identified and did the initial assessment and promptly started CPR intra-op and assigned the other team members specific roles.

26. Early defibrillation In case you have the device. This plus the above are the cornerstone of CPR. Defibrillation should happen in less than 3 minutes of recognition of cardiac arrest. In shockable rhythms we give IV adrenalin 1mg alternate between cycles and IV Amiodarone 150mg in the 5 th cycle. In non-shockable rhythms give 1 mg IV adrenaline alternate with the compressions

27. Cont. Reversible causes of cardiac arrest Identify the reversible causes of cardiopulmonary arrest is ongoing in the process of CPR. 4 Hs: hypoxia, hypovolemia, hyperkaleamia, hypothermia 4 Ts: tension pneumothorax, tamponade, toxins, thrombosis. The identifiable reversible causes in our patient were, hypoxia, hypovoleamia and thrombosis.

28. Post resuscitation care. Return of spontaneous circulation (ROSC) is an important phase in the continuum of CPR. The goal is to return patient to normal cerebral function, stable cardiac rhythm, and normal hemodynamic function. Signs of ROSC, pulse, patient breathing independently Immediate care. Do ABCDE advanced airway spo2 94-98% 12 lead ECG, IV access sBP target 100mmhg. Control temperature. In our client advanced airway was instituted ETT with warm iv fluids.

29. Post cardiac arrest syndrome Post cardiac arrest brain Injury Post cardiac arrest myoclonic dysfunction. Systemic ischeamic/ reperfusion response Persistent preciptatory pathology Our patient suffered post cardiac arrest brain injury she presented with neurocognitive dysfunction. Clinical presentation Coma, seizures, myoclonus, varying degrees of neurocognitive dysfunction, brain death

30. Missed opportunities and way-forward s/n Missed opportunity Recommendation 1 Inappropriate monitoring of patient intra-op Lobby for a patient monitor for theatre and maternity 2 Limited knowledge in cardiopulmonary resuscitation CMEs and drills on basic life support Lobby to enroll more cohorts of staff for ALS training Cross cutting issues 1 Inability to defibrillate patient promptly Lobby for AEDs 2 Ambulances without oxygen source fitted in Ongoing paperwork with health manager

31. References ALS ERC guidelines 2021 Uganda Maternal and Newborn Care Guidelines Uganda clinical guidelines Medscape Padibe health centre IV patient files

32. Thankyou for listening