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Sim Case Series: Perimortem C-Section

Posted Apr 17 2013 12:00am
ALiEM Sim Case Series
Perimortem C-Section

Case Writer: Clare Desmond, MD
Peer Reviewer and Editor: Nikita Joshi, MD
Keywords: Cardiac arrest, Perimortem C-section

Educational Objectives


Recognize and manage cardiac arrest in pregnant patient
Communicate emergent need of perimortem CS to team leader
Identify need for perimortem CS
Consult NICU and OB stat
Perform perimortem CS












Case Synopsis

28 year old female, 37 weeks pregnant, BIBEMS after high speed MVC. Pt was a restrained driver in a head-on collision with a tree. Estimated speed at impact was 75 mph. The car was completely damaged with spider webbing of the windshield. Pt was responsive to pain but was not oriented in the field. EMS noted a protuberant abdomen. Upon arrival in the ED, her initial GCS was 5 (abnormal flexion to pain with decorticate response), it is noted that the pt becomes pulseless within 5 minutes of arrival to the ED and has an asystolic cardiac arrest. 




PDF of more detailed scenario description PDF of case-specific ABEM Milestones PC9
Critical Actions
  1. Initiate ATLS on high speed MVC pt
  2. Initiate ACLS on asystolic cardiac arrest
  3. Identify pregnant pt with uterine fundus greater than 20 cm above pubic symphysis
  4. Initiate and complete perimortem CS within 5 minutes loss of pulses
Learners
  •  ED residents
  • OB residents
  • Pediatric residents
  • Medical students
  • ED nurses
  • Nursing students
Location:  ED resuscitation bay

Patient: 28 yo female, 37 wks pregnant

Equipment
  • Advanced airway equipment
  • Airway adjuncts
  • Bedside ultrasound
  • Cardiac arrest code cart
  • Cervical c-spine collar
  • IV fluid
  • Monitor
  • Neonatal warmer
  • Retractors
  • pRBCs
  • Scalpel – 10 blade
  • Spinal immobilization back board
  • Stretcher with sheets
Moulage
  •  Ecchymotic patches on chest
  • Fetus manikin
  • Gravid abdomen with uterus moulage capable of being cut
  • Manikin for with trauma and pregnancy capabilities
Confederates
  • EMS provider— helpful, gives initial history and discuss initial vitals on scene, gives details of completely destroyed car and tree at the scene of the accident
  • Husband- frantic, informs team that pt is pregnant
  • Nurse – helpful, performs orders given by team, gives helpful hints suggesting decision to perform CS
  • NICU (voice) – calls when consulted, discusses case
  • OB (voice) – calls when consulted, not in house, discusses case
Supporting Files / Media
  • Asystole rhythm strip
  • Bedside ultrasound trans-abdominal images of large fetus with fetal heart movement
  • Labs: Shock panel, Urine HCG, Type and Screen / Cross

Abd
abdominal / abdomen
BIBEMS
brought in by EMS
BP
blood pressure
CS
cesarean section
HR
heart rate
IV
intravenous
MVC
motor vehicle collision
Neg       
negative
RR
respiratory rate
PEA
pulseless electrical activity
pRBCs
packed red blood cells
TA
transabdominal
T
temperature
US
ultrasound

References:
  • Mercado, J. et al Critical Obstetric and Gynecologic Procedures in the Emergency Department. Emerg Med Clin N Am. Elsevier. 31 (2013). 207-236.
  • Newfield E. Third-Trimester Pregnancy Complications. Prim Case Clin Office Pract. Elsevier 39 (2012). 95-113.
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