January 2021
The Generalist: Anesthesia for Crash C-Sections
ROP 2021 January16 Chapters
- January Introduction8:05Reviews and Perspectives with Hobart Lee: Breast Cancer Screening Guidelines14:28Free AudioThe Generalist: Anesthesia for Crash C-Sections22:07Syphilis Testing13:44Free AudioRural Medicine: Cranial Burr Hole16:31Abstract 2: Low-Value Tests Impact on Health Care Use and Clinical Outcomes5:38Abstract 3: L-Thyroxine for Elders with Subclinical Hypothyroidism and Symptoms5:35Abstract 4: Telemedicine Unreadiness Among Older Adults During COVID-194:40Abstract 5: Minesapride vs Placebo for IBS with Predominant Constipation6:00Abstract 6: Ondansetron and Return ED Visits for Peds Gastroenteritis5:17Abstract 7: Assessment and Management of Tinnitus: Summary of NICE Guidance5:14Abstract 8: Characteristics of Concussion in Elementary School-Aged Children6:27Abstract 9: 2020 American College of Rheumatology Guideline: Management of Gout5:48Abstract 10: Initiating Pharmacologic Treatment in Tobacco-Dependent Adults5:21
The Generalist: Anesthesia for Crash C-Sections
Casey Parker, MD; Heidi James, MD; and Vanessa Cardy, MD
Consider the hair-raising scenario where a fetus needs to be delivered ASAP via C-section and you have an obstetrician who can do a C-section but Anesthesia is 30 minutes away. How would you safely anesthetize a late-term pregnant woman in your ED?
- The usual ED anesthetic options include
- Local or regional anesthetic block
- Procedural sedation
- A formal anesthetic including intubation
- A spinal (subarachnoid) block is the standard option for an elective section, but is not the best in the ED:
- Too slow
- The drugs are not familiar to many ED doctors
- Can cause profound hypotension
- Procedural sedation:
- Sedation is fast and familiar to ED doc
- It is complicated in heavily pregnant women.
- This is not a quick procedure and is very stimulating.
- Pregnant women do not do well with sedation:
- hypoventilation
- risk of aspiration
- All the risks but few of the benefits of a formal intubation and anesthesia in ED.
- Ketamine may affect the neonate.
- Dr. Casey Parker recommends a formal rapid sequence intubation (RSI) for urgent C-section in the ED:
- Use all the usual tricks that you would use in a crash airway; for example, apneic oxygenation (ApOx), suction, videolaryngoscope, bougie, etc
- Proper positioning of the woman is key:
- head up
- ramped
- lateral tilt (displace the fundus)
- Make your first attempt your best attempt.
- Follow with light sedation until the baby is born.
- Avoid opiates until after birth.
- Get HELP. Ask for specialist advice from the anesthetist and get a midwife in to help you.
- MIdwives are usually familiar with the medications and normal procedures around a C-section.
- Be prepared for bleeding—it can be big and brisk.
- Contract the uterus to stop the bleeding:
- Use oxytocics aggressively.
- Start with 2-4 units of oxytocin IV slow push after birth.
- Use a massive transfusion protocol as you would in trauma.
- Generally pregnant women need fibrinogen earlier, so use it if you have it.
- While we hope you will never need to do this, now you know how.
Fetal Heart Rate Decelerations