【Case discussion】Postpartum hemorrhage causes respiratory cardiac arrest

Postpartum hemorrhage causes respiratory cardiac arrest

【Case introduction】

The patient, a 23-year-old female, was in a private clinic due to obstructed labor, postpartum hemorrhage, hemorrhagic shock, and the emergency department directly entered the operating room through the "green channel" for rescue, and planned to undergo hysterectomy
.
He was admitted to the emergency
department in March 2004.
When the patient entered the operating room, the anesthesiologist received the patient and found that the heartbeat and breathing stopped, the face was pale, and the bilateral pupils were dilated
.
Quickly implement chest heart compressions, while the mask gives oxygen to prepare the tracheal intubation, after the tracheal intubation, immediately connect to the anesthesia machine, perform mechanical ventilation, while giving epinephrine 1mg intravenously, atropine 0.
5mg, dopamine 5mg, electric defibrillation, the heart is unresponsive, and the electrocardiogram is still a straight line
。 Rapid blood transfusion, infusion, micropump to give the following drugs: epinephrine 0.
1ug / (kg · h), dopamine 10 ug / (kg · h), isoprenaline 0.
07 ug / (kg · h), uninterrupted heart compression, while open to stop bleeding, hysterectomy surgery, in the heart compression can be observed on the pulse blood oxygen saturation of more than 90%, cuff blood pressure 60-85/30-40mmHg, after 30 minutes to stop compression, ECG is still straight, At 45 minutes, nitroglycerin 0.
3ug/(kg·h) was given, and when the heart was rescued for 65 minutes, the patient's heartbeat was restored, after resuming, the patient showed sinus rhythm, the electrocardiogram showed myocardial ischemia, and continued to give epinephrine 0.
08ug/(kg·h), dopamine 10 ug/(kg·h), nitroglycerin 0.
3 ug/(kg·h), the operation was over, the patient's vital signs were stable, and in the process of passing the bed, it was found that the patient's eyes seemed to be open, giving a strong stimulus, The patient has a micro-movement response, the entire rescue observation time is 173 minutes, after the patient is transported to the cardiology ICU, after passing the bed, the patient can open his eyes
for the call instruction.
Two hours after returning to the ward, the patient was fully awake and 9 days after the operation, the patient recovered and was discharged without any neurological sequelae
.

【Discussion of analytical thinking questions】

1.
What are the key points for rescuing patients with cardiac arrest caused by heavy blood loss?

2.
What is the effect of nitroglycerin on myocardial perfusion?

3.
How is epinephrine applied?

4.
Can mydriasis completely determine whether the patient is brain dead?

【Key points of clinical thinking】

1.
The most timely rescue measures for cardiac arrest are artificial ventilation and cardiac compression
.

2.
In the process of rescuing patients with cardiac arrest, the rational use of nitroglycerin plays the role of expanding the crown and reducing pulmonary artery pressure, which is conducive to improving the success rate
of resuscitation.

3
.
Intravenous administration of epinephrine with a micropump after the application of loading dose epinephrine is conducive to improving the rate of heart repetition.

4.
Dilated pupils cannot completely determine whether the patient is brain dead
.

【Reference answer】

1.
Judge the basic condition of the patient at the first time, and quickly judge the cardiac arrest, the time should be less than 10 minutes
.
If the pulse is not palpable, cardiac compressions should be performed to ensure sufficient oxygen supply to the brain tissue to avoid cerebral hypoxia
.
When there were many people in the operating room, another group of people immediately performed mask oxygen, tracheal intubation, and artificial ventilation
.
If there are many hands during this process, epinephrine
is given intravenously.
Never just administer drugs without chest compressions, heart compressions are most useful before the drug works, and early heart compressions are the key to
patients not becoming vegetative.
The most timely rescue of cardiac arrest is artificial ventilation and heart compression
.
It is very important to give drugs and defibrillation, but it is a pity that the time is delayed in order to inject drugs and defibrillation, resulting in cerebral
hypoxia.
For major blood loss, rapid hydration and blood
transfusion should be carried out as soon as possible.

2.
Effect of nitroglycerin on myocardial perfusion