At the EMCrit 2013 Conference we had a Blast Competition. The BLAST rules are easy:
The winner this year was Salil Bhandari with an incredible presentation on peri-mortem caesarean section.
Here is an article:
Eur J Emerg Med. 2011 Aug;18(4):241-2. doi: 10.1097/MEJ.0b013e328344f2c5. Prehospital resuscitative hysterotomy.
Want to know more about peri-mortem c-section? Check out these insanely good posts:
- The post Perimortem C-section at St.Emlyn’s appeared first on St Emlyns.
- A personal take from a doc, Greg Press, who has performed two of these (2 more than me)
Update
Neonatal outcome: mean times from arrest to delivery were 14±11 min and 22±13 min in survivors and non-survivors respectively (Resuscitation. 2012 Oct;83(10):1191-200.)
And here is a simulator video:
And the best video on the procedure I have seen on life-identical model
Update:
In one case series, 12 of 20 women had return of spontaneous circulation immediately after delivery (EMCNA, Vol. 30, pg. 949). HT to emedhome.
Rob Bryant has another great video on resuscitative hysterotomy
Now on to the Wee…
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Scott Weingart
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insanely brilliant presentation! Love the BLAST format!
Great teaser performance at start with the sleight of hand magic tricks!
One suggestion from me.
Dont worry about cutting baby. It happens not too uncommonly doing C sections , even elective ones.
Cuts heal well. hypoxic brain injury not so well.
Interesting choice of midline vertical classic incision both to open abdo and uterus. Makes me think about choice of cut in surgical cric. horizontal vs vertical.
I think for complete novices to abdo surgery then the vertical cut makes a lot of sense for perimortem CS and surgical cric.
The slide images and pace of delivery was perfect.
really enjoyed and I agree that this type of delivery for conference presentations is here to stay! Love it!
Wow! Love the BLAST. Great pearls, memorable and sticky! Look forward to seeing more and trying BLAST and hearing more from emcrit conf
Fantastic presentation Salil! Certainly one of those topics that makes any sane doctor sweat.
Perfect pace and amount of content.
Love the blast idea Scott. There’s a lot of mileage in these and the Pecha Kucha format, can’t wait to see more!
Oli
Great presentation Salil! Great topic pick also. Thanks for putting it up there Scott. Great job once again!
JH
Fantastic Presentation…Thanks Dr. Bhandari
I was just wondering about the insert regarding the midline incision with avoidance of the umbilicus. In the image shown, there appears to be a small hernia, so there would be concern for bowel injury. Is this what you were going for? Otherwise with no hernia, just stay midline?
I also saw on Resus another article listed. My university does not provide access to the journals, so it would be helpful if you could provide a direct link. Thanks again.
1.Prehospital resuscitative hysterotomy
Eur J Emerg Med. 2011 Aug;18(4):241-2
2.Out-of-hospital perimortem cesarean section
Prehosp Emerg Care. 1998 Jul-Sep;2(3):206-8
Yep, it is usually safer to avoid the umbilicus in any midline incision though that may just be dogma.
As a trauma surgeon (almost done with fellowship)…..I wouldn’t worry one cent if you went through or around the umbilicus. There are benefits/drawbacks of both. Believe it or not there are a minority if surgeons who go right through middle of umbicus on elective cases all the time. If my ER colleagues had the guts to do this because I wasn’t available, I would be happy with ANY incision.
Given such speed, I would think there is a good chance of injury to bowel no matter what so please don’t call OB to close!! Call us! If you get into bowel DONT worry it’s easily addressed/fixed. Just get in there quickly! And then quicker! 😉
FEAR!
It’s what holds us back from doing these very rare procedures where the stakes are so high.
But when the S__T hits the fan, most of these procedures are easy. And overcoming the fear of making a mistake is the biggest obstacle we face.
In my career, I’ve done two surgical airways, a few lateral canthotomies, a thoracotomy and each one went well.
Get rid of the fear folks. We Can Do This!
Curious about the timeline — I was always taught the 4-minute rule as well, however I assume that this is based around no-flow time. If CPR (especially bomber, fast, deep, professional compressions) is ongoing, is there a longer window?
Cliff Reid has an article on his site stating the window is longer and we should give it a shot even later in the course.
Running through this procedure in my head, I came to a step where I didn’t know what to do…
After baby is out, hopefully mom gets ROSC, what now?
Do you close her up? If so, does the placenta stay in or come out?
Thanks,
Matt Barden
Loma Linda University EM2
Deliver the placenta. Cover Abd with sterile towels. Let OB do the closure.
According to all major sources; uterine fundus at the umbilicus is 20 weeks, not 24…
Not sure which sources you checked, here is what I saw:
Fundal Height vs. Gest. Age
[…] Perimortem C-section from Scott Weingart’s EMCrit […]
[…] 1. Perimortem C-section : from EMCrit. […]
[…] and sure to leave a deep mental impression. There are some great posts about this topic over at EMCrit, StEmlyns and Broome Docs that cover this topic, and I’d recommend you view all of them, […]
Great video + great format: more please!
I’m currently a med student just finishing my O&G rotation.. A couple of Q’s:
– assumption is post-delivery NICU folk are handy for the baby’s resuscitation. Surely in that length of time if NICU can be recruited, so can the O&G reg?
– if mother regained circulation and consciousness before being closed, would she risk going into shock from the pain of having such a major incision without analgesia or anaesthesia?
Re the above comments, I’ve also come across the fundus at the umbilicus = 20 weeks. And agree with Minh: I’ve seen a few minor cuts on babies post C-section; no biggie.
I have a couple questions:
1. Do we have any actual good data regarding the 5-minute timeframe for fetal prognosis?
2. Would you agree that as long as the resuscitation is going onward–> (irrespective of fetal prognosis) baby’s coming out regardless of the timeframe of arrest in order to optimize mom’s resuscitation?
cliff pisted a study disproving the 5 min
and agree on #2
[…] EMCrit Conference Blast Winner: Peri-Mortem C-Section- Brilliant 8 minute talk from the EMCrit conference. […]
Thanks so much for bringing topics of critically important nature to the EMCrit blogs.
I am certainly not an expert on this but I was involved in 1 perimortem c-section and this is my observational thought.
1. You may not have to make full incision from xyphoid to pubis, like the way Roberts and Hedges recommends, and open up the entire front of abdomen. Eric Reichman’s Emergency Medicine Procedures recommends cut from umbilicus to pubis, and it seems that that’s enough of a cut.
2. Regarding the indications of (>24 weeks, 5 minutes from arrest as Class IIb recommendation, meaning that you can consider doing it. C-section at 4 minutes from arrest also gets the same Class IIb recommendation by the way.
Maybe I missed it, but do you have the BLAST criteria put up somewhere? Its a great, fun format we may be interested in recreating.
It reminds me of the IG NOBEL presentations. Each 24/7 Lecturer explains their topic twice:
First, a complete, technical description in 24 seconds
Then, a clear summary that anyone can understand in 7 words
Anyway great fun lecture…
–Steve
[…] Peri-mortem c-section at EMCrit […]
[…] of stress I try and keep things simple. There are some great online resources to read including Scott Weingart’s podcast and Salil Bhandari’s PK talk on perimortem […]
Assuming the indications for both procedures are present, should you perform ED thoracotomy prior perimortem C-section?
I think it depends on the ultrasound of heart. If there is tamponade, thoracotomy simultaneous. If there is a beating heart with no pulse, c-section takes the front.
[…] life-saving procedure, check out the link at the start of this sentence or these resources over at EMCrit and […]
[…] to deliver the placenta and close the uterus and peritoneum. To recap on how to do PMCS, watch this video at […]
I think this is a topic ripe for an update on your main podcast. PMCS is being increasingly performed as awareness increases, but I find that in reality, very few doctors feel adequately prepared for the scenario and there are some easy things that ED and maternity departments can do to make the process smoother. Also, what our ED found most helpful was the involvement of maternity staff for the nuanced bereavement care for the infant’s body, and the taking of momentos, something never raised in any discussion about this subject.
Amazing presentation! Thank you!
Please list the PCS scenarios if the fetus is less than 24 weeks of age ( is PCS not indicated because the fetus is theoretically not large enough to compress the IVC); do you attempt the procedure anyway knowing the fetus will not survive, soley to save the mother?
I would still consider a PCS in a patient as long as the fundus of the uterus is at the umbilicus or higher regardless of gestational age because it is at this point that hemodynamic compromise occurs in the mother from aorto-caval compression. I know in the video I harped on 24 weeks, however, upon thinking about it more the purpose is more to resuscitate the mom and so I would do it whenever I feel the mother’s hemodynamics are compromised significantly by the baby, which occurs when the fundus of the uterus is at the umbilicus or above. so if you have a fetus that is 20 weeks but the fundus of the uterus is at the umbilicus I would still do it because it could help save the mom even though the baby may not be viable. If the fundus of the uterus is below the umbilicus I would likely not consider doing the procedure as it is quite traumatic and the benefit is less as there likely isn’t much compression of the aorta or ivc at that time. hope this helps.
Thank you Scott and Dr. Bhandari. I had to do this today and having seen this presentation helped.
wow!!
how did it turn out
I”m an ER doc in a community hospital. At that time of day, single coverage so normally don’t respond to codes. Mom and baby both survived and were discharged home. Mom probably had an amniotic embolism; went into DIC afterwards. Baby Apgar 0/2/5. Amazing work by the NICU team, L&D nurses, etc.
Why do you suture in an emergency situation and not just staple it up until the patient’s more stable?
Good question. You should *not* suture *or* staple anything. Simply place sterile towel over the field and wait for surgical consultation. Doing either is unnecessary, time-consuming, can actually result in damaging structures (bowel underneath), and will add time to the surgeon will have to remove each of them anyway when the operation is continued/finished.
[…] EMCrit Conference Blast Winner: Peri-Mortem C-Section […]