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Team Management of Peripartum Spontaneous Coronary Artery Dissection: Explicit Communication Aids in Cardiac-Specific Treatments
Abstract Number: F 9
Abstract Type: Original Research
Albeit rare, spontaneous coronary artery dissection (SCAD) affects a younger and healthier population and accounts for up to 27% of cases of peripartum myocardial infarction (MI)1. Prompt recognition with arrangement for percutaneous coronary intervention (PCI) serves both diagnosis and treatment1. Rapid initiation of adequate cardiopulmonary resuscitation (CPR) is essential for survival when maternal cardiac arrest occurs.
Obstetricians, anesthesiologists, nurse midwives, and labor nurses participated in a recurring team-training course at the Center for Medical Simulation. With IRB approval, 20 of 22 videos with acceptable AV quality were evaluated independently by 2 physician investigators for specific management strategies, teamwork/organization variables, and quality of CPR in the setting of a simulated patient with postpartum SCAD.
Fisher’s exact test (STATA, ©1985-2009 StataCorp LP) was performed to look at associations between administration of aspirin or nitroglycerin (ASA/NTG), calling for cardiology help, stating aloud a differential diagnosis ≥2 considerations (Ddx≥2), stating aloud the possibility of an MI, and identifying an event manager. Speaking aloud a Ddx≥2 was associated with more teams administering either ASA/NTG (Fisher’s exact test, p=0.014), as was speaking aloud a possible MI (Fisher’s exact test, p=0.026).
CPR was substandard in 80% of resuscitations, most commonly due to rate < 90/min, multiple/prolonged interruptions, and not continuing compressions for two minutes after return of spontaneous circulation. Two groups failed to effectively discharge the defibrillator multiple times during attempts in the setting of ventricular fibrillation.
Despite simulated evidence of MI, many teams did not call for cardiology or administer full MONA (morphine, oxygen, nitroglycerin, aspirin). Speaking aloud either “MI” or more than one working diagnosis was associated with more frequent administration of cardiac specific medications (ASA/NTG), confirming the advantage of transparent thinking in diagnostic problem solving.
A performance gap remains for effective, high-quality CPR in this multidisciplinary obstetric team. Prior work has shown that CPR skills quickly degrade2; a more concerted effort to maintain these essential skills is needed.
1. Exp Clin Cardiol 2009;14(1):e8-e16.
2. BMJ 1993;306:1576-7.