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Symptom
dx.
Clinical Reference
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Interpretation guide
POCUS
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Amniotic Fluid Embolism
Cardiovascular Presentations
Abdominal aortic aneurysm
Acute coronary syndrome (NSTEMI)
Acute coronary syndrome (STEMI)
Acute decompensated heart failure
Acute limb ischemia
Acute mesenteric ischemia
Aortic dissection
Aortic stenosis
Atrial fibrillation and flutter
Bradyarrhythmia and heart block
Cardiac arrest
Deep vein thrombosis
Myocarditis
Pericarditis
Pulmonary embolism
Stable angina
Superficial thrombophlebitis
Superior vena cava syndrome
Supraventricular tachycardia
Syncope (cardiogenic)
Unstable angina
Ventricular tachycardia
Respiratory Presentations
Acute bronchitis
Acute respiratory failure
Aspiration pneumonia
Asthma exacerbation
Bronchiolitis
Community-acquired pneumonia
COVID-19 pneumonia
COPD exacerbation
Croup
Croup (laryngotracheobronchitis)
Epiglottitis
Hemothorax
Hospital-acquired pneumonia
Pleural effusion
Pneumothorax (traumatic)
Pulmonary contusion
Spontaneous pneumothorax
Neurological Presentations
Bell's palsy
Benign paroxysmal positional vertigo
Brain abscess
Cauda equina syndrome
Cervical radiculopathy
Concussion (mild traumatic brain injury)
Encephalitis
Guillain-Barré syndrome
Hemorrhagic stroke (intracerebral)
Ischemic stroke
Lumbar radiculopathy
Malignant spinal cord compression
Migraine
Peripheral neuropathy (acute)
Retropharyngeal abscess
Schizophrenia (acute exacerbation)
Seizure (breakthrough:known epilepsy)
Seizure (first-time)
Spinal cord injury
Status epilepticus
Subarachnoid hemorrhage
Tension headache
Transient ischemic attack
Traumatic brain injury (moderate-severe)
Vestibular neuritis
Viral meningitis
Gastrointestinal Presentations
Acute appendicitis
Acute cholecystitis
Acute diverticulitis
Acute pancreatitis
Anal fissure
Choledocholithiasis and cholangitis
Clostridioides difficile colitis
Gastritis
Gastroenteritis (viral and bacterial)
Gastroesophageal reflux disease
Incarcerated or strangulated hernia
Inflammatory bowel disease flare
Large bowel obstruction
Lower GI hemorrhage
Peptic ulcer disease
Perforated viscus
Small bowel obstruction
Upper GI hemorrhage
Genitourinary and Reproductive Presentations
Acute prostatitis
Acute urinary retention
Ectopic pregnancy
Epididymitis
Orchitis
Ovarian torsion
Paraphimosis
Pelvic inflammatory disease
Priapism
Pyelonephritis
Renal laceration
Ruptured ovarian cyst
Testicular torsion
Tubo-ovarian abscess
Urinary tract infection (uncomplicated)
Urolithiasis (renal colic)
Vaginal bleeding (non-pregnant)
Infectious Disease Presentations
Acute sinusitis
Acute tonsillitis
Acute upper respiratory infection
Animal bite
Bacterial meningitis
Cellulitis
Conjunctivitis (bacterial)
Dental abscess
Endocarditis
Febrile neutropenia
Fournier gangrene
Hand-foot-mouth disease
Hepatitis (acute)
Herpes zoster
HIV-related illness
Human bite
Impetigo
Infected diabetic foot ulcer
Infectious mononucleosis
Influenza
Necrotizing fasciitis
Osteomyelitis
Otitis externa
Parasitic infection
Periorbital cellulitis
Peritonsillar abscess
Scabies
Sepsis
Septic arthritis
Spontaneous bacterial peritonitis
Tick-borne illness (Lyme disease)
Tinea infection
Tuberculosis
Viral exanthem
Wound infection
Trauma Presentations
Achilles tendon rupture
ACL and mceniscus tear
Ankle fracture
Ankle sprain
Burn
Calcaneus fracture
Cervical spine fracture
Clavicle fracture
Dental avulsion
Distal radius fracture
Drowning
Elbow fracture and dislocation
Electrical injury
Facial bone fracture
Facial laceration
Femur fracture
Fingertip amputation
Forearm fracture (radius and ulna)
Frostbite
Hand:finger laceration
Heat exhaustion
Heat stroke
Hip fracture
Humeral shaft fracture
Knee dislocation
Knee sprain
Lightning injury
Mandible fracture
Metacarpal fracture
Metatarsal fracture
Muscle strain
Nasal fracture
Non-accidental trauma
Orbital fracture
Patella fracture
Phalanx fracture (finger)
Proximal humerus fracture
Pulmonary contusion
Rib fracture
Rotator cuff tear (acute traumatic)
Scalp laceration
Scaphoid fracture
Shoulder dislocation
Skull fracture
Splenic laceration
Sternal fracture
Supracondylar pediatric fracture
Tendon laceration (hand:wrist)
Thoracic and lumbar spine fracture
Tibia:fibula fracture
Tibial plateau fracture
Toe fracture
Traumatic epistaxis
Traumatic hyphema
Toxicologic Presentations
Acetaminophen toxicity
Alcohol intoxication
Alcohol withdrawal
Anticholinergic toxicity
Anticoagulant overdose
Benzodiazepine overdose
Benzodiazepine:sedative overdose
Beta-blocker and calcium channel blocker toxicity
Carbon monoxide poisoning
Caustic ingestion
Digoxin toxicity
Drug eruption
Foreign body ingestion
Opioid intoxication
Opioid overdose
Opioid withdrawal
Organophosphate
Salicylate toxicity
Serotonin syndrome
Stimulant intoxication (cocaine, methamphetamine)
Tricyclic antidepressant overdose
Psychiatric Presentations
Acute anxiety
Acute psychosis
Agitation:behavioral emergency
Bipolar disorder
Conversion disorder
Major depressive episode
Neuroleptic malignant syndrome
Suicidal ideation and attempt
Musculoskeletal and Rheumatologic Presentations
Acute low back pain (mechanical)
Bursitis
Cervical radiculopathy
Costochondritis
Gout (acute)
Lumbar radiculopathy
Pseudogout
Tendinitis
Dermatology Presentations
Acute eczema (Eczema acute flare)
Allergic contact dermatitis
Erythema multiforme
Henoch-Schönlein purpura
Pressure injury
Psoriasis (acute flare)
Stevens-Johnson syndrome
Toxic epidermal necrolysis
Urticaria (acute)
Environmental and Exposure Presentations
Envenomation (snake, spider, insect)
High-altitude illness
Hypothermia
Hematologic and Oncologic Presentations
Acute chest syndrome
Coagulopathy
Hyperviscosity syndrome
Sickle cell crisis (vaso-occlusive)
Symptomatic anemia
Thrombocytopenia (severe)
Tumor lysis syndrome
Pediatric-Specific Presentations
Bronchiolitis
Croup
Emergency delivery
Febrile seizure
Kawasaki disease
Neonatal jaundice
Neonatal sepsis
Nursemaid's elbow
Pediatric fever 0 to 28 days
Pediatric fever 29 to 60 days
Pediatric fever 61 to 90 days
Pyloric stenosis
Slipped capital femoral epiphysis
Intussusception
Endocrine and Metabolic Presentations
Adrenal crisis
Diabetic ketoacidosis
Hypercalcemia
Hyperosmolar hyperglycemic state
Hypertensive emergency
Hypertensive urgency
Hypoglycemia
Myasthenia gravis crisis
Myxedema coma
Severe hyperkalemia
Severe hyponatremia
Thyroid storm
ENT and Maxillofacial Presentations
Acute laryngitis
Acute otitis media
Acute pharyngitis
Cerumen impaction
Epistaxis (anterior)
Nasal foreign body
Otitis externa
Tympanic membrane perforation
Ophthalmologic Presentations
Acute angle-closure glaucoma
Central retinal artery occlusion
Chemical eye injury
Corneal abrasion
Corneal ulcer
Globe rupture
Ocular foreign body
Orbital cellulitis
Retinal detachment
Obstetric Presentations
Hyperemesis gravidarum
Painful vaginal bleeding in pregnancy
Placenta previa
Placental abruption
Preeclampsia:eclampsia
Preterm labor
Threatened:inevitable:incomplete abortion
Systemic and Miscellaneous Presentations
Anaphylaxis
Angioedema
Cannabis-induced hyperemesis
Amniotic Fluid Embolism
POCUS
Procedures
Calculators
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ECG Guide
Back
Clinical Assessment Checklist
Browse categories and answer follow-up questions to refine your symptom profile.
Approach to the Critical Patient
Immediate priorities
Recognition of catastrophic peripartum collapse
▶
Classic triad in labor or within 30 minutes of delivery
▶
Hemodynamic compromise
Respiratory compromise with hypoxia
Disseminated intravascular coagulation
Sudden cardiovascular collapse during labor or cesarean
▶
Pulseless electrical activity most common arrest rhythm
No reliable warning signs in many cases
If any combination of triad in peripartum setting, activate AFE response
▶
Diagnosis of exclusion but treat empirically
Do not delay resuscitation for confirmatory testing
Airway and breathing threats
▶
Acute severe hypoxia
▶
SpO2 falling rapidly despite supplemental oxygen
Frothy sputum heralding pulmonary edema
Ventilation failure
▶
Tachypnea progressing to apnea
Rising PaCO2
If unable to protect airway or apneic, early intubation with 100% FiO2
▶
Rapid sequence intubation preparation
Anticipate difficult obstetric airway
Circulation threats
▶
Right ventricular failure phase
▶
Acute pulmonary hypertension
Cardiogenic shock
Hemorrhagic shock from DIC
▶
Oozing from IV sites and surgical wounds
Vaginal hemorrhage out of proportion to expected loss
If pulseless, high-quality CPR with manual left uterine displacement
▶
Avoid aortocaval compression
Continuous chest compressions
Resuscitation sequence
Maternal cardiac arrest algorithm
▶
Manual left uterine displacement during compressions
▶
Improves venous return
Reduces aortocaval compression
Resuscitative hysterotomy if no ROSC by 4 minutes
▶
Goal is maternal resuscitation
Splash prep only, do not wait for antibiotics
If refractory arrest, early VA-ECMO activation
▶
Survival 62 to 70 percent in case series
Survival 11 to 44 percent without ECMO
Biphasic hemodynamic phases
▶
Phase 1 within minutes
▶
Acute pulmonary hypertension and RV failure
Cardiogenic shock and arrest
Phase 2 if survival
▶
LV failure with pulmonary edema
DIC with massive hemorrhage
Monitoring and targets
Monitoring bundle
▶
Continuous pulse oximetry
▶
SpO2 target 94 to 98 percent after stabilization
Arterial line for accurate pressures
Cardiac monitor
▶
PEA and bradyasystole vigilance
Ventricular arrhythmia detection
Bedside echocardiography for ongoing guidance
▶
RV size and function trend
LV filling assessment
Escalation triggers
▶
Refractory hypoxemia
▶
Pulmonary vasodilator initiation
ECMO consideration
Persistent shock after initial pressors
▶
Inotrope addition
Transfer to ECMO-capable center
Ongoing coagulopathic hemorrhage
▶
Massive transfusion protocol
Hematology involvement
Immediate consults
Multidisciplinary team activation
▶
Obstetrics and anesthesiology
▶
Delivery and airway management
Neuraxial complication exclusion
Critical care and hematology
▶
Hemodynamic and ventilator support
Transfusion and DIC management
Cardiac surgery and neonatology
▶
ECMO cannulation capability
Neonatal resuscitation at delivery
History
Onset and trigger context
Temporal pattern
▶
Abrupt and unpredictable onset
▶
During active labor
During cesarean delivery
Within 30 minutes postpartum
Relationship to labor events
▶
Rupture of membranes or amniotomy
Intrauterine pressure catheter placement
Delivery of the infant
Prodromal symptoms
▶
Sudden dyspnea
▶
Air hunger
Frothy sputum
Neuropsychiatric prodrome
▶
Agitation and anxiety
Sense of impending doom
Shivering and altered mental status
▶
Restlessness
Loss of consciousness
Classic presentation
Cardiopulmonary collapse
▶
Sudden hypotension or pulselessness
▶
Cyanosis
Respiratory failure
Seizure-like activity
▶
Loss of consciousness
Hypoxic etiology
Hemorrhagic and obstetric clues
▶
Profuse hemorrhage with DIC
▶
Oozing from puncture sites
DIC accompanies over 80 percent of cases
Fetal heart rate abnormalities
▶
Fetal bradycardia preceding maternal collapse
Early warning sign in some cases
Risk factors
Maternal factors
▶
Advanced maternal age
▶
Age 35 years or older odds ratio 1.86
IVF conception association
Multiple pregnancy
▶
Odds ratio 8.5
Polyhydramnios association
Delivery and placental factors
▶
Cesarean section
▶
Odds ratio 12.4
Operative entry into uterus
Placenta previa
▶
Odds ratio 10.5
Abnormal placentation
Placental abruption and accreta spectrum
▶
Highest failure-to-rescue rates 31 to 46 percent
Abnormal maternal-fetal interface
Procedural factors
▶
Operative vaginal delivery
▶
Forceps
Vacuum
Induction and augmentation
▶
Oxytocin use
Cervical lacerations
Uterine rupture and eclampsia
▶
Mechanical disruption
Many patients have no identifiable risk factor
Collateral and past history
Labor team collateral
▶
Timing of membrane rupture
▶
Spontaneous versus amniotomy
Interval to symptom onset
Intrauterine procedures
▶
Pressure catheter placement
Oxytocin administration
Past medical history
▶
Atopy or prior allergic reactions
▶
Theoretical anaphylactoid association
Medication or latex sensitivities
Prior uterine surgery
▶
Previous cesarean sections
Placental abnormalities in prior pregnancies
AFE is not hereditary
▶
Family history not a known contributor
Prior AFE extremely rare but reported
Physical Exam
Vital signs
Hemodynamic instability
▶
Profound hypotension or pulselessness
▶
SBP < 90 mmHg
MAP < 65 mmHg
Heart rate trajectory
▶
Tachycardia to bradycardia to PEA
Arrhythmia onset
Oxygenation and ventilation
▶
Rapid hypoxia
▶
SpO2 dropping despite supplemental oxygen
Cyanosis
Respiratory pattern
▶
Tachypnea progressing to apnea
Increased work of breathing
Focused systems exam
Cardiovascular
▶
Right ventricular failure signs
▶
Jugular venous distension
Muffled heart sounds
Shock signs
▶
Cool and mottled extremities
Delayed capillary refill
Pulmonary
▶
Pulmonary edema findings
▶
Bilateral crackles
Frothy sputum
Hypoxic findings
▶
Cyanosis
Accessory muscle use
Neurologic and obstetric
▶
Neurologic
▶
Altered consciousness or seizures
Fixed dilated pupils if arrest
Obstetric
▶
Boggy atonic uterus
Profuse vaginal hemorrhage
Coagulopathy signs
DIC manifestations
▶
Bleeding from access sites
▶
Oozing from IV and surgical sites
Mucosal and gum bleeding
Cutaneous signs
▶
Petechiae
Ecchymoses
PITFALLS
▶
Attributing collapse to hemorrhage alone
▶
DIC is primary, not dilutional
Coagulopathy out of proportion to blood loss
Delaying response for confirmatory data
▶
No bedside confirmatory test exists
Treat empirically on clinical pattern
Differential Diagnosis
Life-threatening cardiopulmonary mimics
Pulmonary thromboembolism
▶
Sudden dyspnea and collapse
▶
Right heart strain overlap
CT angiography if stable enough
ICD-10 I26.99
▶
Acute pulmonary embolism unspecified
Distinguished by imaging
Acute myocardial infarction or coronary dissection
▶
ECG changes and troponin elevation
▶
ST changes may mimic AFE
Coronary etiology on angiography
ICD-10 I21.9
▶
Acute myocardial infarction unspecified
Primary cardiac event
Air embolism
▶
Procedure and positioning association
▶
Mill-wheel murmur
Temporal link to line or surgery
ICD-10 T79.0
▶
Air embolism traumatic
Echo gas in right heart
Obstetric and hemorrhagic mimics
Placental abruption with hemorrhagic shock
▶
Vaginal bleeding and uterine tenderness
▶
Fetal distress
Hemorrhage-driven shock
ICD-10 O45.9
▶
Premature separation of placenta
Coagulopathy possible but secondary
Uterine rupture
▶
Abdominal pain and loss of fetal station
▶
Hemorrhage
Prior uterine scar
ICD-10 O71.1
▶
Rupture of uterus during labor
Surgical diagnosis
Eclamptic seizure
▶
Hypertension and proteinuria
▶
Seizure without cardiovascular collapse
Preceding preeclampsia
ICD-10 O15.9
▶
Eclampsia unspecified
Magnesium responsive
Distributive and anesthetic mimics
Anaphylaxis
▶
Urticaria and angioedema
▶
Medication or latex trigger
Hemodynamic collapse overlap
ICD-10 T78.2
▶
Anaphylactic shock unspecified
Tryptase elevation supportive
High or total spinal anesthesia
▶
Temporal link to neuraxial procedure
▶
Ascending block
Bradycardia and hypotension
ICD-10 T88.59
▶
Complication of anesthesia
Block level assessment
Septic shock
▶
Fever and infectious source
▶
More gradual onset
Lactate elevation
ICD-10 A41.9
▶
Sepsis unspecified organism
Source identification
Peripartum cardiomyopathy
▶
Heart failure over days to weeks
▶
Not seconds-onset collapse
Reduced ejection fraction
ICD-10 O90.3
▶
Peripartum cardiomyopathy
Echo-based diagnosis
Laboratory Tests
Coagulation studies
DIC panel
▶
Fibrinogen
▶
Often profoundly low
Target above 150 to 200 mg/dl with replacement
PT INR and aPTT
▶
Prolonged in consumptive coagulopathy
Serial trending
D-dimer
▶
Markedly elevated
Nonspecific finding
Hematology
▶
Complete blood count
▶
Thrombocytopenia expected
Hemoglobin for transfusion guidance
Type and crossmatch
▶
Immediate request
Anticipate massive transfusion
Viscoelastic and perfusion testing
Viscoelastic testing
▶
TEG or ROTEM
▶
Rapid hyperfibrinolysis detection
Guides transfusion and TXA
Point-of-care turnaround
▶
Faster than conventional coagulation labs
Proposed diagnostic aid
Perfusion markers
▶
Lactate
▶
Elevated in shock
Serial clearance monitoring
Arterial or venous blood gas
▶
Metabolic acidosis
Hypoxemia and hypercapnia
Organ injury and exclusion labs
Cardiac and organ panels
▶
Troponin
▶
May be elevated from myocardial injury
Helps exclude primary MI
BMP and LFTs
▶
Multi-organ dysfunction assessment
Renal and hepatic baselines
No confirmatory biomarker
▶
Diagnosis remains clinical
▶
Serum tryptase investigated, not validated
Complement C3 and C4 not validated
IGFBP-1 investigational
▶
Insulin-like growth factor binding protein-1
Not validated for clinical use
Diagnostic Tests
Scoring Systems
Clark research criteria
▶
Required components for case definition
▶
Hemodynamic compromise
Respiratory compromise
DIC by ISTH obstetric score
Temporal and exclusion criteria
▶
Onset during labor or within 30 minutes of delivery
Absence of other explanations
Intended use
▶
Research case definition
Not a bedside diagnostic rule
DIC scoring
▶
ISTH overt DIC score
▶
Platelet count
Fibrin marker D-dimer
Prolonged PT
Fibrinogen level
Pregnancy-modified DIC score
▶
Adjusted thresholds for pregnancy physiology
Higher baseline fibrinogen accounted for
Limitations
▶
No validated diagnostic score for AFE
▶
Clinical recognition supersedes scoring
Diagnosis of exclusion
Postmortem confirmation
▶
Fetal squamous cells in pulmonary vasculature
Mucin or lanugo on immunohistochemistry
MRI
MRI role
▶
Limited acute utility
▶
Patient instability precludes scanning
Resuscitation takes priority
Delayed neurologic indications
▶
Hypoxic-ischemic brain injury assessment in survivors
Prognostication after ROSC
Contraindications
▶
Hemodynamic instability
Incompatible support equipment
CT
CT pulmonary angiography
▶
Indication
▶
Only if stable enough
Primarily to exclude pulmonary thromboembolism
Limitations
▶
Resuscitation should not be delayed
Transport risk in unstable patient
Contrast considerations
▶
Renal function in multi-organ dysfunction
Allergy history
CT findings and guidance
▶
Nonspecific pulmonary changes
▶
Bilateral edema pattern
No pathognomonic finding
Imaging secondary to resuscitation
▶
Echocardiography preferred at bedside
Expert consensus supports exclusion role
Ultrasound
Bedside echocardiography
▶
First-line and most important imaging
▶
TTE or TEE
Guides vasopressor and vasodilator therapy
Right heart findings
▶
Acute RV dilation and failure
Interventricular septal bowing
Left heart findings
▶
Reduced LV filling
Increased pulmonary vascular resistance pattern
Point-of-care ultrasound
▶
Hemodynamic assessment
▶
IVC for volume status
Gross LV function estimate
Obstetric and abdominal
▶
Free fluid assessment
Adjunct to clinical exam
Chest radiograph adjunct
▶
Bilateral pulmonary edema nonspecific
Often impractical during resuscitation
Disposition
Level of care
ICU admission for all patients
▶
No exceptions
▶
Ongoing DIC monitoring
Multi-organ support
Multidisciplinary team
▶
OB anesthesiology and critical care
Hematology cardiology and neonatology
Transfer criteria
▶
ECMO-capable center
▶
Refractory to medical management
Not already at such a facility
Timing
▶
Early activation before irreversible failure
Stabilize for transport
Follow up and complications
Copy
In-hospital monitoring
▶
Evolving organ failure 24 to 72 hours
▶
ARDS
Acute kidney injury and hepatic dysfunction
Oxygenation targets
▶
Wean FiO2 to SpO2 94 to 98 percent
Lung-protective ventilation
Secondary complication surveillance
▶
Thrombosis after coagulopathy resolves
▶
VTE prophylaxis when safe
Balance against bleeding risk
Endocrine and infectious
▶
Sheehan syndrome
Nosocomial infection
Reporting and support
▶
AFE Foundation Registry case report
▶
Contributes to epidemiologic data
Supports research criteria
Post-event debriefing
▶
Psychological support for staff and family
SMFM recommendation
Treatment
Immediate stabilization
Resuscitation priorities
▶
CPR with left uterine displacement
▶
High-quality chest compressions
Manual displacement to relieve aortocaval compression
Resuscitative hysterotomy
▶
Begin within 4 minutes of pulseless arrest if no ROSC
Goal is maternal resuscitation
Airway
▶
Early intubation
100 percent FiO2
Hemodynamic support
Vasopressor therapy
▶
Norepinephrine preferred over fluids
▶
0.05 to 3.3 mcg/kg/min infusion
Titrate to MAP 65 mmHg
Class IIa recommendation per SMFM
▶
Vasopressors before large-volume crystalloid
Avoid RV overdistension
Inotropic support
▶
Dobutamine for RV failure
▶
2.5 to 5.0 mcg/kg/min
Titrate to cardiac output
Milrinone alternative
▶
0.25 to 0.75 mcg/kg/min
Inodilator effect on pulmonary vasculature
Pulmonary vasodilators
▶
Inhaled nitric oxide
▶
5 to 40 ppm
Titrate to RV function and oxygenation
Inhaled epoprostenol
▶
10 to 50 ng/kg/min inhaled
IV epoprostenol 1 to 2 ng/kg/min alternative
Sildenafil if awake
▶
20 mg PO
Adjunct for pulmonary hypertension
Fluid strategy
▶
Avoid excessive crystalloid
▶
500 ml boluses with reassessment
Worsens RV failure and pulmonary edema
Prefer blood products over crystalloid
▶
Volume from transfusion
Echo-guided titration
Coagulopathy management
Massive transfusion protocol
▶
Balanced ratio resuscitation
▶
1:1:1 pRBC to FFP to platelets
Activate early
Cryoprecipitate
▶
Preferred over FFP to limit volume overload
Target fibrinogen above 150 to 200 mg/dl
Antifibrinolytic therapy
▶
Tranexamic acid
▶
1 g IV over 10 minutes
Repeat 1 g if bleeding continues after 30 minutes
Evidence base
▶
Supported by WOMAN trial data
SMFM recommendation
Transfusion guidance
▶
TEG or ROTEM directed
▶
Target specific deficits
Identify hyperfibrinolysis
Uterine atony management
▶
Oxytocin prophylaxis
Methylergonovine carboprost or misoprostol
Investigational and refractory therapy
A-OK protocol
▶
Components
▶
Atropine 1 mg IV
Ondansetron 8 mg IV
Ketorolac 30 mg IV
Cautions
▶
Case reports only
SMFM and experts caution against widespread adoption
Ketorolac may worsen bleeding and renal function
Extracorporeal support
▶
VA-ECMO
▶
For prolonged CPR or refractory RV failure
Survival 62 to 70 percent in case series
If refractory to medical therapy, activate ECMO team
▶
Early cannulation
Cardiac surgery involvement
Special Populations
Pregnancy
Peripartum context
▶
AFE is intrinsically a pregnancy condition
▶
Onset during labor or within 30 minutes postpartum
Fifth most common cause of direct maternal mortality
Maternal resuscitation modifications
▶
Manual left uterine displacement during CPR
Resuscitative hysterotomy by 4 minutes if no ROSC
Fetal considerations
▶
Fetal bradycardia may precede collapse
Neonatal team present for delivery
Future pregnancy counseling
▶
Recurrence risk considered very low
Shared decision-making essential
Geriatric
Older parturient considerations
▶
Advanced maternal age as risk factor
▶
Age 35 years or older odds ratio 1.86
IVF conception association
Comorbidity burden
▶
Cardiovascular reserve limitations
Higher failure-to-rescue risk
Note on terminology
▶
Geriatric maternal age refers to 35 years or older
Not classic elderly population
Pediatrics
Neonatal implications
▶
High perinatal morbidity
▶
Neonatal resuscitation team at delivery
Hypoxic-ischemic injury risk
Delivery timing
▶
Expedited delivery during maternal arrest
Improves both maternal and neonatal outcomes
Neonatal monitoring
▶
NICU admission for affected neonates
Multi-organ surveillance
Background
Epidemiology
Incidence and mortality
▶
Incidence
▶
Approximately 1.9 to 6.1 per 100000 births
Rare but catastrophic
Case fatality
▶
11 to 50 percent depending on criteria
Classic severe AFE mortality 38 to 50 percent
Global burden
▶
Fifth most common cause of direct maternal mortality
Leading cause of peripartum collapse
Severity distribution
▶
Classic severe AFE
▶
Cardiac arrest with DIC and hemorrhage
Mortality 38 to 50 percent
Atypical or partial AFE
▶
Isolated coagulopathy or hemodynamic instability
Lower but still significant mortality
Pathophysiology
Mechanism
▶
Immune-mediated anaphylactoid reaction
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Reaction to fetal antigens
Not primarily mechanical obstruction
Mediator release
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Tissue factor activating coagulation
Endothelin causing pulmonary vasoconstriction
Complement activation
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Inflammatory cascade
Analogous to anaphylaxis
Hemodynamic cascade
▶
Phase 1 acute pulmonary hypertension
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RV failure
Cardiogenic shock and arrest
Phase 2 left heart and coagulopathy
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LV failure with pulmonary edema
DIC with consumptive hemorrhage
Therapeutic Considerations
Resuscitation principles
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Empiric treatment over confirmation
▶
No bedside confirmatory test
Treat on clinical pattern
RV protection
▶
Avoid fluid overload
Early pulmonary vasodilators
Hemostatic strategy
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Early balanced transfusion
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1:1:1 ratio
Cryoprecipitate for fibrinogen
Early antifibrinolytics
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TXA 1 g IV
Viscoelastic-guided correction
System and prevention
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Preparedness checklists
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SMFM initial management checklist
Drills and rapid response
Registry participation
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AFE Foundation Registry
Improves understanding and outcomes
Patient Discharge Instructions
copy discharge instructions
Copy
Survivor recovery information
▶
You had a rare and serious condition called amniotic fluid embolism
Your heart, lungs, and blood clotting were affected
Recovery is gradual and may take weeks to months
Attend all follow-up appointments
Warning signs to return to ER
▶
Trouble breathing or chest pain
New or heavy bleeding or easy bruising
Severe headache or confusion
Fainting or palpitations
Leg swelling or pain suggesting a clot
Fever or signs of infection
Follow up plan
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Obstetric follow-up after hospital discharge
Cardiology review for heart function recovery
Neurology review if any brain oxygen injury occurred
Counseling for emotional recovery and trauma
Future pregnancy counseling
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Recurrence risk is believed to be very low
No firm restriction on future pregnancy
Discuss plans with your obstetric specialist
References
Guidelines and key sources
Society guidelines
▶
SMFM Special Statement checklist for initial management of AFE 2021
AHA 2025 guidelines for CPR and emergency cardiovascular care
Clark research case definition criteria 2016
Landmark and review evidence
▶
JAMA Network Open population study on pregnancy characteristics and maternal mortality 2022
WOMAN trial supporting tranexamic acid in obstetric hemorrhage
Critical Care Obstetrics 7th Edition AFE chapter 2024
Coding standards
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ICD-10 O88.1 amniotic fluid embolism
SNOMED CT amniotic fluid embolism disorder concept
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.
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Management Protocols
Amniotic Fluid Embolism