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ACLS-OB. A Maternal Code Are You Ready? Angie Rodriguez ARNP, CS, MSN, CNM, RNC-OB Kerry Foligno RN, BSN, CLC, CPST. ACLS-OB. Advanced Cardiac Life Support with an Obstetric Focus. Why ACLS-OB. Based on AHA guidelines 2010

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ACLS-OB

A Maternal Code

Are You Ready?

Angie Rodriguez ARNP, CS, MSN, CNM, RNC-OB

Kerry Foligno RN, BSN, CLC, CPST


ACLS-OB

Advanced Cardiac Life Support with an Obstetric Focus


Why ACLS-OB

  • Based on AHA guidelines 2010

  • The best hope of fetal survival is maternal survival


Why ACLS-OB

  • Education, preparation and practice are the keys to delivering the safest care for mom and her baby.

  • ACLS-OB includes AHA core cases and algorithms but utilizes specific scenarios that include modifications for pregnant and newly delivered patients.


ACLS-OB

  • Can lightening strikes be prevented?

  • Rapid response teams

  • Chain of survival

    • Recognition of arrest

    • Activation of EMS/Code Blue

    • BLS

    • AED/ACLS


Our Journey at MHW

  • Attended National Convention- booth

  • Requested - Rejected, Persisted

  • 4 staff nurses/CM’s-went to Idaho 2009

  • Magnet journey

  • Brought it back and implemented the program

  • All L&D staff attended from all three facilities

  • Instructor trainer


Are arrhythmias serious?

  • Arrhythmias may be benign,

    symptomatic, life threatening

    or even fatal.


ACLS-OB

  • The most important question is not just

    What is the Rhythm …but

    How is this rhythm affecting

    the patient clinically and how

    are we going to treat the

    rhythm??


Treatable Rhythms

1. Lethal (pulseless) rhythms

  • Shockable

  • Nonshockable

    2. Non-lethal (with a pulse) rhythms


Lethalrhythms

  • Shockable

    • Ventricular Fibrillation

    • Pulseless Ventricular Tachycardia

  • Non-Shockable

    • Pulseless Electrical Activity

    • Asystole


Shockable Lethal Rhythms

Ventricular Tachycardia (Pulseless)

Ventricular Fibrillation


Ventricular Tachycardia

Pulseless


Ventricular Tachycardia


Ventricular Fibrillation

No organized electrical activity


Ventricular Fibrillation

  • Coarse


Ventricular Fibrillation

  • Fine


Pharmacologic Treatment of Ventricular Fibrillation & Ventricular Tachycardia (Pulseless)

  • Vasopressors:

    • Epinephrine

      • 1mg. IVP/IO – 1:10,000 solution

      • Repeat every 3 – 5 minutes

      • Optimizes cardiac and cerebral blood flow

    • Vasopressin

    • To replace 1st or 2nd dose of Epinephrine

      • 40 Units IV/IO


Pharmacologic Treatment of Ventricular Fibrillation/V-Tachycardia

  • Antiarrhythmics – Give during CPR (before or after the shock)

    • Amiodarone – 300 mg (recommend dilution in 20 -30 mL D5W) IV/IO push once, then consider additional 150mg IV/IO once , then followed by IV drip

      oronly after perimortem delivery

    • Lidocaine – 1 to 1.5 mg/kg first dose, then 0.5 to 0.75 mg/kg IV/IO, maximum 3 doses or 3mg/kg


NonshockableLethal Rhythms

  • Asystole

  • Pulseless Electrical Activity


Asystole

CHECK LEADS, CHECK PULSE


Pulseless Electrical Activity


Pharmacologic Treatment of PEA and Asystole

  • Epinephrine – 1 mg IV/IO

    Repeat every 3 to 5 minutes

    OR

  • Vasopressin – 40 Units

    • to replace 1st or 2nd dose of epinephrine


Treat the patient, not the monitor

  • Signs and symptoms such as:

    • Low blood pressure

    • Altered mental status

    • Shortness of breath

    • Chest pain or angina

    • Signs of shock


Non-Lethal Arrhythmias (With a pulse)

  • Tachyarrhythmias

    • Sinus Tachycardia

    • Supraventricular Tachycardia

    • Ventricular tachycardia

      (with a pulse)

  • Bradyarrhythmias

    • Sinus Bradycardia

    • Blocks


Too Fast

  • More than 100 beats per minute

Stable or Unstable ??????????


Sinus Tachycardia


Supraventricular Tachycardia(SVT)

  • Symptomatic?


Pharmacologic Treatment of SVT

Narrow Complex – Regular

  • Vagal Manuevers

  • Adenosine 6mg IV rapid push.

    If no conversion then give

    Adenosine 12 mg IV rapid push,

  • Synchronized Cardioversion-50-100 joules


Ventricular Tachycardia


Ventricular Tachycardia

  • Question- is there a pulse

    • Yes- synchronized cardioversion

    • No-

      • start CPR, Airway management, defibrillate and or meds


Too Slow


Sinus Bradycardia

Rhythm Regular


Pharmacologic Treatment of Non-Lethal Bradyarrhythmias

  • Symptomatic??

    • YES – Altered mental status, chest pain, hypotension, other signs of shock

      • Atropine 0.5 mg IV. May repeat to a total dose of 3 mg.

      • Prepare for transvenous pacing

        • Set rate

        • Set current-(MA) increase by 5 or 10 until capture


H’s and T’s

1

Review for most frequent causes

  • Hypovolemia

  • Hypoxia

  • Hydrogen ion —acidosis

  • Hyper-/hypokalemia

  • Hypothermia

  • Tablets” (drug OD, accidents)

  • Tamponade, cardiac

  • Tension pneumothorax

  • Thrombosis, coronary (ACS)

  • Thrombosis, pulmonary (embolism)


Perimortem Cesarean Kit

  • Knife handle with #10 blade

  • Kelly clamos

  • Mayo scissors

  • Bandage scissors

  • Tooth forceps

  • Needle holders

  • Sutures

  • Laparotomy sponges

  • Clear plastic abdominal drape

  • IV pitocin

  • Normal saline vials

  • Syringes with needle


Highest Risk of Cardiopulmonary Arrest

  • Tocolytic therapy

  • Infection

  • Anesthesia

  • Gestational HTN

  • Substance abuse

  • Thyroid storm

  • Surgery and tissue trauma

  • Cardiac anomalies Polyhydramnios

  • Multiple gestation

  • Prior uterine surgery

  • Hemorrhage


Maternal Cardiopulmonary Arrest

  • Preexisting medical conditions

    • Asthma

    • Hypertension

    • Diabetes

    • Lupus

    • etc

  • Cardiac issues

    • MVP

    • Status post MI

    • Atherosclerosis

    • Preexisting structural defects


Maternal Cardiopulmonary Arrest

  • Accidents/Trauma

    • MVA, Stabbings, Gunshot

    • Domestic Violence

    • Drug use/ Overdose

  • Pregnancy related issues

    • Preeclampsia/eclampsia

    • Uterine placental emergencies resulting in hemorrhage

    • Uterine atony

    • Alterations in clotting

    • Cardiomyopathy

    • Anaphylactoid syndrome of pregnancy


Maternal Cardiopulmonary Arrest

  • Anesthesia incidents

  • Intubation complications

  • Suicidal attempts

  • Medication issue


Maternal Contributing FactorsBEAU-CHOPS

  • B-leeding/DIC

  • E-mbolism:

    • coronary/pulmonary/amniotic fluid

  • A-nesthesia- complications

  • U-terineatony

  • C-ardiac disease-

    • MI. cardiomyopathy/ischemia/aortic

  • H-ypertension- preeclampsia/eclampsia

  • O-ther: usual differential diagnosis

  • P-lacenta: abruption/previa

  • S-epsis


ACLS OB Contributing factors (A CUB HOPES)

  • A-nesthesia

  • C-ardiac disease

  • U-terineatony

  • B-leeding

  • H-ypertension

  • O-ther

  • P-lacenta

  • E-mbolism

  • S-epsis


OB Considerations

  • Search for pregnancy specific

    • H’s and T’s

  • Defibrillation

    • Remove fetal monitors


OB Considerations

  • Meds

    • Vasopressors

      • Epi

      • Vaso

    • Antiarrhythmics

      • Amiodarone-class D

      • Lidocaine-class B

      • Mag Sulfate-class A


OB Considerations

Fibrinolytics

relative contraindications-pregnancy and immediate postpartum due to increased risk of bleeding

Amiodarone

Half life- 40 days

Avoid in pregnancy- fetal hypothyroidism

Use lidocaine- if 24-42 weeks

Ok for gestational age less than 24 weeks or postpartum


Modifications for Pregnancy

  • Higher hand placement of chest

  • Use pulse checks to confirm efficacy of compressions

  • Uterine displacement

  • Timing -for perimortem C/S delivery

  • No fibrinolytics

  • Amiodarone- less than 24 weeks or after delivery of fetus


Modifications for Pregnancy

  • Early advanced airway

  • Complicated intubation

  • Jaw thrust

  • Cricoid pressure/Sellick maneuver

  • Smaller ETT if needed

  • Altered location of confirmatory lung sounds


Modifications for Pregnancy

  • Increased resistance with bag mask ventilation

  • Remove fetal monitors prior to cardioversion, defibrillation

  • Increase paddle pressure if using paddles- use hands free is preferred

  • Maternal Tilt


Potential Causes for Stroke

  • Hemorrhagic stroke

  • Ischemic stroke

  • Hypertensive encephalopathy

  • Preeclampsia or eclampsia

  • Intracranial mass

  • Meningitis/encephalitis

  • Seizure

  • Migraine

  • Craniocerebral/cervical trauma

  • Metabolic conditions

    • Hypo, hyperglycemia, drug overdose


Pulseless VT /VF

  • CPR and defibrillation

  • Vasopressor and 2nd defibrillation

  • Antiarrhythmic and 3rd defibrillation


  • How do I become an ACLS-OB Instructor


How do I become an ACLS-OB Instructor

Become an ACLS instructor in your area

  • Take the on-line Core Instructors course from AHA- (manual purchased from AHA)

  • Attend a one day ACLS instructor class

  • Attend two day ACLS-OB provider class 

  • Do teachback class in your area

  • Set up program with your Organizational Development department- CEU’s etc

  • Offer first class for managers, charge staff


  • Implementing ACLS-OB program at your facility


Implementing ACLS-OB program at your facility

  • Two day provider course- initially

    • Followed by one day renewal

  • Train ACLS instructors

    • Anesthesia, ED, other educators

  • Mock simulations on the units


Implementing ACLS-OB program at your facility

  • Limit class size to 6 participants per 2 instructors

    • Read scenario/run simulator

    • Grade and debrief

  • Organize paperwork into a file box

    • Laminate practice and megacodescenarios

  • ECG simulator- $1700.00 x 2

  • Mannequin, Sample meds, Ambu bag, ETT, Stethescope, IV bag/tubing, O2 mask, Monitor belts, Internal Monitors, Airway, CO2 detector, bathing suit with low transverse incision, baby, placenta.


Considerations

  • Unit specific criteria for instructors

  • Hospital Budget

  • Target audience

  • Administrative /Management challenges

  • Supplies, Equipment- Funding???

  • Startup investment/regulatory issues


Hope you don’t feel like this

ANY QUESTIONS?


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