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ACLS-OB

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  1. ACLS-OB A Maternal Code Are You Ready? Angie Rodriguez ARNP, CS, MSN, CNM, RNC-OB Kerry Foligno RN, BSN, CLC, CPST

  2. ACLS-OB Advanced Cardiac Life Support with an Obstetric Focus

  3. Why ACLS-OB • Based on AHA guidelines 2010 • The best hope of fetal survival is maternal survival

  4. 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.

  5. ACLS-OB • Can lightening strikes be prevented? • Rapid response teams • Chain of survival • Recognition of arrest • Activation of EMS/Code Blue • BLS • AED/ACLS

  6. 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

  7. Are arrhythmias serious? • Arrhythmias may be benign, symptomatic, life threatening or even fatal.

  8. 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??

  9. Treatable Rhythms 1. Lethal (pulseless) rhythms • Shockable • Nonshockable 2. Non-lethal (with a pulse) rhythms

  10. Lethalrhythms • Shockable • Ventricular Fibrillation • Pulseless Ventricular Tachycardia • Non-Shockable • Pulseless Electrical Activity • Asystole

  11. Shockable Lethal Rhythms Ventricular Tachycardia (Pulseless) Ventricular Fibrillation

  12. Ventricular Tachycardia Pulseless

  13. Ventricular Tachycardia

  14. Ventricular Fibrillation No organized electrical activity

  15. Ventricular Fibrillation • Coarse

  16. Ventricular Fibrillation • Fine

  17. 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

  18. 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

  19. NonshockableLethal Rhythms • Asystole • Pulseless Electrical Activity

  20. Asystole CHECK LEADS, CHECK PULSE

  21. Pulseless Electrical Activity

  22. 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

  23. 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

  24. Non-Lethal Arrhythmias (With a pulse) • Tachyarrhythmias • Sinus Tachycardia • Supraventricular Tachycardia • Ventricular tachycardia (with a pulse) • Bradyarrhythmias • Sinus Bradycardia • Blocks

  25. Too Fast • More than 100 beats per minute Stable or Unstable ??????????

  26. Sinus Tachycardia

  27. Supraventricular Tachycardia(SVT) • Symptomatic?

  28. 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

  29. Ventricular Tachycardia

  30. Ventricular Tachycardia • Question- is there a pulse • Yes- synchronized cardioversion • No- • start CPR, Airway management, defibrillate and or meds

  31. Too Slow

  32. Sinus Bradycardia Rhythm Regular

  33. 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

  34. 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)

  35. 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

  36. 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

  37. Maternal Cardiopulmonary Arrest • Preexisting medical conditions • Asthma • Hypertension • Diabetes • Lupus • etc • Cardiac issues • MVP • Status post MI • Atherosclerosis • Preexisting structural defects

  38. 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

  39. Maternal Cardiopulmonary Arrest • Anesthesia incidents • Intubation complications • Suicidal attempts • Medication issue

  40. 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

  41. 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

  42. OB Considerations • Search for pregnancy specific • H’s and T’s • Defibrillation • Remove fetal monitors

  43. OB Considerations • Meds • Vasopressors • Epi • Vaso • Antiarrhythmics • Amiodarone-class D • Lidocaine-class B • Mag Sulfate-class A

  44. 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

  45. 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

  46. Modifications for Pregnancy • Early advanced airway • Complicated intubation • Jaw thrust • Cricoid pressure/Sellick maneuver • Smaller ETT if needed • Altered location of confirmatory lung sounds

  47. 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

  48. 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

  49. Pulseless VT /VF • CPR and defibrillation • Vasopressor and 2nd defibrillation • Antiarrhythmic and 3rd defibrillation

  50. How do I become an ACLS-OB Instructor