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 Lethal rhythms • 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 or only 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 Nonshockable Lethal 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 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) 1 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 Factors BEAU-CHOPS • B-leeding/DIC • E-mbolism: • coronary/pulmonary/amniotic fluid • A-nesthesia- complications • U-terine atony • 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-terine atony 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 megacode scenarios • 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?