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

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Presentation on theme: "ACLS-OB A Maternal Code A Maternal Code Are You Ready? Are You Ready? Angie Rodriguez ARNP, CS, MSN, CNM, RNC-OB Kerry Foligno RN, BSN, CLC, CPST."— Presentation transcript:

1 ACLS-OB A Maternal Code A Maternal Code Are You Ready? 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 2010Based on AHA guidelines 2010 The best hope of fetal survival is maternal survivalThe 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.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 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?Can lightening strikes be prevented? Rapid response teamsRapid response teams Chain of survivalChain of survival Recognition of arrestRecognition of arrest Activation of EMS/Code BlueActivation of EMS/Code Blue BLSBLS AED/ACLSAED/ACLS

6 Our Journey at MHW Attended National Convention- boothAttended National Convention- booth Requested - Rejected, PersistedRequested - Rejected, Persisted 4 staff nurses/CMs-went to Idaho staff nurses/CMs-went to Idaho 2009 Magnet journeyMagnet journey Brought it back and implemented the programBrought it back and implemented the program All L&D staff attended from all three facilitiesAll L&D staff attended from all three facilities Instructor trainerInstructor trainer

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

8 ACLS-OB ACLS-OB The most important question is not justThe most important question is not just What is the Rhythm …but What is the Rhythm …but How is this rhythm affecting the patient clinically and how are we going to treat the are we going to treat the rhythm?? rhythm??

9 Treatable Rhythms 1. Lethal (pulseless) rhythms ShockableShockable NonshockableNonshockable 2. Non-lethal (with a pulse) rhythms

10 Lethal rhythms ShockableShockable Ventricular FibrillationVentricular Fibrillation Pulseless Ventricular TachycardiaPulseless Ventricular Tachycardia Non-ShockableNon-Shockable Pulseless Electrical ActivityPulseless Electrical Activity AsystoleAsystole

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 CoarseCoarse

16 Ventricular Fibrillation FineFine

17 Pharmacologic Treatment of Ventricular Fibrillation & Ventricular Tachycardia (Pulseless) Vasopressors:Vasopressors: EpinephrineEpinephrine 1mg. IVP/IO – 1:10,000 solution1mg. IVP/IO – 1:10,000 solution Repeat every 3 – 5 minutesRepeat every 3 – 5 minutes Optimizes cardiac and cerebral blood flowOptimizes cardiac and cerebral blood flow VasopressinVasopressin To replace 1 st or 2 nd dose of EpinephrineTo replace 1 st or 2 nd dose of Epinephrine 40 Units IV/IO40 Units IV/IO

18 Pharmacologic Treatment of Ventricular Fibrillation/V-Tachycardia Antiarrhythmics – Give during CPR (before or after the shock)Antiarrhythmics – Give during CPR (before or after the shock) Amiodarone – 300 mg (recommend dilution in mL D5W) IV/IO push once, then consider additional 150mg IV/IO once, then followed by IV dripAmiodarone – 300 mg (recommend dilution in 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/kgLidocaine – 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 Nonshockable Lethal Rhythms Asystole Asystole Pulseless Electrical Activity Pulseless Electrical Activity

20 Asystole CHECK LEADS, CHECK PULSE

21 Pulseless Electrical Activity

22 Pharmacologic Treatment of PEA and Asystole Epinephrine – 1 mg IV/IOEpinephrine – 1 mg IV/IO Repeat every 3 to 5 minutes Repeat every 3 to 5 minutesOR Vasopressin – 40 UnitsVasopressin – 40 Units to replace 1 st or 2 nd dose of epinephrineto replace 1 st or 2 nd dose of epinephrine

23 Treat the patient, not the monitor Signs and symptoms such as:Signs and symptoms such as: Low blood pressureLow blood pressure Altered mental statusAltered mental status Shortness of breathShortness of breath Chest pain or anginaChest pain or angina Signs of shockSigns of shock

24 Non-Lethal Arrhythmias (With a pulse) TachyarrhythmiasTachyarrhythmias Sinus TachycardiaSinus Tachycardia Supraventricular TachycardiaSupraventricular Tachycardia Ventricular tachycardiaVentricular tachycardia (with a pulse) BradyarrhythmiasBradyarrhythmias Sinus BradycardiaSinus Bradycardia Blocks Blocks

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

26 Sinus Tachycardia

27 Supraventricular Tachycardia (SVT) Symptomatic?Symptomatic?

28 Pharmacologic Treatment of SVT Narrow Complex – Regular Vagal ManueversVagal Manuevers Adenosine 6mg IV rapid push.Adenosine 6mg IV rapid push. If no conversion then give If no conversion then give Adenosine 12 mg IV rapid push, Adenosine 12 mg IV rapid push, Synchronized Cardioversion joulesSynchronized Cardioversion joules

29 Ventricular Tachycardia

30 Question- is there a pulseQuestion- is there a pulse Yes- synchronized cardioversionYes- synchronized cardioversion No-No- start CPR, Airway management, defibrillate and or medsstart CPR, Airway management, defibrillate and or meds

31 Too Slow

32 Sinus Bradycardia Rhythm Regular

33 Pharmacologic Treatment of Non-Lethal Bradyarrhythmias Symptomatic??Symptomatic?? YES – Altered mental status, chest pain, hypotension, other signs of shockYES – Altered mental status, chest pain, hypotension, other signs of shock Atropine 0.5 mg IV. May repeat to a total dose of 3 mg.Atropine 0.5 mg IV. May repeat to a total dose of 3 mg. Prepare for transvenous pacingPrepare for transvenous pacing Set rateSet rate Set current-(MA) increase by 5 or 10 until captureSet current-(MA) increase by 5 or 10 until capture

34 Hs and Ts Hypovolemia Hypoxia Hydrogen ion acidosis Hyper- /hypokalemia Hypothermia Tablets (drug OD, accidents) Tamponade, cardiac Tension pneumothorax Thrombosis, coronary (ACS) Thrombosis, pulmonary (embolism) Review for most frequent causes 1

35 Perimortem Cesarean Kit Knife handle with #10 bladeKnife handle with #10 blade Kelly clamosKelly clamos Mayo scissorsMayo scissors Bandage scissorsBandage scissors Tooth forcepsTooth forceps Needle holdersNeedle holders SuturesSutures Laparotomy sponges Clear plastic abdominal drape IV pitocin Normal saline vials Syringes with needle

36 Highest Risk of Cardiopulmonary Arrest Tocolytic therapyTocolytic therapy InfectionInfection AnesthesiaAnesthesia Gestational HTNGestational HTN Substance abuseSubstance abuse Thyroid stormThyroid storm Surgery and tissue trauma Cardiac anomalies Polyhydramnios Multiple gestation Prior uterine surgery Hemorrhage

37 Maternal Cardiopulmonary Arrest Preexisting medical conditionsPreexisting medical conditions AsthmaAsthma HypertensionHypertension DiabetesDiabetes LupusLupus etcetc Cardiac issues MVP Status post MI Atherosclerosis Preexisting structural defects

38 Maternal Cardiopulmonary Arrest Accidents/TraumaAccidents/Trauma MVA, Stabbings, GunshotMVA, Stabbings, Gunshot Domestic ViolenceDomestic Violence Drug use/ OverdoseDrug 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 incidentsAnesthesia incidents Intubation complicationsIntubation complications Suicidal attemptsSuicidal attempts Medication issueMedication issue

40 Maternal Contributing Factors BEAU-CHOPS B-leeding/DICB-leeding/DIC E-mbolism:E-mbolism: coronary/pulmonary/amniotic fluidcoronary/pulmonary/amniotic fluid A-nesthesia- complicationsA-nesthesia- complications U-terine atonyU-terine atony C-ardiac disease-C-ardiac disease- MI. cardiomyopathy/ischemia/aorticMI. cardiomyopathy/ischemia/aortic H-ypertension- preeclampsia/eclampsiaH-ypertension- preeclampsia/eclampsia O-ther: usual differential diagnosisO-ther: usual differential diagnosis P-lacenta: abruption/previaP-lacenta: abruption/previa S-epsisS-epsis

41 ACLS OB Contributing factors (A CUB HOPES) A-nesthesiaA-nesthesia C-ardiac diseaseC-ardiac disease U-terine atonyU-terine atony B-leedingB-leeding H-ypertensionH-ypertension O-therO-ther P-lacentaP-lacenta E-mbolismE-mbolism S-epsisS-epsis

42 OB Considerations Search for pregnancy specificSearch for pregnancy specific Hs and TsHs and Ts DefibrillationDefibrillation Remove fetal monitorsRemove fetal monitors

43 OB Considerations MedsMeds VasopressorsVasopressors EpiEpi VasoVaso AntiarrhythmicsAntiarrhythmics Amiodarone-class DAmiodarone-class D Lidocaine-class BLidocaine-class B Mag Sulfate-class AMag 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 weeks Ok for gestational age less than 24 weeks or postpartum

45 Modifications for Pregnancy Higher hand placement of chestHigher hand placement of chest Use pulse checks to confirm efficacy of compressionsUse pulse checks to confirm efficacy of compressions Uterine displacementUterine displacement Timing -for perimortem C/S deliveryTiming -for perimortem C/S delivery No fibrinolyticsNo fibrinolytics Amiodarone- less than 24 weeks or after delivery of fetusAmiodarone- less than 24 weeks or after delivery of fetus

46 Modifications for Pregnancy Early advanced airwayEarly advanced airway Complicated intubationComplicated intubation Jaw thrustJaw thrust Cricoid pressure/Sellick maneuverCricoid pressure/Sellick maneuver Smaller ETT if neededSmaller ETT if needed Altered location of confirmatory lung soundsAltered location of confirmatory lung sounds

47 Modifications for Pregnancy Increased resistance with bag mask ventilationIncreased resistance with bag mask ventilation Remove fetal monitors prior to cardioversion, defibrillationRemove fetal monitors prior to cardioversion, defibrillation Increase paddle pressure if using paddles- use hands free is preferredIncrease paddle pressure if using paddles- use hands free is preferred Maternal TiltMaternal Tilt

48 Potential Causes for Stroke Hemorrhagic strokeHemorrhagic stroke Ischemic strokeIschemic stroke Hypertensive encephalopathyHypertensive encephalopathy Preeclampsia or eclampsiaPreeclampsia or eclampsia Intracranial massIntracranial mass Meningitis/encephalitis Seizure Migraine Craniocerebral/cervical trauma Metabolic conditions Hypo, hyperglycemia, drug overdose

49 Pulseless VT /VF CPR and defibrillationCPR and defibrillation Vasopressor and 2 nd defibrillationVasopressor and 2 nd defibrillation Antiarrhythmic and 3 rd defibrillationAntiarrhythmic and 3 rd defibrillation

50 How do I become an ACLS-OB InstructorHow do I become an ACLS-OB Instructor

51 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)Take the on-line Core Instructors course from AHA- (manual purchased from AHA) Attend a one day ACLS instructor classAttend a one day ACLS instructor class Attend two day ACLS-OB provider classAttend two day ACLS-OB provider class Do teachback class in your areaDo teachback class in your area Set up program with your Organizational Development department- CEUs etcSet up program with your Organizational Development department- CEUs etc Offer first class for managers, charge staffOffer first class for managers, charge staff

52 Implementing ACLS-OB program at your facilityImplementing ACLS-OB program at your facility

53 Implementing ACLS-OB program at your facility Two day provider course- initiallyTwo day provider course- initially Followed by one day renewalFollowed by one day renewal Train ACLS instructorsTrain ACLS instructors Anesthesia, ED, other educatorsAnesthesia, ED, other educators Mock simulations on the unitsMock simulations on the units

54 Implementing ACLS-OB program at your facility Limit class size to 6 participants per 2 instructorsLimit class size to 6 participants per 2 instructors Read scenario/run simulatorRead scenario/run simulator Grade and debriefGrade and debrief Organize paperwork into a file boxOrganize paperwork into a file box Laminate practice and megacode scenariosLaminate practice and megacode scenarios ECG simulator- $ x 2ECG simulator- $ 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.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.

55 Considerations Unit specific criteria for instructorsUnit specific criteria for instructors Hospital BudgetHospital Budget Target audienceTarget audience Administrative /Management challengesAdministrative /Management challenges Supplies, Equipment- Funding???Supplies, Equipment- Funding??? Startup investment/regulatory issuesStartup investment/regulatory issues

56 Hope you dont feel like this ANY QUESTIONS?


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