Presentation on theme: "ACLS-OB A Maternal Code Are You Ready?"— Presentation transcript:
1 ACLS-OB A Maternal Code Are You Ready? Angie Rodriguez ARNP, CS, MSN, CNM, RNC-OBKerry Foligno RN, BSN, CLC, CPST
2 Advanced Cardiac Life Support with an Obstetric Focus ACLS-OBAdvanced 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-OBEducation, 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 survivalRecognition of arrestActivation of EMS/Code BlueBLSAED/ACLS
6 Our Journey at MHW Attended National Convention- booth Requested - Rejected, Persisted4 staff nurses/CM’s-went to Idaho 2009Magnet journeyBrought it back and implemented the programAll L&D staff attended from all three facilitiesInstructor trainer
7 Are arrhythmias serious? Arrhythmias may be benign,symptomatic, life threateningor even fatal.
8 ACLS-OB the patient clinically and how are we going to treat the The most important question is not justWhat is the Rhythm …butHow is this rhythm affectingthe patient clinically and howare we going to treat therhythm??
17 Pharmacologic Treatment of Ventricular Fibrillation & Ventricular Tachycardia (Pulseless) Vasopressors:Epinephrine1mg. IVP/IO – 1:10,000 solutionRepeat every 3 – 5 minutesOptimizes cardiac and cerebral blood flowVasopressinTo replace 1st or 2nd dose of Epinephrine40 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 mL D5W) IV/IO push once, then consider additional 150mg IV/IO once , then followed by IV dripor only after perimortem deliveryLidocaine – 1 to 1.5 mg/kg first dose, then 0.5 to 0.75 mg/kg IV/IO, maximum 3 doses or 3mg/kg
30 Ventricular Tachycardia Question- is there a pulseYes- synchronized cardioversionNo-start CPR, Airway management, defibrillate and or meds
31 Too Slow Defining symptomatic bradycardia Emphasize this point: do not treat a slow heart rate in a stable patient.Emphasize history as the way to decide if the condition is acute or chronic.Emphasize this point: treating the symptoms is the most important concept.Relative bradycardia exists when a hypotensive patient “needs” a faster heart rate, but the rate cannot accelerate due to sinus node disease, conduction system disease, or -blockers.Resting athletes may have sinus rates <40 bpm and still be completely asymptomatic.Patients with inferior MI frequently have sinus bradycardia with or without chest pain.Will the ischemia be alleviated or worsened by increasing the rate?Usually the bradycardia is not the cause of the chest pain.Treat if clearly detrimental symptoms are present (hypotension/shock, decreased level of consciousness, sudden increased pain associated with decreased rate, CHF, or adrenergic symptoms such as pallor and cool, clammy periphery).
33 Pharmacologic Treatment of Non-Lethal Bradyarrhythmias Symptomatic??YES – Altered mental status, chest pain, hypotension, other signs of shockAtropine 0.5 mg IV. May repeat to a total dose of 3 mg.Prepare for transvenous pacingSet rateSet current-(MA) increase by 5 or 10 until capture
34 Review for most frequent causes H’s and T’sReview for most frequent causes1HypovolemiaHypoxiaHydrogen ion —acidosisHyper-/hypokalemiaHypothermiaTablets” (drug OD, accidents)Tamponade, cardiacTension pneumothoraxThrombosis, coronary (ACS)Thrombosis, pulmonary (embolism)
41 ACLS OB Contributing factors (A CUB HOPES) A-nesthesiaC-ardiac diseaseU-terine atonyB-leedingH-ypertensionO-therP-lacentaE-mbolismS-epsis
42 OB Considerations Search for pregnancy specific Defibrillation H’s and T’sDefibrillationRemove fetal monitors
43 OB Considerations Meds Vasopressors Antiarrhythmics Epi Vaso Amiodarone-class DLidocaine-class BMag Sulfate-class A
44 OB Considerations Fibrinolytics relative contraindications-pregnancy and immediate postpartum due to increased risk of bleedingAmiodaroneHalf life- 40 daysAvoid in pregnancy- fetal hypothyroidismUse lidocaine- if weeksOk for gestational age less than 24 weeks or postpartum
45 Modifications for Pregnancy Higher hand placement of chestUse pulse checks to confirm efficacy of compressionsUterine displacementTiming -for perimortem C/S deliveryNo fibrinolyticsAmiodarone- less than 24 weeks or after delivery of fetus
46 Modifications for Pregnancy Early advanced airwayComplicated intubationJaw thrustCricoid pressure/Sellick maneuverSmaller ETT if neededAltered location of confirmatory lung sounds
47 Modifications for Pregnancy Increased resistance with bag mask ventilationRemove fetal monitors prior to cardioversion, defibrillationIncrease paddle pressure if using paddles- use hands free is preferredMaternal Tilt
48 Potential Causes for Stroke Hemorrhagic strokeIschemic strokeHypertensive encephalopathyPreeclampsia or eclampsiaIntracranial massMeningitis/encephalitisSeizureMigraineCraniocerebral/cervical traumaMetabolic conditionsHypo, hyperglycemia, drug overdose
49 Pulseless VT /VF CPR and defibrillation Vasopressor and 2nd defibrillationAntiarrhythmic and 3rd defibrillation
51 How do I become an ACLS-OB Instructor Become an ACLS instructor in your areaTake the on-line Core Instructors course from AHA- (manual purchased from AHA)Attend a one day ACLS instructor classAttend two day ACLS-OB provider class Do teachback class in your areaSet up program with your Organizational Development department- CEU’s etcOffer first class for managers, charge staff
53 Implementing ACLS-OB program at your facility Two day provider course- initiallyFollowed by one day renewalTrain ACLS instructorsAnesthesia, ED, other educatorsMock simulations on the units
54 Implementing ACLS-OB program at your facility Limit class size to 6 participants per 2 instructorsRead scenario/run simulatorGrade and debriefOrganize paperwork into a file boxLaminate practice and megacode scenariosECG simulator- $ x 2Mannequin, 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 instructors Hospital Budget Target audienceAdministrative /Management challengesSupplies, Equipment- Funding???Startup investment/regulatory issues