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

2. Advanced Cardiac Life Support with an Obstetric Focus
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 patient clinically and how are we going to treat the
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 Shockable Nonshockable
1. Lethal (pulseless) rhythms
Shockable
Nonshockable
2. Non-lethal (with a pulse) rhythms

10. Lethal rhythms Shockable Non-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
Coarse VF

16. Ventricular Fibrillation
Fine
Fine VF

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 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

19. Nonshockable Lethal 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 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 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).

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. Review for most frequent causes
H’s and T’s
Review for most frequent causes 1
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 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

41. 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

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

43. OB Considerations Meds Vasopressors Antiarrhythmics Epi Vaso
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 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

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)
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

52. Implementing ACLS-OB program at your facility

53. 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

54. 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- $ 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.

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

56. Hope you don’t feel like this
ANY QUESTIONS?