ACLS-OB

A Maternal Code Are You Ready?

Angie Rodriguez ARNP, CS, MSN, CNM, RNC-OBKerry 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 dripor 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

•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

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 FactorsBEAU-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

AmiodaroneHalf life- 40 daysAvoid in pregnancy- fetal hypothyroidismUse 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?