acls – ob: managing an obstetric code. learning objectives upon completion of this session, the...
TRANSCRIPT
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ACLS – OB: Managing an Obstetric Code
•Angela Walker, MSN, RN-BCLife Support Training Center CoordinatorCenter for Education & Professional Development
&
•Beth Lambertz-Guimarães, MSN, RNC-OBMaternal Outreach Coordinator
The Regional Perinatal Outreach Program at The Medical Center of Central GeorgiaMacon, GA
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LEA
RN
ING
O
BJE
CTIV
ES
Upon completion of this session, the learner will be able to:
• List four modifications to ACLS Algorithms (AHA Guidelines2010) for the Obstetric patient.
• Identify three recommendations for peri-mortem cesarean delivery.
• Describe three steps an institution may take to respond effectively to the pregnant woman requiring resuscitative measures based on scientific evidence.
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ACLS-OB: MANAGING AN OBSTETRIC CODE
Beth Lambertz-Guimaraes, MSN, RNC-OBMaternal Outreach CoordinatorThe Regional Perinatal Outreach Program atThe Medical Center of Central Georgia
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What is A
CLS
– O
B
© ?
ACLS – OB© is…• Authored by a wonderful team at St.
Luke’s Hospital in Boise, Idaho– Teresa Stanfill & Claire Beck
• Provided as adjunct to AHA – ACLS New Provider or Recertification class
• Designed to provide an understanding of modifications of ACLS algorithms to successfully manage a pregnant patient requiring resuscitation.
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Th
e S
cop
e o
f the
Pro
ble
m
• Review of CEMACH (Confidential Enquiries into Maternal and Child Health)2007 data set calculates: Maternal Mortality rate @ 13.95 deaths/100,000 GA is 50th out of 50 states for Maternal
deaths!!! Cardiac arrests now 1:20,000 (↑ from 1:30,000) Jeejeebhoy FM, etal. 2011. Management of Cardiac Arrest in Pregnancy: A systematic Review.
Resuscitation, 82, 801-09
• Why is cardiac arrest in pregnancy on rise? More mature gravidas (more morbidity) Childbearing NICU Grads (growing evidence
suggests ↑ rates of hypertension & heart disease in these women)
ART: Assisted Reproductive TechnologiesSchimmelpfennig K, Stanfill T. When Lightning Strikes. AWHONN Lifelines. 10(4): 306-11 Aug /
Sept 2006
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Surv
ivin
g C
ard
iac A
rrest in
Pre
gnancy
• Pregnancy & it’s complications ↑ both incidence of & difficulty adapting to life- threatening complications.
• Physiologic changes of pregnancy necessitate an altered response & modifications to improve success.
• Key considerations when pregnant woman experiences cardiac arrest: Where are you? Who and what is available to you? Is the fetus viable?
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Com
mon C
ause
s of M
ate
rnal
Morta
lity
• Trauma• Embolic phenomena
(Pulmonary/amniotic fluid) • Hemorrhage• Hypertension• Infection
Datner E, Promes S. Resuscitation in pregnancy. The McGraw-Hill
Co.; 2006. Tintinalli’s emergency medicine; pg. 254
Neufeld J. Trauma in pregnancy. In Marx, editor. Rosen’s
Emergency Medicine 6th Ed. 2006, ch 35.
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AH
A G
uid
elin
es2
01
0
Part 12.3: Cardiac Arrest Associated with Pregnancy
• BLS performed perfectly provides 25-33% of
normal cardiac output
• BLS performed in pregnancy w/o
modifications achieves ≤ 10% !!!
• An algorithm to address specifics of
Maternal Cardiac Arrest management was
included in the 2010 guidelines…you will
see that today
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“Best hope of fetal survival is maternal survival.”
AHA2010
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Vanden Hoek T L et al. Circulation 2010;122:S829-S861
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First Resp
on
der
• Modification #1: hand placement at mid-sternum to accommodate the physiologically elevated heart, which is also displaced to the left.
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Vanden Hoek T L et al. Circulation 2010;122:S829-S861
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Su
bse
qu
en
t R
esp
on
ders
• Modification #2: perform bag-mask ventilation with 100% oxygen & consider advanced airway placement ASAP. Physiologic changes of pregnancy result in compensated respiratory alkalosis…therefore periods of apnea / hypoventilation quickly evolve into acidosis
• Modification #3: anticipate difficult airway; experienced provider preferred for advanced airway placement as soon as possible…
• Confirm placement by auscultation @ mid-clavicle & midline of underarm area
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“Diffi
cult A
irway”
Incidence of failed intubation 1:280 in normal pregnant population vs. 1:2230 in general surgical population
Physiologic alterations in airway mucosa include hyperemia, edema, friability, & hyper-secretion
If possible, intubation should be managed by experienced providers, w/ smaller (by 0.5 – 1.0 mm) E-T tube (#7 or 6.5) or supra-glottic airway
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Airw
ay
Mod
ifica
tion
s
• Use jaw thrust to open airway
• As mentioned,
ventilate w/100% O2
• Expect increased resistance to bag – mask ventilation
• Move to advanced airway placement ASAP
• Cricoid pressure in combination with jaw-thrust to intubate
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Wh
at is C
ricoid
Pre
ssure
?
• Cricoid pressure should be used only if the victim is deeply
unconscious; consists of pushing the cricoid cartilage
toward cervical spine… compressing the esophagus, and may prevent gastric inflation and reduce risk of regurgitation and aspiration.
• Application of cricoid pressure is performed by a rescuer who is not responsible for chest compressions or ventilations.
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Crico
id P
ressu
re
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Vanden Hoek T L et al. Circulation 2010;122:S829-S861
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Ob
vio
usly
Gra
vid
W
om
b?
• Once the fundus of the womb reaches the umbilicus it “qualifies” as an obviously gravid womb…Fundal height ↓ level of umbilicus resuscitate as if non-pregnant
• Generally, if the woman is carrying a normal sized singleton, the fundus is @ the umbilicus @ 20 weeks; each additional week the fundus will be 1 cm / 1 fingerbreadth higher.
• Multiple gestations result in an “obviously gravid” womb before 20 weeks…
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Su
bse
qu
en
t R
esp
on
ders
• Modification #4: perform manual left uterine displacement (LUD) to relieve aorto-caval compression
• Modification #5: assess femoral pulse for effectiveness of compressions.
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LUD
~ 1
-han
d
tech
niq
ue
Vanden Hoek T L et al. Circulation 2010;122:S829-S861
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Vanden Hoek T L et al. Circulation 2010;122:S829-S861
LUD
~ 2
-han
d
tech
niq
ue
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Vanden Hoek T L et al. Circulation 2010;122:S829-S861
LUD
~3
0º Tilt o
f B
ackb
oard
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Peri-M
orte
m
Cesa
rean
• Modification #6: If no ROSC within 4 minutes initiate a
Peri-Mortem Cesarean Delivery (PMCD) with goal to have baby out by 5 minutes.
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PM
CD
• Maternal survival in a woman with an “obviously gravid womb” is greatly influenced by presence of fetus
• Mom’s survival is ↑ by maternal modifications to ACLS which include evacuation of the womb within 4 – 5 minutes in the absence of ROSC, once fundal height is ≥ the umbilicus!
• Getting the infant into the hands of the NICU Team quite possibly improves their survival as well
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PM
CD
• In a Level III or higher nursery, neonatal survival at ≥ 24 weeks is promising…certainly more promising than remaining in the womb of a momma who is not responding to resuscitative measures.
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• >24 wks PMCD ↑ maternal CO & infant survival
• 20-23 wks (1-3 ↑u): better maternal CO; possible fetal survival
• <20 wks (↓ umbilicus): cesarean not likely to improve maternal CO; no fetal survival; proceed w/o modifications to BLS / ACLS algorithms
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Wh
o E
mp
ties th
e
Ute
rus?
• Someone with “scalpel privileges”
OB is so privileged…
No OB?...any physician on staff with
scalpel privileges may empty womb…
Check with Medical Staff Office /
Credentialing Department to see who
might “fit the bill” if you represent a
hospital without obstetric service
provision
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Loca
tion
?
• Scientific evidence supports PMCD at point of entry / location of arrest…
• Movement to OR costs valuable life saving time
• Have PMCD “Kit” available in ER and readily accessible to any labor room
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PM
CD
“Packs” o
r “K
its”
• Knife handle (1) with #10 blade (2)• Kelly clamps (4)• Mayo scissors (1)• Bandage scissors (1)• Tooth forceps (2)• Needle holders (2)• Uterine closure sutures (4) • Laparotomy sponges (2 packs of 5
each)• Adhesive clear plastic abdominal
drape (1)• 1 ml/10 units pitocin vials (2)• 10 ml normal saline vials (2)• 10 ml syringe with intramuscular
needle (1)
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Katz, 1986, reported by Luppi. AWHONN Lifelines. 1999
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Birth
Weig
ht a
nd
Outco
me
Westg
ren a
nd
Paul’s re
vie
w o
f 25
1 ca
ses
Birth Weight (grams)
Number Surviving
Percent Surviving
< 500 0 0%
501 - 750 20 43%
751 - 1000 32 65%
1001 - 1250 43 88%
1251 - 1500 73 92%
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Wh
at D
oesn
’t C
han
ge?
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Wh
at D
oesn
’t C
han
ge
• Don’t delay defibrillation…joules as per AHA ACLS Algorithms If electronic fetal monitor in use, disconnect the
cables Pads preferable to paddles…if paddles = only
option – ↑ pressure on paddles (normal 25#)
• Administer ACLS drugs & doses per AHA ACLS Algorithms
• Note: Amiodarone (FDA Category “D”); 40 day ½ life; use in pregnancy associated w/fetal hypothyroidism
• At point it appears in Cardiac arrest algorithm…if PMCD indicated should have baby out by then or lidocaine = alternative
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AH
A M
nem
onic “B
EA
U-
CH
OPS”
• Bleeding/DIC• Embolism
Coronary / Pulmonary / Amniotic fluid
• Anesthesia- complications• Uterine atony
• Cardiac disease
MI / cardio-myopathy / congenital defects ~ repaired / aortic dissection
• Hypertension
Chronic / Preeclampsia / Eclampsia
• Other usual “H’s” & “T’s” • Placenta ~ previa / accreta / increta /
percreta / abruptio • Sepsis
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Wh
at D
oesn
’t C
han
ge
• Review the Reversible Causes:
Hypovolemia
Hypoxia
Hydrogen Ion
Hypo-/hyperkalemia
Hypothermia
Tension pnuemothorax
Tamponade, cardiac
Toxins
Thrombosis, pulmonary
Thrombosis, coronary
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ACLS – OB / INSTITUTIONAL PREPARATION
Angela Walker, MSN, RN-BC•Nurse Educator Specialist•Training Center Coordinator•Center for Education & Professional Development at•The Medical Center of Central Georgia
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Wh
y A
CLS
-OB
?
Outreach education & support to all providers in the region is a requirement of the contracts.
Beth Lambertz-Guimaraes is the Maternal Outreach Coordinator for MCCG.
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Wh
y A
CLS
-OB
?
• MCCG receives Maternal (& Neonatal) transports from hospitals in our region.
• The moms are often extremely complex, at very high risk for life-threatening complications…not all life-threatening complications have waited to get to MCCG to occur!!!
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Ou
r Jou
rney a
t M
CC
G
• In March of 2012, Beth invited the ACLS-OB authors Teresa Stanfill and Claire Beck to come from St. Luke’s Hospital in Boise, Idaho, to MCCG for three days of intensive training.
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Log
istics, Logistics,
Logistics…
..
Get a ROOM! Set
Up
Agendas
Paperwor
k
Clean UpBreak
it Down!
Schedule
Instructors
Talk to Boise team
Juggle Concur
rent Classes
Sit in on ACLS-
OB Class
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Ou
r Jou
rney a
t M
CC
G
• The original training class included
eight nurses: Beth, our Maternal Outreach nurse.
Nurses from MCCG, including a
department-based educator, a staff nurse,
and the assistant director of Labor &
Delivery.
Nurses from Dodge County Hospital and
Fairview Park Hospital, both in Middle
Georgia and Level I providers.
Nurses from Tift Regional Medical Center,
in Tifton, Georgia and a Level II provider.
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Ou
r Jou
rney a
t M
CC
G
• Program of Study:ACLS Provider ClassACLS Instructor ClassACLS-OB Provider Class
• Results:All nurses enrolled completed and
passed all stations and examinations.All MCCG nurses completed the
process to become ACLS instructors.Beth also completed the process to
become an ACLS instructor.
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AC
LS &
OB
– A G
ood
Fit • ACLS-OB content is provided as an adjunct to
AHA ACLS:
Taught prior to or after ACLS
Standard AHA Provider card
Standard AHA ACLS written exam
Skills tests utilize AHA Algorithms with OB-focused
scenarios.
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Ou
r Jou
rney a
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CC
G
• Roles of the Educator:EducatorFacilitatorConsultantResearcher LeaderChange Agent
• A change agent initiates needed change, and assists others in adopting and adapting to change.
O’Shea, Kristen L. (2002). Staff Development Nursing Secrets. Philadelphia, PA: Hanley & Belfus, Inc.
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Ou
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CC
G
• Working Within the System to Affect Change:
Barriers
Buy-in
Cost
Time
Champions
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Cham
pio
ns in
Change
• Adding this course to our Life Support Training Center Schedule on a regular basis involved the commitment and dedication of many individuals and teams. Administration – especially Betty Casey,
MSN, AVP of Surgical, Women’s & Outpatient Services
The Center for Education & Professional Development at MCCG
The Code Blue Committee at MCCGAnd many others….
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Oth
er C
han
ges…
• Codes We Call at MCCG:
CODE BLU
E
CODE STORK
Both codes called for the same
location means:ACLS-
OB
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Inaugura
l AC
LS O
B P
rovid
er
Cla
ss
The first ACLS-OB Provider Class held at MCCG took place on January 30th and 31st 2014. MCCG is the only hospital in Georgia that teaches this class. This initiative was spear-headed by the Maternal Outreach nurse, Beth Lambertz-Guimaraes, who brought the authors of the program from Boise, Idaho, to train our team of instructors, Jennifer Boland and Lisa Suggs. Pictured from left to right (back row) is Jane Holik, Jennifer Boland, Lisa Suggs, Beth Lambertz-Guimaraes, Kristen Spotts, and left to right (front row) Rita Little, Heather Staley, Phyllis Gresham, and Kayla Blount.
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Team
Appro
ach
(Krueger, 2004)
OB/Maternal Team
BLSUterine displacementAssessment of fetal
viabilityMedical history
Perimortem Cesarean
Neonatal Team
Maternal historyResuscitation history
Gestational age of fetusDisposition of neonate
Code Team
ACLSIntubate-IVs-MedicationsInternal cardiac massage
(Krueger, 2004)
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Wh
at’s N
ext?
• Continue to offer ACLS-OB at MCCG for:
All Labor & Delivery NursesAll Medical Residents Interested Healthcare Providers in
the Community and StateExpand program to include the
Emergency Center Nurses and Physicians at MCCG
Expand program to include the Intensive Care Unit Nurses and Physicians at MCCG
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Con
sidera
tion
s
• Unit-Specific Criteria for Instructors
• Hospital Budget
• Target Audience
• Administrative /Management Challenges
• Equipment, Supplies
• Funding
• Startup Investment/Regulatory Issues
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Don
’t Miss T
his!
• Reduced tuition for conference attendees for the ACLS-OB Provider Class on
• October 16th and 17th, 2014 and • January 29th and 30th, 2015.