Physical Assessment and Physical Assessment and Newborn Stabilization:Newborn Stabilization:

What You Can Do!What You Can Do!

Bette Johnson, CRNP, SCMC NICU Transport Bette Johnson, CRNP, SCMC NICU Transport CoordinatorCoordinator

Randa Bates, RN, NICU Transport NurseRanda Bates, RN, NICU Transport NurseDoug Ferguson, RT, Airlink Respiratory Doug Ferguson, RT, Airlink Respiratory

TherapistTherapist

QuestionsQuestionsto Considerto Consider

How many staff have How many staff have taken Neonatal taken Neonatal Resuscitation(NRP)?Resuscitation(NRP)?

Do you have a infant Do you have a infant appropriate bags?appropriate bags?

Appropriate sized Appropriate sized masks?masks?

Sat Probes?Sat Probes? Glucometer, or Glucometer, or

sticks?sticks?

Appropriate sized BP Appropriate sized BP cuffs?cuffs?

Newborn Newborn Resuscitation Kit?Resuscitation Kit?

Appropriate Sx Appropriate Sx equipment?equipment?

Heat packs?Heat packs? Do you have monitors Do you have monitors

that can monitor an that can monitor an infant? infant?

Provide Warmth, Position, Clear Airway, Dry, Stimulate to Breath

CLINICAL ASSESSMENT Provide supplemental oxygen, as necessary

Room air- 100%Assist Ventilation with

Positive Pressure VentilationMR SOPA

Intubate the trachea

Provide Chest compressions

Administer Medications

Neonatal StabilizationNeonatal Stabilization

MR SOPAMR SOPAIf PPV not workingIf PPV not working

M= mask, right size and fitM= mask, right size and fit R= reposition, neck and/or mask R= reposition, neck and/or mask S= suction, nose and mouthS= suction, nose and mouth O= open mouth while ventilatingO= open mouth while ventilating P= increase pressure if no chest riseP= increase pressure if no chest rise A= consider alternative airway, intubate or A= consider alternative airway, intubate or

LMALMA

What to look for:What to look for:

What You Can DoWhat You Can Do

Continually assess- Five Apgar pointsContinually assess- Five Apgar points Maintain WarmthMaintain Warmth Maintain open and clear airwayMaintain open and clear airway Provide supplemental oxygen Provide supplemental oxygen Call for help earlyCall for help early

KeypointsKeypoints

Initial steps of NRP are the most importantInitial steps of NRP are the most important Most powerful tool initially is maintenance Most powerful tool initially is maintenance

of airway- may prevent further of airway- may prevent further decompensationdecompensation

Oxygen is a powerful drug, start with room Oxygen is a powerful drug, start with room air, then go to 100% if no blenderair, then go to 100% if no blender

Know your equipment, maintain it and Know your equipment, maintain it and keep current on it’s usekeep current on it’s use

Kit ListsKit Lists HatHat ThermometerThermometer Bulb SuctionBulb Suction Baby Booger Getter (BBG)Baby Booger Getter (BBG) Self-inflating bag and newborn Self-inflating bag and newborn

maskmask Infant Sat ProbesInfant Sat Probes BlanketsBlankets DiapersDiapers Umbilical TapeUmbilical Tape SucroseSucrose 5 Fr. Feeding Tube5 Fr. Feeding Tube

HatHat ThermometerThermometer Bulb SuctionBulb Suction Premie MaskPremie Mask Self-inflating BagSelf-inflating Bag Sat probeSat probe Premie Diaper Premie Diaper Premie BP CuffPremie BP Cuff Umbilical tape Umbilical tape Porta WarmerPorta Warmer Plastic bag/plastic wrapPlastic bag/plastic wrap SucroseSucrose 5 Fr. Feeding Tube 5 Fr. Feeding Tube

Newborn Premature

Physical AssessmentPhysical Assessment

Physical AssessmentPhysical Assessment VITAL SIGNS:VITAL SIGNS: Temp range: 97.8-98.6 Temp range: 97.8-98.6 Heart rate: 120’s-160’s, Resp rate: 40-60’sHeart rate: 120’s-160’s, Resp rate: 40-60’s Blood pressure: mean’s approximate gestational age (i.e Blood pressure: mean’s approximate gestational age (i.e

high 20’s low 30’s for preterms, high 30’s low 40’s for high 20’s low 30’s for preterms, high 30’s low 40’s for fullterm)fullterm)

SKIN:SKIN: cyanosis vs acrocyanosis, perfusion, capillary cyanosis vs acrocyanosis, perfusion, capillary refill, rashes, lesions, traumarefill, rashes, lesions, trauma

HEENT:HEENT: HeadHead: scalp swellings, bruising, trauma : scalp swellings, bruising, trauma Eyes:Eyes: equal distance, lids open, pupils reactiveequal distance, lids open, pupils reactive

EarsEars: in line with outer eye : in line with outer eye NoseNose: nares patent or not, : nares patent or not, Throat/NeckThroat/Neck- no masses, clavicles intact or not- no masses, clavicles intact or not

PHYSICAL ASSESSMENT PHYSICAL ASSESSMENT CONTINUEDCONTINUED

CHEST: Tachypnea, Increased work of CHEST: Tachypnea, Increased work of breathing: Barrel chest, retractions, grunting, breathing: Barrel chest, retractions, grunting, breath sounds: clear and equal, coarse, breath sounds: clear and equal, coarse, diminished. Need for oxygen or assisted diminished. Need for oxygen or assisted ventilation. Gasping or apneaventilation. Gasping or apnea

HEART: rate, rhythm, murmur, pulses, blood HEART: rate, rhythm, murmur, pulses, blood pressure, perfusion (capillary refill >3secs)pressure, perfusion (capillary refill >3secs)

ABDOMEN: full and soft, sunken, defect ABDOMEN: full and soft, sunken, defect (omphalocele/gastroschisis), hard/firm/shiny, (omphalocele/gastroschisis), hard/firm/shiny, abnormal color abnormal color

PHYSICAL ASSESSMENT PHYSICAL ASSESSMENT CONTINUEDCONTINUED

EXTREMETIES: Number and placement EXTREMETIES: Number and placement of digits, movement equal, tone, of digits, movement equal, tone, trauma/bruising, lesions or markstrauma/bruising, lesions or marks

NEUROLOGIC: tone, activity, able to NEUROLOGIC: tone, activity, able to focus on caregiver, response to painful focus on caregiver, response to painful stimuli, seizuresstimuli, seizures

GENITOURINARY: male vs female GENITOURINARY: male vs female anatomy, can help tell gestation, anus anatomy, can help tell gestation, anus presentpresent

Premature vs Fullterm; Quick Premature vs Fullterm; Quick AssessmentAssessment

Preterm vs Fullterm:Preterm vs Fullterm: Weight - <5 lbs- full term babies who are small Weight - <5 lbs- full term babies who are small

for gestational age can be under 5 lbsfor gestational age can be under 5 lbs Gestational age- <37 weeks (35-37 weeks= late Gestational age- <37 weeks (35-37 weeks= late

preterm infants) preterm infants) Physical exam: > lanugo, <vernix, <breast buds, Physical exam: > lanugo, <vernix, <breast buds,

< tone, < ear cartilage, decreased creases on < tone, < ear cartilage, decreased creases on bottom of feet, bottom of feet, malemale- < scrotum, testes may not - < scrotum, testes may not be descended, be descended, femalefemale- labia minora may be - labia minora may be bigger than majora, decrease in activity and tonebigger than majora, decrease in activity and tone

Preterm vs Fullterm InfantsPreterm vs Fullterm Infants

Why Does It MatterWhy Does It Matter

Preterm babies brains are vulnerable to Preterm babies brains are vulnerable to pressure changes – fluids, ventilation, cold pressure changes – fluids, ventilation, cold stress etc. affects brain- stress etc. affects brain- bleeding, apnea, bleeding, apnea, seizuresseizures

Preterm babies lungs are not fully formed Preterm babies lungs are not fully formed in number of air sacs, capillaries and in number of air sacs, capillaries and surfactant- surfactant- respiratory distress, cyanosisrespiratory distress, cyanosis

Preterm babies don’t have good glucose Preterm babies don’t have good glucose stores- stores- hypoglycemiahypoglycemia

Why does it matterWhy does it matter

Preterm babies don’t have fat stores- Preterm babies don’t have fat stores- hypothermia, poor temp regulationhypothermia, poor temp regulation

Preterm babies guts are not mature- Preterm babies guts are not mature- dysmotility, aspiration, emesis, perforationdysmotility, aspiration, emesis, perforation

Preterm babies don’t have mature immune Preterm babies don’t have mature immune function- function- vulnerable to infectionvulnerable to infection

Preterm babies don’t have good Preterm babies don’t have good autoregulation of blood pressure- autoregulation of blood pressure- hypotension, bleedinghypotension, bleeding

What You Can Do…What You Can Do…

Estimate weightEstimate weight Estimate Gestational ageEstimate Gestational age Have vital signs available for reportHave vital signs available for report Give summary of most immediate reason Give summary of most immediate reason

for transport i.e. respiratory distress, for transport i.e. respiratory distress, seizures, trauma, unresponsive/floppy, seizures, trauma, unresponsive/floppy, cyanotic etccyanotic etc

Call for specialty team early rather than Call for specialty team early rather than laterlater

Physical Assessment Key PointsPhysical Assessment Key Points

Approximate gestational age and weight are Approximate gestational age and weight are important pieces of information to pass onimportant pieces of information to pass on

Neurologic changes are often the first sign that a Neurologic changes are often the first sign that a baby is getting sickbaby is getting sick

““Comfortably tachypneic” babies may have a Comfortably tachypneic” babies may have a primary congenital heart defect that may be primary congenital heart defect that may be getting worse- watch them closelygetting worse- watch them closely

Preterm babies reach “breaking” points faster Preterm babies reach “breaking” points faster than fullterm babiesthan fullterm babies

Babies in general “jump off cliffs” instead of Babies in general “jump off cliffs” instead of “rolling down a hill”“rolling down a hill”

S.T.A.B.L.E. Program S.T.A.B.L.E. Program “Condensed” Version“Condensed” Version

Developed to help all types of providers stabilize Developed to help all types of providers stabilize sick babies no matter what type of facility they sick babies no matter what type of facility they were born in or out of i.e home, car, fieldwere born in or out of i.e home, car, field

Allows for consistency in careAllows for consistency in care Good communication tool to discuss Neonatal Good communication tool to discuss Neonatal

issuesissues Focus on safety and quality of careFocus on safety and quality of care Sugar, Temperature, Airway, Blood Pressure, Sugar, Temperature, Airway, Blood Pressure,

Lab Work and Emotional SupportLab Work and Emotional Support

SUGARSUGARThings that make you go MMM!!!Things that make you go MMM!!!

Causes of HypoglycemiaCauses of Hypoglycemia

Decreased Glucose Stores: Small for gestational Decreased Glucose Stores: Small for gestational age/Premature/Intrauterine growth restrictionage/Premature/Intrauterine growth restriction

Hyperinsulinemia – Infants of Diabetic Hyperinsulinemia – Infants of Diabetic Moms/Large babies/SyndromesMoms/Large babies/Syndromes 2/3 maternal glucose 2/3 maternal glucose

Stress/Increased Utilization- Depletion of storesStress/Increased Utilization- Depletion of stores Cold stressCold stress Traumatic deliveriesTraumatic deliveries Cardio/pulmonary diseasesCardio/pulmonary diseases InfectionInfection ShockShock

Sugar BABY!Sugar BABY!

Keys for aerobic Keys for aerobic metabolismmetabolism Oxygen + Glucose =Oxygen + Glucose =

ENERGYENERGY

Anaerobic Metabolism Anaerobic Metabolism

Lack of 02 or GlucoseLack of 02 or Glucose Lactic acidosis = Lactic acidosis =

IMPAIRED FUNCTIONIMPAIRED FUNCTION

Symptoms include: Symptoms include: HypotoniaHypotonia LethargyLethargy Poor feedsPoor feeds High pitched or weak cryHigh pitched or weak cry Jittery/IrritableJittery/Irritable SeizuresSeizures Increased RDSIncreased RDS ApneaApnea BradycardiaBradycardia

?what part of body is ?what part of body is responsible for all of these responsible for all of these symptoms???symptoms???

How to check glucoseHow to check glucose

Pre-warm the heelPre-warm the heel Warm water, chemical warmer, warm towelWarm water, chemical warmer, warm towel Cold foot = falsely low readingCold foot = falsely low reading Do not over squeeze heelDo not over squeeze heel

Causes clotting,Causes clotting,

bruising and painbruising and pain

What You Can DoWhat You Can Do Be vigilent in assessment for hypoglycemia:Be vigilent in assessment for hypoglycemia: Ask mother or caregiver for risk factors; Ask mother or caregiver for risk factors;

gestation diabetes, on insulin, symptoms of gestation diabetes, on insulin, symptoms of hypoglycemia herselfhypoglycemia herself

If infant has stable vital signs with no respiratory If infant has stable vital signs with no respiratory distress: Consider breastfeeding if mom able distress: Consider breastfeeding if mom able and willing or giveand willing or give

Oral Sucrose (D25W) – drops in cheek with Oral Sucrose (D25W) – drops in cheek with syringesyringe

Glucose Infusion GuidelinesGlucose Infusion Guidelines

D50W PreparationD50W Preparation Draw up 2 ml of D50 add Draw up 2 ml of D50 add

to 10 ml’s of sterile water to 10 ml’s of sterile water to make D10W solutionto make D10W solution

Approximate infant’s Approximate infant’s weight (1 lb = 2.2 kgs)weight (1 lb = 2.2 kgs)

Give via IV or IOGive via IV or IO 2ml/kg 2ml/kg May give bolus over a May give bolus over a

few minutes, slower if few minutes, slower if pretermpreterm

D25W PreparationD25W Preparation Draw up 5 ml’s of D25 Draw up 5 ml’s of D25

and add to 5 ml’s sterile and add to 5 ml’s sterile water to make D12.5water to make D12.5

Approximate infant’s Approximate infant’s weightweight

Give via IV or IOGive via IV or IO 1-1.5 ml/kg1-1.5 ml/kg Give over a few minutes, Give over a few minutes,

slower if preterm slower if preterm

Sugar Key PointsSugar Key Points

Premature, SGA, LGA and stressed Premature, SGA, LGA and stressed babies at highest risk babies at highest risk

Maintain glucose greater than 50mg/dlMaintain glucose greater than 50mg/dl No sugar = decline in statusNo sugar = decline in status Recheck 30 min after treatment and if Recheck 30 min after treatment and if

baby is symptomaticbaby is symptomatic If can’t check glucose and baby is If can’t check glucose and baby is

symptomatic – treat using guidelinessymptomatic – treat using guidelines

Thermoregulation: If you’re hot Thermoregulation: If you’re hot you’re hot, if you’re not you’re not!you’re hot, if you’re not you’re not!

Normal 36.5 – 37.5 C or 97.8 – 98.6 FNormal 36.5 – 37.5 C or 97.8 – 98.6 F

HEAT LOSS:HEAT LOSS:

Conduction = loss to objects that are colderConduction = loss to objects that are colder

Convection = loss via air currentsConvection = loss via air currents

Evaporative = moisture turns to vaporEvaporative = moisture turns to vapor

Radiation = Loss to colder object not in contact Radiation = Loss to colder object not in contact with baby with baby

WHY?:WHY?:

Large surface area = greater heat lossLarge surface area = greater heat loss

Lack of shivering ability = no heat productionLack of shivering ability = no heat production

Exposed Defects = increased surface areaExposed Defects = increased surface area

Which babies are at risk?Which babies are at risk?

Premature/Low Birth WeightPremature/Low Birth Weight Small for gestational age (SGA)Small for gestational age (SGA) Prolonged ResuscitationProlonged Resuscitation Acutely Ill (often accompanies sepsis)Acutely Ill (often accompanies sepsis) Abdominal or Spinal DefectsAbdominal or Spinal Defects Any infant born in a compromised Any infant born in a compromised

environment – i.e. birth center, home, car, environment – i.e. birth center, home, car, outdoorsoutdoors

Term vs. PretermTerm vs. Preterm

Term ResponseTerm Response Vasoconstriction Vasoconstriction

PeripherallyPeripherally Increased tone and Increased tone and

movementmovement Normal glucose Normal glucose

storesstores Brown Fat Brown Fat

MetabolismMetabolism

Preterm Preterm Response/SGAResponse/SGA

Poor vasoconstrictionPoor vasoconstriction Weak muscle toneWeak muscle tone Limited glycogen Limited glycogen

storesstores Minimal or No Brown Minimal or No Brown

FatFat

Effects of Cold StressEffects of Cold Stress

Significantly increased metabolic rateSignificantly increased metabolic rate Increased Oxygen consumptionIncreased Oxygen consumption Increased Glucose metabolismIncreased Glucose metabolism

• At extreme risk for hypoxemia, hypoxia and At extreme risk for hypoxemia, hypoxia and hypoglycemiahypoglycemia

***Preventing hypothermia is much easier than ***Preventing hypothermia is much easier than overcoming the detrimental effects once overcoming the detrimental effects once hypothermia has occurred.***hypothermia has occurred.***

Adapted from S.T.A.B.L.E Program 5th Edition

What You Can DoWhat You Can Do

What You Can DoWhat You Can Do

All Babies:All Babies: DryDry Place HatPlace Hat Increase Increase

environmental temp environmental temp Decrease DraftsDecrease Drafts Warm blanketsWarm blankets IV bags from warmerIV bags from warmer Chemical WarmersChemical Warmers

Infant dependant:Infant dependant: Skin to skinSkin to skin Saran WrapSaran Wrap Swaddle Swaddle

*** Never microwave *** Never microwave blankets or other blankets or other objects for heatobjects for heat

Always cover Always cover warmers with clothwarmers with cloth

Key PointsKey Points

All infants are at varying risk for hypothermiaAll infants are at varying risk for hypothermia Check axillary temps frequently Check axillary temps frequently Increase environmental temp- you should be Increase environmental temp- you should be

hot!hot! Keeping an infant normothermic can help Keeping an infant normothermic can help

PREVENT the need for further stabilization PREVENT the need for further stabilization

Maternal ConditionsMaternal ConditionsCausing Causing

Infant DistressInfant Distress Diabetes: insulin dependent or gestational Diabetes: insulin dependent or gestational

non-insulin dependent. A1c significancenon-insulin dependent. A1c significance Hypertension: either pre-pregnancy or Hypertension: either pre-pregnancy or

pregnancy inducedpregnancy induced Placental/Uterine disruptions: placenta Placental/Uterine disruptions: placenta

previa, abruption, uterine rupture, cord previa, abruption, uterine rupture, cord prolapseprolapse

Infections: GBS, e.coli, MRSA, listeriaInfections: GBS, e.coli, MRSA, listeria

Airway ManagementAirway Management

RESPIRATORY DISTRESS IN FULLTERM RESPIRATORY DISTRESS IN FULLTERM INFANTS:INFANTS:

MOST COMMON CAUSESMOST COMMON CAUSES TRANSIENT TACHYPNEA- retained TRANSIENT TACHYPNEA- retained

interstitial lung fluidinterstitial lung fluid ASPIRATION- meconium, amniotic fluid, ASPIRATION- meconium, amniotic fluid,

blood, breast milk or formula, gastric blood, breast milk or formula, gastric contentscontents

AIR LEAK SYNDROMES: pneumothoraxAIR LEAK SYNDROMES: pneumothorax PNEUMONIAPNEUMONIA CARDIAC LESIONS: duct dependent CARDIAC LESIONS: duct dependent

RESPIRATORY DISTRESSRESPIRATORY DISTRESSIN PRETERM INFANTS:IN PRETERM INFANTS:

MOST COMMON CAUSESMOST COMMON CAUSES RESPIRATORY DISTRESS SYNDROME:RESPIRATORY DISTRESS SYNDROME:

Surfactant deficiency and immature anatomySurfactant deficiency and immature anatomy ASPIRATION: same as full term babiesASPIRATION: same as full term babies AIRLEAKS: pneumothoraxAIRLEAKS: pneumothorax PNEUMONIA: always have sepsis on PNEUMONIA: always have sepsis on

differential with infant in respiratory differential with infant in respiratory distress- think SHOCKdistress- think SHOCK

SIGNS/SYMPTOMS OF SIGNS/SYMPTOMS OF RESPIRATORY DISTRESSRESPIRATORY DISTRESS

TACHYPNEA- 100 breaths per minute or more- TACHYPNEA- 100 breaths per minute or more- comfortable or increased work of breathingcomfortable or increased work of breathing

APNEA/GASPING – cessation of breathing >15 APNEA/GASPING – cessation of breathing >15 secssecs

RETRACTIONS- intercostal, subcostal, RETRACTIONS- intercostal, subcostal, suprasternal, supraclavicularsuprasternal, supraclavicular

NASAL FLAIRINGNASAL FLAIRING GRUNTINGGRUNTING CYANOSISCYANOSIS

What You Can DoWhat You Can Do

KEEP THEM SWEET - normoglycemicKEEP THEM SWEET - normoglycemic KEEP THEM WARM – neutral thermalKEEP THEM WARM – neutral thermal KEEP AIRWAY CLEAR AND HEAD IN KEEP AIRWAY CLEAR AND HEAD IN

SNIFFING POSITIONSNIFFING POSITION PROVIDE SUPPLEMENTAL OXYGENPROVIDE SUPPLEMENTAL OXYGEN PROVIDE BAG/MASK VENTILATIONPROVIDE BAG/MASK VENTILATION PLACE AN ALTERNATIVE AIRWAY- PLACE AN ALTERNATIVE AIRWAY-

INTUBATE OR USE LMAINTUBATE OR USE LMA KEEP THEM HYDRATEDKEEP THEM HYDRATED

Airway Key PointsAirway Key Points

Respiratory distress can present in babies due Respiratory distress can present in babies due to hypoglycemia, hypo/hyperthermia, to hypoglycemia, hypo/hyperthermia, hypovolemia, sepsis, neurologic injury, cardiac hypovolemia, sepsis, neurologic injury, cardiac disease, pulmonary disease- often first sign of disease, pulmonary disease- often first sign of distressdistress

Preterm babies present faster than full term Preterm babies present faster than full term babies- lack of compensatory mechanismsbabies- lack of compensatory mechanisms

**Clearing the airway and correct use of positive **Clearing the airway and correct use of positive pressure ventilation should be the first course of pressure ventilation should be the first course of action, not cardiac compressionsaction, not cardiac compressions

Oxygen is a powerful drug, use it wiselyOxygen is a powerful drug, use it wisely

INFANT SHOCK !!!INFANT SHOCK !!!

Common Types of ShockCommon Types of Shock

HypovolemicHypovolemic Septic - DistributiveSeptic - Distributive CardiogenicCardiogenic

Hypovolemic ShockHypovolemic Shock Most common cause of shock in the initial Most common cause of shock in the initial

newborn periodnewborn periodCauses:Causes: Intrapartum blood lossIntrapartum blood loss

-fetal-maternal hemorrhage-fetal-maternal hemorrhage-placental abruption/previa-placental abruption/previa-umbilical vessel injury-umbilical vessel injury

- cord prolapse- cord prolapse-twin to twin transfusion-twin to twin transfusion-organ laceration or injury-organ laceration or injury

Hypovolemic ShockHypovolemic Shock

Postnatal hemorrhages: in babiesPostnatal hemorrhages: in babies Brain – intraventricular hemorrhageBrain – intraventricular hemorrhage Lung – pulmonary hemorrhageLung – pulmonary hemorrhage Adrenal glands- traumaAdrenal glands- trauma Scalp – most serious subgaleal, loss of Scalp – most serious subgaleal, loss of

most of blood volume - trauma most of blood volume - trauma

Septic or Distributive ShockSeptic or Distributive Shock

May be either viral or bacterial in originMay be either viral or bacterial in origin May become critically ill rapidlyMay become critically ill rapidly Hypotension may be profound and respond Hypotension may be profound and respond

poorly to fluid resuscitationpoorly to fluid resuscitation *Be prepared to give volume; 10ml/kg may need *Be prepared to give volume; 10ml/kg may need

multiple doses (normal saline or lactated ringers)multiple doses (normal saline or lactated ringers) *Push boluses over 2-3 mins full-term, 5-10 *Push boluses over 2-3 mins full-term, 5-10

pretermpreterm Cultures and antibiotics at referral hospitalCultures and antibiotics at referral hospital *ALS only*ALS only

Cardiogenic ShockCardiogenic ShockHeart FailureHeart Failure

Causes:Causes: Intrapartum/postpartum asphyxiaIntrapartum/postpartum asphyxia Hypoxia and/or prolonged metabolic acidosisHypoxia and/or prolonged metabolic acidosis Bacterial or viral infectionBacterial or viral infection Respiratory failureRespiratory failure Severe hypoglycemiaSevere hypoglycemia Severe metabolic and/or electrolyte Severe metabolic and/or electrolyte

disturbancesdisturbances ArrhythmiasArrhythmias Congenital heart diseaseCongenital heart disease

Evaluation of ShockEvaluation of ShockPhysical ExamPhysical Exam

Neuro-Neuro- tone and activity- floppy, lethargic, not tone and activity- floppy, lethargic, not able to open eyes and look at you, pupils not able to open eyes and look at you, pupils not reactive or sluggishreactive or sluggish

Respiratory-Respiratory- in distress, tachypneic- work of in distress, tachypneic- work of breathing will worsen with shockbreathing will worsen with shock

Cardiac-Cardiac- cyanosis – look at gums not lips, pallor, cyanosis – look at gums not lips, pallor, >cap refill time, weak or absent pulses- compare >cap refill time, weak or absent pulses- compare upper to lower and side to side upper to lower and side to side

Blood pressure is the last to go-Blood pressure is the last to go- “babies jump off “babies jump off cliffs not roll down hill”cliffs not roll down hill”

Differential of CyanosisDifferential of CyanosisCentralCentral

1) Lungs:1) Lungs: “No oxygen in the lungs, no oxygen “No oxygen in the lungs, no oxygen in the blood”in the blood”

Premie lungs, aspirations, pneumothoraxPremie lungs, aspirations, pneumothorax2) Heart:2) Heart: 2 types: a) no blood from heart to 2 types: a) no blood from heart to

lungs (right sided problem or pulmonary lungs (right sided problem or pulmonary hypertension)hypertension)b) No blood from heart to rest of body (left b) No blood from heart to rest of body (left sided problem)sided problem)

3) Blood:3) Blood: “No Oxygen in Blood, no oxygen to “No Oxygen in Blood, no oxygen to the tissues” - anemia the tissues” - anemia

Cyanosis:Cyanosis:Pulmonary vs CardiacPulmonary vs Cardiac

Pulmonary-Pulmonary- baby will be in respiratory baby will be in respiratory distress, cyanosis will improve with distress, cyanosis will improve with adequate oxygenation and ventilationadequate oxygenation and ventilation

Cardiac-Cardiac- babies are usually “comfortably babies are usually “comfortably tachypneic” - cyanosis may not improve tachypneic” - cyanosis may not improve or only slightly improve with oxygen and or only slightly improve with oxygen and ventilation. May be pale, “waxy” and no ventilation. May be pale, “waxy” and no urine outputurine output

Treatment of Shock-Treatment of Shock-What You Can Do………What You Can Do………

Volume, Volume, Volume – 10 ml/kgVolume, Volume, Volume – 10 ml/kgLactated ringers, normal saline,blood Lactated ringers, normal saline,blood not not dextrose dextrose *****keep them hydrated*****keep them hydrated

Maintain neutral thermal environmentMaintain neutral thermal environment *****Keep warm and dry*****Keep warm and dry

Give glucose at 2ml/kg to keep glucoses >50 Give glucose at 2ml/kg to keep glucoses >50 (don’t forget to dilute if you have D25 or D50) (don’t forget to dilute if you have D25 or D50) Make D10W or D12.5W Make D10W or D12.5W *****Keep them sweet*****Keep them sweet

*****Keep oxygenated*****Keep oxygenated with bag/mask or if with bag/mask or if needed intubate/LMA needed intubate/LMA

Blood Pressure/ShockBlood Pressure/ShockKey PointsKey Points

3 Main types of shock in neonates3 Main types of shock in neonates Overlap may occur giving a combined effectOverlap may occur giving a combined effect Keep babies warm, sweet, oxygenated and Keep babies warm, sweet, oxygenated and

hydratedhydrated Older babies with cyanosis not responsive to Older babies with cyanosis not responsive to

oxygen may have CHD that is getting worse with oxygen may have CHD that is getting worse with impending shock impending shock

Always consider sepsis as a cause for shockAlways consider sepsis as a cause for shock

Common Lab WorkCommon Lab WorkNICU TransportsNICU Transports

Glucoses- keep >50 Glucoses- keep >50 *Blood gases- capillary or venous*Blood gases- capillary or venous *CBC – looking for infection*CBC – looking for infection *Blood culture – looking for infection*Blood culture – looking for infection *Electrolytes- not necessary, reflective of *Electrolytes- not necessary, reflective of

Mom’s values for 12-24 hoursMom’s values for 12-24 hours *would most likely never do on your leg of *would most likely never do on your leg of

transporttransport

What WE Can Do For You….What WE Can Do For You….

We would love to help with:We would love to help with: Education – S.T.A.B.L.E, NRP, PALSEducation – S.T.A.B.L.E, NRP, PALS Simulation workshopsSimulation workshops Offer routine competency seminarsOffer routine competency seminars Offer to come out and review equipment, Offer to come out and review equipment,

supplies etc. make recommendationssupplies etc. make recommendations We are available for questions at anytimeWe are available for questions at anytime

We are here to help you provide optimal We are here to help you provide optimal care to your communitiescare to your communities

ContactsContacts

Bette Johnson, MSN, CRNP – NICU Bette Johnson, MSN, CRNP – NICU Transport Coordinator,STABLE Lead Transport Coordinator,STABLE Lead Instructor Instructor

Randa Bates, RN, - NICU Transport Team Randa Bates, RN, - NICU Transport Team NRP Instructor, STABLE support instructorNRP Instructor, STABLE support instructor

Carol Craig,MSN, CRNP- Resuscitation Carol Craig,MSN, CRNP- Resuscitation Coordinator, NRP InstructorCoordinator, NRP Instructor

For all of the above call NICU at 541-382-For all of the above call NICU at 541-382-4321 – SCMC Bend: then ask for x1630 or 4321 – SCMC Bend: then ask for x1630 or x3777 (at night only) x3777 (at night only)