Transcript Questions - Oregon EMS Conference

Physical Assessment and
Newborn Stabilization:
What You Can Do!
Bette Johnson, CRNP, SCMC NICU
Transport Coordinator
Randa Bates, RN, NICU Transport Nurse
Doug Ferguson, RT, Airlink Respiratory
Therapist
Questions
to Consider
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How many staff have
taken Neonatal
Resuscitation(NRP)?
Do you have a infant
appropriate bags?
Appropriate sized
masks?
Sat Probes?
Glucometer, or
sticks?
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Appropriate sized BP
cuffs?
Newborn
Resuscitation Kit?
Appropriate Sx
equipment?
Heat packs?
Do you have monitors
that can monitor an
infant?
Neonatal Stabilization
Provide Warmth, Position, Clear Airway, Dry, Stimulate to Breath
CLINICAL ASSESSMENT
Provide supplemental oxygen, as necessary
Room air- 100%
Assist Ventilation with
Positive Pressure Ventilation
MR SOPA
Intubate the trachea
Provide Chest compressions
Administer
Medications
MR SOPA
If PPV not working
 M=
mask, right size and fit
 R= reposition, neck and/or mask
 S= suction, nose and mouth
 O= open mouth while ventilating
 P= increase pressure if no chest rise
 A= consider alternative airway, intubate or
LMA
What to look for:
What You Can Do
 Continually
assess- Five Apgar points
 Maintain Warmth
 Maintain open and clear airway
 Provide supplemental oxygen
 Call for help early
Keypoints
 Initial
steps of NRP are the most important
 Most powerful tool initially is maintenance
of airway- may prevent further
decompensation
 Oxygen is a powerful drug, start with room
air, then go to 100% if no blender
 Know your equipment, maintain it and
keep current on it’s use
Kit Lists
Premature
Newborn
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Hat
Thermometer
Bulb Suction
Baby Booger Getter (BBG)
Self-inflating bag and newborn
mask
Infant Sat Probes
Blankets
Diapers
Umbilical Tape
Sucrose
5 Fr. Feeding Tube
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Hat
Thermometer
Bulb Suction
Premie Mask
Self-inflating Bag
Sat probe
Premie Diaper
Premie BP Cuff
Umbilical tape
Porta Warmer
Plastic bag/plastic wrap
Sucrose
5 Fr. Feeding Tube
Physical Assessment
Physical Assessment
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VITAL SIGNS: Temp range: 97.8-98.6
Heart rate: 120’s-160’s, Resp rate: 40-60’s
Blood pressure: mean’s approximate gestational age (i.e
high 20’s low 30’s for preterms, high 30’s low 40’s for
fullterm)
 SKIN: cyanosis vs acrocyanosis, perfusion, capillary
refill, rashes, lesions, trauma
 HEENT: Head: scalp swellings, bruising, trauma Eyes:
equal distance, lids open, pupils reactive
Ears: in line with outer eye Nose: nares patent or not,
Throat/Neck- no masses, clavicles intact or not
PHYSICAL ASSESSMENT
CONTINUED
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CHEST: Tachypnea, Increased work of
breathing: Barrel chest, retractions, grunting,
breath sounds: clear and equal, coarse,
diminished. Need for oxygen or assisted
ventilation. Gasping or apnea
 HEART: rate, rhythm, murmur, pulses, blood
pressure, perfusion (capillary refill >3secs)
 ABDOMEN: full and soft, sunken, defect
(omphalocele/gastroschisis), hard/firm/shiny,
abnormal color
PHYSICAL ASSESSMENT
CONTINUED
 EXTREMETIES:
Number and placement
of digits, movement equal, tone,
trauma/bruising, lesions or marks
 NEUROLOGIC: tone, activity, able to
focus on caregiver, response to painful
stimuli, seizures
 GENITOURINARY: male vs female
anatomy, can help tell gestation, anus
present
Premature vs Fullterm; Quick
Assessment
Preterm vs Fullterm:
 Weight - <5 lbs- full term babies who are small
for gestational age can be under 5 lbs
 Gestational age- <37 weeks (35-37 weeks= late
preterm infants)
 Physical exam: > lanugo, <vernix, <breast buds,
< tone, < ear cartilage, decreased creases on
bottom of feet, male- < scrotum, testes may not
be descended, female- labia minora may be
bigger than majora, decrease in activity and tone
Preterm vs Fullterm Infants
Why Does It Matter
 Preterm
babies brains are vulnerable to
pressure changes – fluids, ventilation, cold
stress etc. affects brain- bleeding, apnea,
seizures
 Preterm babies lungs are not fully formed
in number of air sacs, capillaries and
surfactant- respiratory distress, cyanosis
 Preterm babies don’t have good glucose
stores- hypoglycemia
Why does it matter
 Preterm
babies don’t have fat storeshypothermia, poor temp regulation
 Preterm babies guts are not maturedysmotility, aspiration, emesis, perforation
 Preterm babies don’t have mature immune
function- vulnerable to infection
 Preterm babies don’t have good
autoregulation of blood pressurehypotension, bleeding
What You Can Do…
 Estimate
weight
 Estimate Gestational age
 Have vital signs available for report
 Give summary of most immediate reason
for transport i.e. respiratory distress,
seizures, trauma, unresponsive/floppy,
cyanotic etc
 Call for specialty team early rather than
later
Physical Assessment Key Points
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Approximate gestational age and weight are
important pieces of information to pass on
Neurologic changes are often the first sign that a
baby is getting sick
“Comfortably tachypneic” babies may have a
primary congenital heart defect that may be
getting worse- watch them closely
Preterm babies reach “breaking” points faster
than fullterm babies
Babies in general “jump off cliffs” instead of
“rolling down a hill”
S.T.A.B.L.E. Program
“Condensed” Version
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Developed to help all types of providers stabilize
sick babies no matter what type of facility they
were born in or out of i.e home, car, field
Allows for consistency in care
Good communication tool to discuss Neonatal
issues
Focus on safety and quality of care
Sugar, Temperature, Airway, Blood Pressure,
Lab Work and Emotional Support
SUGAR
Things that make you go MMM!!!
Causes of Hypoglycemia
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Decreased Glucose Stores: Small for
gestational age/Premature/Intrauterine growth
restriction
 Hyperinsulinemia – Infants of Diabetic
Moms/Large babies/Syndromes
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2/3 maternal glucose
Stress/Increased Utilization- Depletion of stores
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Cold stress
Traumatic deliveries
Cardio/pulmonary diseases
Infection
Shock
Sugar BABY!
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Keys for aerobic
metabolism
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Oxygen + Glucose =
ENERGY
Anaerobic
Metabolism
Lack of 02 or Glucose
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Lactic acidosis =
IMPAIRED
FUNCTION
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Symptoms include:
Hypotonia
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Lethargy
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Poor feeds
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High pitched or weak cry
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Jittery/Irritable
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Seizures
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Increased RDS
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Apnea
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Bradycardia
?what part of body is
responsible for all of these
symptoms???
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How to check glucose
 Pre-warm
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the heel
Warm water, chemical warmer, warm towel
Cold foot = falsely low reading
Do not over squeeze heel
Causes clotting,
bruising and pain
What You Can Do
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Be vigilent in assessment for hypoglycemia:
 Ask mother or caregiver for risk factors;
gestation diabetes, on insulin, symptoms of
hypoglycemia herself
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If infant has stable vital signs with no respiratory
distress: Consider breastfeeding if mom able
and willing or give
Oral Sucrose (D25W) – drops in cheek with
syringe
Glucose Infusion Guidelines
D50W Preparation
 Draw up 2 ml of D50 add
to 10 ml’s of sterile water
to make D10W solution
 Approximate infant’s
weight (1 lb = 2.2 kgs)
 Give via IV or IO
 2ml/kg
 May give bolus over a
few minutes, slower if
preterm
D25W Preparation
 Draw up 5 ml’s of D25
and add to 5 ml’s sterile
water to make D12.5
 Approximate infant’s
weight
 Give via IV or IO
 1-1.5 ml/kg
 Give over a few minutes,
slower if preterm
Sugar Key Points
 Premature,
SGA, LGA and stressed
babies at highest risk
 Maintain glucose greater than 50mg/dl
 No sugar = decline in status
 Recheck 30 min after treatment and if
baby is symptomatic
 If can’t check glucose and baby is
symptomatic – treat using guidelines
Thermoregulation: If you’re hot
you’re hot, if you’re not you’re not!
Normal 36.5 – 37.5 C or 97.8 – 98.6 F
HEAT LOSS:
Conduction = loss to objects that are colder
Convection = loss via air currents
Evaporative = moisture turns to vapor
Radiation = Loss to colder object not in contact
with baby
WHY?:
Large surface area = greater heat loss
Lack of shivering ability = no heat production
Exposed Defects = increased surface area
Which babies are at risk?
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Premature/Low Birth Weight
Small for gestational age (SGA)
Prolonged Resuscitation
Acutely Ill (often accompanies sepsis)
Abdominal or Spinal Defects
Any infant born in a compromised
environment – i.e. birth center, home, car,
outdoors
Term vs. Preterm
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Term Response
Vasoconstriction
Peripherally
Increased tone and
movement
Normal glucose
stores
Brown Fat
Metabolism
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Preterm
Response/SGA
Poor vasoconstriction
Weak muscle tone
Limited glycogen
stores
Minimal or No Brown
Fat
Effects of Cold Stress
 Significantly
increased metabolic rate
 Increased Oxygen consumption
 Increased Glucose metabolism
• At extreme risk for hypoxemia, hypoxia and
hypoglycemia
***Preventing hypothermia is much easier than
overcoming the detrimental effects once
hypothermia has occurred.***
Adapted from S.T.A.B.L.E Program 5th Edition
What You Can Do
What You Can Do
All Babies:
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Dry
Place Hat
Increase
environmental temp
Decrease Drafts
Warm blankets
IV bags from warmer
Chemical Warmers
Infant dependant:
 Skin to skin
 Saran Wrap
 Swaddle
*** Never microwave
blankets or other
objects for heat
 Always cover
warmers with cloth
Key Points
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All infants are at varying risk for hypothermia
 Check axillary temps frequently
 Increase environmental temp- you should be
hot!
 Keeping an infant normothermic can help
PREVENT the need for further stabilization
Maternal Conditions
Causing
Infant Distress
 Diabetes: insulin dependent or gestational
non-insulin dependent. A1c significance
 Hypertension: either pre-pregnancy or
pregnancy induced
 Placental/Uterine disruptions: placenta
previa, abruption, uterine rupture, cord
prolapse
 Infections: GBS, e.coli, MRSA, listeria
Airway Management
RESPIRATORY DISTRESS IN FULLTERM
INFANTS:
MOST COMMON CAUSES
 TRANSIENT TACHYPNEA- retained
interstitial lung fluid
 ASPIRATION- meconium, amniotic fluid,
blood, breast milk or formula, gastric
contents
 AIR LEAK SYNDROMES: pneumothorax
 PNEUMONIA
 CARDIAC LESIONS: duct dependent
RESPIRATORY DISTRESS
IN PRETERM INFANTS:
MOST COMMON CAUSES
 RESPIRATORY DISTRESS SYNDROME:
Surfactant deficiency and immature anatomy
 ASPIRATION: same as full term babies
 AIRLEAKS: pneumothorax
 PNEUMONIA: always have sepsis on
differential with infant in respiratory
distress- think SHOCK
SIGNS/SYMPTOMS OF
RESPIRATORY DISTRESS
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TACHYPNEA- 100 breaths per minute or morecomfortable or increased work of breathing
APNEA/GASPING – cessation of breathing >15
secs
RETRACTIONS- intercostal, subcostal,
suprasternal, supraclavicular
NASAL FLAIRING
GRUNTING
CYANOSIS
What You Can Do
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KEEP THEM SWEET - normoglycemic
KEEP THEM WARM – neutral thermal
KEEP AIRWAY CLEAR AND HEAD IN
SNIFFING POSITION
PROVIDE SUPPLEMENTAL OXYGEN
PROVIDE BAG/MASK VENTILATION
PLACE AN ALTERNATIVE AIRWAYINTUBATE OR USE LMA
KEEP THEM HYDRATED
Airway Key Points
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Respiratory distress can present in babies due
to hypoglycemia, hypo/hyperthermia,
hypovolemia, sepsis, neurologic injury, cardiac
disease, pulmonary disease- often first sign of
distress
 Preterm babies present faster than full term
babies- lack of compensatory mechanisms
 **Clearing the airway and correct use of positive
pressure ventilation should be the first course of
action, not cardiac compressions
 Oxygen is a powerful drug, use it wisely
INFANT SHOCK !!!
Common Types of Shock
 Hypovolemic
 Septic
- Distributive
 Cardiogenic
Hypovolemic Shock
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Most common cause of shock in the initial
newborn period
Causes:
 Intrapartum blood loss
-fetal-maternal hemorrhage
-placental abruption/previa
-umbilical vessel injury
- cord prolapse
-twin to twin transfusion
-organ laceration or injury
Hypovolemic Shock
Postnatal hemorrhages: in babies
 Brain – intraventricular hemorrhage
 Lung – pulmonary hemorrhage
 Adrenal glands- trauma
 Scalp – most serious subgaleal, loss of
most of blood volume - trauma
Septic or Distributive Shock
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May be either viral or bacterial in origin
May become critically ill rapidly
Hypotension may be profound and respond
poorly to fluid resuscitation
*Be prepared to give volume; 10ml/kg may need
multiple doses (normal saline or lactated ringers)
*Push boluses over 2-3 mins full-term, 5-10
preterm
Cultures and antibiotics at referral hospital
*ALS only
Cardiogenic Shock
Heart Failure
Causes:
 Intrapartum/postpartum asphyxia
 Hypoxia and/or prolonged metabolic acidosis
 Bacterial or viral infection
 Respiratory failure
 Severe hypoglycemia
 Severe metabolic and/or electrolyte
disturbances
 Arrhythmias
 Congenital heart disease
Evaluation of Shock
Physical Exam
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Neuro- tone and activity- floppy, lethargic, not
able to open eyes and look at you, pupils not
reactive or sluggish
 Respiratory- in distress, tachypneic- work of
breathing will worsen with shock
 Cardiac- cyanosis – look at gums not lips, pallor,
>cap refill time, weak or absent pulses- compare
upper to lower and side to side
 Blood pressure is the last to go- “babies jump off
cliffs not roll down hill”
Differential of Cyanosis
Central
1) Lungs: “No oxygen in the lungs, no
oxygen in the blood”
 Premie lungs, aspirations, pneumothorax
2) Heart: 2 types: a) no blood from heart to
lungs (right sided problem or pulmonary
hypertension)
b) No blood from heart to rest of body (left
sided problem)
3) Blood: “No Oxygen in Blood, no oxygen
to the tissues” - anemia
Cyanosis:
Pulmonary vs Cardiac
 Pulmonary-
baby will be in respiratory
distress, cyanosis will improve with
adequate oxygenation and ventilation
 Cardiac- babies are usually “comfortably
tachypneic” - cyanosis may not improve
or only slightly improve with oxygen and
ventilation. May be pale, “waxy” and no
urine output
Treatment of ShockWhat You Can Do………
Volume, Volume, Volume – 10 ml/kg
Lactated ringers, normal saline,blood not
dextrose *****keep them hydrated
 Maintain neutral thermal environment
*****Keep warm and dry
 Give glucose at 2ml/kg to keep glucoses >50
(don’t forget to dilute if you have D25 or D50)
Make D10W or D12.5W *****Keep them sweet
 *****Keep oxygenated with bag/mask or if
needed intubate/LMA
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Blood Pressure/Shock
Key Points
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3 Main types of shock in neonates
Overlap may occur giving a combined effect
Keep babies warm, sweet, oxygenated and
hydrated
Older babies with cyanosis not responsive to
oxygen may have CHD that is getting worse with
impending shock
Always consider sepsis as a cause for shock
Common Lab Work
NICU Transports
 Glucoses-
keep >50
 *Blood gases- capillary or venous
 *CBC – looking for infection
 *Blood culture – looking for infection
 *Electrolytes- not necessary, reflective of
Mom’s values for 12-24 hours
 *would most likely never do on your leg of
transport
What WE Can Do For You….
 We
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would love to help with:
Education – S.T.A.B.L.E, NRP, PALS
Simulation workshops
Offer routine competency seminars
Offer to come out and review equipment,
supplies etc. make recommendations
We are available for questions at anytime
We are here to help you provide optimal
care to your communities
Contacts
Johnson, MSN, CRNP – NICU
Transport Coordinator,STABLE Lead
Instructor
 Randa Bates, RN, - NICU Transport Team
NRP Instructor, STABLE support instructor
 Carol Craig,MSN, CRNP- Resuscitation
Coordinator, NRP Instructor
 For all of the above call NICU at 541-3824321 – SCMC Bend: then ask for x1630 or
x3777 (at night only)
 Bette