Neonatal Emergencies

Question 1

Umbilical IV access

Answer 1

Indications for umbilical vein:
> emergency vascular access
> central venous monitoring
> exchange transfusion
> central Venus Access
Indications for umbilical artery:
> measurement of arterial blood gases
> arterial blood pressure monitoring
> angiography
> Resuscitation
* Umbilical vein is best during resuscitation*
Contraindications for both umbilical arterial and Venus access:
> Omphalocele
> gastroschisis
> omphalitis
> peritonitis
> vascular compromise
> necrotizing enterocolitis

Question 2

Umbilical anatomy

Answer 2

> two smaller arteries
one large vein

Question 3

Umbilical artery cath(UAC) complications

Answer 3

> thrombosis
embolism
vasospasm
loss of an extremity
hypertension
air embolism
necrotizing Enterocolitis
infection
bladder injury
vessel, perforation
factory hypoglycemia
peritoneal perforation
sciatic nerve palsy

Question 4

Umbilical vein cath (UVC) complications

Answer 4

> infection
thromboembolism
perforation of peritoneum
portal hypertension
digital ischemia
Pneumopericardium
pericardial effusion and tamponade
cardiac arrhythmias

Question 5

Anatomy differences in infants

Answer 5

> rib cage is more elastic/flexible
lungs are small and delicate
Mediastinum is more mobile
bones are softer(great force required to break)
liver/spleen are larger and more vascular
fontanelle are present
anterior Fontanelle closes @ 12-18months posterior @ 2months

Question 6

Blood pressure in peds

Answer 6

> 90+(2xage)= normal systolic BP
70+(2xage)=hypotension
gestational age in weeks= neonate MAP

Question 7

Peds ETT sizes (also NGT, OGT, suction)

Answer 7

> age in weeks move the decimal to the left 1 spot example: 25wk = 2.5mm ETT
greater than 1yr: (age +16)/4
double the size of ETT for NGT, OGT, Foley, suction.
quadruple ETT size for chest tube. Also works for adult chest tube sizing.

Question 8

Normal blood volume in peds

Answer 8

> 75 to 80 mL/kg of blood
25% loss can cause shock symptoms

Question 9

Cardiac output in peds

Answer 9

> Normal is 4–8 L/Min
HR is the quickest way to increase Q
diastolic filling is everything = 2/3 MAP
SV is the amount of blood ejected during systolic phase
ejection fraction = 50–70%(60-135mL)
SV is made up of 3 things( preload, afterload, contractility)

Question 10

ST vs SVT in peds

Answer 10

> 220-age = sinus tachycardia
S/S of and unstable tachycardia: decreased LOC, respiratory failure, hypotension
assess fever and try fluids before cardioversion

Question 11

Bradycardia in peds

Answer 11

> peds decompensate FAST
assess respirations and fix right away
Start compressions with rate <60

Question 12

Pericarditis(older peds)

Answer 12

> viral or bacterial in nature
sharp chest pain
easily localized by patient
radiates to the base of the neck
unable to lay supine
global STE without reciprocal changes
downsloping P – R interval

Question 13

Hypoglycemia in peds

Answer 13

Treat if sugar is < 40

Question 14

Peds fluid calculation formula

Answer 14

*Always use D10 or D5 in NS because they burn through there sugar fast
> 0-10kg— 4mL/kg = mL/hr
> 10-20kg— 2mL/kg(+40mL above)=mL/hr
> 20kg— 1mL/kg(+60mL above)=mL/hr

Question 15

Fluid maintenance neonates

Answer 15

> 60-80mL/kg/day—D10 - <28weeks
100mL/kg/day—D10 - >28weeks

Glucose Infusion Rate(GIR)
> 6-8mg/kg/day
> don’t exceed D12
> goal is to increase rate and or adjust percent of dextrose not exceed D12

Question 16

Environmental stimuli considerations

Answer 16

> over stimulus promotes HTN
HTN causes bleeds
keep environment as quiet and as dark as possible, simulate mothers womb.
gentle handling/loading
keep environment warm!

Question 17

Neonatal distress

Answer 17

> rule out common causes like hypoglycemia or environmental stimulus
seizures are very subtle in neonates
seizure examples are as follows: repetitive mouth/tongue movement, bicycle kicks, eye deviation/blinking

Question 18

Neonatal sepsis

Answer 18

> often occurs perinatal
common causes from PROM, maternal, UTI, Group B strep.
often presents as meningitis
may present as respiratory distress
treatment: ABC’s, calculate neutrophil count(ANC) and apply to normogram, Ampicillin and Gentamycin, get blood cultures, and fluid resuscitation.

Question 19

Fetal circulation

Answer 19

> oxygenated blood comes up the inferior vena cava from the placenta
high-pressure right heart
most blood crosses the foramen olvale
RV blood moves from the PA to the aorta through patent ductus arteriosus

Question 20

Cyanotic heart defects

Answer 20

> more common
dependent on ductal blood flow
right to left shunt
SaO2 often 75–80%
may worsen with oxygen
need PGE1

Question 21

Acyanotic heart defects

Answer 21

> ventricular inflow or outflow obstruction
causes fluid back up and CHF
left to right shunt cause hypoxia and pulmonary HTN

Question 22

Truncus arteriosus

Answer 22

> heart defect
single artery that rises from ventricles
associated large VSD
treatment: SURGERY
-maintain PDA patency
-prostaglandin admin for PDA patency (0.03-0.1mcg/kg/min)
-cardiac Cath to enlarge foramen ovale
-Pulmonary arteries are separated
-Truncus artery is used as aorta
-Conduit— homograph pulmonary artery is used to connect PA to right ventricle
-Closure of VSD
-Indomethacin for PDA closure

Question 23

Transposition of the great vessels

Answer 23

> vessel connecting aorta in pulmonary artery causing blood mixing
severe hypoxemia ensues
watch for air embolus
prostaglandin admin for PDA patency, 0.03-0.1mcg/kg/min
surgical intervention needed
- Jatene procedure— arterial switch

Question 24

Tricuspid Atresia

Answer 24

> tricuspid valve, fails to grow; instead of plate of tissue forms in its place
underdeveloped right ventricle
ASD and VSD present
treatment:
-Maintain PDA patency
-Prostaglandin admin for PDA patency— 0.03-0.1mcg/kg/min
-cardiac Cath to enlarge foramen ovale
-Blalock-Taussig shunt-1st week
-Glenn shunt-4-6months
-Fontan procedure-2-3 years

Question 25

Tetralogy of Fallot

Answer 25

> Most common heart defect
huge Ventral Septal defect
stenotic pulmonary valve
PA outflow obstruction
RV hypertrophy
rightward displacement of aorta
“TET Spells”-Agitation. Relieved with crying
severe hypoxia
Treatment:
- PGE1 for PDA patency. 0.03-0.2mcg/kg/min
-surgery is required and VSD needs a patch

Question 26

Total anomalous pulmonary venous return

Answer 26

> Pulmonary veins, do not connect and drain into the atrium like normal
instead connection into right atrium via anomalous connection
treatment:
-Maintain PDA patency
-Prostaglandin admin for PDA patency. 0.03-0.1mcg/kg/min
-cardiac Cath to enlarge foramen of ovale
-surgical repair in first weeks of life
-connection to back of left atrium

Question 27

Coarctation of Aorta

Answer 27

> narrowing of aortic arch typically just distal of left subclavian bifurcation
diagnosis after neonate at home
-closure of PDA – decompensation
-O2 challenge with no response
-BP 15 mmHg higher in upper extremities
Treatment:
-Surgical dilation. Atrial septum defect.

Question 28

What is a common side effect of Prostaglandin therapy

Answer 28

Test tip
> Apnea. Usually associated with a high dose

Question 29

Patent ductus arteriosus

Answer 29

> potential for gross, pulmonary edema and respiratory failure
patency with prostaglandin may be necessary
treatment:
-Meds
-Indomethacin for closure
-prostaglandin for patency
oxygen admin issues for therapeutic PDA patency

Question 30

Ventricular septal defect(VSD)

Answer 30

> dependent on size and location
late identification, due to high PVR
majority close spontaneously
profound, pulmonary HTN & CHF
reversed, RV two LV shunt bypassing pulmonary system, causing hypoxia
treatment:
-Prostaglandin for patency
-Surgical repair “patch”
-Indomethacin for closure

Question 31

Hypoplastic left heart

Answer 31

> critically ill once the PDA starts to close-ductal dependent.
SaO2 70-80%
treatment:
-FI02 <0.21. Add other gases to decrease FiO2.
-PGE
-Multiple surgeries to prepare for future heart transplant
Norwood— pulmonary artery to aorta in first week of life
Glenn procedure- superior vena cava is connected to the pulmonary artery at 4–6 months
Fontan procedure- close off inferior vena cava connection to right atrium at 2–4 years
-Connection into pulmonary artery
-One large functional ventricle

Question 32

Which two medications reduce prostaglandin mediated vasodilation?

Answer 32

Acetaminophen and ibuprofen
-both are used for PDA closure

Question 33

Intussusception

Answer 33

> Telescoping of bowel-can cause ischemia or death

> S/S-palpable sausage mass, jelly, stool, and vomiting.

> treatment- Barium, manual manipulation, or surgical resection.

Question 34

Pyloric stenosis

Answer 34

> thickening of pyloric valve- stomach can’t empty into small intestine
S/S- forceful severe vomiting, electrolyte, imbalance, dehydration, olive shaped mass, in RUQ, and gastric peristalsis
treatment- resection of thickened valve and fluids

Question 35

Volvulus

Answer 35

> bowel strangulation- looping of bowel upon itself/bowel obstruction
S/S- poor feeding, bloody stool, and lethargy
treatment- surgical resection, antibiotic therapy, OG/NG tube, and nothing PO

Question 36

Gastroschisis

Answer 36

> Periumbilical abdominal wall defect-causes bowel ischemia.
S/S- protruding non-encapsulated loops, and often identified in prenatal screenings.
treatment- NG/OG tube, heat retention, placed intestine into a plastic bag silo and squeeze the intestines back in over time like squeezing sausage into a tube. Then surgical closure.

Question 37

Omphalocele

Answer 37

> Umbilical Abdominal wall defect
both liver and bowel can be herniated, causing ischemia
treatment- treated like gastroschisis

Question 38

Hirschsprung

Answer 38

> constipation from absence of anterior neurons – ganglion cells
Enterocolitis
S/S- abdominal distention within 48 hours of birth, vomiting, gaseous dilated x-ray.
treatment- rectal irrigation, surgical resection, electrolyte and malnutrition management

Question 39

Meconium Ileus Syndrome

Answer 39

> Thickened meconium unable to pass through bowels. Associated with cystic fibrosis and Trisomy 13&18
S/S- abdominal swelling, bilious vomiting, and gaseous filled bowel loops.
Barium enema, fluids, and surgical repair

Question 40

Tracheoesphageal Fistula (TEF)

Answer 40

> hole between trachea and esophagus, most common presentation is esophageal atresia with distal TEF.
S/S - copious oral secretions, coughing, choking, rattling respirations, and all S/S worsen while feeding.
treatment – NG/OG tube, ETT distal to fistula, feeding tube, and surgical repair

Question 41

Choanal Atresia

Answer 41

> Nasal passage malformation/obstruction
Often positioned prone for transport
obligated mouth breathers- can’t breathe through their nose.
may need to be intubated
commonly have difficulty feeding and cough a lot.
high potential for aspiration pneumonia
Treatment- surgical repair

Question 42

Pierre Robin Syndrome(Sequence)

Answer 42

> Micrognathia(small lower jaw), cleft palate, and glossoptosis(tongue sits back and to the roof of the mouth)
Anterior airway and a posterior tongue. Definitely a difficult to intubate.
treatment – airway management, NPA, ETT, feed in prone position or NG/OG tube, and surgical repair.

Question 43

Necrotizing Enterocolitis(NEC)

Answer 43

> inflammation of the bowel/bowel lining
typically occurs in premature, formula fed infants
S/S- poor feeders, delayed gastric emptying, decreased bowel sounds, abdominal distention, bloody stool, and erythema over abdomen
treatment- NG/OG tube, hydration/electrolyte correction, surgical, resection, and antibiotic therapy

Question 44

Transfusion rates for PRBCs in pediatrics with severe anemia

Answer 44

3mL/kg for hemoglobin of 3g/dL
4mL/kg for hemoglobin of 4g/dL
5mL/kg for hemoglobin of 5g/dL

Subsequent transfusions are administered at 10-15mL/kg to avoid heart failure.