Neonatal / Pediatric Resuscitation

Question 1

Neonatal/pediatric anatomical differences

Answer 1

Rib cage is more elastic/flexible
“Baby” lungs
Mediastinum is more mobile
Bones of skull are soft
Liver/spleen are larger and more vascular
Bones are softer
Anterior fontanelle closes at 12-18 months
Posterior fontanelle closes by 2 months

Question 2

Peds BP

Answer 2

Infants <44 weeks post-conceptual age
…age (weeks) = neonate MAP
…40 weeks = minimum MAP of 40

Infants >44 weeks post-conceptual age
[age (years) x2] +90 = normal SBP
[age (years) x2] +70 = minimum SBP

Question 3

ETT sizing

Answer 3

Weeks gestation, move decimal

25 weeker = 2.5
35 weeker = 3.5

2.5mm <1kg
3.0mm <1-3kg
3.5-4.0mm >3kg
>1yr: (age +16)/4

Double for NGT, foley, suction
Quadruple for chest tube

Question 4

Peds hypovolemic shock

Answer 4

hemorrhage
free water loss
plasma loss

Kids have circulating blood volume of 75-80 ml/kg

ie 5kg baby = 500mL circulating volume.

25% volume loss can have a significant impact (for a 5kg baby that’s only 100mL blood loss to cause compensation)

Question 5

peds cariogenic shock

Answer 5

left ventricular dysfunction
…diastolic failure
…systolic failure
…apical ballooning
…myocarditis

Question 6

peds obstructive shock

Answer 6

obstruction of circulation/blood flow

cardiac tamponade
pulmonary emboli
tension pneumothorax
congenital disease

Question 7

peds distributive shock

Answer 7

container failure - leak
sepsis
anaphylaxis
neurogenic shock

reduced systemic vascular resistance

Question 8

peds tachycardia

Answer 8

Hypoxic?
Hypovolemic?
Hypotensive?

Don’t automatically assume SVT just because HR >150

Question 9

peds cardiac rhythms - SVT?

Answer 9

SVT vs ST?
220-age?
…rate = 280-290

Stable?
alert
normotensive

unstable?
decreased LOC
respiratory failure
hypotension

Question 10

peds bradycardia

Answer 10

Always bad

Need to maintain HR >100
Start compressions at <60bpm
PP ventilation
Increase FiO2
Begin compressions
Volume resuscitation
up to 30 days: 10mL/kg
>30 days: 20mL/kg

Question 11

peds pericarditis

Answer 11

viral (more common) or bacterial
…often recent viral illness

Sharp chest pain
Pain easily localized by patient
radiates to base of neck
patients unable to lay supine

EKG changes:
Global ST elevation, or isolated
Possibly no reciprocal changes
Downsloping P-R intervals

Question 12

STABLE

Answer 12

Sugar
Temperature
Airway
Blood pressure
Lab values
Emotional support

Question 13

NRP

Answer 13

HR > 100 is the goal
Resuscitate withPPV
Compressions if needed

All O2 treatments stop once minimum goal is achieved

Lowest amount of O2 based on ductal SpO2 after birth (right wrist SpO2)
1 min = 60-65% (treat if <60%)
2 min = 65-70% (treat if <65%)
3 min = 70-75% (treat if <70%)
4 min = 75-80% (treat if <75%)
5 min = 80-85% (treat if <80%)
10 min = 85-90% (treat if <85%)

After 24 hours, if pre-ductal oxygenation is <90%, it is likely a congenital heart defect

Question 14

peds fluid maintenance

Answer 14

Fluid Calculation Formula

4mL/kg up to 10kg PLUS
2mL/kg for 11-12kg PLUS
1mL/kg for 21kg and up

D5 1/2 NS

ie 8kg baby = 4mL x 8kg = 32mL/hr

ie 26kg baby = 4mL x 10 kg =40mL/hr PLUS
2mL x 10 kg =20mL/hr PLUS
1mL x 6 kg = 6mL/hr
Total maintenance fluid = 66mL/hr

Question 15

Neonate fluid maintenance

Answer 15

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

Glucose infusion rate
6-8mg/kg/day - D10 <28 weeks
Do not exceed D12
Goal is to increase rate and/or adjust % of dextrose

Question 16

Standard fetal circulation

Answer 16

Oxygen comes through inferior vena cava from placenta

High pressure right heart
Most blood classes the foramen ovale
RV blood moves from PA to the aorta through ducts arteriosis

Only 5% of blood flow that moves from placenta through this pathway moves into lungs/pulmonary circuit.

Question 17

Congenital defects

Answer 17

cyanotic vs acyanotic

Will oxygenation cause harm in this patient?

yes…cyanotic
no…acyanotic

Question 18

Congenital defects - cyanotic

Answer 18

Dependent on ductal blood flow
right to left shunt
sao2 often 75-80%
May worsen with O2
Needs prostaglandin (PGE1)

Question 19

congenital defects - acyanotic

Answer 19

Ventricular inflow or outflow obstructionn
causes fluid backup and chf
left to right shunt causes hypoxia and pulmonary hypertension

Question 20

Truncus arteriosis

Answer 20

single artery that arises from ventricles
Associated large VSD

Treatment:
maintain PDA patency
prostaglandin 0.03-0.1 mcg/kg/min
foramen ovale - Rashkind procedure
Pulmonary arteries are separated
Trunks artery is used as new aorta
Conduit - homograft pulmonary artery is used to connect PA to right ventricle
Closure of ventricular septal defect
Advil/tylenol

Question 21

How do you close a patent ductus arteriosis?

Answer 21

Test answer: indomethacin administration.

however this is infrequently used as a method to aid in closure of VSD.

Advil/tylenol used more frequently now

Question 22

Transposition of the great arteries

Answer 22

Survival rate >97%
Severe hypoxia at birth
Watch for air embolus
Prostaglandin for PDA patency 0.03-0.1 mcg/kg/min

Surgical intervention:
Jatene procedure - arterial switch
Most complex is switching coronary arteries
Advil/tylenol (indomethacin for test answer

Question 23

Tricuspid atresia

Answer 23

Tricuspid valve fails to grow; instead, a plate of tissue forms in its place

Under-developed right ventricle

ASD and VSD present

Treatment:
maintain pda patency
Prostaglandin 0.03-0.1 mcg/kg/min
Foramen ovale - Rashkind
Blalock-Taussig shunt at 1 week
…right subclavian to pulmonary artery connection
Glenn shunt at 4-6 months
Fontan procedure at 2-3 years
Closure - advil/tylenol

Question 24

Tetralogy of Fallot

Answer 24

Huge ventral septal defect (VSD)

Upward displacement of aorta

Stenotic pulmonary valve

RV hypertrophy

Treatment:
Hypoxia
Decreased spo2
Prostaglandin 0.03-0.1 mcg/kg/min
surgical repair

Question 25

"Tet spells"

Answer 25

Agitated, cranky due to hypoxia Knees to chest

Question 26

Total anomalous pulmonary venous return

Answer 26

Pulmonary veins do not connect and drain into left atrium like normal. Instead, connection into right atrium via an anomalous connection No oxygenated blood moves to the body Hypoxic. Surgical repair in the first week of life Treatment: maintain pda patency prostaglandin 0.03-0.1 mcg/kg/min Foramen ovale - rashkind Connection to the back of the left atrium

Question 27

Coarctation of the aorta

Answer 27

narrowing of aortic arch typically just distal of the left subclavian bifurcation Dx usually occurs after neonate has gone home Closure of PDA leads to decompensation O2 challenge with no response BP 15 mmHg higher in upper extremities Oxygenation will make the pt worse Treatment: surgical dilation atrial septal defect prostaglandin administration

Question 28

Patent ductus arteriosis

Answer 28

closes when we start breathing oxygen shift from high pressure right side to high pressure left side

Question 29

Ventral septal defect

Answer 29

dependent on size and location late identification due to high pulmonary vascular resistance majority close spontaneously profound pulmonary HTN and cha Reversed RV to LV shunt; bypassing pulmonary system, causing hypoxia Treatment: prostaglandin for patency surgical repair indomethacin for closure (test) advil/tylenol

Question 30

Hypoplastic left heart (worst congenital heart defect)

Answer 30

Critically ill onnnce the PDA begins to close - ductal dependent SaO2 70-80% Treatment: FiO2 <21% Add other gases to decrease FiO2 PGE1 Multiple surgeries to prepare for future heart transplant First surgery: Norwood Procedure ...Pulmonary artery is connected to the aorta, completed in 1st week of life Second procedure: Glenn Procedure ...superior vena cava is connected to pulmonary artery. Performed at 4-6 mo. Third procedure Fontane Procedure ...Close inferior vena cava connection to right atrium Performed at 2-4 years Connection into pulmonary artery. One large functional ventricle

Question 31

Most common cyanotic congenital heart defect?

Answer 31

Tetralogy of fallot ...4 heart defects ventricular septal defect overriding aorta pulmonary stenosis right ventricular hypertrophy

Question 32

Which congenital disorder results in a right-to-left shunt?

Answer 32

tetralogy of fallot

Question 33

What is the long term treatment to correct tetralogy of fallot?

Answer 33

Catheterize and dilate the pulmonary artery and patch the ventricular septal defect

Question 34

Left outflow obstruction defect presentation

Answer 34

SpO2 significantly higher in upper extremities than lower extremities No femoral pulses Abdominal distention

Question 35

left outflow obstruction defects

Answer 35

coarctation of the aorta hypo plastic left heart transposition of the great vessels

Question 36

Transposition of the great vessels

Answer 36

pulmonary artery and aorta are switched. Coronary circulation is reversed and connected to the pulmonary artery

Question 37

PDA (congenital heart defects)

Answer 37

will be given indomethacin for closure

Question 38

Hypoplastic left heart tx

Answer 38

Norwood, Glenn, and Fontan procedures

Question 39

Ventral septal defect

Answer 39

Right to left shunt

Question 40

Tricuspid atresia

Answer 40

Hypoplastic right ventricle

Question 41

tetralogy of fallot

Answer 41

Right upward displacement of the aorta, stenotic pulmonic valve, right ventricular hypertrophy, VSD

Question 42

Total anomalous pulmonary venous return

Answer 42

Pulmonary veins do not drain into the left atrium like normal

Question 43

Truncus arteriosis tx

Answer 43

Conduit homograft pulmonary artery is used to connect the PA to right ventricle