Vol.5-Ch.3 "Neonatology" Flashcards
(37 cards)
What is the age range that a baby can be called a “Neonate”?
From birth to 1 month old
For infants that do require resuscitation (even though super rare, 1%) what is the best facility to transport them to if available?
Neonatal Intensive Care Unit (NICU)
What is filling the lungs of the fetus before it is delivered?
What is the process of getting that out and allowing for regular lung function and respirations after/during delivery?
- While in the uterus FETAL LUNG FLUIDS fill the lungs.
- During vaginal delivery, the compression on the chest of the fetus as it passes expels 1/3 of this fluid out of the lungs.
- As it is stimulated to take it’s first breath (from mild acidosis, hypoxia, hypothermia, and/or initiation of stretch reflexes in the lungs) that air inspired displaces the rest of the fluid and opens the lungs, alveoli, capillaries, and arterioles.
- As the arterioles and capillaries open, the blood that rushes to fill them decreases the blood flow resistance in the lungs enough that it is lower than that of the Ductus Arteriosus so it then closes.
What happens if hypoxia or acidosis continue even after the infant takes it’s first breaths and the ductus arteriosus has closed?
If hypoxia or acidosis continue after the ductus arteriosus has closed, it will cause the pulmonary vascular bed to constrict, raising blood flow resistance, and forcing the Ductus Arteriosus back open again reverting back to fetal circulation. This is called PERSISTENT FETAL CIRCULATION and is why it is very important for the medic to make sure hypoxia and acidosis do not occur.
What is Primary and Secondary Apnea?
Primary apnea is when the infant takes its first few breaths but asphyxia continues and respiratory movements cease causing heart rate to and muscle tone to fall. At this point simple stimulation and supp oxygenation may be able to “kick start” respirations again.
If it doesn’t then it is considered Secondary Apnea in which the infant will continue a downward slope until it is unresponsive. Initiate Resuscitation immediately!
ALWAYS ASSUME ITS SECONDARY AND TREAT WITH O2 AND STIMULATION RAPIDLY, IF NO RESPONSE THEN BEGIN RESCUSCITATION EFFORTS
What happens to the Ductus Arteriosus, Ductus Venosus, Foramen Ovale, and Umbilical Vein after delivery?
- The Ductus Arteriosus becomes the Ligamentum Arteriosum
- The Ductus Venosus becomes the Ligamentum Venosum
- The Foramen Ovale closes and becomes the Fossal Ovalis
- The Umbilical Vein becomes the Ligamentum Teres
How are congenital heart defects normally classified?
Into 3 categories:
- if the cause INCREASED pulmonary blood flow
- if they cause DECREASED pulmonary blood flow
- if they OBSTRUCT blood flow
When does most fetal development occur? What is a fetus susceptible to during this time?
Within the first trimester, making it the most at risk time in fetal development for abnormal development due to environmental or ingest substances
What is the leading cause of death in infants?
Congenital anomalies
Congenital HEART DEFECTS are the most common kind
What are some examples of Congenital Heart Defects that INCREASE pulmonary blood flow? (2)
- Patent Ductus Arteriosus ; in which the ductus arteriosus does not close (aka persistent ductus arteriosus)
- Atrial or Ventricular Septal Defects ; in which there is a hole between atria or hole between ventricles that allows for the mixing of oxy and deoxy blood. Either of the two will eventually lead to CHF
What are some examples of Congenital Heart Defects that DECREASE pulmonary blood flow? (2)
- Tetralogy of Fallot ; a combo of 4 different congenital conditions
- Transposition of the Great Vessels ; in which normal outflow tracts of the right and left ventricles are switched
What are some examples of Congenital Heart Defects that OBSTRUCT blood flow? (3)
- Coarctation of the Aorta ; in which there is a narrowing in the arch of the aorta that obstructs blood flow
- Mitral, Pulmonary, or Aortic Stenosis in which there is a problem with the aforementioned valve
- Hypoplastic Left Heart Syndrome ; in which the heart is under developed and usually leads to death within the first month after birth
What are some possible congenital defects that are NOT cardiac related? (6)
- Diaphragmatic Hernia ; in which there is a defect in the diaphragm which allows for abdominal contents to enter the chest cavity. DO NOT give bag-valve-mask or Pos.Press. ventilations as it cause abd distention. Instead INTUBATE IMMEDIATELY.
- Meningomyelocele ; in which some of the spinal cord and structures are exposed. DO NOT place pt on their back and cover the exposed structures with warm sterile saline soaked gauze pads
- Omphalocele ; in which there is a defect around the umbilicus that abdominal contents dill. Cover this defect with an occlusive plastic covering to decrease water and heat loss
- Cleft Lip/Palate ; in which the palate or lip do not completely close during fetal development. This may cause some difficulty attaining a tight seal on a BVM
- Pierre Robin Syndrome ; in which there is a small jaw and large tongue in conjunction with a cleft lip, this presents an easy airway obstruction.
What are normal respiratory rates, heart rates, and O2 sats for newborns?
RR = 40 to 60
HR = 130-180bpm ; 150-180 at birth that slows to 130-140 after. (Less than 100 indicates distress and requires intervention)
O2 Sat = Does not reach normal until 10 minutes, it may start at 60-65% at birth but should steadily raise for 10 minutes to 85-95%. ONLY give supp O2 if the % does not increase or stalls. Remember that it is normal to see cyanosis of extremities for the first few hours after birth, which makes skin color a poor indicator for O2 sat, so ALWAYS go off of a Pulse Oximetry Device
APGAR score covered in the Obstetrics chapter notecards. KNOW THIS FOR TEST
APGAR score covered in the Obstetrics chapter notecards. KNOW THIS FOR TEST
What % of newborns are delivered with no required resuscitation?
What are 3 east questions to ask to identify one of these newborns.
What 4 things should an infant receive as needed when resucsitation is needed?
80% of newborns DO NOT NEED resuscitation
To identify a newborn who does not need resuscitation ask:
- Is this a term gestation?
- Does the infant exhibit good tone?
- Is the infant breathing or crying?
If the answer to all is YES then only ROUTINE care is needed (dry, place skin to skin with mother, cover with dry linens to maintain temp)
If you answer NO to any of the above questions than one or more of the following may be necessary:
- Initial steps in infant stabilization including: warm and maintain temp, position, clear secretions as needed aka maintain airway, dry, stimulate)
- Ventilate and Oxygenate
- Initiate chest compressions and/or the following…
- Admin epi and/or fluid volume
How should a baby be held/positioned immediately after delivery?
In the sniffing position with the head at the same level as the mother’s vagina (this is to reduce hypo/hypertransfusion of blood)
How fast should you cut the umbilical cord after full fetal delivery?
New studies actually show that Delayed Cord Clamping (DCC) can actually be beneficial and minimize the likelihood of intraventricular hemorrhaging.
So if the baby is normal and healthy you may DCC ; BUT IF the baby requires resuscitation you should CUT WITHIN 30-45 seconds after delivery so that you can properly perform resuscitation. Remember you place the first clamp 10cm above the baby and the second 5cm above the first.
What does meconium staining indicate has happened at some point? How does a difference in meconium change when that something has happened?
Meconium staining indicates that at some point fetal distress has occurred.
IF there is PARTICULATE feces in the meconium, then distress may have occurred recently. IF simply stained without particulate, then distress may have occurred at a remote time.
What is the most common problem faced by newborns in the early minutes of life?
What is the most important vital sign to indicate neonate distress and why?
What are the most important early procedures for brand new neonates?
The most common early problem is ventilation
The most important indicator for fetal distress is the heart rate! This is because stroke volume is relatively fixed so cardiac output depends more on heart rate adjustment. This is why if a neonate has a heart rate of LESS THAN 60, it should be treated with chest compressions.
The most important early procedures are suctioning (AS NEEDED), drying, and stimulation especially for the distressed newborn
What are the 5 major steps in resuscitation of neonates?
1) Drying, Warming, Positioning, Suction, & Stimulation
2) Ventilation
3) Supp O2
4) Compressions
5) Meds and Fluids
If advanced resuscitation is needed how can you achieve sniffing position while placing the baby on it’s back?
Place a towel under the neonates shoulder blades to achieve sniffing position
Under which circumstances should you initiate Pos-press ventilations (BVM) or intubate?
What might you have to do to a BVM to achieve adequate vent?
What 2 things will intubation effect in the newborn?
Use BVM if:
- HR less than 100
- Apnea
- SPo2 less than expected
- Persistence of central cyanosis
Most BVMs have a pressure limiting valve set to 30-45cmH2O but neonates may need up to 40-60cmH2O. So you may have have to disable the pop-off valve
Intubate if: (ALWAYS USE AN UNCUFFED ET TUBE)
- Chest compressions performed
- Ventilation is not achieved with mask
- Tracheal suction is required (as in thick meconium)
- Prolonged ventilation will be required
- A diaphragmatic hernia is suspected
- Inadequate resp effort is found
Intubation will surpass Glottic Function and PEEP! So to maintain adequate functional residual capacity, a PEEP of 2-4cmH2O should be provided
(If gastric distention occurs, you should place a naso/orogastric tube into the esophagus AFTER the ET tube is placed) (Measure a Nasogastric tube by starting at tip of nose, around ear, and to the xiphoid ; Orogastric tube from lips to xiphoid process)
How to perform Neonate Chest Compressions
- Wrap around neonates torso and place thumbs on LOWER THIRD of Sternum OR if large baby, use your middle and ring finger (fingers should NOT leave chest during ventilations for 2 rescuer)
- Compression to Ventilation RATIO should be 3:1 AT 90 COMPRESSIONS and 30 VENTILATIONS PER MINUTE. (with 120 movements per minute, each action should be 1/2 a second) with expiration of ventilations occurring AS the first compression is performed
- Reassess heart rate, resp, and color every 30 seconds
- DISCONTINUE compressions once a spontaneous heart rate exceeds 80 bpm
