8- Neonatology Flashcards
Newly born
Infant at time of birth
Newborn
Infant within first few hours of birth
Neonate
Infant within the first month of being born
Antepartum risk factors for resuscitation (8)
- Multiple gestation
- No prenatal care
- Mom is <16 or >35 y/o
- Polyhydramnios or Oligohydramnios
- History of stillbirth
- Post term gestation
- Drug use during pregnancy
- Eclampsia, HTN, Diabetes, Toxemia
Intrapartum risk factors for resuscitation (7)
- Premature labor
- Meconium
- Membrane rupture >24hrs before delivery
- Abnormal presentation
- Prolonged delivery
- Prolapsed cord
- Bleeding
Steps of neonatal resuscitation (5)
1-Dry, warm, stimulate, suction for 30 seconds
2- HR >100 HR w/ central cyanosis, free flow O2 30 seconds
2.5- Poor respirations <100 HR, BVM 40-60/min for 30 seconds
3- HR >60 begin compressions 3:1 and ET
4- No improvement after 30 sec start ALS
5- No signs of life after 10 min, consider termination
Fetal transition
Series of events needed to enable newborn to breath as its delivered
The 3 shunts from adult to newborn
1-Ductus venous
2-Ductus arteriosus
3- Foramen ovale
Weeks of gestation for pre, term and post term delivery
Preterm- Less than 37 weeks
Term- 38 to 42 weeks
Postterm- More than 42 weeks
What causes a newborn to begin its own breathing
Hypoxia and hypercapnia related to partial occlusion of the umbilical cord during normal delivery
NEEDED equipment for newborn delivery (14)
- Bulb syringe
- 5F to 14F suction catheter
- 8F feeding tube with 20 mL syringe
- Pedi BVM
- Laryngoscopes 00, 0, 1
- ET tubes 2 to 4
- EPI (0.1 mg/mL)
- 250 mL D10
- Umbilical catheters 3.5F and 5F
- 1 through 50 syringes
- 26 through 18 g needles
- OPA’s 0, 00, 000
- Plastic wrap
- Warming pad
What is suctioned first in a newborn
MOUTH
What needs to be examined as newborn is delivered
- ABC’s
- APGAR
- Skin discoloration
- Head symmetry
- Eyes
- Umbilical cord
Target O2 sat at 1-10 min for a newborn
1- 60 to 65% 2- 65 to 70% 3- 70 to 75% 4- 75 to 80% 5- 80 to 85% 10- 85 to 95%
How long can you suction a newborn for
No more than 10 seconds
When and how much free flow O2 is applied to a newborn
Cyanotic, pale
5 Lpm
Why would a newborn need an OPA
Bilateral Chantal atresia
Pierre Robin sequence
Macroglossia
Other craniofacial defects
In what case can nasal intubation not be done
Choanal atresia
What is choanal atresia
Bony or membranous obstruction of the back of the nose preventing air flow
Pierre Robin Sequence
Developmental abnormalities including small chin, posteriorly positioned tongue leading to airway obstruction
How to relieve Pierre Robin sequence
OPA, depress tongue dont rotate OPA
Signs of resp distress for BVM use in newborn
Periodic breathing
Intercostal retractions
Nasal flaring
Grunting on expiration
When to use BVM on newborn
Inadequate respiratory effort
HR less than 100 after initial stimulation
Other signs of resp distress
Common causes of respiratory distress in a newborn (11)
- Lung, heart disease
- CNS disorder
- Pneuothorax
- Meconium aspiration
- Premature development
- Shock/Sepsis
- Diaphragmatic hernia
- PERSISTENT PULMONARY HYPERTENSION
- Airway obstruction
- Pneumonia
- Metabolic acidosis
Most common reasons for ineffective BVM in a newborn
- Poor seal
- Incorrect head position
- Copious secretions
- Pneumothorax
- Equipment malfunction
What cases would a newborn need to be intubated
- Meconium stained fluid
- Diaphragmatic hernia
- Prolonged PPV is needed
- Craniofacial defects
Gastric decompression indication in a newborn (4)
-Prolonged ventilations
-Abdominal distention impeding ventilation
-Diaphragmatic hernia
-Gastrointestinal congenital anomaly
(Pyloric stenosis)
Signs of Diaphragmatic hernia
- Decreased breath sounds of left side
- Concave abdomen
- Increased work of breathing
Steps of inserting OG tube in newborn (4)
1- 8F feeding tube measured from bottom of earlobe to nose to in between xiphoid process and umbilicus
2- Insert through mouth, leave nose open
3- Attach 10 mL syringe, bubble, suction stomach
4- Tape to cheek, intermittently suction
When is CPR indicated in a newborn
HR less than 60 despite positioning, clearing airway, drying/stimulation and 30 seconds of effective PPV
2 techniques of CPR for a newborn
- Thumb
2. Two finger
How many compressions and breaths per minute in newborn CPR
90 compressions
30 breaths
Steps to establish umbilical IV (6)
- Clean, drape towels all around
- Put 3mL syringe and 3.5-5F on stopcock
- Cut cord between tie about 1” from skin
- Insert line into umbilical vein at 12 position
- Advance catheter .75 to 1.5” until blood can be aspirated
- Flush with .5 mL NS, tape in place
What is Gastroschisis
Portion of the abdominal organs herniate through weak area of abdominal wall, no membrane covering on them
What is Omphalocele
Portion of abdominal organs protrude through umbilicus, thin membrane covering organs
-Non intact omphalocele = Organ membrane is ruptured or torn
Typical birth weight at
- 28 weeks
- Term
28 weeks- 2.5 lbs avg
Term- 6.5 to 9 lbs avg
What is apnea
- Result
- Causes (6)
Respiratory pause of greater than 20 seconds
- Can lead to BradyC, hypoxemia
- Mom/baby narcotic exposure, resp muscle weakness, septicemia, abnormal labor, gastroesophageal reflux, CNS abnormality
Primary vs secondary apnea
Primary- Short period of hypoxia, period of rapid breathing followed by apnea and BradyC, resolved by stimulation
Secondary- Hypoxia continues during primary apnea, newborn will gas, not resolved by stimulation, PPV is required
What frequently causes BradyC in a newborn
Hypoxia
What may be the cause for BradyC after adequate ventilation, compressions and volume expansion
Acidosis
Acidosis treatment in a newborn
Find and reverse the cause
Pneumothorax (newborn)
- Causes
- S/S
- Treatment
Causes- Inhales meconium, weak lung from infection
S/S-Resp distress w/o any improvement, decreased breath sound, shifted heart sounds
Treatment-Needle decompression
Newborn needle decompression
- Indication
- Procedure
Pneumo, decreased breath sound, shifted heart sound
- 22 g butterfly to extension tubing to stopcock to 20 mL syringe
- Above 2nd rib, remove air and repeat air removal as needed
Can you give Narcan to an infant with chronic or acute narcotic exposure
Acute
Best place for IV establishment in newborns
- Dorasl hand
- Greater saphenous (foot/ankle)
Seizures (Newborns)
Strongly suggest presence fo neurological disorder
- Paroxysmal alteration in neurological function
- More common in premature
- ECG confirms diagnosis
Seizures (Newborn)
S/S (5)
Treatment
S/S-Deviation or fixation of eyes, can be triggered by stimulus, clinic jerking, lethargy, apnea
Treatment-BGL, vitals, CMC benzos, monitor
Hypoglycemia (Newborns)
Causes
S/S
Treatment
BGL less than 45, usually a symptomatic until BGL below 20
Causes- Metabolic, stress
S/S-Cyanosis, apnea, hypotonia (limp), ALOC, Irregualr resps
Treatment- BGL, Vitals, IV, D10
Esophageal atresia
Failure to develop the distal lumen
Infantile Hypertrophic Pyloric Stenosis
Hypertrophy and hyperplasia of the two muscular layers of the pylorus, becomes thickened, obstructs the end of the stomach
Malrotation
Congenital anomaly of rotation fo the midgut
-Small bowel found on R side
Intestinal atresia (Intestinal stenosis)
Congenital, parts of bowel may not have developed or may be narrow
Hirschsprung disease
Last segment of colon fails to relax and causes mechanical obstruction
Causes of neonatal seizures (6)
- Hypoxic ischemic encephalopathy
- Intracranial infection
- Hypoglycemia
- Epileptic syndrome
- Hypocalcemia
- Drug withdraw
Vomiting (Newborn)
S/S
Treatment
S/S- Distended abd, fever/hypothermic (sepsis), apnea/BradyC, Abd tender/guarding, minimal bowel sounds
Treatment- ABC’s, Naso or OG tube?, Fluid (10mg/kg per bolus)
Most common cause of diarrhea in newborns
Viral infection
Diarrhea (Newborn)
Excessive loss of electrolytes and fluid in stool
S/S- Ill looking, poor vitals, Cap refill >2 sec, dry mucous membranes, poor skin turgor, sunken eyes
Treatment- ABC’s, O2, Fluid (10 mL/kg blouses)
Causes of neonatal jaundice
Treatment
Hemolysis, RBC disorders, polycythemia
Treatment- IV fluid, communicate to ER
Fever (Newborn)
Rectal ,Oral and Axillary
Rectal- > 100.4
Oral- > 99.4
Axillary- > 98.4
Can newborns sweat or shiver
NO
Newborn fever treatment
Remove excess clothing layers, improve ventilation in the environment
Newborn hypothermia
Body temp less than 95
Newborn hypothermia risk factors (6)
- 8 to 12 hrs after birth
- Prolonged resuscitation
- Small for gestational age
- CNS problems
- Premature birth
- Sepsis
Increase in metabolic function in newborns to produce heat can result in (4)
- Hypoglycemia
- Metabolic acidosis
- Pulmonary hypertension
- Hypoxemia
Hypothermia (Newborns)
S/S
Treatment
S/S- Cool to touch, pale/acrocyanosis, apnea, BradyC, cyanosis, lethargic, weak cry, sclerema
Treatment- Cap on head, reward, D10W, warm fluid
Sclerema
Hardening of the skin associated with reddening and edema
Birth trauma
Included preventable and non-preventable injuries from mechanical forces during delivery
Caput Succedaneum
Swelling of the soft tissue of the newborns scalp as it presses against the dilating cevrix
Cephalohematoma
Area of bleeding between parietal bone and its covering periosteum, raised lump
Most common brachial plexus injury at birth
Erb palsy (C5, C6)
Klumpke paralysis (C8 to T1)
Rare, results in the weakness of intrinsic muscles of the hand
Pseudoparalysis
Avoiding movement of injured body part to prevent pain
Most frequently injured bone in a newborn
Clavicle
Consider intra-abdominal bleeding in every newborn presenting with
Shock
Unexplained pallor
W/ abdominal distention
Congenital Heart Disease (CHD)
-Presentation
Abnormalities of the heart during development. The most common birth defect
Presentation- Increasing resp distress, poor perfusion, cyanosis, eventual cardiovascular collapse
Best place for a pulse ox reading
Right hand
Noncyanotic disease
Includes Atrial septal, ventricular septal, ductus arteriosus , ductus venous defects and coarctation of the aorta
Effects of Artiral septal defects
Enlargement of both atria
Pulmonary hypertension
OR
Asymptomatic
Effects of ventricular septal defects
Reduced stroke volume
RVH
RAE
Pulmonary hypertension
What is patent ductus arterious
The Ductus arterious fails to close after birth allowing blood flow to bypass the right ventricle and lungs due to the fetus’s lungs being filled with fluid
Patent ductus arterious
S/S
Fatigue Failure to thrive Poor feeding Bounding peripheral pulses Characteristic murmur Increased work of breathing
Coarctation of the aorta (CoA)
S/S
Narrowing of the aorta, LV has to work harder, increased pressure to head and arms and decreased pressure to body and legs.
Can result in heart failure or poor perfusion
S/S Dyspnea, poor weight gain High BP/bounding pulses in arms but not lower body Chest pain, weakness Differential cyanosis Dizzy, nosebleeds
Cyanotic disease
-Examples
Congenital abnormalities which deoxygenated blood (R side) mixes with oxygenated blood (L side)
Called a right-to-left shunt.
Examples- Truncus arteriosus, Tricuspid atresia, Hypoplastic left heart syndrome, tetralogy of Fallot
Pulmonary stenosis
S/S
Disease damages pulmonic valve of the right side of the heart, decreasing blood flow to the lungs
S/S- JVD, Cyanosis, RVH
Truncus Arteriosus
S/S
Pulmonary artery and Aorta are combined into one, causes heart failure early in life
S/S- Lower O2 sat resulting in cyanosis
Tricuspid Atresia
Lack of tricuspid valve, resulting in undersized or absent right ventricle and significantly decreased blood flow into the lungs
Hypoplastic Left Heart Syndrome
Complete underdevelopment of the left side of the heart, extremely small aorta, mitral and aortic valves may be closed
Can not fulfill circulation needs of the body
Tetralogy of Fallot
- Combination of ventricular septal defect, pulmonary stenosis, RVH and overriding aorta
- Aorta is connected between left and right ventricles over ventricular septal defect
Tetralogy of Fallot, tetralogy (tet) spell
S/S
Treatment
Arterial O2 suddenly decreases, from increased constriction of lung outflow, further restricting pulmonary blood flow
S/S- Cyanosis, Irritability, Hyperpnea
-Can result in seizures, syncope, death
Treatment- Knee to chest position, O2, IV/Fluid, CMC meds
Transposition of the Great Arteries
S/S
Positions of Aorta and Pulmonary artery are reversed
Can only survive if heart defects are present
S/S- Heart failure, hypoglycemia, SOB, clubbing
Total Anomalous Pulmonary Venous return
Rare, the 4 pulmonary veins do not connect to left atrium but to right atrium