DR ER WK1 Flashcards
Birth Injury: Incidence
- 2% singleton vag cephalic
- 1.1% c/s
- <2% neonatal death rt birth injury
Birth Injury: DR Complications
- Acute blood loss and shock
- Respiratory insufficiency or failure
- Risk neurological or organ impairment
Birth Injuries: Risk Factors
- BMI >30
- Macrosomia >4,000
- Abnormal presentation (esp vag breech)
- Instrumentation
- Forceps
- Vacuum
- Shoulder dystocia
Volume Expansion DR: Indications
- suspected blood loss
- hypovolemic shock
- palor
- weak pulse
- poor perfusion
- HR fail to increase w other measures
Volume Expansion DR: Agents
- Uncrossmatched O- whole blood
- Crystalloid infusion (NS)
- NOT colloid infusions (albumin)
Volume Expanders DR: Dosing
- 10-20mlkg
- Repeat doses PRN
Volume Expansion DR: Dosing
- 10-20mlkg
- Repeat doses PRN
ICH: Types
- Subdural - rupture veins between dura mater and arachnoid layer
- Subarachnoid - rupture veins subarachnoid space or small leptomeningeal vessels
- Epidural - rupture middle meningeal artery
- IVH
ICH: Risk Factors
- Instrumentaiton
ICH: s/s
- Apnea
- Seizures
- Resp depression
- Altered tone
- Decrease LOC
- Increase irritability
ICH: MGMT
- Common no urgent mgmt DR
- s/s + instrumentation →
- CUS asap
- Definitive study
- CT
- MRI
Extracranial Injuries: Types
- Caput succedaneum
- Cephalohematoma
- Subgaleal hemorrhage - rupture veins subgaleal space (between skull periosteum and epicranial aponeurosis)
Subgaleal Hemorrhage: Patho
- Hemorrhage under aponeurosis
- Traction scalp during delivery → shearing or severing emissary veins in subgaleal space
- Extends from orbital ridges to nape of neck
- 20-40% sequestration blood volume pos
Subgaleal Hemorrhage: Risk Factors
- Instrumentation (esp vacuum)
- Vacuum cup marks
- Over sagittal suture
- <3cm anterior fontanel
- Nulliparity
- APGAR <8 5min
Subgaleal Hemorrhage: s/s
- Fluctuant swelling
- Crosses suture lines
- Poorly defined edges
- Anteriorly displaced ears
- Pallor
- Hypotonic
Subgaleal Hemorrhage: Complicaitons
- Mortality 10-15%
- Hypovolemic shock
- Consumptive coagulopathy (esp large bleed)
- Hyperbili
Subgaleal Hemorrhage: MGMT
- Suspect w s/s (esp w instrument delivery)
- NICU NOT DR mgmt
- VS q1-4hr
- Serial FOC measurements
- Serial hct
- UVC w s/s ongoing blood loss
- Coag studies - rt risk consumptive coagulopathy w large bleeds
- Transfusion PRN coagulopathy
- FFP
- Cryoprecipitate
- Platelets
- Massive subgaleal hemorrhage - pos recombinant activated factor VII
Subgaleal Hemorrhage: DX
- CUS - rapid assessment
- CT/MRI - definitive f/u
Nerve Palsies: Types RT Birth Trauma
- Facial nerve palsy
- Brachial plexus palsy
- Phrenic nerve palsy
Phrenic Nerve Palsy: Incidence
- 1:15,000 live births
- 80% unilateral (esp R side)
Phrenic Nerve Palsy: Patho
- Phrenic nerve - originates anterior rami C3-C5, descends thorax, innervate diaphragm
- Source motor innervation diaphragm - contract w inspiration, dome shape exhalation
- Extreme lateral flexion and traction neck → injury
Phrenic Nerve Palsy: Risk Factors
- Shoulder dystocia (hightest risk)
- Macrosoma
- Instrumented
- Vag breech
Phrenic Nerve Palsy: Complications
- Mortality 10-15%
- Sig respiratory distress
- Diaphragmatic paralysis (esp w brachial plexus injury)
- Low Apgar
Diaphragmatic Paralysis: s/s
- Paradoxical (see-saw breathing)
- Tachypnea
- Cyanosis soon after delivery
Phrenic Nerve Palsy: MGMT
- Sig respiratory distress - DR ER
- Consider w acute resp distress birth (esp w shoulder dystocia, brachial plexus injury, other risk factors)
- Plication diaphragm - if cannot wean resp support
Phrenic Nerve Palsy: DX
- CXR - pos wnl w PPV
- US (preferred) - lack or paradoxical diaphragmatic movement
Spinal Cord Injuries: Types
- Upper cervical (common)
- Lower cervical
- Thoracic
Upper Cervical Injury: Incidence
0.15:10,000
Spinal Cord Injuries: Risk Factors
- Vag breech
- Instrumented delivery
- Forceps rotation >90degrees (esp upper cervical)
- Vertex delivery (esp upper cervical)
- Severe shoulder dystocia
Spinal Cord Injuries: Complications
- Mortality
- Hypotonia
- Flaccid tetraplegia or paraplegia
- Respiratory distress
- Apnea (esp upper cervical)
- Vertebral fractures and spinal dislocations
Spinal Cord Injuries: DX
- US
Spinal Cord Injuries: MGMT
- DR ER
- Immobilize head neck and spine w suspicion spinal injury
- XR frontal and lateral spine
- MRI
- W unclear nature
- Ddx - edema, ischemia, hemorrhage
- Early MRI may appear wnl
- MRI post acute phase predict long term prognosis
Spinal Cord Injuries: Outcome Prediction
- Age of 1st spontaneous breath and rate of recovery motor function <3m predict outcome
Visceral Injuries: Locations
- Hepatic (common)
- Adrenal (esp R)
- Splenic
Visceral Injuries: Types
- Solid organ injury
- Solid organ rupture
Solid Organ Injury: Patho and Phases
- Phase 1 - initial subcapsular hemorrhage
- Phase 2 - rupture hematoma → hemoperitoneum
Solid Organ Injury: s/s
- Anemia
- Tachycardia
- Tachypnea
- Poor feed
- Delayed presentation if contained w/in capsule
Solid Organ Rupture: s/s
- Acute decompensation
- Sudden pallor
- Classic triad - shock, anemia, blue discoloration abdomen
Visceral Injuries: Risk Factors
- Macrosomia
- Breech
- Difficult delivery
- Instrumentation
- Chest compressions
Visceral Injuries: Complications
- Organ rupture
- Severe hemorrhage
- Hemoperitoneum
- Mortality
- Hypovolemic shock
- Persistent coagulopathy
- Adrenal insufficiency (w sustained bilateral adrenal hemorrhage, rare)
Visceral Injuries: Dx
- Abdominal US
- Confirm source - CT
Visceral Injuries: MGMT
- Non surgical mgmt preferred
- Hypovolemic shock
- Volume resuscitation - NS until blood arrives
- Clotting factor replacement PRN
- Persistent coagulopathy
- FFB
- Cryoprecipitate
- Platelet transfusion
- Laparotomy
- W continued bleeding
- AVOID splenectomy rt postsplenectomy sepsis
Birth Injuries: s/s Ongoing Blood Loss
- Decrease hct
- Increase FOC
- +1cm = 30-40ml blood loss
- Tachycardia
CCHD: Types
- Inadequate flow of O2 blood to systemic circulation (decrease intracardiac mixing)
- Decrease pulmonary venous egress
- Associated lung or airway anomaly that compromises O2 and vent
- Decrease CO
CCHD: Types cause inadequate flow O2 blood systemic circulation (decrease intracardiac mixing)
- D-TGA w RAS
CCHD: Types decrease pulmonary venous egress
- TAPVR
- HLHS w RAS
CCHD: Types associated lung or airway anomaly compromises O2 and vent
- Severe Ebstein anomaly
- TOF absent pulmonary valve
CCHD: Decrease CO
- severe arrhythmias
- decrease cardiac function in isolation or w CHD
CCHD: DR Prep
- Review fetal echo
- Decide if delayed cord clamping
- Decide who’s attending
- Decide level of care (cardiologist, reviewed by team)
CCHD: DR what to expect
- Intubation
- UVC
- Chest compression
- Thoracentesis or pericardiocentesis pos
CCHD: DR special equipment to set up
- UVC kit w line flushed
- NS 20-30ml/kg boluses
- Pos thoracentesis set up
- Prefilled epinephrine syringes
CHD Severity Scale: Levels
- Level 1 - low risk
- Level 2 - intermediate
- Level 3 - moderate
- Level 4 - high
CHD Severity Scale: ER cardiac intervention
- Level III - pos
- Level IV - likely
CHD Severity Scale: PGE Dependent
- Level III - likely
- Level IV - likely
CHD Severity Scale: Mode of delivery issues
- Level III - pos
- Level IV
CHD Severity Scale: Neonatologist DR
- Level II - pos
- Level III
- Level IV
CHD Severity Scale: Transport Needed
- Level II - pos
- Level III
- Level IV
CHD Severity Scale: Cardiology/OR/CTICU Standby
- Level III - pos
- Level IV
CHD Severity Scale: Level I Types
- ASD
- VSD
- Mild PS
CHD Severity Scale: Level II Types
- CAVC
- TOF/PS
- Truncus Arteriosus
CHD Severity Scale: Level III Types
- HLHS
- TOF/PA
- PA/IVS
CHD Severity Scale: Level IV Types
- D-TGA/RAS
- HLHS/RAS
- Obstructed TAPVR
CHD: Incidence
- 1% live births
- 25% require intervention
