PEDs/NICU midterm Flashcards
Fertilization
union of the sperm cell and the mature ovum, occurs in the outer third of the fallopian tube
First stage
period from conception to the completion of implantation or about 12-14 days
- Results in two identical cells
- Rapid cell division
Ovum
developing organism name
Second stage
occurs from the end of the ovum stage to the time it measures roughly 3 cm from head to rump or around 54-56 days
- Called an embryo
- Tissues, organs, and organ systems differentiate
Blastodern
some of the cells go father toward one end forming
Third stage
what will remain until the end of pregnancy (210-214 days)
- Continued growth of organ systems
Fetus
organism is called this in the third stage
Neonate
used from delivery through the first month of life
Infant
used for the period from 1 month to 1 year of life
Child
identifies the patient above 1 year of age
Placenta
during the 40 weeks of gestational development, the placenta acts as the organ of respiration for the fetus
- Fetus receives nutrients and oxygen and rids itself of CO2 and other waste
- At term, occupies about ⅓ of the uterine surface, and weighs around 1 pound or 15-20% of fetal weight at term
- Blood coming from the fetus follows the two umbilical arteries to the placenta at which they branch into smaller and smaller vessels
Umbilical cord
lifeline between mother and fetus
- Consist of 3 vessels
Amnion
sac surrounding the embryo that contains the amniotic fluid
- Aries from the trophoblast around the 7th gestational day
Amniotic fluid
fluid that fills newly developed sac
- At term about 1 liter
- Constantly absorbed and replenished
- Allows fetal movement and provides protection
- Aids in thermoregulation
Embryonal stage
first 7 weeks gestation
- Development of anatomical structures of various organ systems
- Lungs begin to develop at 24 days
- Endoderm forms GI tract and CNS in 21 days
- Pharynx develops at 21 days
- Small buds that became right and left main stem bronchi develop at 28 days
- Lobar bronchi forming around day 31
Pseudoglandular stage
7-16 weeks gestation
- Further development of respiratory structures
- Differentiation of nasal cavity, oropharynx, nasopharynx
- Vocal cords develop at week 8
- Lungs continue to develop and begin to look like glands
- Goblet cells develop during 13th gestational week
Canclicular stage
weeks 17-26
- Terminal and respiratory bronchioles multiply
- Lungs become vascularized
- Alveoli begin to develop
- Smooth muscles develop around conducting airways to participate in gas exchange through the thinning air-blood barrier
Saccular stage
26 to between 34-36 weeks
- Baby 24-26 weeks, lungs completely form
- Continued development of the alveoli
Alveolar stage
true alveoli are present between 32-34 weeks
- Number of alveoli will increase until around age 8
Asphyxia
combination of hypoxia, hypercapnia, and acidosis
Fetal asphyxia
can be diagnosed by the use of scalp blood pH determination → 7.2-7.24 pH
- Most dangerous cause of fetal bradycardia (less than 100bpm) is asphyxia
- Oxygen administration to the mother may help reduce the severity of asphyxia to the fetus
- Bradycardia can be seen during second stage of labor
- FHR monitor can detect asphyxia
Tocolytics
Process of stopping labor
- Can be achieved pharmacological and nonpharmacological
- indicated when stage I labor begins prior to 37 weeks gestation and when placenta previa is present
Beta sympathomimetics
= relax smooth muscle contractions
Beta sympathomimetics that stop labor:
- Terbutaline sulfate
- Ritodrine
APGAR
developed as an objective way to evaluate the condition of a neonate
- First score is assessed at 1 minute
- Second score at 5 minutes and every 5 minutes after that up to 20 minutes
- 5 minute APGAR score is a predictive of future impairment with a low score of being associated with a high risk of long-term damage
APGAR 5 areas
- respiratory effort
- heart rate
- muscle tone
- reflex irritability
- color
Causes of increased WOB
- Increase in airway resistance
- Hypoglycemia
- Small diameter of nasal passage → can decrease caliber
Bacterial infection
Often caused by organisms found in the material intestinal and genital tracts
- Can be caused by also poor aseptic technique in the nursery or with equipment
Chorioamnionitis
inflammatory response in amniotic fluid which leads to outpouring leukocytes into the fluid from inflamed amniotic tissues
- mom and baby are malodorous
Streptococcus agalactiae or group B strep (GBS)
serious illness and even death in neonates
- GBS is a normal flora of both intestinal and female genital tract (25% females are colonized)
- Strep A, B, C and Listeria have strong evidence of abortion, premature birth, congenital disease, neonatal disease
Quiet examination
= observe
- Color
- Languo
- Activity
- Overall look
- Respirations/retractions → tachypnea respiratory rate above 160 bpm; bradycardia respiratory rate is below 100bpm
- Chest movements should be symmetrical
- Can see grunting and nasal flaring if baby is in distress
Acrocyanosis
baby’s body is pink but feet and hands are still blue in the first 24 hours following birth
Hand on examination
= start at the head and work down to the extremities
- Inspect head for cuts and bruises
- Inspect mouth to see any clefts or hindered breathing
- Examine ears to determine gestational age assessment scale
- Neck should be examined for presence of cyst or tumors
- Normal heart rate is between 120-160bpm
- Inability to maintain body temperature
- Reduced vigor
- Limp appearance
Neurological examination
= dependent on the degree of intrauterine development toward maturation
- Crying
- Response to touch
- movements
- Muscular tone
Thermoregulation
- Large skin surface area is prone to heat loss
- 80% of body weight is water
- Makes overhydration and dehydration difficult to manage
Thermoregulation techniques
- Placing baby in the warmer
- Placing baby on a warm blanket, warm mattress, warm towels
- Minimizing cold objects to the baby’s body
Cold stress
= hypothermia; is any lowering of the thermoneutral temperature
- Baby should be kept 97.9-99.5 (37 celsius)
**A COLD NEONATE WILL NOT RESPOND TO RESUSCITATIVE EFFORTS
Cold stress consequence
Peripheral vasoconstriction → shunt of blood away from the skin → anaerobic metabolism and metabolic acidosis
Increased metabolism of brown fat → glucose levels begin to fall → hypoglycemia
ROP
Formerly called retrolental fibroplasia (RLF) means the formation of scar behind the lens, which is the culmination of the disease (retinal vessels constrict) → necrosis of the vessels
- Affect infants born before 31 weeks gestation that weigh 1250 grams or less
Etiology ROP
- Supplemental oxygen
- Retinovascular immaturity
- Circulatory instability
- Respiratory instability
Treatment of ROP
Cryotherapy= introduces a probe that has been cooled to -20 celsius with nitrous oxide behind the eye and freezing the avascular portion of the retina, further abnormal vessel proliferation
Laser therapy= argon or diode lasers are used to photocoagulation the avascular portion of the peripheral retina
Vitrectomy and lensectomy are being investigated
Necrotizing enterocolitis (NEC)
= Idiopathic disorder characterized by ischemia and necrosis of the intestine in premature baby
factors causing NEC
prematurity, asphyxia, formula feeding
Mildest form of NEC
abdominal distention
Severe form of NEC
perforation of the intestine leading to sepsis and then death
Etiology of NEC
- Mucosal wall injury= ischemia/decreased blood flow to gut
- Bacterial invasion into the damaged intestinal wall
- Formula in the intestine= seen in 95% of infants with NEC
Treatment of NEC
= avoidance of factors that lead to its presence
- Good hand washing
- Oral feeding stopped → nasogastric suctioning on empty stomach
- Feeding through IV (hyperalimentation)
- Fio2 increased to raise arterial PaO2 levels and aid in mucosal regeneration
Pneumothorax
= develops when the extra alveolar air ruptures to the external surface of the lung and into the pleural space
Spontaneous pneumothorax
isolated pocket of free air in the pleural space that is not fed by a continuous inflow of gas from the point of the leak
Tension pnemothorax
addition of new air through the rupture with each breath, creating a larger air pocket that is under pressure
Signs of pneumothorax
- Increase in respiratory distress with tachypnea
- progressing to bradycardic and cyanotic
- may have periods of apnea and hypotension
Transillumination
placement of high-intensity light source, usually fiber optic, on thethoracic surface to quickly diagnosis pneumothorax
Treatment for pneumothorax
- Depends on severity
- Needle aspiration for life-threatening situations
- Chest tube with a range from -15 cmH2O for small leaks and -25 cmH2O for large leaks
Hyperbilirubin (Jaundice)
= yellowish-orange skin color that accompanies increased levels of bilirubin in the blood
- Occurs in 25%-50% of all term neonates
- Bilirubin levels excess 4-6 mg/dL
- Serum unconjugated (indirect) bilirubin levels exceed 13 mg/dl in term neonates and 15 mg/dlin premature neonates.
- Indirect levels rise more than 5mg/dl in a 24-hour period
- Direct (conjugated) bilirubin levels exceed 1.5 mg/dl.
- The jaundice persists beyond 7 days in term neonates and beyond 14 days in the preemie
Bilirubin
comes from breakdown of old erythrocytes into its constituent parts and is a waste product that is normally eliminated from the body through the intestinal tract or kidneys
Etiology of hyperbilirubinemia
- Reabsorb large amounts of bilirubin
- High percentage of erythrocytes
- Blood disorders (Rh, ABO, G-6PD enzyme)
- Hemorrhages in fetal body
- Lack of enzyme glucuronyl
- transferase
- bacterial/viral infections
- Crigler-Najjar/Lucey-Driscoll
- Diabetic mothers
- Prematurity
- RDS
- Galactosemia
- Hypothyroidism
- Oxytocin to induce labor
Treatment/complications of hyperbilirubin (jaundice)
Treatment:
- Phototherapy lights → blue spectrum most effective
- Exchange transfusion for severe cases
- Administration of phenobarbital/albumin
Complications:
- Kernicterus
- Necrotizing enterocolitis (NEC)
Meconium aspiration syndrome
= fetus passes meconium while still in the utero
Signs of MAS
Low Apgar scores, fetal hypoxia, acidosis, and abnormal fetal heart tracings
Etiology of MAS
= Actual aspiration of meconium into the trachea occurs in about half of
- the neonates born with meconium staining the amniotic fluid
- placental insufficiency
- maternal hypertension
- maternal diabetes mellitus
- Preeclampsia
- Oligohydramnios
- maternal smoking
Treatment of MAS
- Infusion of warm, sterile saline into uterus to dilute•
- Intubate and suction if not vigorous
- Suction mouth and nose with bulb syringe if stable
- Provide warmed, humidified oxygen
Rhythm is shockable
=ventricular fibrillation or unstable ventricular tachycardia
- Administer shock at 2 Joules/kg
- Administer high-quality CPR for 2 minutes
- Check rhythm
Rhythm is not shockable
= asystole or pulseless electrical activity(PEA)
- Administer high-quality CPR for 2 minutes
- Administer epinephrine 0.01 mg/kg IV or 0.1 mg/kg per ETT every 3-5 minutes
- Check rhythm
Insensible water loss (IWL)
= water lost by evaporation from the skin and respiratory tract
- Due to abnormal losses of fluid and electrolytes → diarrhea, emesis, nasogastric tube drainage, thoracostomy tube losses, damaged skin
Factors that increase IWL
- Early gestational age
- Respiratory distress
- Environmental temperature above the neutrothermal zone
- Elevated body temperature
- Skin breakdown and excoriations
- Congenital skin defects (neural tube disorders)
- Radiant warmer
- Phototherapy
- Increased motor activity and crying
Insensible water loss equation (IWL)
IWL= Intake – Output – (change in weight)
RDS ABG
= typical of respiratory distress with worsening or refractory PaO2 to oxygen therapy, increasing PaCO2, and combined acidosis
- PaO2 should be maintained at a minimum between 50 and 80 mmHg,
- PaCO2 maintained below 60 mmHg
- pH should be greater than 7.25
- Administer glucocorticoids to mother before delivery
A base excess above 4mEq/L indicates:
too much bicarbonate or too little acid in the blood.
- A negative value, called a base deficit, or a negative base excess, occurs whenever there is too little base or too much acid
TORCH
= used to identify those perinatal infections that are associated with severe fetal anomalies and even death
T- toxoplasmosis
O- other
“other” infective agents are syphilis, HIV, coxsackie virus, varicella-zoster virus (chicken pox), and parvovirus B19
R- rubella
C- cytomegalovirus
H- herpes simplex type 2
SIDS
= sudden infant death syndrome that remains unknown entity but has the highest number of death in infants of less than 1 year old
- put them supine
- 2-4 months more seen for male than females
- Usually hits winter and at night
Cardiopulmonary system difference
Infant‘s tongue is larger in area than adults
- Large amount of lymphoid tissue in pharynx
- Epiglottis is larger and less flexible
- Larynx is higher
- Diameter of trachea narrow
- Ribs and sternum mostly cartilage
Metabolism difference
- Higher than adults
- The caloric requirement for neonates is approximately 100 cal/kg and decreases to 40 to 50 cal/kg in the adult
- Increases oxygen requirement
- Results in challenges to pharmacotherapy
Pica
= intake of non-foods such as hair, dirt, animal droppings, and paint
- At issue is not just a vitamin and mineral deficiency, but possible poisoning with heavy metals
Anorexia nervosa
= refusal to eat in a relentless pursuit to become thin
Bulimia nervosa
= binging on large quantities of high-caloric food, which then may be followed by self-induced vomiting or use of laxatives to “purge” the body
Attention deficit/hyperactivity disorder (ADHD)
= have trouble paying attention and controlling their impulsive behaviors → overactive
- One of the most common neurobehavioral disorders of childhood
- between 3% and 7% of school-aged children have ADHD
Types of ADHD
- predominantly inattentive type
- predominantly hyperactive-impulsive type
- combined type
Asperger syndrome
= similar to autism, but function better than those with autism
- generally have normal intelligence and near-normal language development, although they may develop problems communicating as they get older
PDD-NOS
=children who have significant problems with communication and play, and some difficulty interacting with others, but are too social to be considered autistic
- sometimes referred to as a milder form of autism
Oppositional defiant disorder (ODD)
- First occurs between 18 and 24 months and is affectionately called the “terrible twos.”
- During this time, the oppositional behavior is related - The second occurrence may be seen during the teenage years when there is another move toward an autonomous identity and a separation from the parents
- These episodes typically last less than 6 months
- children with ODD exhibit oppositional and defiant behavior chronically
- Children with ODD show frequent temper tantrums, excessive arguing, and deliberate attempts to upset people, mean and hateful talking, and revenge seeking
Conduct disorder
= group of behavioral and/or emotional problems that lead toa disregard for rules and socially unacceptable behaviors
- more prevalent in males where it often manifests as aggression
- Of major concern with this disorder is the high rate of mortality, which may approach 50%
Alveolar developement
- Canalicular stage → Weeks 17 through 26
= Alveoli begin to develop - Saccular stage → 26 to between 34 and 36 weeks
=Continued development of the alveoli - Alveolar stage –> True alveoli are present between 32 to 34 weeks
= Number of alveoli will increase until around 8 years old
Foramen ovale
An opening between the right and left atrium is present in the atrial septum; this opening is the second shunt
- shunts blood from right to left atrium
CXR
= managing newborns with lung disease because of their ability to give views of the effect of various disease processes on the internal body structures
It can usually be expected that a chest film of any newborn or intubated pediatric patient is an AP view
Umbilical vessels
The umbilical vein is a single vessel of relatively large diameter that often appears filled with blood
The umbilical arteries are a pair of vessels of smaller diameter that usually are more opaque and whitish in appearance and appear to contain little blood
- After delivery, the umbilical arteries gradually spasm and close
- The cord stump should first be checked to ensure that the umbilical arteries are still pulsatile
Heart rate
The average heart rate in early gestation is 140/min → dropping to an average of 120/min near term
The normal baseline heart rate will range between 120 and 160 beats per minute (bpm)
- A healthy, awake fetus has a constantly changing heart rate, usually between 5 and 10 bpm
Respiratory rate
normally between 30 and 60 bpm
- Tachypnea, or a respiratory rate above 60 bpm → sign of respiratory distress
Periodic breathing
neonates, especially those born prematurely, may have periods of apnea usually lasting 5 to 10 seconds but without cyanosis or bradycardia
Wharton´s jelly
= A cross section of the umbilical cord reveals three vessels surrounded by a tough, gelatinous material, - insulates and protects the umbilical vessels
- The presence of Wharton’s jelly prevents bending and pinching of the umbilical cord
- Following delivery, abrupt temperature changes cause the Wharton’s jelly to collapse the umbilical vessels within about 5 minutes
Amnion
= the sac that surrounds the growing fetus and contains the amniotic fluid
- It arises from the trophoblast around the seventh gestational day
- It begins as a small vesicle and develops into a sac, which covers the dorsal surface of the embryo
Surfactant
= the substance found on the alveolar wall that lowers surface tension
- The first surfactant “immature surfactant” seen at approximately 24 weeks gestation
- Can give 3 times in the span of first 72 hours from birth
- Reduces muscular effort
- Works in tandem with the change in size of the alveoli
- Can be measured in amniotic fluid
Mature surfactant
=present around week 35
- Determined by lecithin-to-sphingomyelin ratio (L/S ratio)2:1 generally around 35 weeks gestation
- Shake or foam test
- Amniotic fluid surfactant-albumin ratio (SAR)
- TDx-FLM assay
- Fluorescence polarization (FP) assay
Bradycardia
= A baseline heart rate of less than 100 bpm or a maintained drop of 20 bpm from the previous baseline rate
- seen during the second stage of labor (after the cervix is dilated to 10 cm through the delivery of the infant) is divided into end-stage and terminal bradycardia
The most dangerous cause of fetal bradycardia:
Asphyxia –> Oxygen administration to the mother may help reduce the severity of asphyxia to the fetus
Arteries
= Blood coming from the fetus follows the two umbilical arteries to the placenta, at which point they branch into smaller and smaller vessel
- The umbilical arteries have relatively thick walls
- Near the upper pelvic region, the aorta splits into the two common iliac arteries → The iliac arteries further divide into the external and internal iliac arteries → It is from the internal iliac arteries that the two umbilical arteries branch
- Throughout fetal circulation, between 17% and 33% of blood flow passes through the umbilical arteries
Tachycardia
= baseline is consistently above 180 bpm
- The most common cause is maternal fever
Atrial septal defect (ASD)
= usually involves a failure of the tissue flap to cover the foramen, allowing the movement of blood between atria
- Often symptomless
- Openings in the atria can also occur in the upper and lower trial septum
- Diagnosis A majority of ASDs are symptomless and go undetected
- Severe ASDs may result in left-to-right shunting with resultant right ventricular overload
Most common ASD
incompetent foramen ovale
= defect is called an osteum secundum defect
Body surface area
= The term neonate has about 0.07 m2/kg
= 28-week neonate has roughly 0.15 m2/kg.4
- This large surface area makes the neonate particularly prone to heat loss and often susceptible to cold stress
Persistent pulmonary hypertension of neonate (PPHN)
= Characterized by severe, persistent pulmonary vasoconstriction, which causes increased blood pressure in the lungs and decreased pulmonary blood flow (persistent fetal circulation)
treatment of PPHN
- inhaled nitric oxide —> mechanical vent
- The maintaining of temperature, fluids and electrolytes, blood sugar, oxygenation,blood pressure and perfusion
- Minimize handling the patient
- Mechanical ventilation
Larynx
- The infant larynx lies higher in the neck in relation to the cervical spine
- The narrowest segment of the larynx is at the level of the cricoid ring
- The narrowest portion of the adult larynx is at the glottis
- A child’s larynx is higher and more anterior anatomically than the adults → at about the level of the first or second vertebrae
Patent ductuc arteriosus (PDA)
= is a congenital heart defect that occurs when the ductus arteriosus, a temporary blood vessel in a fetus, doesn’t close after birth
- Right to left shunting
- Hyperperfusion and engorgement of the pulmonary vessels with resulting pulmonary edema
Truncus arteriosus
= A defect in which one large vessel arises from both right and left ventricles over a large VSD
- Diagnosed by electrocardiography and cardiac catheterization
- Requires surgical treatment
Cyanosis
= caused by decreased blood flow through the pulmonary artery and the resultant passage of venous blood into the aorta
PPV
- peak inspiratory pressure (PIP)
- positive end-expiratory pressure (PEEP)
- continuous positive airway pressure (CPAP)
- rate
= when the neonate is apneic or gasping, or when spontaneous breathing cannot maintain the heart rateabove 100 bpm
PPV equipment
- flow-inflating bag
- self-inflating bag
- T-piece resuscitator
Secondary apnea
= Second attempt of fetus to ventilate
- Respirations are weak, gasping, and ineffective
- During secondary apnea, there will be no attempt to breathe again unless positive pressure ventilation (PPV) is initiated
Lung development
Embryonal stage → First 7 weeks gestation
= Lungs begin to develop at 24 days
Pseudoglandular stage → 7 to 16 weeks gestation
= Lungs continue to develop and begin to look like glands
Canalicular stage → Weeks 17 through 26
= Lungs become vascularized
Saccular stage → 26 to between 34 and 36 weeks
= By 24 to 26 weeks, lungs are completely formed
pH levels
= Safe Range (neonatal and pediatric) 7.35 to 7.45
= Acceptable Range (neonatal and pediatric) 7.30 to 7.50
= Fetal blood pH is considered to be normal above 7.25
- pH of 7.2 to 7.24 shows slight asphyxia
- pH of less than 7.2 signifies severe asphyxia
Intubation indications
1) when thick meconium is present in a nonvigorous infant
2) if bag and mask ventilation is difficult or ineffective
3) if prolonged PPV is required due to lung disease
4) if chest compressions have become necessary
5) in cases of extreme prematurity and need for surfactant administration
Intubation
- term neonate will require a size 1 blade
- size 0 blade is needed for premature neonates
- Should be done in under 30 seconds to prevent hypoxia
Cervix dilation
First stage= Onset of regular contractions to full dilation and effacement of the cervix
- 16–18 hr 7–12 hr
Second stage= Full dilation and effacement of the cervix to delivery of the fetus
- 1 hr (can last up to 2 hr) 20 min
Placenta previa
= placenta covers cervix
- the blastocyst attaches itself somewhere near the upper portion of the uterine cavity → implantation occurs in the lower portion of the uterus
- All types of placenta previa are readily diagnosed by ultrasound
Low implantation
occupies the lower portion of the uterus but does not cover the cervical opening
Partial placenta previa
covers a portion of the cervical opening but does not cover it completely
Total placenta previa
completely covers the opening of the cervix
Cesarean section
25% of delivers in the US are done by C-section
- Tachypnea of the newborn (TTN)
- Prior cesarean delivery
- Dystocia
- Breech presentation
- Fetal distress
- Multiple gestations
OSA signs
It is estimated that 2% to 4% of all children are affected by obstructive sleep apnea
Signs:
- Choking
- drop in the heart rate
- rise in blood pressure
- brain function arousal
- Hypoxemia
- disrupted sleep
Physical causes of OSA
- enlarged tonsils and adenoids
- Obesity
- lower jaw
- tongue abnormalities
- neuromuscular deficits
Untreated OSA
lead to social problems, behavioral and learning disorders, enuresis, growth shunting, obesity, and an increased risk of hypertension and other cardiopulmonary problems
- Up to 25% of children diagnosed with ADHD may also have symptoms of obstructive sleep apnea
Upper airway hazards
= Any swelling or inflammation of these structures greatly increases resistance and the patient’s work when breathing
- Infants also have a large amount of lymphoid tissue in the area of the pharynx compared to the adult
- The epiglottis of the infant is proportionally larger, less flexible, and omega shaped (Ω), which makes it very susceptible to trauma → the infant epiglottis also lies more horizontally than the adult
- the narrowest segment of the larynx is at the level of the cricoid ring &the narrowest portion of the adult larynx is at the glottis
