Test 2 Flashcards
What are causes of fetal asphyxia?
- Maternal hypoxia
- Fetal disorders
- Insufficient placental blood flow
- Blockage of umbilical blood flow
Asphyxia is a combination of what?
- Acidosis
- Hypoxia
- Hypercapnia
Compare and contrast primary and seconday apnea.
Primary apnea may be corrected with stimulation.
With secondary apnea, PPV must be initiated.
What are the steps in preparing for neonatal resuscitation?
- Anticipation: basic knowledge of maternal history
- Preparation of equipment
- Trained personnel
How often should resuscitation equipment be check?
Every shift
At minimum, there should be how many skilled persons present whose sole focus is the resuscitation of the neonate?
Two
According to the NRP guideleines, there are three questions that should be asked upon the delivery of the neonate:
- Is the neonate term?
- Is the neonate crying or breathing?
- Is there good muscle tone?
What are the steps to resuscitating a neonate?
- Thermoregulation
- Open the airway
- Evaluate RR
- Evaluate HR
- Evaluate color
- Evaluate oxygen saturation
What type of heat loss is this and how is prevented?
Transfer of heat from one object to another without their coming into contact.
Radiant heat loss - Immediately placing the neonate under the radiant warmer.
What type of heat loss is this and how is prevented?
The loss heat through direct contact of one object with a cooler surface.
Conductive heat loss - minimized by placing the neonate on warm blankets, towels or heated matresses.
What type of heat loss is this and how is prevented?
Loss of heat through the evaporation of liquids from a surface.
Evaporative heat loss - Thoroughly drying the neonate with a warmed towel as quickly as possible
What type of heat loss is this and how is prevented?
Loss of heat due to the movement of air past the skin and carrying away heat (also known as “blow-by”)
Convective heat loss - Preventing cold drafts over the bed and keeping movement to a minimum.
________ are at a higher risk of heat loss.
Low-birth weight, preterm neonates
When you’re opening the airway, if no air movement is noted, what should you do?
Airway should be repositioned before further steps are taken to ensure that the lack of air movement is not due to poor head positioning.
Suctioning should be gentle and limited because stimulation of the vagal nerve in the oropharynx may induce a _____.
Severe bradycardia
What is a vigorous neonate?
Strong respiratory effort, good muscle tone, and a HR greater than 100 bpm
If there is meconium present and the infant is not vigorous, what should you do?
Suction the trachea
What are suction pressures for neonates?
-80 to -100 mmHg, suction is applied for no more than 3-5 seconds
If no meconium is present or there is meconium present and the neonate is vigorous, what should you do?
Clear the mouth and nose of secretions with a bulb syringe or suction catheter.
Which is suctioned first; mouth or nose?
Mouth
What is the normal respiration range for neonates?
40-60 breaths/min
If the neonate presents with any gasping, apnea or a HR less than 100 bpm, what should happen?
Initiate PPV
If the neonate presents with a HR greater than 100 bpm and labored breathing, grunting, flaring, retractions, what should happen?
Ensure airway is clear and consider CPAP to decrease WOB
How do you assess the HR or neonate?
Grasping the base of the umbilical stump between the middle finger and the thumb.
How do you measure neonates’ HR?
HR is measured for 6 seconds and multiplied by 10
How do you inform other clinicians of the neonate’s HR is you are measuring it?
Example: tap out the heart rate on the bed so providers can visually observe.
If HR below 100, what should happen?
Initiate PPV
If HR above 100 during neonatal resuscitation, what should happen?
Evaulate respiratory effort and color
What is the best way to evaulate the color of the neonate?
Directly observing the central portion or trunk of the body.
True or False.
It is common for neonates to have acrocyanosis, which is blueness of the hands and feet, for several hours after delivery.
True
Since neonates take several minutes to transition to adult circulation, it is possible for oxygen saturation to be as low ______ at time of delivery.
60%
It may take up to ______ for a neonate to obtain an oxygenation saturation of >85%.
10 MINUTES
What is the proper placement of the pulse oximeter?
What happens if its placed anywhere else?
Right hand, wrist or forearm. This will allow assessment of preductal oxygen saturation.
The assessment may include blood flow through the ductus arteriosus, which has not participated in gas exchange.
Saturations of _________ on room air are acceptable for a neonate breathing room air.
85-90%
Preterm neonates are even more susceptible to oxygen toxicity than term neonates, because of this, what is recommended?
Oxygen blender
When is PPV indicated?
Neonate is:
- Apneic
- Gasping
- When spontaneous breathing cannot maintain a HR above 100 bpm
When baggin, the bag is squeezed with the fingertips until chest expansion is observed, you should start with what pressures?
Around 20cmH2O and gradually increase if needed to achieved increased rate.
What should do you if you’re giving PPV, and the HR is more than 60 but less than 100?
Continue PPV and monitor oxygen saturation.
If a persistent HR of less than 60 bpm depsite stimulation and 30 seconds of adequate PPV does not provide adequate CO to meet the needs of the neonate, what is initiated?
Chest compressions
Which chest compression technique is preferred?
Thumb techqniue because it is easier to provide consistent depth and pressure.
If it becomes necessary to place an umbilical catheter for the adminsitration of medications, what chest compression technique must be done?
Two-finger technique as it allows greater access to the umbilical stump
Chest Compression - Neonates
The sternum is compressed one-third of the anterior-posterior diameter at a rate of ______.
90/min
The proper rate of compressions and ventilation is ___.
3:1
In order to maintain a compression rate of 90/min, three compressions and one ventilation must be given in a _____ time period.
2-second
It is recommended in the AAP/NRP guidelines that initial compressions continue for upwards of ________ seconds after well-established circulation before the first HR evaulation.
45-60 seconds
Compressions should be discontinued when the HR rises above _______ and PPV continues until the HR rises above 100bpm.
60 bpm
If the neonate does not improve despite assisted ventilation and chest compressions, what should you consider?
- Underlying causes
- Possible equipment failure
- Ineffective resuscitation techniques
Intubation is indicated during a resuscitation when:
- Thick meconium present in nonvigarous infant
- Bag and mask ventilation is difficult/ineffective
- Prolonged PPV is required due to lung disease
- Extreme prematurity and need for surfactant
- Chest compressions have become necessary
Intubation should be STOPPED if…
Severe bradycardia and/or desaturation occur, allowing time to HR and satuation to return to normal limits.
Equipment for intubation:
- Laryngoscope
- Blade with functioning light
- Several ET tube size
- Stylet (optional)
- LMA
- End tidal CO2 monitor
- Suction equipment
- Securing device
- Scissors
- OPA
- MAS
- Stethoscope
- Bag and mask or T-piece
- Oxygen blender
- Pulse ox
Intubation of a term neonate will require which size blade?
1
Intubation of a premature neonate will require which size blade?
0
Which blade is the only one to be used in neonate and young children up to approximately 6-8 years old and why?
Miller, because the larynx is more superior and the epiglottis is more horizontal than in adults.
Easier to lift the epiglottis and visualize the trachea.
Why is it so easy to extubate a neonate?
The tube has no cuff.
Something to know :)
The upper gums are NEVER used as a fulcrum to pry the blade upward.
You’re going to pass this test!
If you’re intubating a neonate and you can’t visualize the epiglottis, what should you do?
Withdraw the blade until you see it.
For neontates, the ideal placement of tube will have its tip _________.
between the carina and the vocal cords.
For neontates, following the verification of tube position, the end of the tube is cut (between 13-15 cm), leaving only _______ outside the mouth. Why?
4 cm. This helps reduce dead space and airway resistance. Also, its easier to manage the tube.
What is the recommended LMA size for neonates over 2 kg?
1
For neonates that are intubated via LMA, it is slid into place with the tip of the cuff resting in the esophagus. The cuff is inflated with no more than _____ of air.
4 mL
What is the ONLY medication administered during neonatal resuscitation?
Epinephrine
Volume expander may be adminsitered in cases of shock due to significant blood loss.
Epinephrine and volume expanders can be administered via ____.
Catheter inserted in the umbilical vein.
Also, in the endotracheal tube, but it is not recommended.
If the endotracheal administration route for epinephrine is selected , the dose should be increased to ____.
0.5 to 1.0 mL/kg
When is the only time endotracheal administration of epinephrine should be used?
When venous access is not available or while venous access is being obtained in emergent situations.
After giving medications via endotracheal tube, what could assist in the disbursement of the medication to the lung fields for absorption?
Manual positive pressure breaths
What is the most easily accessible route for direct administration of medication and fluids during an acute resuscitation?
Umbilical vein
What are indications for the use of epinephrine during resuscitation?
- HR is zero
- HR remains below 60 bpm despite 30 seconds of effective PPV and 30 seconds of chest compresssions
Placement of a UVC and administration of epinephrine and/or volume expanders is indicated when:
Previous resuscitative efforts have not resulted in improvement of the infant.
Epinephrine causes peripheral _____.
Vasoconstriction
What is the dosage of epinephrine?
One mL of a 1:10,000 solution is drawn up and delivered at a dosage of 0.1 to 0.3 mL/kg
After giving epinephrine via endotracheal tube, what can you do to aid delivery?
Dilute with 1-2 mL of normal saline
How often can epinephrine be readministered?
Every 3-5 minutes
Consider increasing the dose within suggested range if no response is noted after first dose.
When is the use of volume expanders indicated?
In infants showing signs of hypovalemic shock due to acute blood loss.
What are signs of hypovalemic shock?
- Low BP
- Pallor in the face of adequate oxygenation
- Poor capillary refill
- HR above 100bpm with weak pulses
- Failure to respond to resuscitation
What scale was developed as an objective way to evaluate the condition of the neonate?
APGAR scale
The Apgar scale examines what 5 areas?
- Respiratory effort
- Heart rate
- Muscle tone
- Reflex irritability
- Color
The first Apgar score is assesed at _______ after delivery.
1 minute. Second one performed at 5 minutes.
Apgars can be assessed every 5 minutes as needed for ______, or when resuscitation ends.
20 minutes
What drives a resuscitation?
Heart rate
During intrauterine life, the nutritional needs of the fetus are continously supplied by the maternal circulation and regulated by the _____.
Placenta
The rate of glucose uptake by the fetus through the placenta is directly related to _______.
Maternal blood glucose level
What are the clinical signs of hypoglycemia?
- Tremors or jitteriness
- Irritability
- Exaggerated or decreased moro reflex
- Apnea/tachypnea
- Cyanosis
- Seizures
- Lethargy
- Hypothermia
- High-pitched or weak cry
- Poor feeding
- Vomiting
- Cardiovascular failure and/or collapse
Define hypogylcemia.
Plasma glucose level less than 30 mg/dL in the first 24 hours of life and less than 45 mg/dL thereafter.
A common cause of hypoglycemia is ___.
Hyperinsulinism
Causes of decreased glycogen stores:
- Prematurity
- Intrauterine growth retardation
- Starvation
- Sepsis
- Shock
- Asphyxia
- Hypothermia
- Glycogen storage disease
- Galactosemia
- Adrenal insufficiency
- Polycythemia
- Congenital cardiac malformations
- Iatrogenic causes
High risk for hypoglycemia.
- Infants of diabetic mothers
- Rh incompatibility
- Prematurity
- Neonates who are small for their gestational age
_____________ provides the most easily accessible route fo arterial blood sampling.
Umbilical stump
The usual site for insertion of a UAC is _____.
Near the umbilicus
What size catheter is used for UAC insertion for neonates weighing more than 1250g?
5 F
What size catheter is used for UAC insertion for neonates weighing less than 1250g?
3.5 F
What is the most common complication of UAC?
Thrombus formation on the catheter. tip, which may lead to a decreased circulation to one of the legs.
Additional thromboembolic complications:
- Hypertension
- Necrotizing enterocolitis
Complications of UAC:
- Perforation of the vessel is a direct complication of the procedure.
- Vasospasm of arterial supply to a toe, foot or leg
- Hemorrhage
What does STABLE stand for?
- Sugar
- Temperature
- Airway
- Blood pressure
- Lab work
- Emotional support
A program that was intiated to educate those who work with newborns to stabilize infant post-resuscitation.
STABLE
To help in the assessment of sexual maturity that accompanies puberty, this scale utilizes changes in the male genitalia, pubic hair presence and distribution and female breast development and pubic hair growth.
Tanner scale
Infants require around ________ to meet their basal metabolic needs along with the energy needed for growth.
120 kcal/kg/day
Developmental delays can occur in any one or any combination of areas and ar estimated to have a prevalence of around ____.
10%
When there is a significant delay in two or more of the examined areas it is termed _____.
Global developmental delay
Developmental disabilities that cause significant social, communication, and behavioral challenges are termed ____.
Autism spectrum disorders (ASDs)
One of the most common neurobehravioral disorders of childhood is ____.
ADHD - attention deficit/hyperactivity disorder
Children with ____ have trouble paying attention, controlling their impulsive behaviors and are also overactive.
Attention deficit/hyperactivity disorder - ADHD
How is Asperger different from autism?
Children with Asperger syndrome typically function better than those with autism. Generally have normal intelligence and near-normal language development although when they get older, they may communication issues.
The term ________ refers to children who have problems with communication, play and some difficulty interacting with others but are too social to be considered autistic.
PDD-NOS - milder form of autism
What are some vaccines for persons aged 0-18?
- Hepatitis A/B
- Roravirus
- Diptheria
- Tetanus
- Pertussis
- Haemophilus influenza
- Pnemococcus
- Polio
- Influenza
- Measles
- Mumps
- Rubella
- Varicella
- HPV
- Megingococcus
How much sleep does a adolescent need a day?
8-9 hours
Infants less than 6 month typically spend how much of their sleep time in active REM sleep?
Half of their sleep time
Childhood sleep patterns approach those of adults after _____ of age.
6 months
These type of children exhibit oppositional and defiant behavior chronically.
- Frequent temper tantrum
- Excessive arguing
- Deliberate attempts tp upset ppl
- Mean/hateful talking
- Revenge seeking
ODD - Oppositional defiant disorder
Up to ______% of children diagnosed with ADHD may also have symptoms of obstructive sleep apnea.
25
_________ is a group of behavioral and/or emotional problems that lead to disregard for rules and socaially unacceptable behaviors.
- Displays aggression toward ppl or animals.
Conduct disoder
Intake of non-foods such as hair, dirt, animal dropping and paint.
Pica
The symptoms of __________ are manifest as a refusal to eat in a relentless pursuit to become thin.
Anorexia 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.
Bulimia nervosa
Symptoms of eating disroders in adolescence:
- Insomnia
- Skipping a majority of meals
- Dental caries and erosion of tooth enamel
- Loss of hair or nail dystrophy
- Constipation
- Frequent weight taking
- Usual eating habits
- Extreme exercise habits
- Unusual hyperactivity
The traditional definition of fever is a rectal temperature above ____.
100.4 F or 38. C
Fever is a response to endogenous proteins that raise the temperature set-point in the ___.
Hypothalamus
In most instances, pediatric fever is caused by _________ that are mostly self-limiting.
Viral infections
One method proposed to help identify febrile infants at low risk for serious bacterial infections is the __.
“Rochester Criteria”
__________ follows only upper respiratory infections as the most common disease of childhood.
Acute Otitis Media
AOM occurs when ____.
Fluid accumulates in th middle ear, leading to inflammation secondary to bacterial infection.
What is the leading cause of AOM?
Eustachian tube dysfucntion
Acute Otitis Media
In children, the eustachian tube is more __________ than adults, making it difficult for fluid to drain out the middle ear.
Smaller and more level
AOM typically occurs recurrently throughout childhood with _______ of children having 6 or more episodes by age 7.
1/3
What are the three specific criteria that must be present to diagnose AOM?
- Acute onset of symptoms
- Presence of fluid in the middle ear
- Signs and symptoms of inflammation
The most common occurence of hypothermia in the pediatric population occurs duing ______.
Trauma and the subsequent care of the patient.
What are some things that contribute to heat loss in a pediatric patient during traumatic injury?
- Open wounds and blood loss
- Lying on the cold ground
- Injury of CNS may impair ability to shiver and detect heat loss
- Placed on a cold backboard
- Supine position
- Administration of non-warmed IV fluids
- Sedatives and muscle relaxants may impair shivering response
BLS vs PALS
BLS is typically designed for one rescuer whereas PALS assumes the resuscitation will take place in a hospital ER where other rescuers will perform a focused task.
Oropharyngeal airways should only be used in what kind of patients?
Unresponsive without a gag reflex
What are some medications used during pediatric resuscitation?
- Adenosine
- Amiodarone
- Atropine
- Calcium
- Epinephrine
- Glucose
- Lidocaine
- Magnesium
- Procainamide
- Sodium bicarbonate
- Vasopressin
What are nonshockable rhythms?
- Asystole
- PEA
Generally, it is accepted that bradycardia is any HR less than 100 bpm in the first _____ years of life.
3
Generally, it is accepted that bradycardia is any HR less than 50 bpm in the ______ year old patient.
9- to 16
Generally, it is accepted that bradycardia is any HR less than 60 in the ____ year old.
3-9
The overall goal in the face of bradycardia is to ____.
Assess and reassess the patient for signs of cardiopulmonary compromise.
Anytime the HR drops below 60/minute with signs of poor perfusion in the presence of effective ventilation with oxygen, what should happen next?
Initiate CPR.
Statistics of the CDC show that the majority of non-fatal injuries are caused by ___.
Falls
What are the steps to conducting primary survey assessment?
- Assess the child’s airway while protecting the cervical spine
- Assess breathing
- Assess circulation
- Diasbility is assessed next
Something to know:
Always assume there is cervical spine injury until CXR and examination prove otherwise.
FACTS
Upon arrival of the patient, the intial primary survey is performed by assessing and managing the child’s ____________.
Airway, cervical spine, breathing and circulation.
What maneuver is recommended for opening the airway when cervical injury is suspected?
Jaw-thrust maneuver
As a general rule of pediatric resuscitation, the patient should be placed on how many liters/min?
10-liter/min
Once the patient is stabilized and the primary survey is completed. The secondary survey is done. During the secondary survey, the child is continously monitored for ____.
- Airway
- Breathing
- Circulation
- Mental state
The inability of the body to deliever necessary nutrients to the tissues, and at the same time, the inability to remove the waste products of metabolism.
Shock
What type of shock refers to a condition of adequate cardiac output and tissue perfusion but the blood flow is maldistributed?
Compensated shock
What type of shock occurs when cardiac output and other compensatory mechanisms are not adequate to perfuse the tissues and severe cellular damage follows?
Decompensated shock
What type of shock is the condition in which tissue perfusion is so extreme that cell death occurs and recovery is unlikely?
Irreversible shock
In ________ shock, trauma to the respitatory tract leads to a reduction in oxygen and carbon dioxide exchange.
Respiratory
Hypovolemic shock occurs following a ______.
Loss of intravascular volume
______ shock occurs when injury or trauma to the CNS damages nerve impulse to blood vessels.
Neurogenic
What are causes of hypovalemic shock?
- Severe gastroenteritis
- Fluid loss from burns
- Blood loss
Introducition of inefective organisms into the circulatory system and th release of their toxins causes an inflammatory response that can lead to ____ shock.
Septic
_______ shock results from a reaction to a substance to which the patient is allergic.
Anaphylactic
The failure of the heart to adequately pump blood leads to _____ shock.
Cardiogenic
What is the most common cause of cardiogenic shock in children?
Dysrhythmias and congenital lesions that impede left ventricular outflow.
______ shock occurs with some type of metabolic disruptions, such as hyper- or hypoglycemia.
Metabolic
______ shock is typically seen in the presence of overwhelming emotional factors and is related to a sympathetic response causing temporary decrease in cerebral perfusion.
Psychogenic
What is the overriding for treating shock?
The restoration of perfusion and oxygenation.
Term that indicates surviving an underwater suffocation at least temporarily.
“Near drowning”
Patient dies secondary to underwater suffocation.
Drowning
Which gender is more likely to drown?
Males
The World Health Organization defines drowning as….
The process of experiencing respiratory impairment from submission/immerision in liquid.
A deterioration of pulmonary function following the loss or inactivation of surfactant.
Leads to failing gas exchange and pulmonary failure.
Secondary drowning syndrome
What two age groups are most susceptible to drowning?
Adolescents and children under 5.
A phenomenon called the _______ causes a rapid slowing of metabolism and a shunting of blood away from the extremities and to the brain, heart and major organs.
Mammalian dive reflex
Hypoxia in the face of 100% oxygen indicates the need for what?
PEEP or CPAP
In the absence of neck injury, the head can be elevated to ____.
Help control ICP
What are ways to prevent hypothermia in near drowning patients?
- Remove wet clothing
- Core warming with warmed IV fluids
- Heat lamps
- Warmed blankets
Epiglottitis is traditionally associated with ____.
H. influenza
The classic presentation of epiglottitis is that acute onset of _____.
- Sore throat
- Fever
- Dysphagia (difficulty swallowing)
that progresse to respiratory distress
With _______, the child often leans forward with the mouth open and allows the saliva to drool from the mouth.
Epiglottitis
Lateral x-ray, “Thumb sign”
Epiglottitis
What is the most common cause of croup?
Parainfluenza virus (75%)
Mycoplasma pneumoniae (25%)
What season does epiglottitis most likely occur?
Any season
What season does croup most likely occur?
Winter
X-ray Examination: Narrowing of the subglottic airway (hourglass) seen on A-P flim.
Croup
Clinical presentation: May be febrile or afebrile. Hoarse, barky cough; tight upper airway stridor
Croup
Croup is the name give to a group of inflammatory diseases that affe th _________ area of the larynx.
Subglottic
What is the most common manifestation of croup?
Laryngotracheitis
Croup (LTB): CXR
Steeple sign; narrowing of the airway at the level of the larynx.
“Hourglass, pencil and a steeple”
How is common croup treated?
By support and administration of drugs the reduce swellin until infection subsides.
0.2-0.5 mL Nebulized racemic epinephrine mixed with 2.5 mL of normal saline.
Decadron, a steriod, is often given because it is much more potent than hydrocortisone.
Racemic epinephrine causes local ________ on the swollen tissues and reduces the edema.
Vasoconstriction
What are some reasons why children are vulnerable for foreign body obstruction?
- Narrowness of airway
- Aspiration of gastric contents
Which of the following is a frequent finding in patients suffering from carbon monoxide poisoning and smoking inhalation?
Pulmonary edema
Hyperbaric oxygen administration is the treatment of choice when COHb is greater than ___%.
25
What is one of the most common causes of burn injury?
Scalding especially in the population less than 3 years old
When only the epidermis is involved, a burn is classified as ______________. The skin becomes erythematous, but no blisters form.
First degree burn
__________ is a common type of first degree burn.
Sunburn
When a burn extends beyond the epidermis to the superficial dermis, it is called a “partial-thickness,” or _____________. The skin becomes edematous, blistered, erythematous, and painful to the touch.
Second-degree burn
When the burn destroys the dermis and dermal appendages, it is considered a “full- thickness,” _____________. The skin appears to be charred, with a whitish color and a leathery feel. Sensation is lost.
Third-degree burn
BURNS:
Criteria for hospitalization include:
Burns greater than 10% in a child; any burn in the very young; any full-thickness burn; burns to the face, neck, hands, feet or perineum; circumferential burns; inhalation injury; and associated trauma or significant pre-burn illness.
Initial care of the burned area involves covering the burned areas with ___.
sterile saline soaked dressings at room temperature.
______ during an automobile accident is a common cause of spinal cord injury.
Sudden hyperflexion or hyperextension of the neck
What are the three goals of management of spinal cord injuries?
(1) preservation of neurologic function and prevention of further neurologic deteriorations
(2) maximization of neurologic recovery (3) prevention of intercurrent nonneurologic complications.
It is estimated that head injuries in children aged 1–19 lead to over _____ hospitalizations a year.
600k
_____ percent of children with multiple trauma have severe head injury as compared to adults in which only 50% have severe head injury.
80
The overriding goal of treating a head injury is to ___.
Prevent any secondary injury to the brain, which includes hypoxemia, ischemia, and increased ICP.
The most important aspect of treating a head-injured patient is to ____.
Maintain and protect the airway from aspiration and to provide adequate ventilation and oxygenation.
_____ accounts for the highest number of deaths in infants of less than 1 year old.
Sudden Infant Death. Syndrome
SIDS Risk Factors
- Infant sleeping with parents in same bed
- Soft bedding in crib
- Multiple birth babies (being a twin, triplet, etc)
- Born to a teen mother
- Sleeping on stomach
SIDS usually hits during _____, and the most common ages are 2 to 4 months with males being affected more frequently than females.
Winter and at night
How does activated charcoal work to treat poisoning?
The charcoal binds to the toxin (adsorption) and allows it to pass through the GI tract without being absorbed into the circulatory system.
The mainstay of treatment for anaphylaxis is _______ Additionally, antihistamines, both H1 and H2, as well as corticosteroids are included in the treatment plan.
epinephrine administered IM.
One of the most obvious anatomical differences between an adult and child is the ____.
Tongue - it’s larger. The tongue of a child is more prone to occlude the upper airway and often makes ventilation difficult with any degree of airway swelling.
Anatomic and Physiologic Difference: Adults vs. Children
- Children have larger BSA.
- In neonates, larger BSA can lead to IWL and issues with thermoregulation
- Child’s skin is immature, less keratinized, more prone to trauma and chemical absorption
A child’s larynx is ______ and ______ than adults.
Higher and more anterior anatomically
Why is aspiration more likely to occur in children than adults?
Both mainstem bronchi have less of an angle
Describe the epiglottis of a pediatric patient.
Proportionally larger and U-shape
Describe the trachea of a pediatric patient.
Narrower and easier to collapse
What is DDx (differential diagnosis)?
List of all potential problems that could be causing reported signs and symptoms
For a well-child visit, the following areas should be investigated during the history taking.
- Development and growth
- Medical history
- Nutritional status
Whether an examination is being done on a well child, or an ill one, the setting of the examination is always an important consideration. First and foremost is __________.
Safety
A good examination requires a pleasant and comfortable environment with _________ that will help calm the child’s nerves. If possible the temperature should be slightly warmer than that needed for adults.
strong lighting, warm inviting colors and decorations
What are the steps for well child head-to-toe assessment?
- General assessment of patient (general appearance, behavior and overall state)
- Examine skin for cyanosis, pallor, jaundice
- Examine HEENT
- Pediatric pulmonary system
What is the first part of HEENT exam?
Inspect head and face for symmetrical and irregularities in shape and size.
When examining the pulmonary system of the pediatric patient, there are three primary goals to achieve:
1) to evaluate and localize the disease, if one is present
2) to observe for adequacy of gas exchange
3) to determine the nature of the patient’s ventilations. Each of these areas will be reviewed separately.
Signs of hypercarbia include:
a rapid bounding pulse, confusion or drowsiness, muscular twitching, and, in severe cases, coma.
After age 1, any resting quiet respiratory rate above ____ should be investigated further.
40
As the child reaches 5 years and above, a resting rate above ____ is cause for concern and should be followed up to assess its underlying cause.
35
A basic auscultation of the heart can then be done by placing the stethoscope at approximately the ________. This position, also called Erb’s point, is a good area to hear all the valves.
3rd intercostal space of the left sternal border
The term _______ refers to educating parents about what to expect in the first months and years of their child’s life as far as pro- moting health and safety.
Anticipatory guidance
Contraindications to performing a PFT on a pediatric patient are few and include:
- Active pulmonary bleeding
- Recent ophthalmic surgery 3. Current pneumothorax
The diffusing capacity of carbon monoxide (DLCO) is rarely done on the pediatric patient for three main reasons:
1) Smaller lung volumes necessitate smaller washout volumes
2) Difficult to get a 10-second breath hold from kids
3) Low incidence of interstitial lung disease in pediatrics
That temperature range in which the metabolic rate is at a minimum and, thus, oxygen consumption is at its lowest.
Thermoneutral zone
When the thermoneutral zone is achieved, what does this mean?
Neonate is thermally balanced. It’s neither gaining or losing heat.
Normal thermoregulatory mechanisms maintain a balance of heat production and heat loss to maintain a core temperature of ____.
37°C (98.6°F).
_____ can best be defined as the maintenance of equality between heat dissipation and heat production by the body.
Homeostatic thermoregulation
_____ is abundant in the neonate and has a primary role of producing heat when shivering is not possible.
Brown fat, or brown adipose tissue
Where does the fetus store brown fat?
The fetus stores the brown fat around the great vessels, kidneys, scapulas, axilla, and the nape of the neck.
The temperature difference between the warm body core and the cooler skin
Internal thermal gradient (ITG)
The temperature difference between the skin and the environment is called the ____.
External thermal gradient (ETG)
The initial response to hypothermia is peripheral ____.
vasoconstriction.
The electrical activity of the brain becomes abnormal as core temperatures drop below ____.
33°C (91.4°F) and at 20°C (68°F) the EEG mimics brain death.
Hyperthermia may result from ___.
Infection, dehydration, improperly functioning incubators, radiant warmers, humidifiers, and phototherapy lights.
What is the goal of thermoregulation?
Maintain an environmental temperature such that the neonate’s core temperature remains in the normal range of 36.5°C to 37.5°C (97.7°F and 99.5°F).
A common cause of convective heat loss in the incubator is ____.
a resuscitation bag that is left on, blowing cold gas over the patient’s head.
A common source of conductive heat loss is ___.
weighing the neonate.
The primary advantage of the open warmer ___.
is access to the patient.
Disadvantages of the open warmer ___.
Disadvantages include difficulty in thermal man-
agement and the inability to control the environment.
Advantages of incubators:
- Controlled environment/better thermoregulation
Disadvantages of incubators:
Patient access
Describe the nervous system of neonate.
Anatomically immature
Something to know: Neonates should not be stimulated while they are asleep.
To conserve energy and prevent negative response/irritability
True or False.
Clustering of caregiving and procedures should be minimized to allow adequate recovery time between treatments and to decrease the chance of overstimulation. Nonemergency procedures should be postponed or delayed if possible.
True
The respiratory therapist should ensure that oxygenation is adequate before and during interventions. If oxygen saturations decrease during intervention, what should happen next?
it should be stopped and then restarted when saturation is acceptable.
The skin of the preemie is additionally sensitive because the _____ layer is extremely thin.
stratum corneum
This is the top layer of the epidermis, which serves as the main barrier against microorganisms.
The skin of the premature neonate is very ____ to anything placed on it.
permeable
What is the major component of both the fetus and the newborn?
Water
Total body water (TBW) decreases from a high of 95% of body weight at 13 to 14 weeks to approximately ____ of body weight at term.
78%
As gestation increases, and continuing postnatally, ECF decreases while ICF ______.
Increases
At term, ECF is roughly _____ of body weight, whereas ICF is _____ of body weight.
At term, ECF is roughly 45% of body weight, whereas ICF is 33% of body weight.
During the first days after birth most neonates experience a decrease in TBW caused by a reduction in :
a. ICF
b. ECF
b. ECF
The total amount of sodium and chloride per kg/weight decreases with _______.
increasing gestational age.
What are the main electrolytes of the ECF?
Sodium and chloride.
The major electrolytes of ICF are _____.
potassium, magnesium, and phosphate
Postnatally, the intake of the neonate will influence the establishing of electrolyte homeostasis. Most important in this regard is _____ intake.
Sodium
Which of the following content per kg/weight remains relatively constant throughout gestation?
Potassium content
Assessing the patient for fluid deficit and estimating the amount requires looking at three categories of data:
1) history
2) physical exam
3) laboratory values
Examination of the _______ is most helpful when assessing for fluid deficit.
skin and head
Examination of the head can show a ________ in the presence of fluid deficit.
sunken anterior fontanelle with increased overlapping of sutures
Tugor skin also means fluid deficit
With increasing fluid deficits, what tend to increase?
- Hct
- Sodium
- Serum protein
- BUN
Insensible water loss is water lost by ______.
evaporation from the skin and respiratory tract.
Factors that influence IWL.
- Skin integrity
- Temperature
- Environment
Premature neonates have greater evaporative losses due to what?
decreased skin thickness.
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
What is important in the regulation of water balance and the distribution of water in body components by virtue of its osmotic activity? It is also necessary for muscular and neuronal function.
Sodium
_____ is one of the main constituents of ICF. It plays an important role in acid–base balance.
Potassium
What plays an important role in the clotting mechanism and is integral in muscular and heart function. It is also the major mineral deposited in bone?
Calcium
Magnesium is also deposited in the bone
______ is a major anion providing electrical neutrality and is important in acid–base balance.
Chloride
_______ is an essential component in energy metabolism and bone deposition.
Phosphate
What are some causes of hyponatremia?
Inadequate sodium intake, excess loss secondary to diuretics or renal immaturity, excess body water
What are some causes of hypernatremia?
Loss of body water in excess of sodium
What are some causes of hypokalemia?
Inadequate potassium administration, diuretic therapy, gastric losses, high-output renal failure
What are some causes of hyperkalemia?
Excessive administration of potassium, acute renal failure
What are some causes of hypocalcemia?
Early onset: maternal factors— hyperparathyroidism, pregnancy-induced hypertension, diabetes mellitus
Neonatal factors: asphyxia, cesarean delivery, prematurity
Late onset: phototherapy, furosemide therapy, renal disease, intravenous lipid infusions, ingestion of formula with suboptimal calcium to phosphorus ratio
What are some causes of hypercalcemia?
Excess IV calcium administration, maternal and neonatal factors
What are some causes of hypomagnesemia?
Associated with hypocalcemia
What are some causes of hypermagnesemia?
Maternal magnesium sulfate therapy during labor, administration of magnesium containing antacid to the neonate
The yellowish-orange skin color that accompanies increased levels of bilirubin in the blood, called hyperbilirubinemia.
Jaundice
Bilirubin is a waste product that is normally eliminated from the body through the _____.
intestinal tract or the kidneys.
What is a frequent cause of jaundice?
Maternofetal blood incompatibility, either Rh or ABO
Jaundice may result from ______ in the fetal body.
Hemorrhages
Infants of ________ have a high incidence of jaundice.
Diabetic mothers, also often seen in breast-fed neonates.
Jaundice also seen in presence of galactosemia and hypothyroidism.
The most serious complication of hyperbilirubinemia is ___.
kernicterus (bilirubin encephalopathy).
The cause of NEC is known to be multifactorial, but three main factors are seen as key etiological factors:
1) mucosal wall injury
2) bacterial invasion into the damaged intestinal wall, and 3) formula in the intestine.
An idiopathic disorder characterized by ischemia and necrosis of the intestine.
NECROTIZING ENTEROCOLITIS (NEC)
The first confirmatory sign that will be seen in the presence of NEC is ______.
- guaiac-positive stools, which is the presence of blood in the stools
- then, abdominal distention
- bile-tainted emesis (STOP ORAL FEEDINGS, start NG suctioning to empty stomach of bile residuals)
- poorly tolerated feedings
- frequent emesis
- general signs of sepsis
- lethargy
- increased FiO2 requirements
_______ is mandatory when treating all neonates, especially those with suspected NEC.
Good hand washing
What are some anatomical differences between the infant and adult?
- Larger tongue
- Large amount of lymphoid tissue in pharynx area
- Larger, less flexible epiglottis
- Omega-shaped epiglottis, it also lies more horizontally
The infant larynx lies higher in the neck in relation to the _____.
cervical spine.
In the infant, the narrowest segment of the larynx is at the level of the ____.
cricoid ring.
The diameter of the trachea above the carina is roughly ____ mm at birth.
4
For neonates, any increase in minute ventilation is accomplished by increasing the ___.
respiratory rate, not the tidal volume.
Three factors are responsible for the low pulmonary reserve in infants.
- Large heart
- Stability of thoracic cage, makes it difficulty to increase VT by chest expansion
- Large abdominal contents push up against the diaphragm
Due to the differences in metabolism, infants do not respond to medications and pharmacotherapy in any predictable manner.
Something to know. Metabolic rate is higher in neonates and infants than adults.
Because ____% of the neonate’s total body weight is water, fluid balance in neonates is precarious.
80
The purpose of the physical assessment is just that—to determine ____.
how well the extra-uterine transition is taking place.
A white, cream cheese-like material that covers the fetus in utero.
Vernix
Physical Examination to Determine Gestational Age
- Vernix
- Skin maturity
- Lanugo
- Ear coil (pinna)
- Breast tissue
- Genitalia
- Sole creases
What are the three cardinal signs of respiratory distress?
- Nasal flaring
- Grunting
- Retractions
Normal neonatal HR
120-160 bpm
The apical pulse, which is the point on the chest where the heart sounds are heard the loudest, is evaluated next. Where is it is normally heard?
in the fifth intercostal space, midclavicularly on the left chest wall.
The neonate’s head could be edematous from the pressure generated during labor. This produces what is called ______.
caput succedaneum
A normal neonate will have a protruding abdomen. However, if the abdomen is scaphoid (sunken or flat), the respiratory therapist should assess for presence of a ______.
diaphragmatic hernia
What type of temperature is a reliable indicator of thermoregulation?
Axillary
Does APGARs relate to oxygenation?
No, don’t be fooled!
Increased netonate metabolism means what?
Increased need for oxygen consumption
Oxygen from a resuscitation bag blowing on a neonate’s face can lead to which of ABG result?
Metabolic acidosis
Which antibody is the only immunoglobulin that is transported through the placenta from mother to fetus?
IgG
