Vol.5-Ch.3 "Neonatology"

Question 1

What is the age range that a baby can be called a “Neonate”?

Answer 1

From birth to 1 month old

Question 2

For infants that do require resuscitation (even though super rare, 1%) what is the best facility to transport them to if available?

Answer 2

Neonatal Intensive Care Unit (NICU)

Question 3

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?

Answer 3

• 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.

Question 4

What happens if hypoxia or acidosis continue even after the infant takes it’s first breaths and the ductus arteriosus has closed?

Answer 4

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.

Question 5

What is Primary and Secondary Apnea?

Answer 5

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

Question 6

What happens to the Ductus Arteriosus, Ductus Venosus, Foramen Ovale, and Umbilical Vein after delivery?

Answer 6

• 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

Question 7

How are congenital heart defects normally classified?

Answer 7

Into 3 categories:

• if the cause INCREASED pulmonary blood flow
• if they cause DECREASED pulmonary blood flow
• if they OBSTRUCT blood flow

Question 8

When does most fetal development occur? What is a fetus susceptible to during this time?

Answer 8

Within the first trimester, making it the most at risk time in fetal development for abnormal development due to environmental or ingest substances

Question 9

What is the leading cause of death in infants?

Answer 9

Congenital anomalies

Congenital HEART DEFECTS are the most common kind

Question 10

What are some examples of Congenital Heart Defects that INCREASE pulmonary blood flow? (2)

Answer 10

• 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

Question 11

What are some examples of Congenital Heart Defects that DECREASE pulmonary blood flow? (2)

Answer 11

• 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

Question 12

What are some examples of Congenital Heart Defects that OBSTRUCT blood flow? (3)

Answer 12

• 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

Question 13

What are some possible congenital defects that are NOT cardiac related? (6)

Answer 13

• 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.

Question 14

What are normal respiratory rates, heart rates, and O2 sats for newborns?

Answer 14

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

Question 15

APGAR score covered in the Obstetrics chapter notecards. KNOW THIS FOR TEST

Answer 15

APGAR score covered in the Obstetrics chapter notecards. KNOW THIS FOR TEST

Question 16

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?

Answer 16

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

Question 17

How should a baby be held/positioned immediately after delivery?

Answer 17

In the sniffing position with the head at the same level as the mother’s vagina (this is to reduce hypo/hypertransfusion of blood)

Question 18

How fast should you cut the umbilical cord after full fetal delivery?

Answer 18

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.

Question 19

What does meconium staining indicate has happened at some point? How does a difference in meconium change when that something has happened?

Answer 19

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.

Question 20

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?

Answer 20

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

Question 21

What are the 5 major steps in resuscitation of neonates?

Answer 21

1) Drying, Warming, Positioning, Suction, & Stimulation
2) Ventilation
3) Supp O2
4) Compressions
5) Meds and Fluids

Question 22

If advanced resuscitation is needed how can you achieve sniffing position while placing the baby on it’s back?

Answer 22

Place a towel under the neonates shoulder blades to achieve sniffing position

Question 23

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?

Answer 23

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)

Question 24

How to perform Neonate Chest Compressions

Answer 24

• 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

Question 25

What is the most common cause of cardiopulmonary arrests in neonates?

Answer 25

Hypoxia

Question 26

If IV access is required, what are the best steps to achieving it?

How much normal saline or lactated ringers should be given and how for fluid resuscitation?

Answer 26

• Trim umbilical cord to 1cm above the abdomen, leaving enough that additional lines can be placed
• Insert a 5-Fr umbilical catheter into the umbilical vein and connect a 3-way stopcock and fill with saline and secure it

(The Umbilical Vein is going to be the larger of the 3 vessels in the umbilical cord and has a much thinner wall)

Give 10mL/kg of Saline or LR as a SLOW IV PUSH (NOTE NOT A DRIP) (I believe that is a NS flush worth per kg)

Question 27

How can maternal use of narcotic affect newborns?

Answer 27

They often come out weighing less, and may exhibit withdrawal symptoms (tremors, shivering, decreased alertness). But the BIGGEST RISK is RESPIRATORY DEPRESSION at birth!

Narcan is NOT indicated for use in neonates

Question 28

How is transport different for a healthy newborn vs one in distress?

Answer 28

A healthy newborn can begin bonding with the mother ASAP. But a distressed newborn must be positioned on its side to prevent aspiration and be transported rapidly!

Question 29

What exactly is Meconium?
What could possibly happen if a baby is in Meconium and delivered with it?
What should you do about it?

Answer 29

Meconium is a dark green substance found in the digestive tract of the full-term newborn. It comes from carious digestive glands and amniotic fluid.

IF present at birth, the chances of aspirating this thick substance is high and can risk probably airway obstruction (partial or complete), or pneumonia. If there is an obstruction from aspiration it is very possible that atelectasis will progress to a pneumothorax which may progress to a tension pneumothorax that must be decompressed.

IF infant is born with a thick, particulate, meconium stained fluid INTUBATE IMMEDIATELY before the first ventilation. The book says to intubate and suction at 100cmH2O or less with a meconium aspirator attached and as you suction pull the ET tube out and then reintubate???? no more than 2 times. Once meconium is clear from airway and the infant can breath on it’s own you can just give supp O2 as needed.

Question 30

Steps to treat apnea found with neonate

Answer 30

• Start with tactile stimulation aka flick soles or rub back
• If needed progress to BVM with Pop-Off-Valve disabled
• If spontaneous breathing has still not occurred and there is expectation of a long transport, then intubate.
  (or if the HR is less than 60bpm, also intubate and start chest compressions)

Question 31

Where and why does Diaphragmatic Herniation occur in neonates?

What signs and symptoms are associated that can help you dictate if this has happened?

What should you do?

Answer 31

Typically, diaphragm herniation occurs in the posterolateral segments on the left side, caused by the failure of the pleuroperitoneal canal (Foramen of Bochdalek) to close completely.

(SEVERE cases involve the stomach, some large intestine, spleen, liver, and kidneys may enter the chest cavity)

The easiest S&Ss you may see are bowel sounds in the chest, and heart sounds displaced to the right, as well as a small, flat abdomen.

You should:

• position with torso and head higher than abdomen (gravity will help reduce herniation)
• Apply suction with naso/orogastric tube (low setting and intermittently)
• DO NOT USE BVM, this may apply gastric distention and force abd contents up through herniation

Question 32

What is the most common cause of bradycardia in a neonate?

Answer 32

Hypoxia!

Quick correction of hypoxia will help minimize risk of further cardiac depression

Question 33

What is considered to be a premature neonate?
What are they at risk for?
What are some reasons premature neonates have an even harder time fighting hypothermia?

Answer 33

A premature newborn is an infant born prior to 37weeks or with a weight ranging from 0.6-2.2kg.
(Fetal viability is considered to be 23-24 weeks of gestation)

They are at risk for:

• resp depression
• head/brain injury secondary to hypoxemia
• changes in BP
• Intraventricular Hemorrhage
• Fluctuation in serum osmolarity
• HYPOTHERMIA

Reasons they are more at risk for hypothermia include:

• relatively large body surface area and comparatively small weight
• can’t regulate their own temp yet
• small subcutaneous stores of insulating fat
• they CANT SHIVER

Question 34

What is the most common factor causing respiratory distress and cyanosis in the newborn?

Answer 34

Prematurity (especially when less than 1200grams or less than 30wks)

Question 35

Hypovolemia is the leading cause of shock in newborns. What is the most common cause of hypovolemia in newborns? How can you treat hypovolemia?

Answer 35

The most common cause of hypovolemia is Dehydration

To fight this you can give 10mL/Kg bolus of NS or LR over a 5-10 minute period. They may need to get 40-60mL/kg in the first hour of resuscitation

DO NOT USE DEXTROSE containing fluids ; this may produce hypokalemia or worsen ischemic brain injury

Question 36

Seizures in Neonates should not happen and if they do it represents a serious medical emergency!!! What are some types of seizures they can experience? (5)

Answer 36

• Subtle Seizures: Consist of chewing motions, excessive salivation, blinking, sucking, swimming movements of the arms, pedaling improvements of the legs, apnea, and color change
• Tonic Seizures: Rigid posturing of the extremities and trunk. more common in premature infants especially when intraventricular hemorrhages
• Focal Clonic Seizures: Rhythmic twitches of muscle groups, particularly in the extremities and face.
• Multifocal Seizures: Similar to focal seizures except that multiple muscle groups are involved. Clonic activity randomly migrates. These mostly occur in full term babies
• Myoclonic Seizures: Involve brief focal or general jerks of the extremities or parts of the body that tend to involve a distal muscle group. May occur singly or in a series or repetitive jerks

Question 37

Stopped at “Fever”

Answer 37

Stopped at “Fever”