# Neonatal Scenario



## WTEngel (Oct 6, 2011)

Is anybody interested at all in a new born (think neonatal) case scenario? I can put a pretty decent one together to make you think, if you would like. 

If you liked the croup scenario, this one may very well melt your face off.

TE


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## usalsfyre (Oct 6, 2011)

Abso-freaking-loutely


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## fast65 (Oct 6, 2011)

Go for it


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## systemet (Oct 6, 2011)

The last scenario was great, would love another one!


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## abckidsmom (Oct 6, 2011)

Absolutely.


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## WTEngel (Oct 6, 2011)

*Here you go..*

You are dispatched to a local residence for a 18 hour old male with sudden onset of difficulty breathing.

On arrival you find a mother, father, and multiple family members, mostly in a state of general panic. Mother appears in fine health, other than anxiety, so you do not consider her an immediate concern (not a second patient, yet.)

The baby's appearance is average weight and size, lightly cyanotic around the lips and nail beds, decreased activity, weak cry. Vitals are, pulse 120, respirations 65, cap refill 4+ seconds, SPO2 is 65%. The baby is afebrile.

Birth history: Home birth, without complications (they did everything they read on a website and it worked out great...) Baby has been reluctant to feed, although has tolerated minimal PO intake (2 ounces since birth.) When the onset of symptoms occurred, the baby was simply being held by a family member. 

Mother had minimal pre natal care, her GBS was negative, she does not have any relevant STDs, and she has been generally healthy for the duration of pregnancy. No one else in the home is sick. 

Initial impression? Initial interventions? Pertinent questions? Differentials?


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## fast65 (Oct 6, 2011)

Well my initial intervention for this child is going to be some blow-by O2, the respiratory rate is slightly elevated (I believe it should be around 35-60 at this age range) so I'm not considering assisting ventilations, yet. I'm gonna want to get the infant packaged for immediate transport and get the mother and the infant into the ambulance. 

A-open? any obstructions or meconium staining? nasal passages clear of any obstructions/secretions?
B-work of breathing? any change with O2?
C-Skin CTC?

So, upon my physical assessment, do I note any abnormalities? 

Head/Neck:
-Fontanelles?
-Eyes? 
-Abnormalities in the neck?

Chest:
-Crepitus?
-Instability?
-LS bilaterally? What are the LS?
-Retractions?

Abd:
-Guarding, stiffness?
-Other abnormalities?

Extremities:
-Any abnormalities other than cyanosis in the nail beds?

History:

Did the mother use any medications, alcohol, or illicit substances during her pregnancy?

Is there any significant medical history for the mother or father?

What kind of a home birth? Was it a water birth? Was there any trained medical staff that assisted in the delivery?

How was the baby acting at birth?

Does the mother currently have any complaints?

Vitals:
Can we get a CBG please?

I that will do for now at least, I know there's a lot I'm probably missing.

EDIT: I almost forgot to put a cardiac monitor on them


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## WTEngel (Oct 6, 2011)

Fairly text book initial treatment. I will wait for a few more to join in before we start the real "fun." 

This scenario gets a lot better...


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## fast65 (Oct 6, 2011)

WTEngel said:


> Fairly text book initial treatment. I will wait for a few more to join in before we start the real "fun."
> 
> This scenario gets a lot better...



Oh, I assumed it would, should I intubate now to get it over with?


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## usalsfyre (Oct 6, 2011)

Hmmm, I hear galloping, and I don't think it's horses...

So with minimal prenatal care and home delivery I'm very suspicious of a cyanotic lesion. Heart tones? CAREFULLY try some O2, if the baby shows any sign of getting worse, remove. Establish access, and have alprostadil handy. Be prepared to intubate and ventilate (although, honestly, I'm not sure how to go about an intubation when preoxygenation will kill your patient) because he's likely to tire quickly.

If the O2 doesn't make the patient worse, use the minimum level of O2 needed to maintain a decent WOB and central color. I'm not hugely concerned about the acrocyanosis and depending on how your SpO2 probe is placed it may be reflecting that rather than central oxygenation.

Another important thought is maintenance fluid and watching his BGL if he's not been eating well. Sick infants are going to be burning glucose they don't have. So let's get a BGL and start a D51/4NS infusion using the 4-2-1 formula.


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## skivail (Oct 6, 2011)

Supportive care and drive.  I'm thinking a very early Tet Spell or some undetected aspiration.


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## fast65 (Oct 6, 2011)

usalsfyre said:


> Hmmm, I hear galloping, and I don't think it's horses...
> 
> So with minimal prenatal care and home delivery I'm very suspicious of a cyanotic lesion. Heart tones? CAREFULLY try some O2, if the baby shows any sign of getting worse, remove. Establish access, and have alprostadil handy. Be prepared to intubate and ventilate (although, honestly, I'm not sure how to go about an intubation when preoxygenation will kill your patient) because he's likely to tire quickly.
> 
> ...



Dammit usalsfyre, you're posts always make me feel like I know nothing  Off to Google!


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## usalsfyre (Oct 6, 2011)

Fast65 it doesn't get any better, because there's a lot of posters (including the OP) on here that make me feel like a blubbering idiot .


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## fast65 (Oct 6, 2011)

haha, well then there's no hope for me h34r:


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## WTEngel (Oct 6, 2011)

All of these are some good guesses...Let's talk about real life here. 

Teach me some ways you could rule in/rule out your suspicions...

Do not get beat down fast, I haven't given out any answers yet. Your guess is as good as the next. All of your questions are appropriate. Tell me some of your actions based on both positive and negative responses to your questions, because you have laid out a logical and thorough line of questioning.

usal, you're not getting off that easy. Does oxygen hurt cardiac lesions? If so why?


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## WTEngel (Oct 6, 2011)

skivail, tell me why you suspect TOF? Other than the peripheral cyanosis, what indicates this condition?


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## skivail (Oct 6, 2011)

WTEngel said:


> skivail, tell me why you suspect TOF? Other than the peripheral cyanosis, what indicates this condition?



Delayed cap refill, mild cyanosis and lethargy.  From my understanding of TOF the onset is usually between 1 and 3 years old but who knows.


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## usalsfyre (Oct 6, 2011)

WTEngel said:


> usal, you're not getting off that easy. Does oxygen hurt cardiac lesions? If so why?


Depends. Something simple like a VSD? Not particularly. Something like great vessel transposition or hypoplastic left heart where your relying on a PDA to supply the body? You betcha. Oxygen causes (or at least helps) close the ductus arteriosis (I believe it inhibits prostaglandin) and as such for infants relying on a PDA will not do well on O2 (hence the old joke NICU about getting a pillow ) 

Honestly I don't have enough experience with neonates to say if the kid would look sicker than presented with one of the above conditions. My gut says yes, but I also know neonates can be remarkably resilient. I guess that's why I'd try O2, but carefully. Chances are it's not going to affect him greatly, but it's something to be aware of.

Am I close? Pediatrics in general, and neonates in particular are not my strongest area.


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## fast65 (Oct 6, 2011)

WTEngel said:


> All of these are some good guesses...Let's talk about real life here.
> 
> Teach me some ways you could rule in/rule out your suspicions...
> 
> ...



Based off of my airway findings I would manage things as appropriately as possible. If I notice meconium staining and my vitals begin to pattern down then I would start thinking about the possibility of intubation and tracheal suctioning with a meconium aspirator. However, I would have expected the infant to displays signs of respiratory distress awhile ago, but it's still something I'll be thinking about.

Of course if there's any secretions I'll suction those out and hope that that will relieve some of the respiratory difficulty. As far as the work of breathing goes, if it doesn't seem to be improving with the blow-by O2 then I'm going to attempt to assist ventilations, if it's improving them I'm going to continue on with the blow-by O2.

At this point I'm trying to rule out dehydration/hypoglycemia due to the lack feeding. The infant has had a very minimal amount of nourishment in the past 18 hours so it's likely that they're burning glucose they don't have (as usalsfyre said). So based upon those findings I'll look into giving a fluid bolus and a dose of D10. 

As for the chest, well that will give me some idea as to whether or not someone was holding the infant just a little too tight. We can't rule out some sort of flail chest at this point that may be causing the respiratory difficulty. 

The medical history of the parents will of course give us a little more info as to what might be plaguing this child. For example, do they have a history of heart disease or diabetes?

The birthing history will clue us into a trending of the infant's condition, like has it been a slow decompensation or did it happen all of a sudden. 

I think I touched on most of the important points in my original post


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## WTEngel (Oct 6, 2011)

Sorry, had a class to go to real quick. 

fast,good observation on the meconium. Meconium aspiration is usually pretty obvious at birth, so the sudden onset 18 hours postpartum doesn't quite line up with this. 

I am always reluctant to intubate neonates when I am not with my specialty crew. Even with my experience, I would probably bag a neonate in lieu of intubation if I was on a standard 911 truck. Even the smallest blades carried by most EMS systems are going to be on the verge of too big for this kid, and the idea of getting an IV, medicating in the appropriate dose, intubating, dealing with possible vagal tone complications, securing the tube, etc. without a few extra sets of skilled hand is daunting to say the least.

There are no signs of abuse or trauma. 

The fluids at maintenance and glucose concerns are great catches! These are a few things a lot of EMS providers miss. High marks for catching these things.

When we look at the vitals of this child, which one jumps out as alarming? The SPO2 of 65% is pretty low, and the blue extremities do seem to correlate with this number, but the pulse is relatively stable. Most would suspect an infant with this SPO2 to be bradying down, right?

One question we need to think about when we see this number in an infant less than 24-48 hours old is where is the SPO2 being measured at? The upper right extremity is the "pre ductal" saturation. The other extremities are considered "post ductal" saturation points. What this means is that the upper right extremity is perfused with blood that does not pass the PDA, where blood that feeds post ductal extremities comes from a point after the PDA, which means it is mixed with both red and blue blood.

usal is correct that oxygen causes the PDA to close. The PDA closes for the most part after the first 24-72 hours of life, with full closure taking a week or so longer. This is when the infant is breathing regular 21% concentration room air. If high flow oxygen is applied, this constriction is much faster. High flow o2 will worsen this infant's condition, in the presence of a ductal dependent lesion.

So, if this SPO2 was taken from the lower left extremity, I would place a monitor on the upper right extremity and see what my SPO2 is. In this case, it could be in the mid to upper 70s to mid 80s, depending on how much mixing is going on. When we see this mis match in pre a post ductal saturation, it is a clear indication that we are likely dealing with a "ductal dependent" lesion, which literally means we are depending on the PDA in order to oxygenate all post ductal circulation. If there is no mismatch, then we are dealing with a whole other scenario, which I may post next time.

Another important test to perform if you can is 4 extremity blood pressures. One ductal dependent defect is coarctation of the aorta, which will cause higher pressures in the upper right extremity or both upper extremities depending on where along the arch the coarctation is located. Elevated pre ductal sats with large difference in upper and lower extremity blood pressures would lead us to a high index of suspicion of coarct, which is definitely ductal dependent, and definitely responds poorly to oxygen.

Alright, sorry to leave half way through, but I have to catch dinner real quick. That will give you guys something to think about for a bit and digest. Come up with some questions or suggestions, and let's meet back here in a few hours.

Good work so far...although I was hoping more people would jump in and play.


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## fast65 (Oct 6, 2011)

Good Lord, usalsfyre was right, I feel like the village idiot  Great stuff though, I'm learning a lot, thanks!

Yeah, I was thinking that 18 hours later was too long for this to be meconium related, but I was also thinking that they may not have noticed it at birth, this being a "Google birth". 

That heart rate was one of the things that jumped out at me as abnormal, I would have expected this kid to be bradying down with an SPO2 like that, and I would expect an associated increase in his WOB with a further decreasing LOC, both of which seem to be absent with this child (well, except the LOC is a little depressed). 

I'm a bit rusty on the vascular system of neonates, so I just need a little clarification. The pre-ductal extremities will have deoxygenated blood and post-ductal extremities will have a mixture of oxygenated and preoxygenated blood, is that correct?

Well ya had to go scare everyone else off with the whole "face-melting" talk


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## WTEngel (Oct 6, 2011)

The upper right extremity (pre ductal) actually has blood with higher oxygen concentration. The post ductal has a lower oxygen saturation. 

Don't feel like an idiot, you did exactly what you have been trained to, and thought of some things most medics wouldn't.

What would almost every medic do automatically when they see a bluish baby and a SPO2 of 65%? High flow oxygen right....usal has a bit of an unfair advantage here. He has some additional experience and resources that made this scenario pretty obvious to him. Well done though usal...

So a few take home points here:

Low post ductal SPO2 in a 24 hour or so old baby, little pre natal care, no evaluation at hospital...check pre ductal sats. If there is a large difference, you likely have a ductal dependent heart defect, and oxygen will likely cause the patient to deteriorate.

If this patient must be intubated or the airway otherwise managed, room air only is good. Do any of your services carry prostaglandin? Does anybody know what it is and want to explain it? I could do it, but I only like to type so much, and really like getting everyone in on the learning process here.

You can assess 4 extremity blood pressures and if there is a large variance of upper extremity vs. lower extremity, then the specific defect may be a coarct. 

So, can EMS fix a heart defect? No way, but they can be taught how to assess for one, and treat appropriately. This type of information is being incorporated into the new PALS program I believe. Unfortunately, I don't think enough PALS instructors have the experience to adequately teach it.

I am glad you guys brought up maintenance fluid requirement, and the risk of hypoglycemia in the neonate. If either of you want to expand on it, be my guest. I really think it is important info for people to know.


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## fast65 (Oct 7, 2011)

WTEngel said:


> The upper right extremity (pre ductal) actually has blood with higher oxygen concentration. The post ductal has a lower oxygen saturation.
> 
> Don't feel like an idiot, you did exactly what you have been trained to, and thought of some things most medics wouldn't.
> 
> ...



Haha, thanks, I feel a little better 

This was a really great scenario though and I learned a lot, so thanks for that! I can't wait for the next one.

Looks like I'll be doing even more reading on neonates tomorrow, especially on the cardiac side of things. 

I only vaguely remember prostaglandin from A&P, so I won't be too much help there unfortunately, but I'll add that to my research list for tomorrow.


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## systemet (Oct 7, 2011)

WTEngel said:


> Good work so far...although I was hoping more people would jump in and play.



We will! Just bear in mind some of us are in different time zones (CET here!)


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## systemet (Oct 7, 2011)

Wow great scenario.

So we have a term infant?  Or close enough - judging from "average weight and size"?

Normal presentation, atraumatic birth, no dystocia - moving arms and legs, parent's haven't done anything crazy and aggressive.  No nucchal cord, etc.? Fontanelles, as suggested earlier?

The child's afebrile now, so they've been keeping them warm.  Baby's not feeding much.  Is it particularly skinny?  Does it look like it's been living off its fat stores in utero in the last few days?

Any more obstetrical history on mum?  Previous children, hx of miscarriage, genetic syndromes (I hear Turner Syndrome can be an issue here?).  With the "minimal prenatal care", has she had an U/S at any point?  Intrapartum drug/EtOH/nicotine?

Anything more remarkable on the physical exam?  No spina bifida?  Normal number of fingers and toes?  Has all the normal orifices?  Any unusual jugular or carotid impulses around the neck?  Heart sounds, as usalsfyre suggested.  How are the lung sounds?  Any suspicion of diaphragmatic hernia?

I agree with the bG, IV access, maintenance fluids.  

* Can I ask why the D5 1/4 NS? Just curious?

* Any tips or insights on good sites for access?  I've started IVs in the hand on healthy neonates, but am wondering what the best options are here?

* Never thought of using SpO2 to look for preductal-postductal gradient.  How much is significant?  [I found a paper showing up to 15 mins after birth in a series of healthy children and it suggests that there's a difference of about 5-10%, more pronounced in C/sections vs. vaginal delivery - Mariani et al.]  

* Can someone explain the 4-2-1 formula for me?  This is new to me.


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## systemet (Oct 7, 2011)

Here's a great website for reviewing fetal circulation, for anyone who's scratching their head:

http://www.indiana.edu/~anat550/cvanim/fetcirc/fetcirc.html

Take home points:

* The fetus receives oxygenated, nutrient-rich blood into the IVC from the umbilical vein / placenta.  This replaces key roles of the liver and lungs.  

* The lungs are also vasoconstricted and collapsed in utero, increasing pulmonary vascular resistance.

* As a result the fetus has shunts in place to allow blood to move from the right side of the heart to the left side of the heart (foramen ovale), and from the pulmonary artery to the aorta (ductus arteriosus).

* After birth these shunts begin to close as filling pressures in the heart change (due to oxygenated lungs, with vasodilated vessels and lower resistance).

* In some congenital heart defects it's useful to keep the ductus arteriosus open, using prostaglandin E1


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## myfuturegoals (Oct 7, 2011)

bring it on!


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## usalsfyre (Oct 7, 2011)

4-2-1 formula is used for calculating pediatric maintenance fluid needs. It goes:

4ml/kg for the first 10kgs (up to 40mls)

2mls/kg for 10-20kgs (up to 20mls, so 40+20=6mls)

1ml/kg for everything after that. 

So for a 26kg kid you need to run the fluid at 66mls/hr (40 for the first 10kgs, 20 for the next 10, and  6 for the remaining 6 kilos). Normally D5 1/4NS is used for <1year old with D5 1/2NS being used for older kids.

Keep in mind this is maintenance fluid to keep up with normal fluid loss, to rehydrate the patient you will have to add additional fluid on top of that.


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## fast65 (Oct 7, 2011)

usalsfyre said:


> 4-2-1 formula is used for calculating pediatric maintenance fluid needs. It goes:
> 
> 4ml/kg for the first 10kgs (up to 40mls)
> 
> ...



Wow, I'd never heard of that rule. Now this is probably a stupid question, but what is D5 1/4 NS?


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## usalsfyre (Oct 7, 2011)

1/4 NS is one quarter of the strength of 0.9 NS, so 0.225 NS. D5 simply means 5 percent dextrose is also dissolved in it.


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## fast65 (Oct 7, 2011)

usalsfyre said:


> 1/4 NS is one quarter of the strength of 0.9 NS, so 0.225 NS. D5 simply means 5 percent dextrose is also dissolved in it.



Oh, alright then, thanks for the explanation


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## abckidsmom (Oct 7, 2011)

usalsfyre said:


> 4-2-1 formula is used for calculating pediatric maintenance fluid needs. It goes:
> 
> 4ml/kg for the first 10kgs (up to 40mls)
> 
> ...



So realistically, if you carry D5 and NS, are you going to mix this in a syringe or buretrol?  

How bad would it be if the first bit of fluid for this kid was one or the other?  And which would you (collective you) give?  I would love to say that I'd just mix it up for him, but I'm thinking that as the sole medic on the truck, I'd rather spend my time looking at the baby, not the IV fluids.  We have a long transport, so I might get to it.


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