Neonatal Scenario

[WTEngel]

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

 

[usalsfyre]

Abso-freaking-loutely

 

[fast65]

Go for it

 

[systemet]

The last scenario was great, would love another one!

 

[abckidsmom]

Absolutely.

 

[WTEngel]

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?

 

[fast65]

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

 

[WTEngel]

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...

 

[fast65]

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?

 

[usalsfyre]

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.

 

[skivail]

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

 

[fast65]

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.

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

 

[usalsfyre]

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 .

 

[fast65]

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

 

[WTEngel]

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?

 

[WTEngel]

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

 

[skivail]

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.

 

[usalsfyre]

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.

 

[fast65]

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?

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

 

[WTEngel]

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.