Neonatal Scenario

[fast65]

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

 

[WTEngel]

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.

 

[fast65]

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.

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.

 

[systemet]

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!)

 

[systemet]

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.

 

[systemet]

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

 

[myfuturegoals]

bring it on!

 

[usalsfyre]

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.

 

[fast65]

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.

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

 

[usalsfyre]

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.

 

[fast65]

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

 

[abckidsmom]

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.

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.