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Chapter Introduction
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hello and welcome to chapter 35 pediatric emergencies of the emergency care and transportation of the sick and injured 12th edition after you complete this chapter and the related coursework you will understand the anatomy and physiology of the child as compared to the adult you will learn the appropriate assessment and care for all the types of illnesses and injuries affecting children of all ages including patterns based on size and special body systems injuries you will also learn the indicators of abuse and neglect and the medical and legal responsibility of an emt okay so let's get started
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Introduction to Pediatric Care
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children differ anatomically physically and emotionally from adults the illness and injuries that children sustained and their responses to them vary based on age and developmental level it's important to remember that children are not just small adults depending on his or her age the child may not be able to tell you what's wrong fear of ems providers and pain can make the child difficult to assess parents or primary caregivers may be stressed frightened or behaving irrationally for these reasons pediatrics the specialized medical practice devoted to the care of young patients can be challenging once you learn how to approach children of different ages and what to expect when caring for them you will find that treating children also offers some very special rewards their innocence and openness can be appealing children often respond to treatment much more rapidly than adults do
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Communication With the Patient and the Family
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so first let's start with communicating with the patient and the family caring for an infinite child means that you must care for the patients and caregivers as well family members or caregivers often need emotional support a calm parent usually results in a calm child the parent can often assist you and with the child's care an agitated parent means the child will act the same way which may make the child's care more difficult so remain calm efficient professional and sensitive
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Growth and Development
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growth and development many physical and emotional challenges and changes occur during childhood childhood extends from birth to age 18. the thoughts and behaviors of the children as a whole are often grouped into five different stages so first is the infancy and this is the first year of life then there's the toddler and that's ages one to three years then preschool age that is three to six then school age that's age six to twelve and then adolescence from thirteen to eighteen
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The Infant
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so first let's talk about the infant the infancy is usually defined as the first year of life first month after birth is called the neonatal or newborn period okay so then we're gonna let's break it down a little bit more so zero to two months infants less than two months spend most of their time sleeping and eating and infants cannot tell the difference between parents and strangers so crying is one of the main modes of expression an unconsolable infant after all obvious needs have been addressed could be a sign of a significant illness their heads have a relatively larger surface area between area which predisposes them to hypothermia all right so ages two to six months they can recognize their parents or caregivers and turn their head towards a loud sound or familiar voice persistent crying irritability or lack of contact contact can be an indicator of a serious illness depressed mental status or a delay in development and then from six to 12 months they become mobile which predisposes them to physical danger they could place things in their mouth which leads to choking or poisoning and they may cry if separated from their parents or caregivers persisting crying or irritability can be a symptom of a serious illness so when we're talking about assessing an infant we begin assessment by observing the infant from a distance we let the caregiver continue to hold the baby during the physical assessment provide as much sensory comfort as possible do any painful procedures at the end of the assessment process complete each procedure efficiently and avoid interruptions explain each procedure to the parent or caregiver before you perform it because the procedure and the infant's reaction may be upsetting
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The Toddler
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all right so now let's talk about the toddler after infancy until three years so one year to three years of age a child is called a toddler toddlers experience rapid changes in growth and development from 12 to 18 months because they are explorers by nature and not afraid injuries in this group increase because of the lack of molars they may be they may not be able to fully chew their food and this leads to an increase in choking when we talk about the assessment they may have stranger anxiety they may resist separation from caregiver and demonstrate the assessment on a doll or stuffed animal first if possible may they may be unhappy about being restrained or held for procedures and toddlers can have a hard time describing or localizing pain so use visual cues clues such as the one baker faces pain scale they may be distracted by a toy begin your assessment at the feet or away from the location of pain if possible persistent cries or irritability can be a symptom of a serious injury and previous medical experiences may lead to hesitation towards you if a parent or
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The Toddler Continued
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caregiver is unavailable reassure the child using simple words and a calm soothing voice
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The Preschool-Age Child
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okay now after the toddlers we're into that preschool aged child and this is ages three to six years old they can have a rich imagination and can be fearful about pain they may believe injury is a result of earlier bad behavior so when i talk about the assessment we can under um they can understand directions and be specific in describing their painful areas despite increased ability to communicate much of the history must still be obtained from the caregivers communicate simple and directly appealing to the child's imagination may help facilitate the examination process do not lie to this patient because it will be hard to regain lost trust the patient may be easily distracted by games or toys or conversation and begin the assessment at the feet and move towards the head use adhesive bandaging to cover the sight of an injection or a small wound and modesty is developing so keep the child covered as much as possible
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School-Age Years
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okay so after the toddler and the school age we're gonna move to the school age and this is six to twelve at this stage children begin to understand death is final but their understanding of death it is and why it occurs is still unrealistic assessment begins to be more like an adult to help gain trust talk to the child not just the caregiver the child is probably familiar with the process of a physical exam start with the head and work towards the feet as in with an adult assessment and if possible give the child choices for example ask only the type of questions that let you control the answer allow the child to listen to his or her own heartbeat through the stethoscope these children can understand the difference between physical and emotional pain so give them simple explanations about what is causing their pain and what will be done about it ask the parents or caregivers advice about which distraction will work best
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Adolescents
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okay and after that we're gonna get into
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Adolescents Continued
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the adolescence and this is ages 13 to 18 physically similar to adults but they are still children on an emotional level and time of um this time they're doing experimentation and taking risk behaviors so adolescents can often understand very complex complex concepts and treatment options so allow adolescents to be involved in their own care an emt of the same gender should perform the physical exam if possible to lessen the stress of the event allow the adolescents to speak openly and ask questions and risk taking behaviors are common at this age
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Adolescents Continued Again
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female patients can be pregnant so adolescents also have a clear understanding of the purpose and meaning of pain
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Anatomy and Physiology
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so let's start to talk about the anatomy and physiology okay so the body is growing and changing rapidly during childhood you must understand the physical differences between children and adults and alter your patient care accordingly
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The Respiratory System
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first we're going to talk about the respiratory system so the anatomy of a pediatric airway differs from adults pediatric airway is smaller in diameter and shorter in length and lungs are smaller the heart is higher in the child's chest opening is higher in position more anteriorly and the neck appears to be non-existent as children develop the neck gets proportionately longer as the vocal cords and epiglottis achieve a correct adult position the occipit is a large it's larger and rounder which requires more careful positioning of the airway the tongue is larger relative to the size of the mouth and in a more anterior location in the mouth a child's tongue can easily block the airway a long flappy u-shaped epiglottis in infants and toddlers is larger than the adults and the rings of cartilage in the trachea are less developed and may easily collapse if the neck is flexed or hyper-extended the upper airway has a narrowing funnel shaped uh compared to the cylinder shape of the of the lower airway okay so the diameter of the trachea and infants is about the same size as a drinking straw so this means that airways can easily become obstructed and also that the infants are they are nose breathers and they may require suctioning and airway maintenance and the respiratory rate is uh from 20 to 60 is newborn uh is uh normal for the newborn so children also have an oxygen demand twice of that of the adult the muscles of the diaphragm dictate the amount of air the child inspires anything that places pressure on the abdomen of a young child can block the movement of the diaphragm and cause respiratory compromise you must make and use caution when applying the straps of a spinal immobilization device because it may hinder the tidal volume gastric distension can interfere with movement of the diaphragm and lead to hypoventilation breast sounds are more easily heard because of their thinner chest walls and less air is exchanged with each breath so detection of poor air movement or complete absent of breast sounds may be more difficult the circulatory system it's important to
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The Circulatory System
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know the normal pulse ranges when evaluating children an infant's heart
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The Circulatory System Continued
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rate can beat 160 times or more in a minute and children are able to compensate for decreased perfusion by constricting the vessels in the skin signs of vasoconstriction include pallor and that's an or an early sign weak distal pulses in the extremities delayed cap refill and cool hands or feet the table on this slide list responsive pediatric pulse rates
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The Nervous System
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all right so let's move on to the nervous system and so the differences are the pediatric nervous system is immature underdeveloped and not well protected head to body ratio of infant and young children is disproportionately larger the occipital region of the head is larger which increases the momentum of the head during the fall the subarachnoid space is relatively smaller leaving less cushing for the brain and the brain tissue and cerebral vasculature are fragile and prone to bleeding from shearing forces the pediatric brain also requires a higher amount of cerebral blood flow oxygen and glucose than does the adult brain tissue and it places them at risk for secondary brain damage from hypotension and hypoxic events spinal cord injuries are less common in pediatric patients if cervical spine is injured it is more likely to be an injury to the ligaments because of a fall for suspected neck injuries perform manual inline stabilization or follow local protocols
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The Gastrointestinal System
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the gastrointestinal system okay so abdominal muscles are less developed in pediatric patients this gives them less protection from trauma liver spleen and kidneys are proportionately larger and situated more anteriorly so they are more prone to bleeding and injuries because of minimum direct impact
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The Musculoskeletal System
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the muscular skeletal system the child's bones are softer and than those of an adult and open growth plates allow bones to grow during childhood so as a result of open growth plates bones are softer and more flexible making them prone to stress fractures and bone length discrepancies can occur if there is an injury to the growth plate the bones of an infant's head are flexible and soft and soft spots called fontanelles are located at the front and back of the head the fontanels can be used for an assessment tool for such issues as increased intracranial pressure or dehydration the thoracic cage of children is highly elastic and pliable because it is primarily composed of cartilage connective tissue the ribs and vital organs are also less protected by muscle and fat into mega
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The Integumentary System
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terry system of the pediatric population differs in a few ways the skin is thinner with less subcutaneous fat composition of the skin is thinner and tends to burn more deeply and easily with less exposure and the higher ratio of body surface area to body mass can lead to a larger fluid loss and heat losses
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Scene Size-up
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so let's get into our patient assessment and we're going to start with that scene size up okay so assessment begins at the time of that dispatch remember so prepare mentally for approaching and treating an infant or child plan for pediatric scene size up pediatric equipment and age appropriate patient physical assessments if possible collect the age and gender of the child location of the same scene mechanism of injury or nature of illness and chief complaint from dispatch note the position in which the patient is found the patient may be a safety threat if he or she has an infectious disease so complete an environmental assessment
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Primary Assessment
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okay so next um we're going to talk about the p-a-t and the p-a-t is the pediatric assessment triangle and we're gonna um the objective of this primary assessment is to identify and treat in immediate and potential life threats so we're going to use the pediatric assessment triangle to determine if the patient is sick or not sick and it can be performed in less than 30 seconds okay so let's talk about it the p-80 consists of three elements and requires no it uh no equipment and so the first is going to be the appearance and this is the muscle tone or mental status then the work of breathing and then finally the circulation okay so the appearance note the level of consciousness or interactiveness and muscle tone these will provide you with information about the adequacy of the patient's cerebral perfusion and overall function of the central nervous system the pneumonic t-i-c-l-s tickles can also help to determine if the patient is sick or not tickles includes tone interactiveness consult consolability look or gaze and speak speech or cry then is the work of breathing so signs of increased work of breathing often presents with abnormal airway noise accessory muscle use retractions and head bobbing nasal flaring tachypnea and the tripod position okay so the body will attempt to compensate for abnormalities in oxygenation and ventilation and then finally the third is the circulation to the skin so polar of the skin and mucous membranes may be seen in compensated shock it may also be a sign of anemia or hypoxia modeling is another sign of poor perfusion and cyanosis reflects a decreased level of oxygen in the blood from the pat findings you will decide if the pediatric patient is stable and requires urgent care if the patient's unstable assess the xabc's treat any life threats and transport immediately if the patient is stable continue with the remainder of the patient's assessment process perform necessary interventions and discuss transport options with the parents and caregivers hands-on so we're going to really look for do a hands-on assessment and we're going to assess and treat those life threats as we identify them following the x abcs so the x is a signification airway breathing circulation disability and exposure now we're going to talk about those next okay so if the airway is open and the patient can adequately keep it open assess respiratory adequacy if the patient is unresponsive or has difficulty keeping the airway clear ensure that is properly positioned and that it's clear of mucus vomit blood and foreign bodies always position the airway in the neutral sniffing position and establish whether the patient can maintain his or her own airway then breathing so look listen and feel technique we're going to place both hands on the patient's chest to feel for chest rise and fall of the chest wall belly breathing in infants is considered adequate because of the soft pliable bones of the chest and the strong musculature diaphragm comes to circulation we must determine if the patient has a pulse is bleeding origin shock in infants we're going to palpate the brachial pulse or femoral pulse in children older than one year we're going to palpate the carotid pulse strong central pulses indicate that the child is not hypotensive but it does not rule out the possibility of compensation we graphs and peripheral pulses indicates decreased per perfusion and tachycardia may be an early sign of hypoxia or shock or a less serious condition such as a fever anxiety pain or excitement interpret the pulse with in the context of the overall patient history the p-a-t and the primary assessment a trend of an increasing or decreasing pulse rate may suggest worsening hypoxia or shock or improvement after treatment fuel the skin for temperature and moisture and estimate the cap refill time d when it comes to disability we're going to use the av pills avpu score or the pediatric calcoma score to assess level of consciousness we want to check the responsiveness of the pupils and look for symmetrical movement of the extremities pain is present with most types of injuries so assessment of pain must take into consideration the developmental age of the patient and then e is exposure so the hands-on abcs require that the caregiver move remove part of the patient's clothing to allow observation of the face chest wall and skin the pediatric population is more prone to hypothermic events during due to immature system thinner skin and lack of that subcutaneous fat so infants and young children should be kept warm during the during the transport or when the patient is exposed to excessive or reassessing an injury and then d is that transport decision okay so if the pediatric patient is in stable condition obtain a patient history perform a secondary assessment at the scene transport and provide additional treatment as needed okay so rapid transport is indicated if any of the following conditions exist so if there's a significant mechanism of injury if there's a history of capable of or with a serious illness if a physical abnormality is noted during the primary assessment or if a potentially serious um at atomic abnormality or significant pain or an abnormal level of consciousness altered mental status or any signs of or symptoms of shock we want to also consider the following so we want to know the type of clinical problem the expected benefits of advanced life support treatment in the field and local ems systems treatment and transport protocols your comfort level and also the transport time to the hospital if the pediatric patient condition is urgent then immediate transport to the closest facility should be initiated special facilities such as trauma centers or children's hospitals have the training staff and equipment to provide complete care for all levels of pediatric patients so the most appropriate facility is not always the closest so you want to ask yourself can i deliver this pediatric patient to the most appropriate facility without the risk or delay to the pediatric patient if the answer is no you need to transport the patient to the closest facility if patients weigh less than 40 pounds who do not require spinal immobilization you should transport them in a car seat mount a car seat to the stretcher and follow the the seat manufacturer's instructor instructions to secure the car seat to the captain's chair patients younger than two years must be transported in a rear-facing position because of the lack of mature neck muscles for pediatric patients who require spinal immobilization the patient should be immobilized to a long backboard or other suitable spinal immobilization devices pediatric patients in cardiopulmonary arrest should be on a device that can be secured to the stretcher you should not use the pediatric patient's car seat the goal is to secure the and protect the patient for transport in the ambulance okay so history taking your approach to the history will depend on the age of the pediatric patient historical information for the infant toddler or pre-school-aged child will have to be obtained from the parent or caregiver when dealing with adolescent most information will be obtained from the patient sexual activity possibility of pregnancy and drugs or alcohol should be obtained from the patient in private questioning the parents or child about the immediate illness or injury should be based on the child's chief complaint when interviewing the parent caregiver or child about the chief complaint obtain the following you want to know the mechanism of injury or the nature of illness how long the pediatric patient has been sick or injured the key events that led to the injury or illness the presence of fever
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History Taking
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effects of the illness of or injury on the pediatric patient's behavior and the pediatric patient's activity level recent eating drinking and urine output change in bowel or bladder habits or the presence of vomiting diarrhea abdominal pain and the presence of rashes you want to obtain the name and phone number of the caregiver if they are not able to come to the hospital with you and then let's talk about the history taking as far as the sample history so it's the same as the adults but you uh the question should be based on the pediatrics patient's age and development stage of life the process for obtaining opqrs t is the same as the children same for the children and as it is the adults so questions should be based on the pediatrics patient's age and developmental stage as well
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Secondary Assessment
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okay and then your secondary assessment so a secondary assessment of the entire body should be used when pediatric patients have the potential for hidden illness or injuries okay so it may help identify problems that were not as obvious during the primary assessment but over time the presenting signs and symptoms have become more apparent use the dcap btls pneumonic a focused assessment should be performed on a pediatric patient without life-threatening illness or injuries
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Secondary Assessment Continued
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infants toddlers and pre-school-aged children who do not have life-threatening illness or injuries should be assessed starting at the feet and ending with the head school-aged children and adolescents can be assessed using the head-to-toe approach as with the adult patients okay so when it comes to that physical exam we're going to look at the head bruising decap btls and of course assess the fontanels and infants and with the nose um nasal congestion needs to be cleared because it can cause respiratory distress so you could use a bulb syringe or a suction cap a soft selection cap then the ears you have to look for the drainage in the ears of this indicates the skull fracture just with the the same as adults and the mouth of course we're looking for bleeding or any type anything that could cause an airway obstruction and of course the mouth as with the um adolescent onset or child onset of diabetes we want to note the smell of the breath the neck we're going to look for tracheal deviations same as the adult in the chest decap btls we're going to look listen and feel to the chest area and the clavicles in the back we're going to look for a dcap btls the abdomen we're going to inspect for distension we're going to palpate and note any um guarding or pain or tenderness okay and then of course looking for the seat belt abrasions or bruising and then the extremities we're going to do pms looking for extra um some symmetry and uh and then just rotate to see if there's full range of motion in the extremities vital signs so uh of course these are used uh to assess uh circulatory status and um but they have there is some important limitations when it comes to pediatric patients so normal heart rates vary in age with those pediatric patients and blood pressure is also usually not assessed in pediatric patients younger than three years old and then assessment of the skin is a better indication of the pediatric patient's circulatory status so use appropriately sized equipment when assessing a pediatric patient's vital signs you have to use a cuff that covers two-thirds of the pediatric patient's upper arm all right so when we talk about how to formulate a blood pressure in children 1 through 10 years old we're going to basically just take the child's age in years and multiply it by 2 and then add it to 70. so a systolic blood pressure is a that's a useful tool in determining blood pressure in children um but the cir respiratory rates can also be difficult to interpret so count the respiratory or the respirations for at least 30 seconds and then double it and in infants and children younger than three evaluate respirations by assessing the rise and fall of the abdomen we're going to assess the pulse rate by counting for at least a minute noting quality and regularity okay so normal vital signs in the pediatric patient of course are going to vary with age we want to assess respirations and then pulse and then blood pressure last and we're going to compare the size of the pupils with each other and pulse ox is a valuable tool to measure the oxygen saturation in a pediatric patient with respiratory distress
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Reassessment
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and then of course we're going to reassess and uh 15 minutes if they're in stable condition every five if they're in unstable and we of course continually monitor respiratory effort skin color condition and level of consciousness or their interactiveness parents and caregivers may be able to assist you by calming and reassuring that patient down and then of course we have to communicate and document all that info to the emergency department personnel
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Respiratory Emergencies and Management
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okay now we're going to get into specific emergencies and management of those types of emergencies okay so specifically to respiratory emergencies it's the leading cause of cardiopulmonary arrest in the pediatric population failure to recognize and treat declining respiratory status will lead to death during respiratory distress the pediatric patient is working harder to breathe and will eventually go into respiratory failure if left untreated in the early stages of respiratory distress you may not know changes in the pediatric patient's behavior such as combativeness restlessness and anxiety signs and symptoms of increased work of breathing include nasal flaring abnormal breath sounds uh accessory muscle use and they might be in the tripod position as the pediatric patient progresses to possibly respiratory failure efforts of uh to breathe decrease the chest rise less with inspiration and the body has used up all its available energy stores and cannot continue to support the extra work of breathing changes in behavior will also occur until the pediatric patient demonstrates an altered level of consciousness patients may also experience periods of apnea as the lack of oxygen becomes more serious the heart muscles become hypoxic and the heart rate slows down respiratory failure does not always indicate airway obstruction it may indicate trauma nervous system problems dehydration or metabolic disturbances a pediatric patient's condition can progress from respiratory distress to respiratory failure at any time a child with an infant or respiratory distress needs supplemental oxygen assist ventilation with a bag valve mask and 100 oxygen if needed allow the patient to remain in a comfortable position okay so airway obstruction children can obstruct their airway with any object that can fit in their mouth in cases of trauma teeth may have been dislodged into the airway
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Airway Obstruction
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blood vomit or other secretions can also cause mild or severe airway obstructions infections including pneumonia croup epiglottitis and bacterial tracheitis can also cause airway obstructions infections should be considered if patient has congestion fever drooling and cold symptoms the figure on this slide shows the effects of epiglottitis and this is an infection that can cause an upper airway obstruction in the pediatric patients
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Airway Obstruction Continued
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obstructions by a foreign object may involve the upper or lower airway it may be partial or complete signs and symptoms frequently associated with a partial upper airway obstruction include decrease or absent breath sounds and strider signs and symptoms of a lower airway obstruction include wheezing and or crackles the best way to auscultate breast sounds in a pediatric patient is to listen on both sides of the chest and at the armpit level immediately begin treatment of a pediatric patient with an airway obstruction if the patient is conscious and coughing forcefully and someone saw him or her in just a foreign object encourage the child to cough to clear the airway if you see signs of severe airway obstruction attempt to clear the airway immediately if an infant is conscious with a complete airway obstruction we're going to perform up to five back blows and chest thrusts if the child is conscious with the complete airway obstruction we're going to perform abdominal thrusts and this is the heimlich maneuver we need to use a head tilt chin lift and a finger sweep to remove a visible foreign body in an unconscious pediatric patient chest compressions are recommended to relieve a severe airway obstruction in an unconscious pediatric patient okay so let's talk about asthma specific this is a condition in which the similar or the smaller airway passages the bronchioles have become inflamed and they swell and produce excessive mucus which leads to difficulty breathing it's a true emergency if not promptly identified and treated common causes for an asthma attack include upper airway or respiratory infection exercise exposure to cold air or smoke and emotional stress signs and symptoms are wheezing cyanosis respiratory arrest or the tripod position what we want to do is treatment of that pediatric patient with asthma we want to allow the patient to maintain a position of comfort we want to administer supplemental oxygen albuterol alone with ibuproprium via uh mdi or nebulizer and um contact advanced life support and assist ventilations if needed
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Pneumonia
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okay that was asthma now let's get into pneumonia pneumonia is a general term that refers to an infection of the lungs often a secondary affection it occurs after a pre-existing infection infections such as a cold and it can also occur from chemical ingestion or direct lung injury or a submersion event children with diseases cause causing immunodeficiency are at an increased risk for developing pneumonia incidence is greatest during fall and winter months presentation in a pediatric patient so unusual rapid breathing or they'll breathe with grunting or wheezing sounds there's also nasal flaring tachypnea hypothermia or fever or unilateral diminished breath sounds or crackles over the affected lung segments so treatment of pneumonia in the pediatric patient will be primary treatment will be supportive we want to administer supplemental oxygen if they need it and administer a bronchodilator it's a chest or if the child's wheezing so diagnosis of the mono pneumonia must be confirmed at the hospital
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Croup
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okay and then there's croup
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Croup Continued
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so croup is an infection of the airway below the level of the vocal cords and usually caused by a virus typically seen in children between six months and three years it's easily passed between children starts with a cold cough and a low-grade fever it develops over two days the hallmark sign of croup is strider and a seal bark cough it responds well to oxygen or administration of humidified oxygen and bronchiodilators are not indicated for group and can actually make the child worse
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Epiglottitis
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and then there's epiglottitis so that's an infection of the soft tissue in the area above the vocal cords it's bacterial infection is the most common cause and since the development of a vaccine against one organism that causes epiglottitis the incident of this disease has dramatically decreased in preschool and school-aged children especially the epiglottitis can swell to two or three times its normal size children with this infection look ill and they report a very sore throat and high fever they will often be found in the tripod position and drooling
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Bronchiolitis
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and then um bronchulitis okay so specific viral infections of newborns and toddlers often caused by rsv causes inflammation of the bronchioles rsv is highly contagious and spread through coughing and sneezing and viruses can survive on surfaces and virus tends to spread rapidly through schools and child care centers more common in premature infants and results in copious secretions that may require suctioning okay so it occurs during the first two years of life and is more common in males most widespread in winter and early spring and the bronchioles become inflamed swell and fill with mucus airway of the infants and young children can become easily blocked so you want to look for signs of dehydration shortness of breath and fever how we're going to treat bronchiolitis in pediatric patients is we're going to allow the patient to remain in that position of comfort we need to administer humidified oxygen and consider advanced life support backup
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Pertussis
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and then there's pertussis it's a communicable disease caused by a bacterium that is spread through respiratory drop as a result of vaccinations this potentially deadly disease is less common in the united states the typical signs and symptoms are similar to that of a common cold sneezing and a runny nose and as the disease progresses the coughing becomes more severe and characterized by a distinctive whoop sound heard during inspiration infants infecting with pertussis may develop pneumonia or respiratory failure to treat pediatric patients make sure you keep the airway open and transport follow standard precautions including wearing a mask and eye protection let's talk about some airway adjuncts next and
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Airway Adjuncts
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these devices that help maintain the airway or assist in providing artificial ventilation include so they're ops and nps bite blocks or bag valve mass devices
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Airway Adjuncts Continued
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so the op it's designed to keep the tongue from blocking the airway and make suctioning easier it should be used for pediatric patients who are unconscious and in possible respiratory failure it should not be used in conscious patients or those who have a gag reflex or who have ingested caustic or petroleum-based products
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Airway Adjuncts Continued Again
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the nasal pharyngeal it's usually well tolerated and not as likely to cause vomiting it's used in responsive pediatric patients used in association with possible respiratory failure and it's rarely used in infants younger than one year should not be used in pediatric patients with a nasal obstruction or head trauma when it comes to potential problems with airway adjuncts the airway with a small diameter may easily become obstructed with mucus blood vomit or other soft tissues of the pharynx if the airway is too long it may stimulate the vagal nerve and slow the heart rate down or enter the esophagus and that will cause gastric distension so may cause a spasm of the larynx and result in vomiting if inserted into a responsive patient nasopharyngeal airways should not be used when patients pediatric patients have facial trauma because the airway may be soft and the tissues will cause bleeding into the airway
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Oxygen Delivery Devices
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so when it comes to oxygen delivery devices treating infants and children who require more than the usual 21 of oxygen that's found in the air um there are several options the blow by technique and this is uh um at six liters provides more than 21 oxygen concentration nasal cannula at one to six liters provides 21 or 24 to 44 non-rebreather at 10 to 15 is up to 95 percent and bag valve mass device is 10 to 15 liters it'll provide nearly 100 percent concentration use of a non-rebreather mask a nasal cannula or a simple face mask is indicated only for pediatric patients who have adequate respirations or tidal volumes children with respirations fewer than 12 breaths a minute or more than 60 an altered level of consciousness or an inadequate title volume should receive assisted ventilations with a bvm device okay so now let's go through these oxygen delivery devices and the blow by method this is not nearly as effective as a face mask or nasal cannula but it it and it also does not deliver that high concentration but it's better than no oxygen then there's the nasal cannula and some pediatric patients prefer the nasal cannula but other fine others find it uncomfortable okay so the figure on this slide shows the blow by technique and the nasal cannula and then there's that non-rebreather and this delivers up to 90 oxygen to that pediatric patient allows them to exhale all the carbon dioxide without rebreathing it then of course the bag valve device this is indicated for pediatric patients who have respirations that are either too slow too fast who are unresponsive or who do not respond in a purposeful way to painful stimulus figures on this slide show a pediatric patient non-rebreather and a one-person bag valve mass ventilation remember there's two-person bag valve mass ventilation and this procedure is similar to that one person except that one rescuer holds the mask on the patient's face and the other maintains the head position while the other ventilates usually more effective in maintaining a tight seal as it provides an open airway dur due to a properly body position
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Cardiopulmonary Arrest
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cardiopulmonary arrest so most often associated with respiratory arrest like we said children are affected differently than adults when it comes to decreasing oxygen concentration we want to focus on effective cpr early use of an aed and transport
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Shock
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and then shock so shock it develops when the circulatory system is unable to deliver a significant amount of blood to those vital organs it results in organ failure and eventually cardiopulmonary arrest compensated shock in early stages is when the body can still compensate for that loss and decompensated shock is a later stage and this is when the blood pressure is falling pediatric patients the most common cause of shock is it includes traumatic injury dehydration severe infection or neurologic injury
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Shock Continued
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a severe allergic reaction anaphylaxis or disease of the heart tension pneumo or blood around the heart pediatric patients respond differently to adults than fluid to fluid loss they may respond by increasing their heart rate increasing respirations and showing signs of pale or blue skin signs of shock in children are tachycardia poor capillary refill time so this is going to be greater than two seconds they could also have a mental status change begin treating shock by assessing the xabcs and intervene when required so if there's an obvious life-threatening external hemorrhage the order becomes cab because bleeding control is the most critical step and if cardiac arrest is suspected the order also becomes cab because chest compressions are essential so pediatric patients in shock often have increased respirations but do not demonstrate a fall in blood pressure until this shock is very severe we want to limit our management to these simple interventions we have to ensure the airways open prepare for artificial ventilation control bleeding and give that supplemental oxygen by mask or blow by we want to keep the patient warm provide rapid transport to the nearest appropriate facility and contact advanced life support backup as needed okay so now let's talk about anaphylaxis um so associated with shock anaphylaxis is all always called anaphylactic shock and it's a life-threatening allergic reaction that involves a generalized multi-system response to an antigen it's characterized by airway swelling and dilation of blood vessels and common causes are insect stings medications or food signs and symptoms are hypoperfusion strider and wheezing increased work of breathing the appearance of restlessness agitation and sometimes the sense of impending doom and hives what how we're going to treat it is we're going to try and keep the patient calm administer oxygen re or assist the parent with administering that prescribed epi auto injector and provide rapid transport
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Bleeding Disorders
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okay so then there's some bleeding disorders and hemophilia is a congenital condition in which the patient lacks one or more of the normal clotting factors most forms are hereditary and are severe predominantly found in the male population bleeding may occur spontaneously and all injuries become serious because of blood loss the blood does not clot we have to transport them immediately and we're not going to delay to apply tourniquets for a life threatening hemorrhaging
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Altered Mental Status
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neurologic emergencies is what we're going to talk about next and of course we use that mnemonic aeio tips and this reflects the major causes of altered mental status and we just want to understand normal development or age related changes in behavior and listening carefully to the caregiver's opinion signs and symptoms very simple vary from simple confusion to a coma and we want to manage them focusing on that abcs okay
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Seizures
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the first one we're going to talk about is seizures and of course this is a
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Seizures Continued
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disorganized electrical activity in the brain in in a variety of ways depending on the the age of the child seizures and infants are very subtle consisting only of gay sometimes sucking motion or bicycling movements and older children's seizures are more obvious and typically consist of repetitive muscle contractions and unresponsiveness
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Seizures Continued Again
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in this slide shows the common causes of seizures once the seizure shot stops the patient's muscles relax becoming more flaccid or floppy and the breath becomes labored during the post-ictal state okay once the pediatric patient regains a normal level of consciousness the post-dictal state is over seizures that continue every four a few minutes without regaining consciousness in between or lasting longer than 30 minutes is referred to status epileptics this recurring or prolonged seizures should be considered potentially life-threatening if the patient does not regain consciousness or continues to seize protect the patient from harming him or herself and call for advanced life support back up how you manage seizures is you want to make sure that you protect the airway and that's our top priority you want to place the child in the recovery position if they are vomiting and have the suction available and provide 100 oxygen by non-rebreathing mask or blow by method and begin bag mass ventilations if there are no signs of improvement some caregivers will have given the child a rectal volume dose okay and this is prior to our arrival monitor breathing in the level of consciousness carefully and a transport to the appropriate facility
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Meningitis
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meningitis meningitis is the inflammation of tissues or meninges that cover the spinal cord and brain they be being able to recognize a pediatric patient with meningitis is very important some are at a greater risk so we have males newborns children with compromised immune systems children who have a history of brain spinal cord or back surgery or children who have head trauma or children who have shunts pins or other foreign bodies within their brain or spinal cord signs and symptoms of meningitis vary depending on the age of the patient fever and altered level of consciousness are common symptoms in all ages children may also experience a seizure which may be the first sign of meningitis in infants younger than two to three months they could have apnea cyanosis fever a distinct high-pitched cry or hypothermia the meningeal irritation or meningeal signs are terms used by doctors to describe the pain that accompanies movement it's often results in characteristic stiff neck one sign of meningitis and an infant is increasing irritability and bulging fontanelle without crying this bacterium that causes a rapid onset of meningitis symptoms often leads to shock and death okay um children with the bacterium typically have small pinpoint cherry red spots or a larger purple black rash on their face or body so the figure on this slide shows the that type of um of rash and typically with the small cherry point spots all pediatric patients with suspected meningitis should be considered contagious you want to follow standard precautions with these patients and follow up to learn the diagnosis because if exposed to the saliva or respiratory secretions you need to receive antibiotics treatment of patients with this suspected meningitis you want to give them oxygen and assist ventilations if needed reassess vital signs frequently during transport to the highest level of service available
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Gastrointestinal Emergencies and Management
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all right so gastrointestinal emergencies never take a complaint of abdominal pain lightly because a large amount of bleeding may occur within the abdominal cavity without any outward signs of shock monitor for signs and symptoms of shock complaints of gastrointestinal origin are common in pediatric patients ingestion of certain foods or unknown substances in some cases the pediatric patient will be experiencing abdominal discomfort with nausea vomiting and diarrhea and remember that vomiting and diarrhea can cause dehydration is also very common and if you suspect appendicitis promptly transport to the hospital for further eval and of course we have to obtain the history from the caregiver and in particular how many wet diapers is the child tolerating liquids how many times has a child had diarrhea and when he or she cries our tears present all right so next we're going to talk about poisoning emergencies and poisonings unfortunately are common in children they can occur by ingesting inhaling injecting or absorbing a toxic substance common sources of poisonings in children are alcohol aspirin cosmetics household cleaning products such as bleach household plants iron prescription medicines illicit drugs or vitamins and the signs and symptoms of poisonings are going to vary widely it's going to depend on the substance and the age and weight of the child they could look normal at first or be confused sleepy or unconsciousness and some substances only take one pill to be lethal in a small child infants may be poisoned as a result of being fed harmful substances by a sibling parent or caregiver so be alert to signs of abuse and may be exposed in a setting in which a harmful substance are being smoked so offer or after you have completed the primary assessment ask the patient or caregiver the following questions what substance was involved the approximately how much of it or how long ago and are there any changes in the behavior or level of consciousness and was there any choking or coughing after the exposure medical control for assistance in identifying poisons in treatment of the poison pediatric patient of course we're going to perform that external decon assess the abcs and monitor breathing provide oxygen and ventilations if necessary and if the child demonstrates signs of shock we want to position them supine keep the child warm and transport properly in some cases give activated charcoal according to medical control or local protocol so dehydration emergencies and management dehydration occurs when fluid loss is greater than fluid intake vomiting and diarrhea are also most common causes of dehydration if left untreated dehydration can lead to shock and death infants and children are at a greater risk than adults for dehydration because their fluid reserves are smaller than those of adults life-threatening dehydration can overcome an infant in a matter of hours signs and symptoms of mild are dry lips decrease saliva or if you wet diapers signs and symptoms of moderate are sunken eyes sleepiness irritability loose skin sunken fontanelles and then severe dehydration is modeled cool clammy skin delayed cap refill and increase respirations treating dehydration and pediatric patients so we need to assess those abcs if dehydration is severe advanced life support backup is necessary okay all patients with moderate or severe dehydration have to be transported all right so fever emergencies is what we're going to talk about next an increase in body temp usually in response to an infection temperatures of a hundred degrees point four or higher are considered abnormal and fever is rarely life-threatening but fever with a rash can be a sign of a serious condition such as meningitis common causes of fever in pediatric patients include infection status epilepsis cancer or drug ingestion such as aspirin arthritis and systemic lupus high environmental temperatures or fever is a result of the internal body mechanism in which heat generation is increased and heat loss is decreased an accurate body temp is an important vital sign a rectal temperature is the most accurate for infants and toddlers depending on the source of that infection the pediatric patient may present with signs and symptoms of respiratory distress shock a stiff neck rash skin that is hot to the touch flushed cheeks seizures and an infant's bulging fontanelles you want to assess for any other signs and symptoms provide rapid transported management and follow standard precautions if you suspect a communicable disease is present when it comes to febrile seizures these are extremely common and in children between six to six months to six years most pediatric seizures are a result of the fever alone which is why they are called febrile seizures they typically occur in the first day of the feveral illness characterized by generalized tonic chronic seizure activity they last fewer than 15 minutes with no or little post uh actual state and they may be a sign of a more serious problem though such as meningitis of course we're just going to um assess the abcs provide those cooling measures and all patients with febrile seizures need to be seen at the hospital okay next we're going to talk about drowning emergencies and this is the second most common cause of unintentional death in children age one to four in the u.s children often fall into the swimming pools and lakes but may drown in the bathtubs and even puddles or buckets of water older adolescent drown when swimming or boating and alcohol can be a cause okay so the principal condition that results from drowning is lack of oxygen even a few minutes without oxygen affects the heart lungs and brain submerging submersion in icy water can lead to hype hypothermia diving into water increases the risk of neck and spinal cord injuries so signs and symptoms are going to vary based on the length and time of submersion and they could be coughing or choking difficulty breathing altered seizure or unresponsive um so you're going to manage them by requesting advanced life support assess the management of abc's administer oxygen or bvm and if trauma suspected have a cervical collar in place and put the patient on the backboard so pediatric trauma emergency these are unintentional injuries are the number one killer of children in the u.s okay so quality of care in the first few minutes after they've been injured is going to have an enormous impact on that child's chances for complete recovery the muscles and bones of children continue to grow well into adolescence and adolescents are prone to fractures of the extremities the fracture of the femur is very rare in pediatric patients but when it occurs it is a source of major blood loss so children's bones and soft tissues are less well-developed than those of an adult and therefore the force of the injury affects these structures differently because a child's head is proportionately larger than the adults it's it exerts greater stress on the neck structures during a deceleration injury children are often injured because of their underdeveloped judgment and their lack of experience so always assume that a child has serious neck or head injuries when it comes to vehicle collisions the exact area that is struck depends on the child's height and the position of the bumper at the time of impact high energy injuries to the head spine or abdomen pelvis or legs when it comes to sport activities children are often injured in organized sports activities so head and neck injuries can occur after high speed collisions remember to mobilize the cervical spine when caring for children with sports related injuries when it comes to head injuries these are common in children once again because of the child's head in relation to the body an infant is also has a softer thinner skull and it could result in injury to the brain tissues the scalp and facial vessels can bleed very easily and may cause a great deal of blood loss if not controlled and then nausea and vomiting are common signs and symptoms of head injuries in children when it comes to mobilization it's necessary for all children who have a possible head injury or spine injury after a traumatic event we can it can be difficult because of the child's body portions so we can mobilize a pediatric patient into a car seat to see the skill drill of 35-6 when it comes to chest injuries it could be a result of blood rather than penetrating trauma in check because the chest is flexible in children it can produce a flailed chest although there are no external signs of injury there may be significant injuries within the chest abdominal injuries are common we have to monitor for shock and if the patient shows signs of shock we need to prevent hypothermia by keeping them warm with blankets and if the patient is has a low pulse we should ventilate and monitor during transport the figure on this slide illustrates the impact of blood loss on the potential for developing shock so a child all children with abdominal injuries should be monitored closely for signs and symptoms of shock burns so they're generally considered more serious than burns to adults infants and children have more surface area to total body mass so children are also more likely to go into shock develop hypothermia and experience airway problems the most common ways that children are burned are exposure to hot substances such as scolding water in the bathtub hot items on the stove exposure to caustic substances such as cleaning solvents or paint thinners and older children are more likely to be burned by flames from the fire infection is also common following a burn injury so sterile techniques should be used in handling the skin of children with burn wounds if possible we want to consider the possibility of abuse in any burn situation and we want to make sure we report any information about suspicions to the appropriate authorities severity of burns there could be minor moderate or severe so minor are partial thickness burns involving less than 20 or 10 percent moderate or partial thickness burns involving 10 to 20 severe is any full thickness burn a partial thickness burn involving more than 20 percent or any burn involving the hands feet face airway or genitalia when it comes to burns um pediatric patients are going to be managed the same as adults injuries to the extremities so children have immature bones with active growth centers and growth of the long bones occur from the ends of the specialized growth plates now the growth plates are potential weak spots incomplete or green stick fractures can occur generally extremely injuries in children are managed in the same way as adults pain management so the first step in pain management is recognizing the patients and pain since some pediatric patients use non-verbal or low limited vocabulary look for visual clues and use the wand baker faces pain skill you are limited to the following pain interventions so positioning ice packs and extremity evaluation those interventions will decrease the pain and swelling to the injury site and then als interventions may be needed another important tool is kindness and providing emotional support okay so next we're gonna stop talk about disaster management use the jumpstart triage system instead of start triage it's jump start and this is intended for patients younger than 8 or who appear to weigh less than 100 pounds there are four triage categories with jumpstart and designated by colors corresponding to different levels of urgency so um we are going to have the green tag and the green is minor not an immediate uh treatment care of treatment and these are people are able to walk except of course for the infants and then there's yellow that's delayed and yellow is they have uh spontaneous breathing they have peripheral pulses and uh they responsive to painful stimuli when it comes to red tag these are the immediate and that is uh apnea and respiratory failure breathing but without a pulse or a proc of inappropriate painful response so apnea and without a pulse or apnea and unresponsive to rescue breathing are black tagged so the figure on the screen illustrates jumpstart triage system all right so child abuse and neglect child abuse means an improper or excessive action that injures or otherwise harms a child or infant this includes physical abuse sexual abuse neglect war and emotional abuse over half a million children are victims of abuse annually many of these children suffer life-threatening conditions and some die if you suspect child abuse and you need to report it and this abuse is likely to happen again perhaps causing permanent injury and even death signs are child abuse occurs in every socio-economic status so you must be aware of the patient's surroundings and document your findings objectively you may be called to testify in abuse cases and it's essential that you record all findings okay you have to ask yourself is the injury typical for the developmental level of the child is the mechanism of injury reported consistent is the pair is the parent or caregiver behaving appropriately is there evidence of drinking or abuse at the scene was there a delay in seeking help for the child and is there a good relationship between the caregiver and the child does the child have multiple injuries at different stages of healing does the child have an unusual mark or bruise that may be caused from cigarettes heating or branding injuries does the child have several types of injuries and does the child have any burns on the hands or feet that involve a glove distribution is there an unexpected decreased level of consciousness is the child clean an appropriate weight for their age is there any rectal or vaginal bleeding and what does the home look like is it clean or dirty is it warm or cold and is there food the mnemonic child abuse may help you remember the points to look for so bruises you want to observe the color and location of the bruises bruises on the back buttocks or face are suspicious and are usually inflicted by a person then burns to a penis testicles or vagina or buttocks are usually also inflicted by someone burns that encircle a hand or foot to look like a glove are usually also inflicted by someone suspect abuse of the child has cigarette burns or grid pattern burns then there's fractures so fractures of the humerus or femor do not normally occur without major trauma falls out of bed are usually not associated with fractures maintain an index of suspicion to an infant or young child who sustains a femur fracture or a complete fracture of any bone shaken baby syndrome so infants may sustain life-threatening head trauma or by being shaken or struck in the head there is bleeding within the head in it damage to the cervical spine resulting from severe shaking and then there's neglect so refusal or failure on the part of the caregiver to provide life necessities children who are neglected are often dirty thin or appear developmentally delayed because of the lack of stimulation symptoms and other indicators of abuse are abused children appear withdrawn fearful or hostile be concerned if a child does not want to discuss how the injury occurred occasionally a parent or caregiver will reveal a history of accidents be alert for conflicting stories or lack of concern from the caregiver the abuser may be a parent caregiver relative or friend of the family emts in all states must report suspected abuse even states or most states have special forms to do so supervisors are generally forbidden to interfere with reporting of suspected abuse law enforcement and child protective surgeries will determine whether there is abuse when it comes to sexual abuse children of all or any age or gender can be victims you want to maintain a high index of suspicion you should the assessment should be limited to determining what type of dressing any injuries need treat the bruises and fractures as well and do not determine if the genitalia of a young child unless there is evidence of bleeding do not allow the emt or the child to wash urinate or defecate ensure the emt or police officer of the same age remains with the child and maintain professional composure the entire time obtain as much information as possible transport all children who are victims and sexual abuse is a crime next we're going to talk about sids so sudden uninspected unif unexpected infant death syndrome and sudden infant death syndrome the sudden and unexpected infant death refers to the sudden unexpected death where the cause is not known until the investigation is conducted and one of the causes of suid is sudden infant death syndrome which is sids which results in death that cannot be explained by another cause about 3 500 infants die of sins annually the american academy of pediatric recommends that a baby be placed on his or her back in a crib that is free of bumpers blankets and toys the csc recommends having a baby sleep in the same room but not the same bed breastfeeding and use of a pacifier are also associated with a lower risk of sids although it is impossible to predict sids risk factor there are some that include a mother younger than 20 mothers who smoke mothers who use alcohol or illicit drugs and a low birth weight death as a result of sids can occur at any time of the day you will face three with three tasks so assessment of the scene assessment and management of the patient and then communication and support of the family you will patient assessment so an infant who has been a victim of sids will be blue and pale not breathing and unresponsive other causes include overwhelming infection child abuse airway obstruction or meningitis accidental poisoning hypoglycemia congenital metabolic deficit defects or begin with the assessment so xabc's you're going to provide interventions as necessary and depending on how much time has passed the child may show signs of postmortem changes if the sign if the child shows these signs call medical control if there is no sign of post-mortem change you want to begin cpr immediately pay special attention to any marks or bruises on the child before you perform these procedures and know any intervention that was not done prior to your arrival you wanna with the scene you need to inspect the environment noting any condition the scene where the infant was found assessed the scene should concentrate on signs of illness including medications humidifiers or thermometers a general condition of the house signs of poor hygiene family interaction and the site where the infant is discovered you have to communicate and support the family after the death of a child the sudden death of an infant is devastating uh event for a family and it tends to evoke strong emotional responses among health care providers follow the family or allow them to express their grief offer the family a high level of empathy and understanding the family may want you to initiate resuscitation efforts which may or may not conflict with your ems protocols always introduce yourself to the child's parents and caregivers and ask about the child's date of birth and medical history do not speculate on the child's cause of death the family should be asked whether you they want to hold the child and say goodbye the following interventions are helpful so learn and use the child's name rather than the impersonal your child speak to the family members at eye level and maintain good contact with them and use the word dead or died when informing the family of the child's death euphemisms such as passed away or gone are ineffective acknowledge the family's feelings offer to call family members keep any instructions short simple and basic and ask each family member individually whether he or she wants to hold the child wrap the child in a blanket and stay with the family members when they hold the child ask them to ask them to not remove tubes or other equipment that is used in an attempted resuscitation each individually in each culture will express grief in a different way some will require intervention most caregivers feel directly responsible for the death of the child and some ems systems arrange for home visits after the child's death so the ems providers and family members can come to some sort of closure you need special training for these visits a child's death can be very stressful take time before going back to the job talk to other ems colleagues be alert for signs of post-traumatic stress in yourself and others and consider the need for professional help if these signs occur apparent life-threatening events so infants who are not breathing or cyanotic and responsive unresponsive when found sometimes resume breathing and color with stimulation this is called an apparent life-threatening event a-l-t-e in addition to cyanosis and apnea an alte or an alt is characteristic by characterized by a distinct change in muscle tone choking or gagging after the event the child may appear healthy and show no signs of illness or distress pay strict attention to airway management assess the infant's history allow caregivers to ride in the back and physicians will have to determine the cause brief result unexplained event so signs and symptoms include brief changes in colors such as pale skin or cyanosis choking absence low or irregular breathing abnormal muscle tone decreased level of consciousness no abdominality found on assessment and transport is required for evaluation okay so this concludes chapter 35 let's see what we've learned by doing the review questions how does a pediatric anatomy differ from adult all right d it's the head that head is proportionately larger when a small child falls from a significant height the blank most often strikes the ground first and we know that's the head it's proportionately larger when assessing a conscious and alert nine-year-old what should we do we want to ask them the questions if they're capable of answering right the purpose of a shunt is to and we know that the purpose of the shunt and a v p shunt is going to be to minimize pressure within the skull which of the following statements regarding febrile seizures is correct all right so we know that febrile seizures are going to be d um and that is uh that usually lasts only 15 minutes and often does not have that postal state okay we respond to a sick child at night the child appears very ill has a high fever it's drooling sitting in that tripod positioning is struggling to breathe all right so the patient's drooling so we think epiglottitis because their apple guys have swollen and they can't swallow treatment for a semi-conscious child who swallowed an unknown quality of pills is gonna be all right if it's semi or unconscious we're going to monitor for vomiting give oxygen and transport fast when using the pneumonic child abuse to assess the child for signs of abuse the d is going to stand for and that's going to stand for delay of seeking care right okay so four-year-old fell from the second-story balcony and landed on her head she's unresponsive slow irregular breathing has a large hematoma to the top of the head and bleeding from her nose oh goodness all right so when somebody has bleeding from their nose we're going to suspect um that she has some type of um of fracture right so head fracture so we got to stabilize our head we're going to jaw thrust put in an airway a jug and then bvm foo what does p stand for and we know that that is painful he is painful all right thank you for joining us with the chapter 35 lecture and we hope you've enjoyed it
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Introduction to Neonatal Care
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hello and welcome to chapter 42 neonatal care this chapter reviews the physiologic changes that occur in a newborn during birth the care that should be provided during and immediately after birth and the special needs of premature births and bursts complicated by other factors it also reviews the steps involved in neonatal resuscitation and outlines the process of transporting an infant to a hospital or in between hospitals okay so let's get started a newborn or neonate care must be tailored to meet the needs of the population so a newborn is an infant within the first few hours after birth and a neonate is an infant within the first month after birth so if a newborn needs special support an intervention by trained caregivers parents may feel inadequate supporting the needs of both the newborn and caregiver is important so allow them to be physically close as possible and explain what is being done and provide details for transport plan to the next level of care so skilled care interventions to optimize cardiopulmonary function are routinely required in only about 5 to 10 percent of deliveries approximately eight percent of newborn delivered each year weigh less than 5.5 pounds the most common cause of low birth weight is prematurity and mortality increases as birth weight and gestational age decrease so let's talk about the transition from
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The Transition from Fetus to Newborn in Utero
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fetus to newborn in utero the fetus receives oxygen from the placenta and fetal circulation has three major blood flow deviations or shunts from that of an adult so it has the ductus venus the forman oval the ductus arterious and these shunts begin to close off at birth so the figure on the slide shows fetal circulation as a fetus is delivered fetal transition occurs and it enables the newborn to breathe so the first breath is triggered by mild hypoxia and hypercapnia from partial occlusion of the umbilical cord during delivery tactile stimulation and cold stress promote early breathing and pulmonary vasculature resistance drops as the lungs fill with air more blood flows into the lungs picking up oxygen a delay in the decrease of pulmonary pressure leads to delayed transition hypoxia brain injury and death
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Gestational Time
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gestational time so when you talk about pre-term that is less than 37 weeks term is 38 to 42 weeks and post-term is more than 42 weeks so let's talk about the arrival of the
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Arrival of the Newborn
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newborn next
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Patient History
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you want to obtain the patient history and prepare the environment and equipment with any available time okay so key questions to help determine resuscitation and the needed equipment include the woman's age the length of pregnancy presence and frequency of contractions any pregnancy complications if the membranes have ruptured and if so the timing and the makeup of the fluid if they know if they're having multiple fetuses medications that they are taking so 90 to 95 percent of all newborns require no active interventions at birth minimal needs are warm dry blankets and maybe a bulb syringe two small clamps or ties and a pair of clean scissors complications need prompt management if delivered in the ambulance cover the foot of the stretcher with clean warm blankets for the initial stabilized stabilization after confirming adequate airway breathing and pulse rate place a newborn on the mother's chest if more extensive resuscitation is necessary transition the newborn to a second ambulance with a neonatal transport incubator suction the mouth then the nose with a bulb syringe once the head is delivered keep the newborn at the level of the mother after delivery with the head slightly lower than the body clamp the umbilical cord in two places and cut between the clamps if the cord comes out ahead of the newborn the blood supply of the fetus may be cut off so relieve the pressure on the cord by gently moving the newborn's body off the cord and pushing the cord back
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Primary Survey of the Newborn
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primary survey of the newborn may be done simultaneously with any treatment interventions you need to note the time of the delivery monitor the abcs assess the airway patency and respiratory rate and effort tone pulse rate and color inspect the skin for abnormalities examine the head for symmetry and abnormalities and examine the eyes of the neonate for irregularities a newborn who truly cannot open his or her eyes may have a congenital defect so watch for abnormal eye movement as well examine for any drainage or ocular discharge and inspect the newborn's umbilical cord to detect abnormalities a newborn is at risk for hypothermia so ensure thermoregulation by placing the newborn on pre-warm towels and drying the head and body thoroughly and discarding wet towels and covering with a dry towel and cover the head with a cap position the newborn to ensure the patent airway clear secretions and assess the respiratory effort all babies are cyanotic right after birth so if the newborn stays vigorous and begins to turn pink within five minutes maintain ongoing observation and continue thermoregulation with direct skin contact with the mother while enroute okay so the apgar score helps record the
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Apgar Score
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newborns condition in the first five minutes after birth and it helps paramedics determine specific resuscitation measures needed and their effectiveness so the categories of the apgar are appearance pulse rate grimace activity and respiratory effort each sign is given the value of 0 1 or 2. so you want to record record it at 1 and 5 minutes after birth if the 5 minute score is less than 7 an additional score should be done every 5 minutes until about 20 minutes after birth if resuscitation is necessary the apgar score is done by determining the resuscitation results okay so now we're going to talk about
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The Algorithm for Neonatal Resuscitation
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the algorithm for neonatal resuscitation if a problem arises follow current natal resuscitation guidelines to optimize the outcome initial steps so there's reevaluation and beginning ventilation should occur within the first 60 seconds follow the initial steps of bulb syringe suctioning the mouth and nose drying and stimulating the newborn if the newborn does not respond further intervention is necessary you want to assess the respiratory rate effort pulse rate and color count the respiratory rate and pulse for 6 seconds then multiply by 10 to determine the per minute rate many newborns have blue hands and feet but are centrally pink meaning they're center core of their body if there is a normal breathing pattern and the pulse rate is greater than 100 beats mean but maintain central cyanosis of the trunk or mucous membranes provide supplemental oxygen if still apneic or has a pulse rate of less than 100 after 30 seconds of drying and stimulates stimulation and oxygen begin positive pressure
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Positive Pressure Ventilation
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ventilation buy a newborn size bag valve mask be careful not to squeeze the bag too hard in order to avoid delivering too much volume room air is preferred when resuscitating term infants and the addition of supplemental oxygen might be necessary additional oxygen may be necessary if the neonate is not achieved the target pre-ductal oxygen set for the value of their age if the newborn's pulse rate is less than 100 beats check the chest movement take ventilation corrective steps if needed and insert an et tube or laryngeal mask as appropriate if the newborn's pulse rate is less than 60 begin chest compressions effective chest compressions should result in a palpable pulse use the pulse ox when resuscitation is anticipated and the newborn appear cyanotic if ventilation and chest compressions do not improve the bradycardia administry preferably via an iv line when no sign of life pulse or respiratory effort or present after 10 minutes of resuscitation changes chances of successful recitation resuscitation are low overall outcomes are associated with high early mortality the figure on this slide shows the
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Algorithm for Neonatal Resuscitation
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algorithm for neonatal resuscitation so let's talk about drying and stimulation after ensuring airway patency dry and stimulate the newborn nasal suctioning stimulates the newborn to breathe so position the infant on the back or side with the neck in the sniffing position if the airway is not clear suction the head turn to the side suction mouth and nose and flick the soles of the feet or gently rub the back so next we're going to talk about free
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Free Flow Oxygen
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flow oxygen so if a newborn is cyanotic or pale provide supplemental oxygen provide oxygen to a pale newborn until a pulse ox reading can give an accurate breathing so if positive pressure ventilation is not indicated oxygen can initially be delivered through an oxygen mask or oxygen tubing cupped and held to the nose of the newborn's nose or mouth so oxygen flow rate should be about five liters a minute do not blow oxygen directly on the newborn's eyes okay so there are oral airways but
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Oral Airways
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they're usually rarely used on newborns and there are some conditions that require the oral airways however in all these cases an et tube is inserted down a nostril so keep the mouth open to provide adequate ventilation so the pearl robin sequence is a series of development abnormalities and they include a small chin and posteriorly large physician tongue back valve mask it's indicated when a newborn is apnic and has inadequate respiratory rate has a pulse rate of less than 100 beats per minute airway is cleared of secretions tongue obstruction is relieved and the newborn is dried and stimulated so signs of respiratory
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Signs of Respiratory Distress
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distress suggest need for bag valve mass ventilation and they include periodic breathing or intercostal retractions nasal flaring or grunting on expiration
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Three Devices To Deliver Bag Valve Mass Ventilations to Newborns
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there are three devices to deliver bag valve mass ventilations to newborns we have self-inflating bag with an oxygen reservoir and that's most likely used in the field and then there's flow inflating bag and that needs a gas source more commonly in surgery and there's a t-piece respirator and that needs a gas source as well usually found in neonatal in intensive care units always use the infant size when available and that's the 240 milliliter bag and um only one tenth of the bags volume will be used for each breast so if a neonatal bag is not available use a bag designed for adults or larger children provided that the delivered breast size is appropriately small and the chest rise is monitored for excessive volume during delivered breaths when administering back valve mass
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Back Valve Mass Ventilation
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ventilation with 100 oxygen the face mask should uh provide an airtight seal and um the airway should be patent and the head should be in the sniffing position the first few breaths after birth frequently need higher pressures and subsequent breaths should have enough pressure to deliver a visible but not excessive chest rise a ventilation rate of about 40 to 60 breaths is important because a higher rate can cause hypocapnia air trapping in a pneumo so continue the positive pressure ventilations as long as the pulse rate is less than 100 beats per minute on the or the respiratory effort is ineffective so if more than one minute of positive pressure ventilation is needed hook the system to a pressure manometer so the cause of the ineffective back valve mass ventilation could be an inadequate mass seal in correct head position copious secretions and pneumo or equipment malfunction all right so innovation is indicated when meconium stained fluid is present and the newborn is not vigorous so by that we mean poor muscle tone or bradycardia inadequate ventilation or no respiratory effort at all routine tracheal suction is no longer recommended for a depressed newborn delivered through meconium stained amniotic fluid congenital diaphragmatic
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Congenital Diaphragmatic Hernia
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hernia is known and suspected and the respiratory support is necessary so abdominal organs herniate through the opening in the diaphragm into the chest cavity and that's what the congenital diaphragm herme hernia is a prolonged positive pressure ventilation is needed and cranial facial defects impede an inadequate airway so that could be why you need to do innovation the following equipment should be available when you're doing that
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Suction Equipment
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innovation so suction equipment the laryngoscope blades they want you to use straight and a shoulder roll adhesive tape an e.t tube and a stylet used by some paramedics must be secured to the top of the et tube of course to properly innovate a newborn you're going to refer to skill drill 42-1 in your book
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Complications of the Et2 Placement
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and there are complications of the et2 placement and they include oropharyngeal or tracheal perforation esophageal innovation with subsequent persistent hypoxia and then of course right mainstay main stem integration risk can be minimized by ensuring optimal placement of the laryngoscope blade and noting how far the et tube is advanced and gastric depression so it's indicated if the you're gonna have a prolonged back valve mass ventilation and we consider prolonged more than five to ten minutes abdominal distension is impeding ventilations that could be another reason you're going to do the gastric depression and diaphragmatic hernia and gastrointestinal congenital anomaly so this is when the diaphragm hernias in when you could suspect them are decreased breath sounds on the left side or increased work of breathing to properly insert an oral gastric tube in a newborn you're going to refer to skill drill 42-2 so let's talk about circulation next chest compressions are indicated if the pulse rate remains less than 60 beats per minute despite positioning airway clearing drying and stimulations and 30 seconds of effective positive pressure ventilations two people are needed for effective chest compressions while ventilating there are two different techniques there's a thumb technique and the two finger techniques so the thumb technique is preferred because it generates superior peak systolic and corneal arterial profusion pressure while causing less fatigue on the provider you encircle the torso with both hands with fingers supporting the spines place two thumbs side by side over the lower third of the sternum once the airway is secure or the newborn is innovated chest compressions can be delivered from the head of the bed and allow easier access to the umbilicus then the two finger technique that you place the tips of the index finger and middle fingers of one hand over the lower third of the sternum and the second hand supports the spine the compression depth is one-third of the anterior posterior diaphragm or diameter of the chest the two the thumbs or fingers should be in contact with the chest at all times this allows the chest to completely recoil after each compression chest compressions and artificial ventilation should not be delivered simultaneously you want to coordinate 90 compressions and 30 press so this equals about 120 events per minute and the person doing the compression should count out loud reassess for the presence of a pulse after 60 seconds of well-coordinated chest compressions and ventilations limit the number of pauses in compressions to maximize the chances of achieving return of spontaneous circulation so if the pulse rate is above 60 chest compressions can be stopped if the pulse rate is above 60 chest compressions and positive pressure ventilations check pulse rate after 30 seconds when the pulse rate goes above 100 gradually slow the rate and decrease the positive pressure ventilations
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Vascular Access
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so vascular access emergent access is necessary for fluid administration to support circulation and iv resuscitation medication and therapeutic drugs the umbilical vein can be catheterized with an umbilical vein line so you need to clean the cord with an antiseptic drape at the area with sterile towels keeping the stump exposed place a sterile tie firmly around the base of the cord to control bleeding and then cut the cord with the scalpel between the clamp and the cord tie keeping about one to two centimeters from the skin insert the low uv line into the umbilical vein and insert the catheter into the vein for a distance of about 0.75 to 1.5 inches or 2 to 4 centimeters until blood can be aspirated flush the catheter with half a milliliter of normal saline and tape in place a peripheral iv and io can also be used but a smaller needle should be used in newborns okay so medications are rarely needed in newborn resuscitation because they can be resuscitated with effective ventilatory support so medication doses though are based on weight a full term newborn usually weighs about 6.5 to 9 pounds and is about 20 inches long in newborn at 28 weeks of gestation weighs about 2.5 to and is about 14.75 inches long so transport to the nearest facility to provide the next level of care once a newborn is stabilized as much as possible contact the facility for advance regarding care and disposition provide ongoing communication with the family about the current care and do not be specific about survival statistics if you cannot answer questions tell them you will put them in touch with those who can during transport monitor the newborn and frequently assess for status changes and vitals to check are the thermal regulation respiratory effort airway patency skin color and pulse rate and so development of new techniques for newborn care has reduced mortality among high-risk newborns it may be necessary to transfer critically ill newborns to a regional center to get needed treatment
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Transport of a High-Risk Newborn
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transport of a high-risk newborn should include the following steps a physician at the referring hospital initiates a request for transport and a mode of transport is chosen depending on the distance availability and weather conditions the transport team is immobilized and the equipment is assembled and of course the ideal team consists of a nurse with special training in neonatal intensive care a respiratory therapist a paramedic with an apprenticeship apprentice shift in neonatal intensive care and a physician could be a part of the team for critically ill patients highly specialized equipment include appropriately designed ventilation and oxygen units and an incubator meeting stringent criteria on arrival at the right referring hospital the transport team continues to stabilize the newborn conditions that should be treated before leaving the referring hospital include hypoxia acidosis hypoglycemia and hypovolemia the team collects information while stabilizing the newborn including a copy of the mother and infant's charts and any radiographic studies of the newborn
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Apnea with Newborns
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so let's talk about apnea with newborns and it's common it delivered before 32 weeks of gestation and it's rarely seen in the first 24 hours defined as respiratory pause of greater than 20 seconds and it can lead to hypoxia and bradycardia often follows hypothermia other causes include maternal or infant narcotic exposure or airway or respiratory muscle weakness prolonged or difficult labor or a gastro esophageal reflex or central nervous system abnormalities also there's seizures and metabolic disorders and metabolic disorders are the pathophysiology depends on the underlying ideology so newborns need respiratory support to minimize hypoxic brain damage and other organ damage so assessments you're going to gather the history perform a physical exam and differ differentiate between primary apnea or secondary apnea so primary apnea is after a relatively short period it may have a period of rapid breathing
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Bradycardia
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followed by apnea and bradycardia secondary apnea is if hypoxia continues during primary apnea the newborn will gasp and go into secondary phase and the positive pressure ventilation by bag valve mask is gonna be necessary so we talked about apnea now we're gonna talk about bradycardia so the most it most frequently occurs in newborns because of inadequate ventilation so often responds to positive pressure ventilation effectively other causatives are causes are hypothyroidism acidosis maybe congenital heart defect prolonged suctioning or vagal stimulation so morbidity and mortality are determined by underlying cause and how quickly it is correctly corrected you want to assess and manage this and if the heart rate is assessed by auscultation or palpating the base of the umbilical cord the heart rate is less than 100 provide positive pressure ventilations assess the airway if it's less than 60 despite 30 seconds of positive pressure ventilations of course you're going to start chest compressions if less than 60 after 30 seconds of effective ventilation and 30 seconds of chest compressions you want to administer epi the low umbilical vein catheter is the preferred access to administer medications during resuscitation and after about a minute of administering epi you want to check the pulse rate ensure that the et tube is not dislodged and ensure that the chest compressions are be being given at the adequate depth of about one-third focus on maintaining normothermia and transport to the facility that is able to handle high-risk neonates we talked about apnea bradycardia and now we're going to talk about acidosis so suspect metabolic metabolic acidosis if bradycardia persists after ventilation chest compressions and volume expansion consider administering a bolus of normal saline to aid in the improved profusion and clearance of acid the best treatment is to identify and correct the underlying cause of this acidosis okay and then the next we're going to talk about is pneumothorax and it can
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Pneumothorax
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occur if the infant inhales meconium or lung is weak by infection and positive pressure ventilation is going to be
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Signs of Significant Pneumo
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needed so signs of significant pneumo is severe respiratory distress unilateral breath sounds and shift of heart sounds if the pneumo is on the left side so it's going to push you want to clear the area with alcohol around the second intercostal space mid-clavicular and you're going to
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Prepare the Equipment
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prepare the equipment so a 22 gauge through a stopcock and a 20 ml syringe you have to palpate the upper edge of the second rib and insert the needle above it at the same time you're going to pull back on a syringe slowly advancing the needle until the air is recovered if the syringe fills with air turn the stopcock off to the newborn push the air out of the syringe open the stopcock and continue with drawing air remove the needle when there is no more air to be withdrawn if symptomatic ongoing air leak insert the 22 gauge angiocatheter in the similar location and tubing may be taped to the chest and briefly occluded and transport and monitor for re accumulation of the pneumothorax and then of course the next one is going to be meconium and a small percentage of the babies delivered in the presence of meconium stain amniotic fluid may develop meconium aspiration it carries a high risk for mortality and morbidity and it's more common in post term and those small further age newborn stress before
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Newborn Stress before or during Delivery
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or during delivery if the newborn passes stool before birth they may inhale the meconium stained amniotic fluid so the airway may become clogged or plugged causing hypoxia so this may um cause a delayed drop in pulmon pulmonary vascular resistance which can cause right to left shunting causing the patient to persistent pulmonary hypertension of the newborn to decrease the risk for this ensure the airways clear keep the newborn warm minimize stimulation and administer supplemental oxygen when necessary if meconium aspiration occurs follow closely for signs of deterioration and you're going to assess the activity level if crying in vigorous use standard
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Standard Interventions
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interventions if depressed use of positive pressure ventilation positive pressure ventilation is ineffective than innovating suction may be required to remove any obstructions if the newborn is not responding well to the care outlined in the neonate resuscitation algorithm suspect airway occlusion or pneumo and takes the steps to minimize hypothermia reassess frequently the newborn has prolonged hypoxia after significantly delayed resuscitation the outcome will likely be poor so when transporting stay in communication with the facility support the family and do not discuss chance of survival okay so after meconium the next thing we're going to talk about
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Low Blood Volume
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is the low blood volume so fluid resuscitation may be needed if the newborn has significant depletion due to some conditions such as abrupto placenta or twin to twin transfusions or placenta previa or septic shock so signs of hypovolemia occur include pallor persistent low pulse rates weak pulse or no improvement in circulatory status despite efforts a newborn place a a low umbilical line in a neonate who is uh more than a few days old place a peripheral iv or io line consider administering a fluid bolus and multiple boluses may be administered if the patient remains clinically hypovolemic next condition we're going to talk about
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Diaphragmatic Hernia
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is a diaphragmatic hernia it's an abnormal opening in the diaphragm that causes the umbilical contents to herniate into the chest cavity causes the heart and the mediastinum to shift to the contralateral side of the hernia so postnatal signs include respiratory distress heart tones which are shifted decreased breath tones bowel sounds heard in the chest an overall survival of infants born with a diaphragmatic hernia is about 67 percent so assessment and management of a newborn may uh demonstrate so they may demonstrate a few or no symptoms severe hypoxia with an increased work of breathing resuscitate with 100 oxygen if hypoxic monitor the heart rate continuously during transport and all ultimately this is going to require surgical interventions so transport to a facility with a neonatal intensive care and pediatric surgery
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Respiratory Distress and Cyanosis
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and then there's respiratory distress and cyanosis so it's the single most common cause in the neonate is prematurity so respiratory causes include airway obstruction aspiration pneumonia pneumothorax or congenital diaphragmatic hernia or also immature lungs so other causes are any process resulting in a delay in the drop of pulmonary vascular resistance central nervous system depression septic shock or cardiac abnormalities so assessment and management you want to ensure the airway check the breathing is adequate check to see if the pulse rate is present assess respiratory rate and ask the parents about increased symptoms with feeding when with the feeding attempt so treatment is going to be establishing the airway adequate oxygen delivery effective ventilations and adequate circulation so if resuscitation efforts do not result and improve improvement needle thorough centesis may be necessary respiratory depression secondary to narcotics so administer narcan to the newborn of a drug addicted mother it may participate seizures that can potentially cause death so it's no longer recommended as a first-line drug in resuscitation in the case of a newborn experiencing respiratory depression for the mother's chronic use of narcotics provide ventilatory support and transport immediately and if respiratory depression is a result of the mother being treated acutely with narcotics so without chronic exposure narcan may be administered to the newborn via the iv or im route to reverse the narcotic effects next we're going to talk about premature
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Premature and Low Birth Weight Infants
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and low birth weight infants so
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Premature Newborns
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premature newborns are delivered before 37 weeks and if idiopathic but maternal conditions associated with preborn labor and delivery include maternal infection or maternal illness leading to dehydration placental insufficiency preeclampsia and pregnancy-induced hypertension in addition to increased mortality and number of morbidities are associated with prematurity including respiratory distress syndrome respiratory suppression and apnea hypothermia sepsis and central nervous system compromise low birth weight newborns weighing less than 5.5 pounds the most common etiology is prematurity
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Factors Contributing to Premature Delivery
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and factors contributing to premature delivery include genetic factors infection abruption multiple gestations previous delivery of premature infants drug use and trauma other chronic factors um contributing to low birth weight include um maternal hypoten or hypertension placenta abnormalities and smoking also chromosomal abnormalities morbidity and mortality rate are related to the degree of prematurity so those born at 24 weeks of gestation are likely unlikely to survive and those born after 32 weeks of gestation or weight at least three pounds who receive cardiopulmonary support survive long term assessment and management of course to determine prematurity rely on the physical features so the maturity of the skin size of the infant and the degree of the respiratory distress information from family about the gestational date and information related to maternal and fetal complications to optimize survival of the newborn delivered prematurely in the field provide cpr and provide thermo-neutral environment use only minimal pressures necessary to move chest when providing the positive pressure because the risk of retinopathy of prematurity worsened by long-term oxygen exposure you want to manage you want to focus on clearing the airway gentle stimulation administering supplemental to providing chest compressions if effective ventilation does not result in adequate heart rate increase and then maintain a warm environment there's also the risk of seizures in the
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Risk of Seizures in the Newborn
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newborn and it strongly suggests the presence of a neurologic disorder most common and premature newborns the following are often mistaken for
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Seizures
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seizures though so normal movements when a newborn is drowsy or sleep and jitteriness so that's most common seen in hypoglycemia or drug withdrawal seizures are usually related to an underlying abnormality and seizures may interfere with cardiopulmonary function feeding metabolic function and prolonged seizures may cause brain injury so there's types of seizures there's subtle seizures and they are characterized by eye deviation blinking chewing mouthing or apnea there's clonic seizures or focal or multifocal and then
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Tonic Seizures
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there's tonic seizures and that's characterized by focal or generalized spasms um that could be a single brief sun movement resulting in a tick or a jerk or mono monoclonic seizures and that's focal monofocal or generalized and it could be just a flexation of an arm or generalized and bilateral jerking or flexation of arms or legs there are causes and it could be hypoglycemia or another metabolic disturbance and metabolic abnormalities include disturbances in levels of glucose calcium magnesium or other electrolytes amino acids blood ammonia or certain toxins so assessment and management you want to evaluate pre prenatal and birth history perform a careful physical exam hypoglycemia must be recognized and treated promptly so blood glucose
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Blood Glucose Measurement and Dextrose Administration
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measurement and dextrose administration should occur obtain baseline vital signs and provide oxygen assist ventilation blood pressure evaluation and iv access is necessary if blood glucose is less than 40 give iv bullish of 10 dextrose solution and recheck in 30 minutes iv administration of dexter should uh often needs to be followed by a 10 glucose infusion before giving an anticoagul convulsive medication consult medical control because benzodiazepines are commonly used to terminate neonatal seizures and may be administered regularly or intravenously monitor respiratory status and oxygen saturation carefully and maintain normal body temperature and then of course keep the family informed as you transport okay so we just talked about seizures which can be caused by hypoglycemia
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Hypoglycemia
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but now we're going to talk about hypoglycemia itself and it's considered a blood glucose level of less than 45 milligrams uh in full term or pre-term newborns and an imbalance between glucose supply and utilization with low glucose levels due to inadequate intake or increased glucose utilization so now remember that most newborns are asymptomatic until glucose levels fall below 20 and then they may result in seizures or severe permanent brain damage
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Assessment and Management of Symptoms
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assessment and management of symptoms may be non-specific but including cyanosis apnea irritability poor sucking or feeding limpnessness irregular respirations or eye rolling symptoms may be associated with lethargy tremors or seizures coma tachycardia tachypnea or vomiting so check blood glucose levels in all sick newborns and evaluate vital signs manage hypoglycemia after establishing good oxygenation ventilation and circulation and establish an iv medical control may order dextrose solution if the newborn's blood glucose is less than 40 and it may be followed by an iv infusion of dextrose based on the newborn's gestational age recheck the blood glucose about every 30 minutes and maintain normal body temperature okay so we just talked about hypoglycemia
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Vomiting
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now we're going to talk about vomiting and it's common in newborns it ranges from spit up to severe bloody or projectile vomiting so persistent vomiting is a warning sign though and can cause excessive fluid loss dehydration and electrolyte imbalances so persistent vomiting in the first 24 hours may be may indicate upper digestive tract obstruction or increase intracranial pressure so vomitus with dark red blood indicates gut bleeding and this may be life-threatening and then vomitous aspiration may cause respiratory insufficiency or airway obstruction
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Common Causes in Newborns
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so there are common causes in newborns they seen with excessive frothing soon after birth or possible choking when trying to feed gastroesophageal reflux it may vomit either immediately or a few hours after feeding so in infants and young children it persists as typical and or atypical crying apnea poor appetite it could be wheezing strider weight loss or poor growth so sun and unexpected and forceful vomiting may occur in conjunction with um asphyxia or meningitis or hydrocephalus so meningitis and hydrocephalus may be associated with increased intracranial pressure or icp there are also withdrawal symptoms in an addicted mom can include vomiting so assessment and
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Assessment and Management
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management you wanna the stomach may be distended due to vomiting and suspect infection if the newborn has a fever it may also indicate temperature instability apnea or abdominal tenderness or guarding or minimal or absent bowel sounds you want to start management with the
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The Abcs
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abcs of course the airway keep the face turned on the side to prevent aspiration suction the airway with a catheter or suction bulb consider a nasogastric or oral gastric tube to depress the stomach do not administer antibiotics in the field the newborn may need fluid resuscitation of normal saline the signs point to dehydration
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Dehydration
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and some of those uh signs of dehydration include dry mucosa tachycardia or sunken fontanelles place a newborn on the sign when transporting to a facility that can manage a high-risk newborn and then of course diarrhea so five to six stools a day is normal especially when breastfeeding and diarrhea is excessive loss of electrolytes and fluid in the stool it can cause acute causes are infection or poisoning gastroenteritis or lactose intolerance neonatal abstinence syndrome or cystic fibrosis severe causes can cause dehydration and electrolyte balances and of course a poor this will show with poor vital signs or cap refill delayed dry mucous membranes or absenteers assessment and management you're going to estimate the number and volume of the loose stools decrease urinary output in the great you're trying to get the degree of dehydration based on the skin trigger presence of salt sunken eyelids and the mucous membranes and patient management begins with the abcs of course you have to ensure the adequate oxygen and ventilation cpr if needed and fluid therapy may be necessary okay now we're going to talk about neonatal
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Neonatal Jaundice
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jaundice the results from immaturity of the liver to get rid of the bilirubin in the first week it's considered pathologic when clinically visible in the first 24 hours and basically clinical jaundice persists for more than one week in full term infants or more than two weeks in preterm and it can result in red blood cells disorders or excessive bruising and severe hyper bilirubin anemia can lead to kern etritus it's a form of developmental delay from the death deposition of bilirubin in the neurological tissues so assessment and management you want to transport is essential for bilirubin measurements at the hospital then additional assessment not available in the field so start iv fluids if the neonate shows significant clinical jaundice communicate with medical control about the newborn with jaundice okay so next we're going to talk about
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The Thermoregulation
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the thermoregulation and it's limited in newborn but average normal temperature of a newborn is 99.5 degrees it ranges between about 97.9 and 99 degrees and the production of heat by metabolism is the newborn's primary source of heat production so brown fat is unique in newborns and heat loss occurs when the heat is lost to the environment and uh
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Fever
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of course we're gonna talk about fever next fever is a rectal temperature greater than a hundred point four degrees fahrenheit or an oral temp of one fahrenheit lower than a rectal temp on average auxiliary temp is a 1.1 degrees celsius or 2 degrees lower than rectal temp a newborn may not always present with a fever in the illness or infection because of the immaturity of its temperature regulation system so no matter the pres presenting signs or symptoms it is imperative to identify serious bacterial infection in newborns so they can be treated fever may be caused by overheating or dehydration then there's a limited ability to control their temperature within newborns they don't sweat when they're hot and they do not shiver to raise temperatures so signs and symptoms are irritability decreased feeding or warmth to the touch
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Assessment of Management
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assessment of management so you're going to examine for the presence of rashes especially petechiae or pinpoint pink or red lesions obtain a careful history and note increased respiratory rate and work of breathing obtain the vital signs and provide free flow supplemental oxygen and chest compressions if necessary and anti-pyritic agents are controversial in the field so do not give them anything and then to cool remove just layers of clothing to improve ventilation hypothermia is a drop in body temperature less than 95 degrees fahrenheit it's more common during the winter months moderate hypothermia is linked with increased risk of death in low birth weight newborns and newborns have increased surface area to ratio volume ratio and are sensitive sensitive to environmental conditions especially when wet after delivery if a newborn is hypothermic investigate for the infections
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Assessment
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assessment okay so you're gonna hypothermic newborns may be cool to the touch or pale may present with decreased respiratory effort apnea bradycardia cyanosis weak cry or lethargic
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Preventative Measures
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preventative measures include warming your hands before you touch them drying thoroughly after birth placing a pre-warmed cap on the head and placing the newborn skin to skin with the mom if the newborn is hypoglycemic administer d10 um warm fluids can assist in rewarming once stabilized it is ideal if possible to place a critically ill newborn in a pre-warmed incubator okay so let's talk about common birth
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Common Birth Injuries in the Newborn
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injuries in the newborn so birth trauma comes from injuries resulting in mechanical forces during the delivery process most are self-limiting with a favorable outcome so newborn injuries can occur because of the newborn size or the position during the labor and delivery conditions associated with a difficult birth include the first pregnancy prolonged labor or prolonged rapid labor abnormal presentation large size or the shoulder dystocia prematurity or low birth weight
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