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Obstetric Emergencies, Stabilization & Transport Considerations
Yvette Gonzalez, MS, RN, C-NPT, C-EFM, RMH High Risk Obstetric & Neonatal Transport Clinical Manager
Objectives
• Review normal physiologic changes in pregnancy and assessment of obstetric patients
• Review HROB clinical presentations, pre-transport & transport clinical considerations
• Review HROB transport case studies and apply principles of maternal-fetal physiology through selection of clinical interventions appropriate for the clinical scenario.
• Review HROB peri-transport stabilization priorities
• Review in-utero resuscitation measures for pre-transport and transport application
• Review neonatal peri-transport stabilization priorities
This outreach education presentation is intended as an overview of basic concepts surrounding assessment of the
pregnant patient, OB complications and stabilization priorities for maternal patients.
Follow designated county protocols, policies and guidelines for actual care of obstetric and newborn patients.
60% of Maternal Deaths
PREVENTABLEhttps://www.youtube.com/watch?v=I5Dsn4obCa4&feature=youtu.be
Source: Maternal Mortality Review. https://www.cdcfoundation.org/sites/default/files/files/ReportFromNineMMRCs.pdf. Accessed March 2018.
Causes Of PREVENTABLE Mortality & Severe Morbidity
Failed CommunicationLack Of Recognizing Signs & Symptoms
Misdiagnosis & Ineffective TreatmentFailure In Care Systems & Processes
https://www.youtube.com/watch?v=URJfczEUA78 questions pertaining to Neo/HROB.
Sources:1. Maternal Mortality Review. https://www.cdcfoundation.org/sites/default/files/files/ReportFromNineMMRCs.pdf. Accessed March 2018.2. Preventing Maternal Death. TJC Sentinel Event Alert. Sentinel Events. https://www.jointcommission.org/assets/1/18/SEA_44.PDF. Accessed March 20183. Near Miss Mothers. NPR. https://www.youtube.com/watch?v=I5Dsn4obCa4&feature=youtu.be. Accessed May 2018
For every American woman who dies from childbirth, 70 nearly die
US Maternal Morbidity & MortalityLeading Causes & Regions
Louisiana, Georgia, Indiana, Arkansas, New Jersey, Missouri, Texas
Source: 1. National Vital Statistics Maternal Morbidity. https://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_04.pdf. Accessed March 2018.2. Meeting the Challenges of Measuring and Preventing Maternal Mortality in the United States. https://www.cdc.gov/grand-rounds/pp/2017/20171114-maternal-mortality.html. Accessed April 2018. 3. Sentinel Event Alert: Preventing Maternal Death. TJC. https://www.jointcommission.org/assets/1/18/SEA_44.PDF. Accessed April 2018
Causes of Arrest-Near Arest in OB Patients
B –E –A –U –C –H –O –P –S
Bleeding-DIC, Embolism, Anesthetic complications, Uterine atony, Cardiac
disease, Hypertensive disease, Other, Placental, Sepsis
Other Considerations: Peripartum Cardiomyopathy, & Vascular Dissections,
Source:1. The American Heart Association 2010 Guidelines for the Management of Cardiac Arrest in Pregnancy: Consensus Recommendations on Implementation Strategies. http://www.jogc.com/article/S1701-2163(16)34991-X/pdf . 2. American Heart Association: AHA. Maternal Cardiac Arrest. http://circ.ahajournals.org/content/132/18/1747. Accessed March 20173. Direct Causes of Maternal Mortality. Dartmouth.edu. Countdown to 2015 Decade Report (2000-2010), World Health Organization (2010).
OB Case Study
• Scene call: CC pelvic pressure/cramping, “leaking”
• Transport time: 35 minutes
• 28 y/o G5P2T1P1A2L1
• 25.3 weeks
• Maternal VS: HR 118, RR 20, sp02 97%, 105/70, temp 100.9 F
• FHR-EFM tracing: FHR 170, minimal variability, no decels or accels
What are clinical priorities---what would/can you do to stabilize?
Tick Tock...Every Minute Matters
Preterm Labor &
Preterm Premature Rupture of Membranes
• Primary Impression?, Consult, & Pre-transport Stabilization
• Optimize Tocolysis: Nifedipine, Indomethacin, Terbutaline, Magnesium
• Fetal Protection: Magnesium Sulfate, Antenatal Steroids & Antibiotics
• Evaluate Progression Of Labor PTD: Cervical Exam & UC evaluation
• Transfer To Higher Level Of OB & Neonatal Care: if able Source:1. Society For Maternal Fetal Medicine. Implementation of the Use of Antenatal Corticosteroids in the Late Preterm Birth Period in Women at Risk for Preterm Delivery. August 2016. Accessed March 2017. 2. ACOG. Management of Preterm Labor. https://www.acog.org/Womens-Health/Preterm-Premature-Labor-and-Birth. October 2016. Accessed March 2017 3. The American College of Obstetricians and Gynecologists Committee on Obstetric Practice Society for Maternal-Fetal Medicine. Magnesium Sulfate In Obstetrics. January 2016. https://www.acog.org/-/media/Committee-Opinions/Committee-on-Obstetric-Practice/co652.pdf?dmc=1&ts=20171212T2253317113. Accessed August 2017.
Normal Physiologic Changes In Pregnancy
Cardiovascular • Influence of Hormones, Hemodynamics & Vital Signs
Hematologic • Increased Circulating Blood Volume & Coagulation
Respiratory• Compensated Respiratory Alkalosis: pH 7.4-7.45 & PaCO2 27-32
• O2 Consumption, MV, & Tv
• Delayed gastric emptying---risk for aspiration!
Sources:1. Hayes, Meghan; Larson, Lucia (2012). "Chapter 220. Overview of Physiologic Changes of Pregnancy". Principles and Practice of Hospital Medicine The McGraw-Hill Companies.
https://accessmedicine.mhmedical.com/content.aspx?bookid=496§ionid=41304210 March 20182. Cardiac Arrest In Pregnancy. AHA Scientific Statement. https://doi.org/10.1161/CIR.0000000000000300 Circulation. 2015;CIR.0000000000000300. Accessed March 2018. Originally published October 6, 2015
Pregnancy Vital Signs & Labs
Normal Pregnant VS
• HR: 85
• SBP: 114
• DBP: 70
• MAP > 70 &/or SBP >90
• Goal: vital organ perfusion
• If Hypotensive: ensure adequate preload before initiating vasoactive drugs
Normal Labs
• Hct 34
• Platelets > 150
• AST & ALT ~ 35
• Creatinine < 1.0
• WBC < 16
Source: Hayes, Meghan; Larson, Lucia (2012). "Chapter 220. Overview of Physiologic Changes of Pregnancy". Principles and Practice of Hospital Medicine The McGraw-Hill Companies. https://accessmedicine.mhmedical.com/content.aspx?bookid=496§ionid=41304210 Accessed March 2018
Common HROB MedicationsMagnesium Sulfate:
• Preterm labor & fetal neuro protection
• Preeclampsia/HELLP seizure prophylaxis
• Eclamptic seizure treatment
Tocolytics: Nifedepine, Indomethacin (NSAID)& Terbutaline
Fetal Protection: Steroids, Magnesium Sulfate & Antibiotics
OB Hypertension-Antihypertensives:
• Labetalol vs. Hydralazine-- Goal not to normalize BP---achieve a range of 140-160/90-100mmHg
Eclamapsia-Anticonvulsants: Magnesium, Ativan, Versed, Diazepam, Phenytoin, Keppra
Uterotonic: Pitocin after delivery of placenta with fundal massage.
Fundal Height, How Many Weeks & Viable Fetus?
> 23 weeks?
Estimated Fetal Weight Based On Weeks of Pregnancy
600 grams 1Kg 2Kg 3Kg 4Kg
Source:1. NEJM. Survival and Neurodevelopmental Outcomes among Periviable Infants. February 2017. Accessed May 2017. 2. ACOG & Society For Maternal-Fetal Medicine. Periviable Birth. https://www.acog.org/Resources-And-Publications/Obstetric-Care-Consensus-Series/Periviable-Birth. October 2017. Accessed November 2017.
Rapid OB Assessment Primary Impression, CC & Priorities?
Prenatal care, history & current condition?• GPTPAL?
• How many weeks is she?
• Complications with this pregnancy?
• Complications with past pregnancies?
• Medical History? Medications?
• Vaginal bleeding? Leaking fluid?
• Pain: location, continuous or rhythmic?
• Injured: MOI?
• Ultrasound Findings: Placental pathology & location?
What about the fetus??• Does she feel fetal movement (typically present by 20 weeks)?
• Doppler or EFM FHR (normal 110-160)?Source: ASTNA, Patient Transport: Principles & Practice. 4th Edition
Peri-Transport Optimal Maternal Positioning
Lateral Uterine Displacement Improves Maternal CO &
Fetal Perfusion!
Source: Aortocaval Compression Conundrum in Obstetrics. https://journals.lww.com/anesthesia-analgesia/Citation/2017/12000/The_Aortocaval_Compression_Conundrum.7.aspx. Accessed March 2018.
OB Care Priorities: Stabilization & TransportABCs
Lateral Positioning: ~ 15 degrees
Vascular Access & Fluid Bolus • If indicated: LR or NS
Treat Mom To Treat Fetus!!• Uteroplacental Unit-New “End-Organ”
During Transport: • Ensure stability of mother and fetus during transport• Obtain frequent maternal vital signs & fetal assessment
• Fetal movement? Doppler FHR? Vaginal bleeding present?
Source: Trauma in the Obstetric Patient. American College of Emergency Physicians. https://www.acep.org/Clinical---Practice-Management/Trauma-in-the-Obstetric-Patient--A-Bedside-Tool/. Accessed March 2018.
Uteroplacental Blood Flow & Risk For Bleeding During Pregnancy
Source: 1. ACOG. Bleeding During Pregnancy. https://www.acog.org/Patients/FAQs/Bleeding-During-Pregnancy. Accessed March 2017.2. https://www.acog.org/-/media/Districts/District-II/Public/SMI/v2/he-06b-AF-140516-HemChecklist-Binder.pdf?dmc=1&ts=20171212T2152159656. Accessed March 2017.
She’s Pregnant & Bleeding….Placental Abruption??
Does she have any Risk Factors?
Abruption = Placental Detachment• May present with dark red & painful bleeding, OR
• Bleeding may be occult, rigid abdomen with severe pain !!
Source: Bleeding During Pregnancy. ACOG. https://www.acog.org/Patients/FAQs/Bleeding-During-Pregnancy. Accessed March 2018
She’s Pregnant & Bleeding: Abnormal Placental Implantation??
• Previa: Bright red, painless bleeding with or without UC’s
• Invasive Placental Implantation: C/S & Hemorrhage Risk
•Rapid transport to surgical & MTP capability center
Source: Placenta Previa-Obstetric Risk Factors & Pregnancy Outcome. https://www.ncbi.nlm.nih.gov/pubmed/11798453. Accessed March 2018
#1Cause of Maternal Death: OB Trauma
Primary Causes: MVA, Intimate Partner Violence Abuse, & Falls• Risk of abdominal trauma & hemorrhage
Physiologic Changes Can Mask Signs of Shock• Increased blood volume, cardiac output, mild tachycardia
Uteroplacental Unit Compromise: Increases risk for Maternal Fetal Hemorrhage & Fetal Compromise
Source: Trauma In The Obstetric Patient. American College of Emergency Physicians. https://www.acep.org/Clinical---Practice-Management/Trauma-in-the-Obstetric-Patient--A-Bedside-Tool/. Accessed March 2018
OB Trauma: Stabilization, Assessment & Transport
• Coms w/Receving : Trauma Center, OB & Neonatal Teams: Prepare For 2+ Patients
• OB Assessment • Primary & Secondary Survey
• ABCDE
• MOI
• Fetal Assessment: FHR – FetalMovement?
• Vaginal Bleeding?
• Rigid Abdomen?
• EDD? Viability?
• Labs & Diagnostics: • KB, Rh & FAST Scan-Ultrasound
1. ACOG. Bleeding During Pregnancy. https://www.acog.org/Patients/FAQs/Bleeding-During-Pregnancy. Accessed March 20172. High Risk & Critical Care Obstetrics. N. Troiano, C. Harvey, B. Flood Chez. AWHONN 2013, 3rd Edition.
Intrauterine Resuscitation MeasuresNormal Fetal Heart Rate: 110 – 160
Lateral Positioning• Optimize perfusion to uteroplacental unit
IV Fluid Bolus: Based on clinical condition
• Correction of maternal hypotension is essential!!
Oxygen Supplementation :• May optimize maternal oxygenation status and fetal oxygen delivery.
Reduction of Uterine Activity: Tocolysis (if needed/able)
Source: Maternal Oxygen Administration As An IntraUterine Resuscitation Measure During Labor. Simpson, Kathleen Rice. MCN: The American Journal of Maternal/Child Nursing: March/April 2015 - Volume 40 - Issue 2 - p 136http://www.sfnmjournal.com/article/S1744-165X(08)00061-9/abstract. Accessed March 2018.
OB Cardiac Arrest & Perimortum Cesarean Delivery
Recognition, CRM, & Teamwork
BLS, ACLS & ATLS
Positioning• Laterally to improve preload & CO
Primary Impression & Delivery• Every Minute Matters
• Rapid Assessment: Is Fetus Viable & Alive?
• Maternal Death Imminent?
• Prepare for Delivery & NRPSource: 1. Aortocaval Compression Conundrum in Obstetrics. https://journals.lww.com/anesthesia-analgesia/Citation/2017/12000/The_Aortocaval_Compression_Conundrum.7.aspx. Accessed March 2018.2. Cardiac Arrest In Pregnancy. AHA Scientific Statement. https://doi.org/10.1161/CIR.0000000000000300 Circulation. 2015;CIR.0000000000000300. Accessed March 2018. Originally published October 6, 20153. Preparing For Clinical Emergencies In Obstetrics. ACOG. https://www.acog.org/-/media/Committee-Opinions/Committee-on-Patient-Safety-and-Quality-Improvement/co590.pdf?dmc=1&ts=20180426T2325399798. Accessed March 2018
OB Case Study
Dispatch: IFT ED to regional OB center25y/o G1PO, 23 weeks, primary impression uterine contractions/PTL Transport time/Flight time 1:15
Maternal/fetal condition upon TT arrival: Maternal HR 86, Sp02 94%, RR20, B/P 209/104, temp 98, Cx 1.5cm/100%/-1, UC’s Q 3-5 (2/10), FHR 150+ IV MIVF @ 150ml/hr, HA X 3 days, RUQ pain
The Pressure Is On…..OB Hypertensive Emergencies
Defined: SBP >160mmHg, or DBP > 100mmHg, acute-onset, & persistent (>15 min)
Severe systolic hypertension--most important predictor of cerebral hemorrhage in OB patients• Goal B/P: Range of 140-160/90-100 mmHg to preserve fetal perfusion!!• Severe hypertension can occur antepartum, intrapartum or post-partum (6 wks)
Stabilization: • Magnesium Sulfate bolus & infusion, Antihypertensives-control B/P, Transport & Delivery• Be prepared to treat eclamptic seizures
Source:1. California Maternal Quality Care Collaborative: CMQCC. https://www.cmqcc.org/. Accessed August 20172. ACOG. Emergent Therapy for Acute-Onset, Severe Hypertension During Pregnancy and the Postpartum Period. April 2017. https://www.acog.org/-/media/Committee-Opinions/Committee-on-Obstetric-Practice/co692.pdf?dmc=1&ts=20171212T2343034025.
Accessed May 2017
Image Source: https://www.thirdstopontheright.com/may-is-preeclampsia-awareness-month-do-you-know-the-signs-and-symptoms/. Accessed April 2018
https://www.youtube.com/watch?v=URJfczEUA78 questions
Preeclampsia, HELLP & Eclampsia
Cerebral Effects Cardiac/Vascular
Pulmonary Liver Renal Fetal
Occurance: Up to 6 weeks PP
Labs: Obtain Hct, Platelets, LFT’s, Cr, Coags
Preeclampsia Assessment
Treatment-Stabilization: Magnesium Sulfate, Antihypertensives, Anticonvulsants, Delivery
Source: 1. California Maternal Quality Care Collaborative: CMQCC. https://www.cmqcc.org/. Accessed August 20172. https://www.propublica.org/article/die-in-childbirth-maternal-death-rate-health-care-system. Accessed December 2017
HELLP Syndrome: Severe Form Of Preeclampsia & State of Coagulopathy
Variant of severe preeclampsia
Presentation similar to pre-eclampsia with or without hypertension
Diagnosis determined by laboratory confirmation of: • Hemolysis• Elevated Liver Enzymes• Low Platelets
Treated similar to PEC with addition of blood products (as needed): • PRBC’s and Platelets• Antihypertensive Medications: Labetalol or Hydralazine (as needed)• Magnesium Sulfate infusion
Source: 1. California Maternal Quality Care Collaborative: CMQCC. https://www.cmqcc.org/. Accessed August 2017
Eclampsia: Onset of Seizures With PEC• Initiate Magnesium Sulfate: Bolus then continuous infusion
• Rebolus Magnesium if seizure continues
• Lorazepam or Versed
• Other options: Diazepam, Phenytoin, & Keppra
• Maintain ABC’s and protect patient
• Difficult to obtain EFM tracing during maternal seizuresSource: 1. California Maternal Quality Care Collaborative: CMQCC. https://www.cmqcc.org/. Accessed August 20172. https://www.propublica.org/article/die-in-childbirth-maternal-death-rate-health-care-system. Accessed December 2017
Delivery Outside Of OB Unit : Now What??• Supplies: OB Kit & Neo Ventilation Device
• Place infant on mothers abdomen after birth
• Clamp cord 8-10 inches from baby• Use 2 clamps several inches apart: cut between clamps
• Delayed Cord Clamping X 30-60 seconds IF VIGOROUS
• Immediate Cord Clamping IF NONVIGOROUS
• Provide basic newborn care• Clear Airway & Optimal Airway Positioning
• Dry Thoroughly & Provide Warmth
• Continuous assessment of ABC’s
• Thermoregulation & Blood Glucose
Source: Neonatal Resuscitation Program. AAP. 7th Edition
Tiny Ones: Preterm Delivery
Delayed Cord Clamping:
IF vigorous DCC reduction of IVH
IF NONVIGOROUS immediate umbilical cord clamping & NRP
Thermoregulation & Neuroprotection:
Warming mattress, isolation bag, hat, nesting, & head alignment with gentle handling
NRP Guidelines:
Sp02 & ECG, CPAP, PPV, airway & perfusion support, careful fluid administration, glycemic control, early activation of neonatal & transport teams!
Source:1. AAP. Neonatal Resuscitation Program. 7th Edition.
Delivery of Placenta: Now What?
Anticipate within 20 min after delivery• Do not pull on cord
Normal blood loss ~ 500ml
Provide vigorous fundal massage!!
• Support lower uterine segment
• Ensure uterus stays contracted-firm
• Uterotonics: as needed/if able
Source: ACOG Guidelines For Management Of Hemorrage. https://www.aafp.org/afp/2007/0401/p1101.html. Accessed 3/2018.
Leading Causes of Postpartum Hemorrhage: 4 T’s
•Tone• Uterine Atony = Inability of the uterus to contract
• Over-distension, muscle exhaustion-long labor, infection,
•Trauma• Lacerations, rupture, inversion
•Tissue• Retained tissue, clots, placental implantation
•Thrombin• Coagulopathy
Causes Of PP Hemorrhage
Atony Tissue Trauma Thrombin
Uterine Atony80%
Uterine Atony & Postpartum Hemorrhage Clinical Priority #1: Provide Vigorous Continuous Fundal MassageGoal: uterus remains contracted & firm
Ongoing Clinical Priorities:• Adequate Vascular Access• Continuous Fundal Massage• Uterotonics: Pitocin-dose & rate• Consider TXA: Consult • Rapid Transport To Surgical/Regional Center• D&C -- Removal of Placental Parts (if needed)• OR --- Looking For Bleeders• Activate Massive Hemorrhage Protocol
Source: OB Hemorrhage V2 Toolkithttps://www.cmqcc.org/resources-tool-kits/toolkits/ob-hemorrhage-toolkit. CMQCC. California Maternal Quality Care Collaborative. Accessed 3/20/2018
Image Source: dailymom.com
Thank You & Questions
Neonatal Resuscitation & Pre-Transport Stabilization
Yvette Gonzalez, MS, RN, C-NPT, C-EFM, RMH High Risk Obstetric & Neonatal Transport Clinical Manager
Objectives
• Review rapid assessment of neonatal patients
• Review differences between NRP and PALS
• Review neonatal clinical presentations, pre-transport & transport clinical considerations
• Review neonatal case studies and apply principles of NRP & STABLE through selection of clinical interventions appropriate for the clinical scenario.
• Review neonatal peri-transport stabilization priorities
• Review neonatal airway management, vascular access options, warming measures, & glycemic control
This outreach education presentation is intended as an overview of basic concepts surrounding assessment of the
pregnant patient, OB complications and stabilization priorities for maternal and newborn patients.
Follow your designated hospital and county protocols, policies and guidelines for actual care of obstetric and newborn patients.
Case Study: EMS Dispatch Female With Abdominal Pain
You Arrive On-Scene: Unexpected Newborn Delivery ~ 26 weeksRapid Newborn Assessment: Apnic, Dusky, HR palpable ~ 80bpm
What Are Your Clinical Priorities?
Delivery Outside Of OB Unit : Now What??• Supplies: OB Kit & Neo Ventilation Device
• Place infant on mothers abdomen after birth
• Clamp cord 8-10 inches from baby• Use 2 clamps several inches apart: cut between clamps
• Delayed Cord Clamping X 30-60 seconds IF VIGOROUS
• Immediate Cord Clamping IF NONVIGOROUS
• Provide basic newborn care• Clear Airway & Optimal Airway Positioning
• Dry Thoroughly & Provide Warmth
• Continuous assessment of ABC’s
• Thermoregulation & Blood Glucose
Source: Neonatal Resuscitation Program. AAP. 7th Edition
Tiny Ones: Preterm Delivery Priorities
Delayed Cord Clamping:
IF vigorous DCC reduction of IVH
IF NONVIGOROUS immediate umbilical cord clamping & NRP
Thermoregulation & Neuroprotection: Keep em’ warm & handle gently
Warming mattress, isolation bag, hat, nesting, & head alignment with gentle handling
NRP Guidelines: ABC, ensure chest rise and correct PPV/BVM rate
Sp02 & ECG, CPAP, PPV, airway & perfusion support, careful fluid administration, glycemic control, early activation of neonatal & transport teams!
Source:1. AAP. Neonatal Resuscitation Program. 7th Edition.
Neonatal Resuscitation & Stabilization Priorities
•NRP: A, B, C versus PALS• Airway, Airway, Airway• Ventilation Rate Adequate? Do You Have Slight Chest Rise?
• Stabilization Measures: The S.T.A.B.L.E. Program
• Glycemic Control• Thermoregulation• Perfusion Support• Preparation For Transport • Transfer to higher level of care
Source: http://www.abclawcenters.com/wp-content/uploads/2014/11/original_resuscitation_with_bagging_and_chest_compressions.jpg. Accessed August 2017.
Neonatal Airway Management: Babies are different…..• Anatomical Challenges• Ventilation Device Options• Establishing Effective Ventilation
• Ensure Adequate Rate: 40-60• Slight Chest Rise
• Oxygenation
• Ongoing Airway Support modalities• Alternative Airway Needed?• Vt’s of newborns compared to adult?• Common ventilation support: BVM Rate & Pressures?
Source1. AAP. Neonatal Resuscitation Program. 7th Edition2. The S.T.A.B.L.E. Program. 6th Edition
Neonatal Vascular Access Emergent UVC: o18-20 gauge IV catheter: Prep—Tie—Cut--Cannulateo Single lumen UVC catheter 3-5 cm, obtain blood return o <1500 Grams/30 weeks 3.5 F and >1500 Grams/30 weeks 5.0 F
PIV Placement • 24g
IO Placement• Proximal Tibia & Distal Femur
• EZ IO >3kg• Manual IO <3kg
Fluid Resuscitation • NRP versus PALS
Source1. AAP. Neonatal Resuscitation Program. 7th Edition2. The S.T.A.B.L.E. Program. 6th Edition
Neonatal Fluid ResuscitationIndication?
• Not responding to resuscitation• Appears in “shock” hypo-perfused• History of blood loss
DOSE: 10 ml/kg
SOLUTION: Normal Saline or O Rh- negative PRBC’s (if indicated)
ROUTE: PIV, UVC or IO (proximal tibia or distal femur)
RATE: Over 5-10 min. Preterm precautions
Total neonatal circulating blood volume: • 80-90ml/kg
Source:1. AAP. Neonatal Resuscitation Program. 7th Edition.
Neonatal EZ IO Insertion Sites
Neonatal IO Insertion Sites
• EZIO > 3kg: Distal Tibia, Proximal Tibia & Distal Femur
• Manual IO < 3kg: Proximal Tibia
Image Source: https://www.teleflex.com/global/clinical-resources/ez-io/8082_Rev_02_-_FDA_Intraosseous_Infusion_System_IFU_ATH_v2_-_PRESS.pdf. Accessed 6/14/19.
Keep Em’ Dry, Warm & SweetThermoregulation Measures & Blood Glucose Surveillance
Case Study: ED Admit37.5 weeks, 5do, 3.1kg difficulty breathing, hypothermia Clinical Priorities?
Tachypnea: Respiratory Rate 70-80
Increased WOB Grunting Retractions: Moderate/Severe
Hypoxemia: sp02 low 90’s
Hypoglycemia: BG 41
Hypothermia: 35.9 C
Hypotonic: decreased responsiveness
I/O’s: Decreased PO Intake X 1day & 3 diapers in the last 24 hours (consider eating is a newborn vital sign)https://www.youtube.com/watch?v=NBA9iigiDgk
CXR Findings In The ED: Suspected Pneumonia
Birth History Risk Factors?Before & During Birth
PPROM &/or Prolonged Rupture of Membranes> 18 hours?PTD maternal administration of antibiotics?
Maternal Chorioamnionitis?Maternal fever/ infectionFetal tachycardiaFoul smelling amniotic fluidDid MOB receive antibiotics during labor >4 hrs before
birth?
Meconium aspirationSources:1. https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Intrapartum-Management-of-Intraamniotic-Infection. Intrapartum Management Of Intraamniotic Infection. ACOG. Number 217, August 2017. Accessed
Neonatal Sepsis Clinical Priorities
• Rapid Consult, Stabilization & Transport to Regional Center
• NRP then STABLE
• Airway Support: noninvasive and/or invasive
• Perfusion Support: • Volume resuscitation/bolus: assess perfusion parameters & liver margin
• Pressor support (ensure adequate preload)
• Glycemic Control: Glucose bolus (as needed) + MIVF
• Thermoregulation: Goal temp 36.5C-37.5C
• Sepsis screen: CBC w/differential and Blood Cultures
• Early initiation of antibiotics: Ampicillin & Gentamycin • Consider/discuss antivirals if neuro assessment abnormal
Source1. AAP. Neonatal Resuscitation Program. 7th Edition2. The S.T.A.B.L.E. Program. 6th Edition3. https://pediatrics.aappublications.org/content/129/5/1006. Management of Newborns With Suspected or Proven Early Onset Bacterial Sepsis. AAP 2016. Accessed January 15, 2019.
Case Study:ED, born @ term, 3.9 kg, 22 d/o
• Tachycardic: HR 170’s
• Labored Breathing
• Compromised Perfusion
• Acidotic
• Tender, distended abdomen
• Bilious vomiting
• Bloody stools
• Stopped eating
• Fussy all day
Suspected Bowel ObstructionClinical Priorities
• Rapid Consult, Stabilization & Transport to Pediatric Surgical Center
• Airway & Oxygenation Support
• Perfusion Support
• Gastric Decompression: Orogastric Tube 8F or 10F
• Glycemic Control: Glucose bolus (as needed) + MIVF = D10W
• Thermoregulation: initiate warming measures
• Comfort Measures
• Rapid Transport: Potential Surgical Emergency & Time Sensitive Source1. AAP. Neonatal Resuscitation Program. 7th Edition2. The S.T.A.B.L.E. Program. 6th Edition
3. Journal of Obstetric Gynecologic and Neonatal Nursing. JOGNN. Lockridge, Caldwell, Jason (2003). Neonatal Surgical Emergencies: Stabilization & Management. Volume 31, Number 3.
Free Air On Xray Is A Surgical Emergency
Considerations For Neonatal Altered LOCTHE MISFITS
• T= Trauma
• H= Heart disease or Hypovolemia
• E= Endocrine – Hypoglycemia
• M= Metabolic--Electrolytes
• I= IEM
• S= Sepsis
• F= Formula error
• I= Intestinal catastrophes
• T= Toxins/ Poisons
• S= Seizures
Neonatal Skills Review
• Neonatal Airway Management• Positioning: shoulder roll & sniffing position
• BVM/PPV: Mask size, rate, pressures, & devices
• CPAP
• LMA
• Intubation
• Vascular Access
• Thermoregulation: warming measures
• Glycemic Control: Calculating D10W Bolus & MIVF
Thank You & Questions
Febrile Seizuresand…
My BIG Secret
Jennifer Cochran, RN, BSN, MICN, CFRN
REACH Air Medical Services
Objectives
Review the basics of seizures
Discuss the diagnosis of
complex febrile seizures
Identify signs and symptoms
of complex febrile seizures
Demonstrate the proper
treatment of complex febrile
seizures.
What’s the difference
between school and life?
“In school you’re taught a
lesson and then given a test.
In life, you’re given a test that
teaches you a lesson”
- - - Tom Bodett
As a health care provider,
have you been:
Caught off guard?
Unprepared?
Surprised?
Thrown off?
Confused?
Good!
Now… what did you do about it?
I’ve been a “xxxx” for
“xxx” years….
Quick survey of the room…years of experience
Are you ever done LEARNING??
Are you giving honest advice/guidance… not the
typical cliches
Let’s be Honest
We don’t know everything
We have not SEEN everything
BUT…
Why can’t we share our fears,
shortcomings, lack of
understanding…
Why is it a secret…. ?
We Aren’t Perfect…
So Stop Pretending
Healthcare professionals should share their learnings
Admit your mistakes
Discuss your critical thinking
Share the way you re-directed or corrected the situation
Volunteers…?
How many years experience
and what did you recently
learn?
How many years experience
and what advice would you give
to someone beginning in your
field?
Speaking of kindness…
I have a unique perspective
Every call has unique
challenges
Family
Acuity
Story changes
Poor historian
Scene time is limited
Are you a professional when
speaking with one another?
Radio Reports
Bedside Hand-offs
Admission Reports
Calls to Physicians
Think about your reports
to the floor….
Sit down, get yourself prepared
Not multitasking while on the
phone giving report
Same with EMS
Move the patient
Get full report
Ask questions when finished.
Stop and think…
Don’t judge, you have no idea what they are going through
Could you walk a mile in their shoes?
Criticizing others doesn’t make you better
EMS is a family… definitely dysfunctional… but still family
I’ll Tell you about my
experience…
1345 on a Friday
Launched to rural East County
4 y/o seizure
What are your
thoughts on the
10 minute flight
to the scene?
By the book…
Landing safely
Parents
Initial ABC’s
RSI drugs & doses
Differential Diagnoses
Weather
Destination options
My Actual Thoughts…
eh - probably just a febrile
seizure. No biggie
Parents probably panicked
Child will be awake & crying by
the time I get there
Be Honest..
You totally thought
that too!!
Paramedic AssessmentNPA with BVM by BLS engine company
Clenched jaw after multiple seizures
GCS = 3
Room Air saturation = 35%
ETCO2 = 87
HR = 135, BP = 135/74
Blood Sugar = 176
Temp = 94.9
HPI
Sick, fever & runny nose for past few days
Father witnesses two seizures called 911 and placed
her in cool bath
Engine reports two more seizures lasting 1 minute or
less
NO LUCID INTERVAL….
Paramedic Intervention
Recognized seizure without lucid interval and
respiratory compromise!!
Continue BVM with 100% oxygen
24 ga to left hand
2mg Versed (per LBRT)
Drive patient to LZ
Your Initial Assessment
Seizures continue
Medics giving 2nd dose of Versed (2mg)
GCS = 3
Oxygen saturations = 100%
ETCO2 = 24 with BVM
20kg
YIKES!!
Not what I was
expecting…
#$^&$%!!!!
GOOD OL’ A… B… C’s
Airway: Patent, but NOT maintainable
Breathing: Ineffective
Circulation: So far… so good
Your
Treatment?
Airway: Intubate via RSI
Breathing: BVM until in aircraft
Circulation: Second IV started
RSI
0.3mg/kg Etomidate = 6mg
1mg/kg Rocuronium = 20mg
Tube size = age + 16 = 5.0
Visualized tube through the cords via video laryngoscopy4
Feeling Good??
Load into aircraft
Place on ventilator (pressure, SIMV, rate 24, PS 10, peep 5)
Fentanyl 20mcg
Differential Diagnoses??
Epilepsy
Brain Tumor
Trauma
Atrial-Venous Malformation
Electrolyte Imbalance
Toxins
Bacterial Infection
Meningitis
Something else weird?
Neuro blah blah blah?
On Arrival To ER
GCS = 3, sedated, postictal
Tube confirmed, but a tiny bit too high
CT head
CXR
Labs
Diagnosis:
Complex Febrile Seizure
Actually, I didn’t know it
Seizures are difficult to remember
and assess
I just focused on ABC’s
Don’t you hate not knowing!
But… it’s ok.
“Wow, I’ve never seen that before. How interesting! I am lucky to have
learned something today!”
AND…
Don’t make others feel
incompetent when they
admit they learned
something new!!
Pathogenesis of Fever
Phagocytic cells release
several substances into
the blood stream.
Two types of WBCs are
phagocytic:
Leukocytes (microphages) - small,
appear quickly
Monocytes (macrophages) - large,
appear days later
Pathogenesis of Fever
Phagocytic cells release Cytokines
Cytokines travel via blood to anterior hypothalamus
Cytokines induce an abrupt increase in the synthesis
of prostaglandins
The prostaglandins raise the set-point for body
temperature
Hypothalamus Set-Point
Similar to a thermostat in
your house
Temperature is set
The body responds to
keep in limits
Set-Point is Increased…
Thermoregulatory center recognizes the current
body temp is too low and initiates a series of
events to raise the body temperature
Increases metabolic rate
Increases muscle tone
Decreases heat loss through vasoconstriction
to skin
Quick question ??
We know fever is an integral part
of the inflammatory response.
But…. is a fever harmful or
helpful??
Is it a defense mechanism gone
crazy?
Still Disputed…
Potential Benefits
Slows growth of some
bacteria & viruses
Enhances immunologic
function at moderately
elevated temps
?Play a role in fighting
infection
As temp increases… are
the benefits reduced?
Potential Dangers
Increases:
Metabolic rate
O2 consumption
CO2 production
Demands on cardiac
and pulmonary
systems
Febrile Seizure: Definition
Temp >38 C (100.4 F)
3 months - 6 years (also saw 6 months - 5 yrs)
Absence of central nervous system infection
Absence of metabolic abnormality
No history of previous afebrile seizures
Febrile seizures are not considered a form of
epilepsy
Cause of Febrile Seizure?
Unknown
Likely related to vulnerability of developing nervous
system AND underlying genetic predisposition
Risk factors: fever, viral infection, recent
immunizations & family history of febrile seizures
Other Bits of Knowledge
Maximum height of fever is probably the main
determinant (supported w/research)
Seizure threshold is reduced with certain
medications, water & electrolyte imbalances,
especially hyponatremia.
Viral infections are more commonly associated
with febrile seizures than bacterial.
Febrile Seizure
Most common neurologic disorder <5yrs
Age dependent with strong genetic predisposition
Low risk for future epilepsy
2 types: simple & complex
Simple Febrile Seizure
Most common type
Single generalized seizure lasting <10 - 15min
Most last < 5min
Typically spontaneously resolved
Few require benzodiazepines
Prophylactic antiseizure drugs typically not needed
Complex Febrile Seizure
Focal onset (eg: shaking of a limb or one side of body
Prolonged (>15 min)
Recurrent within 24hrs
25% of febrile seizures
Complex Febrile Seizure
An initial simple febrile seizure may be followed by
complex seizures
An initial complex febrile seizure does not indicate that
all subsequent seizures will be complex.
Febrile Status Epilepticus
Extreme end of complex seizures
Continuous seizure or intermittent seizure without
lucid interval > 30 min
Prospective Study of 119 children (FEBSAT study)
Median duration 68 minutes
2/3 were partial seizures
52% continuous & 48% intermittent
Treatment
Midazolam, Lorazepam or Diazepam
Antipyretics:
Facilitates heat loss
Does not inhibit heat production
Does not lower seizure threshold
Summary
Febrile Seizures
Usually in the setting of
viral or bacterial infection
3mos - 6yrs
Typically on the first day
of illness
Take Home Points
Be suspicious of reports for repeated seizures
Observe closely for focal or partial seizures
Ask about family history
It is SCARY for the parents…
Be Kind…
Respect each other
Admit your learnings
Be prepared
Thank you!
Questions?
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