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Physical Assessment and Newborn Stabilization: What You Can Do!

Physical Assessment and Newborn Stabilization: What You Can Do!. Bette Johnson, CRNP, SCMC NICU Transport Coordinator Randa Bates, RN, NICU Transport Nurse Doug Ferguson, RT, Airlink Respiratory Therapist. How many staff have taken Neonatal Resuscitation(NRP)?

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Physical Assessment and Newborn Stabilization: What You Can Do!

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  1. Physical Assessment and Newborn Stabilization:What You Can Do! Bette Johnson, CRNP, SCMC NICU Transport Coordinator Randa Bates, RN, NICU Transport Nurse Doug Ferguson, RT, Airlink Respiratory Therapist

  2. How many staff have taken Neonatal Resuscitation(NRP)? Do you have a infant appropriate bags? Appropriate sized masks? Sat Probes? Glucometer, or sticks? Appropriate sized BP cuffs? Newborn Resuscitation Kit? Appropriate Sx equipment? Heat packs? Do you have monitors that can monitor an infant? Questionsto Consider

  3. Assist Ventilation with Positive Pressure Ventilation MR SOPA Provide Chest compressions Provide supplemental oxygen, as necessary Room air- 100% Administer Medications Provide Warmth, Position, Clear Airway, Dry, Stimulate to Breath CLINICAL ASSESSMENT Intubate the trachea Neonatal Stabilization

  4. MR SOPAIf PPV not working • M= mask, right size and fit • R= reposition, neck and/or mask • S= suction, nose and mouth • O= open mouth while ventilating • P= increase pressure if no chest rise • A= consider alternative airway, intubate or LMA

  5. What to look for:

  6. What You Can Do • Continually assess- Five Apgar points • Maintain Warmth • Maintain open and clear airway • Provide supplemental oxygen • Call for help early

  7. Keypoints • Initial steps of NRP are the most important • Most powerful tool initially is maintenance of airway- may prevent further decompensation • Oxygen is a powerful drug, start with room air, then go to 100% if no blender • Know your equipment, maintain it and keep current on it’s use

  8. Hat Thermometer Bulb Suction Baby Booger Getter (BBG) Self-inflating bag and newborn mask Infant Sat Probes Blankets Diapers Umbilical Tape Sucrose 5 Fr. Feeding Tube Hat Thermometer Bulb Suction Premie Mask Self-inflating Bag Sat probe Premie Diaper Premie BP Cuff Umbilical tape Porta Warmer Plastic bag/plastic wrap Sucrose 5 Fr. Feeding Tube Kit Lists Premature Newborn

  9. Physical Assessment

  10. Physical Assessment • VITAL SIGNS: Temp range: 97.8-98.6 Heart rate: 120’s-160’s, Resp rate: 40-60’s Blood pressure: mean’s approximate gestational age (i.e high 20’s low 30’s for preterms, high 30’s low 40’s for fullterm) • SKIN: cyanosis vs acrocyanosis, perfusion, capillary refill, rashes, lesions, trauma • HEENT:Head: scalp swellings, bruising, trauma Eyes: equal distance, lids open, pupils reactive Ears: in line with outer eye Nose: nares patent or not, Throat/Neck- no masses, clavicles intact or not

  11. PHYSICAL ASSESSMENT CONTINUED • CHEST: Tachypnea, Increased work of breathing: Barrel chest, retractions, grunting, breath sounds: clear and equal, coarse, diminished. Need for oxygen or assisted ventilation. Gasping or apnea • HEART: rate, rhythm, murmur, pulses, blood pressure, perfusion (capillary refill >3secs) • ABDOMEN: full and soft, sunken, defect (omphalocele/gastroschisis), hard/firm/shiny, abnormal color

  12. PHYSICAL ASSESSMENT CONTINUED • EXTREMETIES: Number and placement of digits, movement equal, tone, trauma/bruising, lesions or marks • NEUROLOGIC: tone, activity, able to focus on caregiver, response to painful stimuli, seizures • GENITOURINARY: male vs female anatomy, can help tell gestation, anus present

  13. Premature vs Fullterm; Quick Assessment Preterm vs Fullterm: • Weight - <5 lbs- full term babies who are small for gestational age can be under 5 lbs • Gestational age- <37 weeks (35-37 weeks= late preterm infants) • Physical exam: > lanugo, <vernix, <breast buds, < tone, < ear cartilage, decreased creases on bottom of feet, male- < scrotum, testes may not be descended, female- labia minora may be bigger than majora, decrease in activity and tone

  14. Preterm vs Fullterm Infants

  15. Why Does It Matter • Preterm babies brains are vulnerable to pressure changes – fluids, ventilation, cold stress etc. affects brain- bleeding, apnea, seizures • Preterm babies lungs are not fully formed in number of air sacs, capillaries and surfactant- respiratory distress, cyanosis • Preterm babies don’t have good glucose stores- hypoglycemia

  16. Why does it matter • Preterm babies don’t have fat stores- hypothermia, poor temp regulation • Preterm babies guts are not mature- dysmotility, aspiration, emesis, perforation • Preterm babies don’t have mature immune function- vulnerable to infection • Preterm babies don’t have good autoregulation of blood pressure- hypotension, bleeding

  17. What You Can Do… • Estimate weight • Estimate Gestational age • Have vital signs available for report • Give summary of most immediate reason for transport i.e. respiratory distress, seizures, trauma, unresponsive/floppy, cyanotic etc • Call for specialty team early rather than later

  18. Physical Assessment Key Points • Approximate gestational age and weight are important pieces of information to pass on • Neurologic changes are often the first sign that a baby is getting sick • “Comfortably tachypneic” babies may have a primary congenital heart defect that may be getting worse- watch them closely • Preterm babies reach “breaking” points faster than fullterm babies • Babies in general “jump off cliffs” instead of “rolling down a hill”

  19. S.T.A.B.L.E. Program “Condensed” Version • Developed to help all types of providers stabilize sick babies no matter what type of facility they were born in or out of i.e home, car, field • Allows for consistency in care • Good communication tool to discuss Neonatal issues • Focus on safety and quality of care • Sugar, Temperature, Airway, Blood Pressure, Lab Work and Emotional Support

  20. SUGARThings that make you go MMM!!!

  21. Causes of Hypoglycemia • Decreased Glucose Stores: Small for gestational age/Premature/Intrauterine growth restriction • Hyperinsulinemia – Infants of Diabetic Moms/Large babies/Syndromes • 2/3 maternal glucose • Stress/Increased Utilization- Depletion of stores • Cold stress • Traumatic deliveries • Cardio/pulmonary diseases • Infection • Shock

  22. Keys for aerobic metabolism Oxygen + Glucose = ENERGY Anaerobic Metabolism Lack of 02 or Glucose Lactic acidosis = IMPAIRED FUNCTION Symptoms include: Hypotonia Lethargy Poor feeds High pitched or weak cry Jittery/Irritable Seizures Increased RDS Apnea Bradycardia ?what part of body is responsible for all of these symptoms??? Sugar BABY!

  23. How to check glucose • Pre-warm the heel • Warm water, chemical warmer, warm towel • Cold foot = falsely low reading • Do not over squeeze heel Causes clotting, bruising and pain

  24. What You Can Do • Be vigilent in assessment for hypoglycemia: • Ask mother or caregiver for risk factors; gestation diabetes, on insulin, symptoms of hypoglycemia herself • If infant has stable vital signs with no respiratory distress: Consider breastfeeding if mom able and willing or give Oral Sucrose (D25W) – drops in cheek with syringe

  25. Glucose Infusion Guidelines D50W Preparation D25W Preparation Draw up 5 ml’s of D25 and add to 5 ml’s sterile water to make D12.5 Approximate infant’s weight Give via IV or IO 1-1.5 ml/kg Give over a few minutes, slower if preterm • Draw up 2 ml of D50 add to 10 ml’s of sterile water to make D10W solution • Approximate infant’s weight (1 lb = 2.2 kgs) • Give via IV or IO • 2ml/kg • May give bolus over a few minutes, slower if preterm

  26. Sugar Key Points • Premature, SGA, LGA and stressed babies at highest risk • Maintain glucose greater than 50mg/dl • No sugar = decline in status • Recheck 30 min after treatment and if baby is symptomatic • If can’t check glucose and baby is symptomatic – treat using guidelines

  27. Thermoregulation: If you’re hot you’re hot, if you’re not you’re not!

  28. Normal 36.5 – 37.5 C or 97.8 – 98.6 F HEAT LOSS: Conduction = loss to objects that are colder Convection = loss via air currents Evaporative = moisture turns to vapor Radiation = Loss to colder object not in contact with baby WHY?: Large surface area = greater heat loss Lack of shivering ability = no heat production Exposed Defects = increased surface area

  29. Premature/Low Birth Weight Small for gestational age (SGA) Prolonged Resuscitation Acutely Ill (often accompanies sepsis) Abdominal or Spinal Defects Any infant born in a compromised environment – i.e. birth center, home, car, outdoors Which babies are at risk?

  30. Term Response Vasoconstriction Peripherally Increased tone and movement Normal glucose stores Brown Fat Metabolism Preterm Response/SGA Poor vasoconstriction Weak muscle tone Limited glycogen stores Minimal or No Brown Fat Term vs. Preterm

  31. Effects of Cold Stress • Significantly increased metabolic rate • Increased Oxygen consumption • Increased Glucose metabolism • At extreme risk for hypoxemia, hypoxia and hypoglycemia ***Preventing hypothermia is much easier than overcoming the detrimental effects once hypothermia has occurred.***

  32. Adapted from S.T.A.B.L.E Program 5th Edition

  33. What You Can Do

  34. All Babies: Dry Place Hat Increase environmental temp Decrease Drafts Warm blankets IV bags from warmer Chemical Warmers Infant dependant: Skin to skin Saran Wrap Swaddle *** Never microwave blankets or other objects for heat Always cover warmers with cloth What You Can Do

  35. Key Points • All infants are at varying risk for hypothermia • Check axillary temps frequently • Increase environmental temp- you should be hot! • Keeping an infant normothermic can help PREVENT the need for further stabilization

  36. Maternal ConditionsCausing Infant Distress • Diabetes: insulin dependent or gestational non-insulin dependent. A1c significance • Hypertension: either pre-pregnancy or pregnancy induced • Placental/Uterine disruptions: placenta previa, abruption, uterine rupture, cord prolapse • Infections: GBS, e.coli, MRSA, listeria

  37. Airway Management

  38. RESPIRATORY DISTRESS IN FULLTERM INFANTS:MOST COMMON CAUSES • TRANSIENT TACHYPNEA- retained interstitial lung fluid • ASPIRATION- meconium, amniotic fluid, blood, breast milk or formula, gastric contents • AIR LEAK SYNDROMES: pneumothorax • PNEUMONIA • CARDIAC LESIONS: duct dependent

  39. RESPIRATORY DISTRESSIN PRETERM INFANTS:MOST COMMON CAUSES • RESPIRATORY DISTRESS SYNDROME: Surfactant deficiency and immature anatomy • ASPIRATION: same as full term babies • AIRLEAKS: pneumothorax • PNEUMONIA: always have sepsis on differential with infant in respiratory distress- think SHOCK

  40. SIGNS/SYMPTOMS OF RESPIRATORY DISTRESS • TACHYPNEA- 100 breaths per minute or more- comfortable or increased work of breathing • APNEA/GASPING – cessation of breathing >15 secs • RETRACTIONS- intercostal, subcostal, suprasternal, supraclavicular • NASAL FLAIRING • GRUNTING • CYANOSIS

  41. What You Can Do • KEEP THEM SWEET - normoglycemic • KEEP THEM WARM – neutral thermal • KEEP AIRWAY CLEAR AND HEAD IN SNIFFING POSITION • PROVIDE SUPPLEMENTAL OXYGEN • PROVIDE BAG/MASK VENTILATION • PLACE AN ALTERNATIVE AIRWAY- INTUBATE OR USE LMA • KEEP THEM HYDRATED

  42. Airway Key Points • Respiratory distress can present in babies due to hypoglycemia, hypo/hyperthermia, hypovolemia, sepsis, neurologic injury, cardiac disease, pulmonary disease- often first sign of distress • Preterm babies present faster than full term babies- lack of compensatory mechanisms • **Clearing the airway and correct use of positive pressure ventilation should be the first course of action, not cardiac compressions • Oxygen is a powerful drug, use it wisely

  43. INFANT SHOCK !!!

  44. Common Types of Shock • Hypovolemic • Septic - Distributive • Cardiogenic

  45. Hypovolemic Shock • Most common cause of shock in the initial newborn period Causes: • Intrapartum blood loss -fetal-maternal hemorrhage -placental abruption/previa -umbilical vessel injury - cord prolapse -twin to twin transfusion -organ laceration or injury

  46. Hypovolemic Shock Postnatal hemorrhages: in babies • Brain – intraventricular hemorrhage • Lung – pulmonary hemorrhage • Adrenal glands- trauma • Scalp – most serious subgaleal, loss of most of blood volume - trauma

  47. Septic or Distributive Shock • May be either viral or bacterial in origin • May become critically ill rapidly • Hypotension may be profound and respond poorly to fluid resuscitation • *Be prepared to give volume; 10ml/kg may need multiple doses (normal saline or lactated ringers) • *Push boluses over 2-3 mins full-term, 5-10 preterm • Cultures and antibiotics at referral hospital • *ALS only

  48. Cardiogenic ShockHeart Failure Causes: • Intrapartum/postpartum asphyxia • Hypoxia and/or prolonged metabolic acidosis • Bacterial or viral infection • Respiratory failure • Severe hypoglycemia • Severe metabolic and/or electrolyte disturbances • Arrhythmias • Congenital heart disease

  49. Evaluation of ShockPhysical Exam • Neuro- tone and activity- floppy, lethargic, not able to open eyes and look at you, pupils not reactive or sluggish • Respiratory- in distress, tachypneic- work of breathing will worsen with shock • Cardiac- cyanosis – look at gums not lips, pallor, >cap refill time, weak or absent pulses- compare upper to lower and side to side • Blood pressure is the last to go- “babies jump off cliffs not roll down hill”

  50. Differential of CyanosisCentral 1) Lungs: “No oxygen in the lungs, no oxygen in the blood” • Premie lungs, aspirations, pneumothorax 2) Heart: 2 types: a) no blood from heart to lungs (right sided problem or pulmonary hypertension) b) No blood from heart to rest of body (left sided problem) 3) Blood: “No Oxygen in Blood, no oxygen to the tissues” - anemia

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