NEO - U1 flashcards combined (17/101)

Know NRP algorithm (remember to do the various steps before jumping to PPV or chest compressions). 

Each progressive step after checking HR:

1. warm, dry, stim

2. <100bpm? PPV

3. MR SOPA

4. <60bpm? intubate, 100% FiO2

5. CPR

6. IV epi

MR SOPA

Mask adjustment
Reposition airway

Suction
Open mouth
Pressure increase
Alternative airway (intubation)

What is ALL the equipment needed at a delivery and any applicable settings?

1. typical intubation shit (capnometry, ETT, stylet, etc.)

2. surfactant

3. NeoPUFF/ventilator + O2 blender

4. sxn (bulb, wall, catheters, meconium aspirator)

Know preductal SpO2 ranges for first 5 minutes of life

@1min = 60%

+5% per minute.

Know how APGAR definition and how to assign

Appearance (blue | acro | pink)

Pulse (0 | <100 | >100)

Grimace (none | grim | reaction)

Activity (none | some | flexed)

Respiratory effort (none | weak | strong)

What are some of the risk factors that cause a high-risk delivery?

1. mom problems (infection, chronic health problems, gravida)

2. baby problems (genetic, growth, positional abnormalities)

3. social/environmental problems

4. preggy problems (placenta issues, gestational issues, abnormal births) 

What are the 4 questions you ask your L&D RN at a delivery?

1. GA?

2. color of amniotic fluid

3. risk factors

4. umbilical cord plan?

What are the antenatal steroids & when do they start working? 

BETAMETHASONE (12mg IM x2 QD)

DEXAMETHASONE (6mg IV x4 BiD)

Start working 2-7 days

What is the compression to breaths ratio for CPR in neonates, infants?

Neonates: 3:1

Infants: 30:2 (like adults)

What is the quickest way to determine a pneumothorax at bedside? 

Transillumination

Pink on one side = +pneumo

What are the complications for PPROM, a diabetic mom, and preemie baby?

What FIO2 should you start with at a delivery ( <30 week GA, >30 week GA)

21% >30

21-30% <30

Gravida

G#P#, or the number of pregnancies and number of children

Ex. G3P2 = lost a child

Antenatal

before birth

GA

weeks and days for gestational age

Ex. 37w2d

Full term, early term and pre term GAs

Full: 39w0d - 40w6d

Early: 37w0d - 38w6d

Pre: <37w

Late pre: 32 - 36w6d
Very pre: 28w - 31w6d
Extremely pre: <28w

Important maternal factors (5)

1. maternal age (<18 or >35 has increased risk)

2. past pregnancies

3. chronic condition (hypertension, CF, sickle cell, etc.)

4. infection (GBS+)

5. complications (mental health, where they live, etc.)

Diabetes mellitus cause and types (2)

persistent high blood sugar due to insulin issue:

1. pregestational: leads to fetal structural malformation (CVS MC)

2. gestational: increased risk of DKA, proliferative retinopathy and preeclampsia; adverse fetal outcomes (stillbirth, macrosomia), neonatal metabolic disorders and shoulder dystocia

Infectious disease importance + types (5)

Major contributors to morbidity and mortality as WHAT MOM GETS, BABY GETS!!!! Can also be sexual transmitted. Includes:

1. GBS+

2. HSV (MC sexually transmitted)

3. HBV (high risk of infection during fluid contact during delivery)

4. HIV

5. cytomegalovirus, rubella, toxoplasma gondii, listeria monocytogenes, mycobacterial species, syphilis

Toxic habits in pregnancies

1. Alcohol: fetal alcohol syndrome, causing IUGR, abnormalities, cognitive defects

2. Smoking: IUGR, low birth weight, PROM, placental abruption (detaches from uterine wall)

3. drugs: stimulants and opioids. stimulants cause low birth weight, PTL/PROM, and placental abuprtion; whereas, opioids cause NAS (floppy baby)

High-risk conditions: hypertensive disorders (4). How NOT to treat?

1. hypertension: complicates pregnancies with IUGR, placental abruption, preterm delivery, fetal demise

2. preeclampsia: low dose aspirin can decrease risk, managed up to 37wk.

3. eclampsia: preeclampsia w/ seizures, life threatening

4. HELLP: hemolysis, elevated liver enzymes, low platelets (high mortality of 25%)

Treatment that lowers BP negatively impacts profusion of fetus. Treat by DELIVERY!

Placental disorders: placental absorption

Complete or partial separation of placenta prior to delivery of fetus.

Fetal complications: hypoxia, acidosis, death
maternal complications: life threatening hemorrhage and coagulopathy

Placental disorders: placenta previa

partial or complete coverage of cervix/hole. Cannot remove baby normally so need a c-section.

Umbilical cord normal length + vessels

55cm, 3 vessels (2 arteries, 1 vein)

Abnormal umbilical cord types (4, 2Vs?)

1. Short = increased risk of abruption

2. Long = increased risk of nuchal, prolapse and knots

3. Velamentous = vessels crossover, unsupported by placenta or cord structure

4. Vasa previa = unprotected vessels near or on cervix, increased risk of rupture

PROM + PPROM, treatments for it

AKA water breaking! fetus w/i fluid-filled amniotic sac rupturing. Antibiotics are given to prolong period b/w rupture + labor.

PROM = premature rupture of membranes
PPROM = preterm premature rupture of membranes (<37wk, increasing risk of pulm. hypoplasia)

AFI. What happens with high AFI? low AVI?

AFI: amniotic fluid index

1. Oligohydraminos: AFI<5 = UNDERDEVELOPMENT.

   1. early GA = lung hypoplasia

   2. late GA = cord compression

2. polyhydraminios: AFI>25 caused by diabetes or infection. Over distends uterus and leads to PROM, PTL or cord prolapse, affecting swallowing.

antenatal assessment: US, amniocentesis, NST, BPP

US: evaluates multiples, fetal anatomy, growth, position, placenta and fluid volume.

amniocentesis: INVASIVE US determining lung maturity through chromosomal abnormalities in late gestation with Lecithin-to-sphingomyelin (L:S) ratio

NST: non-stress test, traces HR and uterine activity in a normal state for 20min, assessing its function. Accelerations = spont. fetal movement

BPP: biophysical profile, evaluating placental fxn and fetal well-being. 8 points for fetal breathing, tone, gross body movement and amniotic fluid volume (<4 is poor).

preterm birth GA and what it increases risks of (7)

GA <37wk, being the greatest cause of infant mortality. Increases risk of:

1. sepsis

2. RDS, BPD, ROP

3. intraventricular hemorrhage (IVH) and necrotizing enterocolitis (hole in gut escaping into abdominal cavity)

4. cerebral palsy

How to treat PTL? (3, what steroids and tocolytics?)

preterm labor (SHIT).

1. Steroids:

   1. betamethasone: 12mg IM Q24H x2,

   2. dexamethasone: 6mg IV Q12H x4 

2. Hydration

3. Tocolytics (delay labor to let steroids work)

   1. magnesium sulfate

   2. beta mimetic agents (terbutaline)

   3. indomethacin (prostaglandin inhibitor)

   4. nifedipine (calcium chanel blocker)

Magnesium fxn + indications (5)

Short-term vasodilator protecting + stabilizing CNS. prolonged exposure = floppy baby due to sedative effect.

Indications: HTN, pre-eclampsia, eclampsia, tocolysis, fetal neuroprotection for fetus <32wk GA

Post-term risks (6)

GA >40/42wk, causing an increased risk for:

1. MAS

2. placental insufficiency

3. stillbirth

4. large for gestational age (LGA)

5. shoulder dystocia

6. C-section or assisted vaginal delivery

Intrapartum monitoring: FHR tracing

Fetal heart rate tracing done either noninvasively or w/ electrodes, categorizing results based on accelerations + decelerations of HR, + contractions, showing fetal tolerance to labor.

I = normal
II = indeterminate, requires closer monitoring
III = in distress, requiring immediate attention

Modes of delivery

Most deliveries are VAGINAL, as natural squeeze helps get fluid out of body. Cesarean sections are 33%. Assisted vaginal delivery includes forceps and vacuum.

High-risk delivery

10% of all births requires some resuscitation, so its equipment should be readily available and properly functioning. Team should include: neonatologist, NNP, NICU RN, RT

2 key takeaways:

1. what mom gets, baby gets

2. ventilation is KEY for resuscitation to recruit airways.

high-risk delivery rates

10% require basic resuscitation, premature (w/ 36% mortality)

1% are extensive

Golden questions (5)

1. GA?

2. color of amniotic fluid? (should be clear)

3. 1+ risk factors?

4. what is your umbilical cord plan (placenta can have half of baby’s blood)

5. CHECK EQUIPMENT!!!

What should you always do when getting paged to a delivery?

Ask golden questions and CHECK THE EQUIPMENT!!! (capnometry, neoPIP/vent, blender, surfactant)

Radiant warmer + warm blankets

Newborns struggle w/ temp as NEED warm + dry. <32wk GA has babies plastic bag/wrapped or thermal mattress

Sxn equipment (4)

1. bulb sxn

2. wall sxn @80-100mmHg

3. 8Fr, 10Fr, 12Fr catheters

4. meconium aspirator 

Ventilation: types + what to set neopuff at

Most IDEAL is NEOPUFF! Good bc set pressure won’t change and damage lungs, ideally set @25.

Second ideal is the manual resuscitator, and the last one is the self inflating one.

Self-inflating bag benefits (3) and what it requires (2)

1. does NOT require gas source

2. exact, free-flow FiO2

3. CPAP w/ reliable control of PIP and PEEP

requires circuit connection and ventilating pressures to be set before use.

Flow-inflating bag details does (3) vs does not (4)

DOES require gas source to fxn, provides CPAP and delivers exact FiO2 from source.

DOES NOT deliver free-flow O2, reliable control of PIP and PEEP, require circuitry and ventilating pressures to be set before use.

T-piece bag details

DOES requires gas source to fxn, delivers exact FiO2, reliable control PIP and PEEP, CPAP and free-flow O2. Also requires proprietary circuitry and ventilating pressures to be set before, and monitors delivered pressure w/ a built in manometer

Ventilation equipment (3)

1. Flowmeter set @10LPM

2. Air/O2 blender @21%(-30% if <35wk)

3. various sized masks

Intubation equipment

1. laryngoscope s0, 1 straight blades

2. ETT (2.0-4.0)

3. stylet

4. CO2 detector

5. ETT securement

6. LMA s1 w/ lubricant + syringe if needed

7. stethoscope

8. pulse ox (right arm pre AND post

9. ECG monitoring

10. vascular access supplies

11. resuscitation medications

12. transport equipment

Rapid assessment (4)

1. term? preterm babies need more resuscitaiton

2. Tone? good = flexed, bad = flaccid, extended extremities 

3. breathing? crying?

4. appearance? cyanosis; acrocyanosis (blue hands/feet, pink torso); central cyanosis (mucous membranes); vernix (greasy, waxy cheese-like white substance on skin)

Pulse (normals and when should extra therapy be done)

Normal = 120-170

PPV = <100

compressions = <60

Grimace + activity

1. reflexes/response to stimulation

2. muscle tone

Respiratory assessment (normal RR?)

1. RR: 40-60 (longer GA = higher RR)

2. Periodic breathing: normally are irregular, so count for 1min

3. apnea

4. BS (common is coarse crackles)

5. nasal flaring

6. grunting (attempt to increase PEEP/FRC)

7. paradoxical breathing 

APGAR

A = appearance (pale blue 0, acrocyanosis 1, pink 2)
P = pulse (none 0, <100bpm 1, >100 bpm 2)

G = grimace (no response 0, grimace 1, cry, cough, sneeze 2)
A = activity (limp/none 0, some flexion 1, well flexed 2)
R = resp effort (none 0, weak/irregular 1, strong cry 2)

Normal = >7, max of 10 is rare. assigned @1min and 5min of age, if <7 @5min, repeating scoring Q5M until <7

What happens when born?

EVERY BABY is warmed, dried, and stimulated as cold stress increases O2 consumption. Cord clamping can be delayed if infant is vigorous ~1min. 

CLEAR THE AIRWAYS! sxn UA and VENTILATE!  can utilize sniffing pos.

Sxn

intrapartum and routine sxn is not recommended, but if need to sxn, use bulb and deep sxn.

CPAP + supplemental O2

CPAP increases WoB (+5, 21%) and titrated per SpO2 goal

Target pre-ductal SpO2 per minute

Age per minute, +5%. Example:

1min = 60-65%
2min = 65-70%
3min 70-75%, etc.

PPV

Initiated for apnea, gasping respirations, HR<100. Watch for chest rise, listen for BS. RR should be 40-60bpm

MR. SOPA

M = mask readjustment
R = reposition airway

S = sxn
O = open mouth
P = pressure increase (increase PIP in 5-10 increments, max 40)
A = alternative airway 

LMA

Check if cuffed or iGel, apply lube, press mask against hard palate and maintain pressure against + advance until feel resistance. inflate cuff to seal and attach PPV.

Remove by sxn, deflating and withdrawing.

CPR: when, what + how to do

ONLY DONE IF HR<60BPM after 30s of effective PPV!!!!

Increase FiO2 to 100%, place cardiac monitor leads, CPR @ 3:1 ratio.

If HR remains <60, get vascular access (UVC), push meds (preferably IV epi, volume expanders if blood loss is expected)

Post resuscitation care

Transport to NICU and STABLE:
S = sugar monitoring
T = temp stabilizations
A = airway patency
B = BP
L = lab work
E = emotional support

Normal vital signs (HR, RR, BP, temp)

HR = 120-170
RR = 40-60
BP = varies w/ weight in grams
Temp = axillary 97.6±1, rectal 99.6±1

Chest and CV system assessment (7)

1. Capillary refill <3s

2. BP (MBP = GA +5, normal BP varies w/ weight)

3. murmurs (common but requires investigation)

4. pectus carinatum/excavatum. 

5. palpate (brachial + femoral simultaneously, if femoral weak = COA, if bounding = PDA or L→R shunt)

6. pre + post ductal SpO2 (Pass <95% w/ <3% diff on RS. If Post<pre = venous admixture + PPH)

7. transillumination of chest (rapid, bedside assessment for pneumo.). positive = excessive pink + illumination on one side vs other)

Abdomen assessment + its 3 disorders

Observe overall shape. Ex include:

1. prune belly (lack of abdominal structure)

2. gastroschisis (defect in abd. wall lateral to midline w/ protrusion of intestines)

3. omphalocele (protrusion of sac w/ abd. contents through opening in abd. wall into umbilical cord

Head and neck assessment (5)

1. bruising, molding, swollen + edematous eyes (common)

2. fontanelles (soft spots b/w cranial bones)

3. edema under scalp

4. congenital defects (choanal atresia, microstomia, micrognathia, clef palate)

5. clavicles (Broken?)

Additional assessment (4 idk wtf these words are)

1. symmetry, normal pos., movement of limbs?

2. spina bifida (failure of embryonic neural tube to form correctly in 3rd-5th wk GA)

3. myelomeningocele (defects occurring over spine)

4. encephalocele (involves brain)

neuro assessment (3 reflexes)

1. grasp reflex (grasps finger placed in palm)

2. mono reflex (startle reflex, eventually goes away, abnormal if doesn’t)

3. stepping reflex (baby imitating walking when held up straight)

GA + size assessment (3)

based off 3 main factors:

1. last menstrual period

2. prenatal US

3. post-natal findings based on physical + neurological exams

ABG sampling spots (8)

ABG, VBG or CBG

1. radial + ulnar

2. axillary + brachial

3. temporal

4. femoral

5. dorsalis pedis + posterior tibial

ABG pain control for infants + non-intubated infants

Infants >4mo = anesthetic cream and lidocaine intradermal injection

Non intubated infants + premi = 24% sucrose

Modified Allen’s test

ABG complications (4)

1. hematoma (treat w/ applying adequate pressure)

2. scarring

3. laceration (deep cut) of artery

4. nerve damage (brachial, femoral, posterior, tibial)

CBG indications and sites (4)

Used for pH and CO2, and is much less invasive than ABGs. Inaccurate PO2 esp w/ hypotension, -thermia, -volemia due to poor perfusion. Complications are stereotypical per blood gas (damage, inflammation)

Sites = posterolateral foot, palmar or fleshy surface of distal aspects of fingers + toes (higher risk of nerve damage), and earlobes (rare).

CBG contraindications (5)

1. O2 inaccurate

2. drawn only <24h (b/c of shunts)

3. decreased peripheral BF

4. polycythemia

5. injured areas (burns, edematous, inflamed, infected, calloused).

Umbililcal artery catheter placements for neo (2) and for peds (2)

In Neonates: T6-T8 or L3-L4 (more risky, less common)

in Peds: use of perc. or cutdown method w/ radial being MC

Arterial catheter measurements benefits (4) + indications (5)

Directly measures aBP, determining latency of A-line, quality of pulse pressure (dec. = hypovolemia, inc. = restoration), and calculates MAP. Indicated for:

1. cardiovascular instability

2. IV volume disturbance

3. administration of drugs, fluid, nutrition

4. CVP monitoring

5. when other peripheral sites cannot be accessed.

central venous catheter site placements (5)

Where peripheral vein can be cannulated (perc. or cutdown) + advanced to central location in vena cava

1. E/IJ

2. subclavian

3. brachial

4. saphenous

5. umbilicus

central venous catheter complications (4)

1. sepsis

2. PE

3. cardiac dysrhythmias

4. perforation of trachea

central venous catheter measurements (3)

1. RAP (2-7cmH2O)

2. ScVO2 (central venous O2 sat)

3. CVP (dec. = fluid issues, vasodilation and shock; inc. = increased fluids (hypervolemia, RV + LV insufficiency, increased resistance/vasoconstriction, cardiac tamponade

Serum lactate importance + normal

Informs about oxygenation as lactic acid is a byproduct of anaerobic metabolism.

Normal = 0.7-1.3mmol/L, w/ 4.8+ = increased morbidity/mortality.

Normal values for premies (pH, PaCO2, PaO2, HCO3)

28-40 weeks:

pH = >7.25
PaCO2 = 45-55
PaO2 = 50-70
HCO3 = 18-20

Normal values for toddlers (pH, PaCO2, PaO2, HCO3)

<2yr

pH = 7.3-4
PaCO2 = 30-40
PaO2 = 80-100
HCO2 = 20-22

Abnormal Hb types (3)

1. fetal Hb: 85% of Hb in full-term infant causing a LEFT SHIFT (increased affinity of Hb for O2)

2. Methemoglobin: Hb oxidized to ferric state caused by nitrate-containing medications causing a LEFT SHIFT

3. carboxyhemoglobin: CO + Hb, reducing ability of Hb to be w/ O2, also being a LEFT SHIFT.

These cause a LEFT SHIFT in the sense of because there are other occupying factors, Hb does not want to LET GO of the O2. The shift does not relate to it wanting to pick up more O2, but is more relevant to letting go.

CPAP fxn

Keeps alveoli open to maintain/increase FRC for better gas exchange. It decreases shunting, resistance, WoB and lung injury.

What disease processes/health defects should CPAP be used for? (2ish)

1. prematurity

2. obst and restr. lung disease such as: pneumonia, TTNB, MAS, paralysis, CHF, PE, hemorrhage

CPAP contraindications (4)

1. PaCO2>60, pH <7.25

2. UA and NM abnormalities

3. CNS depressant medications

4. central/frequent apnea

CPAP hazards + complicaitons (4)

1. pressure issues (pneumo, intracranial, nasal trauma due to prongs)

2. fluid issues (dec. urine, GI BF)

3. obstruction

4. desat due to leaks

CPAP is delivered through what interfaces?

short, binasal prongs or nasal mask

B-CPAP

Baby exhales air into exp circuit that is submerged underwater (~10cm), causing a pressure change that generates PEEP. This PEEP then carries on throughout the circuit, producing PEEP for each breath. This exhalation into the water also creates a bubbling affect, which acts as added backpressure on top of PEEP, allowing the airways to stay inflated and flexible.

IF-CPAP

Infant flow nasal CPAP

Delivers more CONSISTENT pressure for effective recruitment compared to other forms, allowing for DECREASED leakage + WoB

HFNC OD dimensions + flow

outer diameter @3mm w/ 2L flow.

Management strategies of applying CPAP

Recruitment, stabilization and prevention (of further invasive therapies)! Should NOT be used w/ apnea or resp failure.

SHOULD BE ASSESSED FREQ. + @REGULAR INTERVALS TO EVALUATE EFFECTIVENESS.

Weaning strategy types off CPAP (3)

Pressure weaned in increments of 1-2cmH2O to a level b/w 3-5cmH2O. This is done through either:

1. decreasing CPAP to predefined level → completely stop CPAP

2. Remove CPAP for predetermined #hours each day (CPAP holidays)

3. Stop CPAP → heated HFNC (w/w/o FiO2)

NIPPV

Nasal intermittent PPV

Augments CPAP by delivering NONINVASIVE ventilator breaths to improve effectiveness. This is done by allowing PIP to be a changeable setting ontop of PEEP, influencing better WoB by reducing efforts needed for inhalation.

IF-SiPAP

Basically BiPAP but for babies

Infant flow “sigh” positive airway pressure. Gives PC-IMV w/ time triggered AND cycled breaths, allowing the baby to breathe @2 separate CPAP levels (by setting baseline + another +2/3cmH2O above baseline (PEEP)

Fundamental monitoring types (4)

1. Vital signs (HR, RR, BP)

2. ECG (HR + rhythm)

3. impedance RR (same electrodes used like during ECG monitoring, does NOT measure gas exchange)

4. NIV BP

Pulse ox. pre vs post ductal sats

Preductal = pre shunt and post ductal = post shunt, possibly showing any pulmonary hypertension.

Pulse ox limitations (4)

1. motion artifact, ambient light

2. nail polish

3. low CO, hypothermia, hyperoxia, vasoconstriction

4. carboxyhemoglobin

Capnography (side vs main)

Uses infrared + mass spectrometry with PetCO2 to show pCO2 @end expiration.

Mainstream has the detector at the circuit but adds weight to circuit; whereas, side stream has a chamber that carries the gas to a remote analyzer and can cause auto triggering in low Vt.

Both cause condensation + secretions

PetCO2 and numerical difference b/w Pet and PaCO2

Ensures adequacy of CPR + ETT placement. Difference b/w PetCO2 + PaCO2 is 2-5mmHg due to DEADSPACE.

CO2 waveform

A-B = exhalation of CO2 free gas from DS

B-C = DS + alveolar gas

C-D = pplat

D = end-tidal (max CO2 exhalation point)

D-E = inhalation of CO2 free gas