Comprehensive Neonatology and Pediatric Paramedic Study Notes

Neonatology: General Pathophysiology and Assessment

Introduction to Neonatal Needs * Newborn/Neonate: Defined by unique physiological and developmental needs. * Dependence: Completely reliant on others for nourishment, warmth, and protection from the environment.
Epidemiology and Risk Identification * Intervention Requirements: Approximately $6\%-10\%$ of newborn deliveries require additional skilled care interventions. * Risk Correlation: The rate of complications increases as birth weight and gestational age decrease.
Antepartum (Before Birth) Risk Factors * Gestation specifics: Multiple gestation, Post-term gestation ( $> 42 \text{ weeks}$ ), Premature/Preterm gestation ( $< 37 \text{ weeks}$ ). * Maternal health: Toxemia, hypertension, diabetes, chronic maternal illness (e.g., cardiac). * Maternal age: $< 16 \text{ years}$ or $> 35 \text{ years}$ . * Amniotic fluid volume issues: Polyhydramnios (excessive fluid) and Oligohydramnios (decreased fluid). * Pregnancy complications: Fetal anemia, fetal malformation, premature rupture of membranes (PROM), and inadequate prenatal care. * Substance use: Use of drugs or medications, whether illicit or prescribed.
Intrapartum (During Birth) Risk Factors * Membrane issues: Rupture of membranes $> 24 \text{ hours}$ before delivery. * Placental issues: Placenta previa or placental abruption bleeding. * Delivery complications: Prolapsed cord, abnormal presentation, shoulder dystocia (often involving a large infant), prolonged labor, or precipitous delivery. * Fetal distress: Meconium-stained amniotic fluid, fetal tachycardia, or fetal bradycardia. * Maternal factors: Fever or use of narcotics within $4 \text{ hours}$ of delivery.

Transition from Fetus to Newborn

In Utero State * Oxygenation: The fetus receives all oxygen via the placenta. * Lung Condition: The fetal lungs are collapsed and filled with fluid.
Fetal Transition Process * Trigger: The umbilical cord is clamped. * Vascular Changes: As breathing begins, lungs expand with air, and pulmonary vascular resistance drops. * Gas Exchange: Blood begins flowing to the lungs for active gas exchange. * Risks: Anything delaying this transition can cause hypoxia, brain damage, or death.
Gestational and Nutritional Categories * Preterm: Delivered before $37 \text{ weeks}$ . * Term: Delivered between $37 \text{ and } 42 \text{ weeks}$ . * Post-term: Delivered after $42 \text{ weeks}$ . * SGA: Small for gestational age. * LGA: Large for gestational age. * AGA: Appropriate for gestational age.

Arrival and Stabilization of the Newborn

Antenatal Preparation Questions * Has the mother received antenatal care? * How many babies are expected? * What is the length of pregnancy? * What is the frequency/onset of contractions? * Is there fetal movement? * Have membranes ruptured? * Are there known pregnancy complications or medications?
Essential Equipment * Warm, dry blankets. * Bulb syringe. * Two small clamps or ties. * One pair of clean scissors.
Management in Transit * Ambulance Setup: The foot of the bed can be used for initial stabilization. * Post-ABCs: The newborn may be placed on the mother's chest after airway, breathing, and circulation are confirmed. * Neonatal Transport: Second ambulances should be equipped with a neonatal transport incubator.
Umbilical Cord Management * Prolapsed Cord: More common in cases of polyhydramnios; pressure relief is life-saving as the cord supply may be cut off. * Cutting: Keep the infant at the level of the mother. Clamp the cord in two places and cut between the clamps.
Initial Rapid Assessment * Timing: Record the exact time of delivery. * Monitoring: Respiratory rate and effort, pulse rate (via 4-lead monitor), skin color, and capillary refill. * Cyanosis: Nearly $100\%$ of newborns are cyanotic immediately after birth but should quickly become centrally pink.

The Apgar Score

Purpose and Origin * Developed by Dr. Virginia Apgar in 1953. * Uses condition assessments at $1 \text{ and } 5 \text{ minutes}$ post-birth to determine resuscitation effectiveness.
Scoring Thresholds * $7 \text{ to } 10$ : Normal. * $4 \text{ to } 6$ : Moderately distressed; requires oxygen and stimulation. * $< 4$ : Severely distressed; requires immediate resuscitation.

Neonatal Resuscitation and Algorithm

Statistics and Chain of Survival * $6\%-10\%$ need assistance; $1\%$ require major resuscitation. * Chain of Survival: Prevention -> Recognition/Activation -> Initial Steps -> Ventilation -> Advanced Resuscitation -> Postnatal Care -> Recovery.
Resuscitation Procedures * Pulse Counting: Count for $6 \text{ seconds}$ and multiply by $10$ . * Acrocyanosis: Extremity cyanosis; requires supplemental free-flow oxygen and stimulation (FiO2: $0.21$ ). * Positive-Pressure Ventilation (PPV): Indicated if pulse rate is $< 100 \text{ bpm}$ (with QRS present); use BVM at FiO2 $0.21$ for approximately $30 \text{ seconds}$ . * CPR Protocol: Indicated if pulse is $< 60 \text{ bpm}$ after $30 \text{ seconds}$ of effective PPV, or if the patient is apneic/asystolic. * Ratio: $3:1$ (3 compressions to 1 ventilation). * Rate: $> 120 \text{ bpm}$ ( $90 \text{ compressions}$ and $30 \text{ ventilations}$ per minute). * Prohibitions: No rhythm analyses or defibrillation for neonates.
Target Oxygen Saturations * $2 \text{ min}$ : $65\%-70\%$ * $3 \text{ min}$ : $70\%-75\%$ * $4 \text{ min}$ : $75\%-80\%$ * $5 \text{ min}$ : $80\%-85\%$ * $10 \text{ min}$ : $85\%-95\%$
Drying and Stimulation * Methods: Flick the soles of the feet or gently rub the back. * Contraindications: Do not rub roughly or slap the newborn.
Chest Compression Details * Depth: One-third of the anteroposterior diameter of the chest. * Technique: Two thumbs placed over the sternum. * Risks: Liver laceration and rib fractures.

Specific Neonatal Conditions

Airway Abnormalities * Bilateral Choanal Atresia: Bony/membranous obstruction at the back of the nose; requires an oral airway. * Pierre Robin Sequence: Features a small chin, cleft palate, and posteriorly positioned tongue; position infant prone or use an oral airway. * Diaphragmatic Hernia: Opening in the diaphragm (usually left-sided); mortality up to $50\%$ . Avoid BVM as it distends the intestines; requires surgery.
Respiratory and Fluid Complications * Meconium-Stained Fluid: Present in $10\%-15\%$ of deliveries. If the infant is depressed, suction the trachea before drying/stimulation. If vigorous, routine care applies. * Pneumothorax Signs: Severe distress, unilateral decreased breath sounds, shift of heart sounds, unresponsive to PPV. * Apnea: Common in infants $< 32 \text{ weeks}$ gestation. Etiologies include prematurity, GER, or drugs.
Abdominal Defects * Gastroschisis/Omphalocele: Exposed abdominal contents. Place from waist down in a sterile bag to maintain cleanliness and heat; nurse on side.
Seizures in the Neonate * Significance: Most distinct sign of neurological disease. * Classification: Subtle, Tonic, Focal clonic, Myoclonic. * Primary Causes: Hypoxic ischemic encephalopathy (HIE), meningitis, hypoglycemia, hypocalcemia ( $2-3 \text{ days}$ post-delivery). * Anticonvulsants: PCP/ACP may use Phenobarbital, Phenytoin, or Benzodiazepines.

Thermoregulation and Metabolic Balance

Temperature Mechanics * Average Normal: $37.5^\circ\text{C}$ . * Nonshivering Thermogenesis: Metabolism of "Brown Fat" (unique to newborns). * Heat Loss Mechanisms: Evaporation, Convection, Conduction, Radiation. * Hypothermia Prevention: Warm hands, remove wet blankets, head cap, skin-to-skin contact, prewarmed incubator.
Metabolic Disorders * Hypoglycemia: Defined as pulse rate/blood glucose $< 2.6 \text{ mmol/l}$ . * Glycogen Stores: Usually last $8 \text{ to } 12 \text{ hours}$ after birth. * Fever: Rectal temperature $> 38^\circ\text{C}$ . Newborns do not sweat or shiver effectively to regulate temperature.

Gastrointestinal Emergencies

Vomiting Analysis * Prevalence: $85\%$ in first week; $10\%$ by $6 \text{ weeks}$ . * Red Flags: Persistent vomiting or vomit containing blood. * Differential Diagnoses: * Esophageal atresia (excess mucus, choking during feeding). * GER: Prevalence $2\%-10\%$ . * Pyloric Stenosis: Hypertrophy of the pylorus; $4:1$ male-to-female ratio; $30\%$ are first-born males. * Malrotation: Congenital anomaly where small bowel is on the right side ( $1 \text{ in } 500$ live births). * Hirschsprung Disease: Segment of colon fails to relax; history of not passing meconium in first $24 \text{ hours}$ .
Diarrhea and Dehydration * Normal Stool Frequency: $5 \text{ to } 6 \text{ per day}$ . * Severe Signs: Capillary refill $> 2\text{ seconds}$ , dry membranes, absent tears, weight loss, low urine output.

Birth Injuries and Transport

Common Birth Injuries * Incidence: $2-7 \text{ per } 1,000$ live births. * Types: Caput succedaneum (scalp swelling), cephalhematoma, linear fractures, brachial plexus injuries, facial/laryngeal nerve injury.
Transport Considerations * Regional Referral: Once stabilized, transport to a regional center or nearest appropriate facility. * Communication: Maintain ongoing contact with family; avoid specific survival statistics.

Pediatric Anatomy and Physiology

Head and Neck * Head Size: Comprises $2/3$ of the adult head size in infancy; large mass and surface area lead to excessive heat loss. * Neck: Short and stubby. * Airway: Smaller overall; disproportionately large tongue; cricoid cartilage is the narrowest part.
Chest and Heart * Chest: Thin wall, less fat/muscle; rib cage is more compliant. * Respiration: Primarily diaphragm-based. * Cardiac Output: Heavily rate-dependent. * ECG shifts: Transition from right-side dominance to left ventricular dominance with age.
PEDIATRIC VITAL SIGNS (2026 PICPSP Guidelines) * < 1 Month (Neonate): RR: $30-60$ , HR: $100-180$ , TAS: $60 \text{ mmHg}$ . * 1 Month to < 1 Year (Infant): RR: $30-60$ , HR: $100-180$ , TAS: $70 \text{ mmHg} + (2 \times \text{age})$ . * 1 to 2 Years (Toddler): RR: $20-40$ , HR: $100-140$ , TAS: $70 \text{ mmHg} + (2 \times \text{age})$ . * 3 to 5 Years (Preschool): RR: $20-30$ , HR: $80-120$ , TAS: $70 \text{ mmHg} + (2 \times \text{age})$ . * 6 to 11 Years (School): RR: $15-25$ , HR: $80-120$ , TAS: $70 \text{ mmHg} + (2 \times \text{age})$ . * \ge 12 Years (Adolescent): RR: $12-20$ , HR: $60-100$ , TAS: $90 \text{ mmHg}$ .

Developmental Stages

Neonate and Infant (< 1 Year) * Holding head up by $4 \text{ months}$ . * Non-verbal; assess in the presence of caregivers.
Toddler (1 to 3 Years) * "Terrible twos"; rapid language development; stranger anxiety. * Poor sense of cause and effect.
Preschool-Age (3 to 6 Years) * Interactive; speaks in plain language; can localize pain.
School-Age (6 to 12 Years) * Capably of abstract thought and understanding cause and effect.
Adolescent (13 to 18 Years) * Risk-taking behaviors; friends are key support; needs accurate information and privacy.

Assessment Tools: PAT and TICLS

Pediatric Assessment Triangle (PAT) * Components: Appearance, Work of Breathing, Circulation.
TICLS Mnemonic (Appearance) * T: Tone. * I: Interactiveness. * C: Consolability. * L: Look or Gaze. * S: Speech or Cry.
Work of Breathing Signs * Grunting: Form of "auto-PEEP"; exhaling against partially closed glottis; suggests hypoxia. * Wheezing: Constricted small airways; primarily during exhalation. * Sniffing and Tripod positions: Compensatory postures for respiratory distress.
Circulation (Skin) Indicators * Pallor: Initial sign of vasoconstriction, anemia, or hypoxia. * Mottling: Lacy pattern reflecting vasomotor instability. * Acrocyanosis: Localized cyanosis of extremities. * Central Cyanosis: Late finding of respiratory failure or shock.
Mental Status: AVPU * Alert: Normal interactiveness for age. * Verbal: Responds to name. * Painful: Withdraws or makes sound/movement without localization. * Unresponsive.

Pediatric Emergencies and Management

Upper Airway Management * Foreign Body Obstruction (Infant): $5 \text{ back slaps and 5 chest thrusts}$ . * Foreign Body Obstruction (Child): Abdominal thrusts (Heimlich) until expelled or unresponsive. * Advanced Technique: Direct laryngoscopy with Magill forceps at a $45^\circ \text{ angle}$ . * Anaphylaxis: Treated with intramuscular (IM) Epinephrine. * Croup: Viral Laryngotracheobronchitis; Hallmark sign is stridor; treat with $5 \text{ mg}$ nebulized Epinephrine if unstable. * Epiglottitis: Supraglottic inflammation; classic rapid progression; rare due to vaccines.
Lower Airway Management * Asthma: Bronchospasm and ventilation-perfusion mismatch. Medications: Salbutamol, Ipratropium, Epinephrine. * Bronchiolitis: Often caused by RSV (Respiratory Syncytial Virus); common in children $< 2 \text{ years}$ ; management is entirely supportive.
Cardiovascular and Shock * Shock Types: Hypovolemic (most common), Distributive (Sepsis, anaphylaxis), Cardiogenic (pump failure). * Compensated vs. Decompensated: Hypotension is a late, ominous sign. * Pulseless Arrest: Asystole is most common. Defibrillation energy: Initial dose is $50 \text{ J}$ . * Bradyarrhythmias: Most often secondary to hypoxia; prioritize airway/ventilation.
Medical and Neurological Emergencies * Meningitis: Infection of meninges; symptoms include nuchal rigidity and petechial/purpuric rash (if Neisseria meningitidis). * Febrile Seizures: Unique to children $6 \text{ months to 6 years}$ ; occurs in $2\%-5\%$ . * Status Epilepticus: Requires benzodiazepines; avoid intubation during active seizure; use nasal/oral airways. * Toxicology: Ingestions common in toddlers; recreational drug use in adolescents. Treatments include Activated Charcoal or syrup of ipecac (substance dependent).

Sudden Infant Death Syndrome (SIDS)

Epidemiology * Leading cause of death for infants aged $1 \text{ month to 1 year}$ . * Peak incidence: $2 \text{ to } 4 \text{ months}$ . * Canada Statistic: Three babies die of SIDS each week.
Risk Factors * Male gender, prematurity, low birth weight, young maternal age. * Sleeping conditions: Prone position, soft surfaces, bulky blankets/toys, tobacco smoke exposure.

Child Maltreatment and Special Needs

Maltreatment * Forms: Physical, sexual, emotional abuse, and neglect. * Reporting: Paramedics are mandatory reporters in many provinces. * Mimics: Mongolian spots, coining, or cupping (cultural customs).
Technology-Assisted Children * Tracheostomy tubes: Risk of obstruction or displacement. * Gastrostomy tubes (G-tubes): Surgically placed in the stomach. * CSF Shunts: Used for hydrocephalus; obstruction signs include Cushing's Triad (late) or headache/vomiting.
Burns * Rule of Nines: Modified for young children; Rule of Palms used for smaller areas. * Management: Clean minimally to avoid hypothermia; cover with clean dry cloth; early analgesia.