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

Questions to Consider 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?

Neonatal Stabilization Provide Warmth, Position, Clear Airway, Dry, Stimulate to Breath CLINICAL ASSESSMENT Provide supplemental oxygen, as necessary Room air- 100% Assist Ventilation with Positive Pressure Ventilation MR SOPA Intubate the trachea So we know from NRP that approximately 10% of newborns require a degree of assistance to begin breathing at birth and approximately 1% of newborns require extensive resuscitative measures. This diagram is directly from the NRP manual. The top tier represents most infants and the bottom tier represents the interventions needed by very few newborns. Today we will be focusing on the stabilization process for those infants that would fall in the lower tier of the diagram. Provide Chest compressions Administer Medications

MR SOPA If 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

What to look for:

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

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

Kit Lists Premature Newborn 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

Physical Assessment

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

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

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

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

Preterm vs Fullterm Infants

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

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

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

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”

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

SUGAR Things that make you go MMM!!!

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

Sugar BABY! Keys for aerobic metabolism Anaerobic 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???

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

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

Glucose Infusion Guidelines D50W Preparation D25W Preparation 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 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

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

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

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

Which babies are at risk? 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

Term vs. Preterm 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

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.***

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

What You Can Do

What You Can Do 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

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

Maternal Conditions Causing 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

Airway Management

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

RESPIRATORY DISTRESS IN 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

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

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

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

INFANT SHOCK !!!

Common Types of Shock Hypovolemic Septic - Distributive Cardiogenic

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

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

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

Cardiogenic Shock Heart 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

Evaluation of Shock Physical 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”

Differential of Cyanosis Central 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

Cyanosis: Pulmonary vs Cardiac Pulmonary- baby will be in respiratory distress, cyanosis will improve with adequate oxygenation and ventilation Cardiac- babies are usually “comfortably tachypneic” - cyanosis may not improve or only slightly improve with oxygen and ventilation. May be pale, “waxy” and no urine output

Treatment of Shock- What You Can Do……… Volume, Volume, Volume – 10 ml/kg Lactated ringers, normal saline,blood not dextrose *****keep them hydrated Maintain neutral thermal environment *****Keep warm and dry Give glucose at 2ml/kg to keep glucoses >50 (don’t forget to dilute if you have D25 or D50) Make D10W or D12.5W *****Keep them sweet *****Keep oxygenated with bag/mask or if needed intubate/LMA

Blood Pressure/Shock Key Points 3 Main types of shock in neonates Overlap may occur giving a combined effect Keep babies warm, sweet, oxygenated and hydrated Older babies with cyanosis not responsive to oxygen may have CHD that is getting worse with impending shock Always consider sepsis as a cause for shock

Common Lab Work NICU Transports Glucoses- keep >50 *Blood gases- capillary or venous *CBC – looking for infection *Blood culture – looking for infection *Electrolytes- not necessary, reflective of Mom’s values for 12-24 hours *would most likely never do on your leg of transport

We are here to help you provide optimal care to your communities What WE Can Do For You…. We would love to help with: Education – S.T.A.B.L.E, NRP, PALS Simulation workshops Offer routine competency seminars Offer to come out and review equipment, supplies etc. make recommendations We are available for questions at anytime We are here to help you provide optimal care to your communities

Contacts Bette Johnson, MSN, CRNP – NICU Transport Coordinator,STABLE Lead Instructor Randa Bates, RN, - NICU Transport Team NRP Instructor, STABLE support instructor Carol Craig,MSN, CRNP- Resuscitation Coordinator, NRP Instructor For all of the above call NICU at 541-382-4321 – SCMC Bend: then ask for x1630 or x3777 (at night only)