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. 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?

3. 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

4. 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

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. 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

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. SUGAR Things 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. 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???

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 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

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. 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

30. 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

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. 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

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 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

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 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

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 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

49. 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”

50. 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

51. 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

52. 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

53. 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

54. 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 hours
*would most likely never do on your leg of transport

55. 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

56. 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 – SCMC Bend: then ask for x1630 or x3777 (at night only)