Nov 2007 ACoRN © 2006-07 Cardiovascular Sequence Case Two

Nov 2007Nov 2007ACoRN © 2006-ACoRN © 2006-

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Cardiovascular SequenceCardiovascular Sequence

Case TwoCase Two


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EthanEthan


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• Breathing is easy and regularBreathing is easy and regular

• HR is 140 bpmHR is 140 bpm

• Colour …Colour …

• What do you do?What do you do?

EthanEthan


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Problem List Respiratory Cardiovascular Neurology Surgical conditions Fluid & glucose Thermoregulation Infection

Support

Respiratory Laboured respiration* Respiratory rate > 60/min* Receiving respiratory support*

Surgical Conditions Anterior abdominal wall defect Vomiting or inability to swallow Abdominal distension Delayed passage of meconium or imperforate anus

Thermoregulation T < 36.3 or > 37.2ºC axillary* Increased risk for temperature instability

Fluid & Glucose Management Blood glucose < 2.6 mmol/L At risk for hypoglycemia Not feeding or should not be fed

Neurology Abnormal tone* Jitteriness Seizures*

Cardiovascular Pale, mottled, or grey* Weak pulses or low BP* Cyanosis unresponsive to O2

Heart rate > 220 bpm

Baby at risk Unwell Risk factors Post-resuscitation requiring stabilization

Sequences

Resuscitation Ineffective breathing Heart rate < 100 bpm Central cyanosis

Infection Risk factor for infection ACoRN alerting sign with * Clinical deterioration

Consider transport


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You now observeYou now observe• Regular respirations, RR 55Regular respirations, RR 55

• Heart rate 140/minHeart rate 140/min

• Remains dusky despite oxygen Remains dusky despite oxygen administrationadministration

• You leave the Resuscitation You leave the Resuscitation Sequence to complete the Primary Sequence to complete the Primary Survey.Survey.

EthanEthan


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• SpOSpO22 is 75% on 70% oxygen administered is 75% on 70% oxygen administered via oxygen hood – colour remains cyanoticvia oxygen hood – colour remains cyanotic

• Breathing remains easy, breath sounds Breathing remains easy, breath sounds are heard bilaterallyare heard bilaterally

• HR120/minHR120/min• BP 59/32, M 43 mmHgBP 59/32, M 43 mmHg• Tone flexedTone flexed• Temperature 36.7Temperature 36.7°C°C

Complete the Primary Survey.Complete the Primary Survey.

EthanEthan


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Problem List Respiratory Cardiovascular Neurology Surgical conditions Fluid & glucose Thermoregulation Infection

Support

Respiratory Laboured respiration* Respiratory rate > 60/min* Receiving respiratory support*

Surgical Conditions Anterior abdominal wall defect Vomiting or inability to swallow Abdominal distension Delayed passage of meconium or imperforate anus

Thermoregulation T < 36.3 or > 37.2ºC axillary* Increased risk for temperature instability

Fluid & Glucose Management Blood glucose < 2.6 mmol/L At risk for hypoglycemia Not feeding or should not be fed

Neurology Abnormal tone* Jitteriness Seizures*

Cardiovascular Pale, mottled, or grey* Weak pulses or low BP* Cyanosis unresponsive to O2

Heart rate > 220 bpm

Baby at risk Unwell Risk factors Post-resuscitation requiring stabilization

Sequences


Infection Risk factor for infection ACoRN alerting sign with * Clinical deterioration

Consider transport

?

?


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Organization of CareOrganization of CareProblem

List


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ResponseResponseProblem

List


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• As close to 100% oxygen as possible is As close to 100% oxygen as possible is administered for 15 to 20 minutes. administered for 15 to 20 minutes.

What response are you looking for?What response are you looking for?

EthanEthan


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Next StepsNext StepsProblem

List


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• Mother is 32 years old, G1P0.Mother is 32 years old, G1P0.

• Pregnancy has been uneventful. Pregnancy has been uneventful.

• Antenatal scan at 19 weeks was normal. Antenatal scan at 19 weeks was normal.

• Labour was spontaneous at 39 weeks Labour was spontaneous at 39 weeks gestation. gestation.

• No evidence of fetal distress.No evidence of fetal distress.

• Ethan was born in good condition. Ethan was born in good condition.

EthanEthan


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• The focused cardiovascular examination The focused cardiovascular examination is unremarkable, other than for cyanosis.is unremarkable, other than for cyanosis.

• SpSpOO22 remains 75% during the hyperoxia remains 75% during the hyperoxia test.test.

Can Ethan tolerate this degree of cyanosis?Can Ethan tolerate this degree of cyanosis?

Would you wean the oxygen?Would you wean the oxygen?

EthanEthan


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Next StepsNext StepsProblem

List

Cyanotic Cyanotic heart heart

disease?disease?


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Consult!Consult!

Transport!Transport!

Cyanotic Cyanotic heart heart

disease!disease!


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• The team has quickly completed the Fluid & The team has quickly completed the Fluid & Glucose, Thermoregulation and Infection Glucose, Thermoregulation and Infection Sequences.Sequences.

• A blood culture was not done - nor were A blood culture was not done - nor were ampicillin and gentamicin ordered. ampicillin and gentamicin ordered.

• An assessment was done of the resources An assessment was done of the resources needed to look after this baby.needed to look after this baby.

• The chest radiograph and blood gas results The chest radiograph and blood gas results have returned. The hgb is 180.have returned. The hgb is 180.

• You re-enter the Cardiovascular Sequence to You re-enter the Cardiovascular Sequence to complete Specific Diagnosis and Specific complete Specific Diagnosis and Specific Management.Management.

EthanEthan


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EthanEthan


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Normal radiograph for comparisonNormal radiograph for comparison


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Specific DiagnosisSpecific Diagnosis


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Specific ManagementSpecific Management


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• Arterial blood gas: Arterial blood gas: – pH 7.35pH 7.35– pCOpCO22 35 mmHg 35 mmHg– BD 2 mmol/LBD 2 mmol/L– HCOHCO33 22 mmol/L 22 mmol/L– pOpO22 40 mmHg 40 mmHg

Interpret the blood gas.Interpret the blood gas.How would this affect your How would this affect your

management plan? management plan?

EthanEthan

basebaseacidacid

pHpH


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• Would you initiate Would you initiate Prostaglandin Prostaglandin EE11??


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• On arrival of the transport team, Ethan On arrival of the transport team, Ethan was stablewas stable

• He was transported to the level III center He was transported to the level III center without incidentwithout incident

• 12 hours later, the physician from the 12 hours later, the physician from the level III center calls you to report on level III center calls you to report on Ethan’s condition … Ethan’s condition …

EthanEthan


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EthanEthan

• Ethan had TGAEthan had TGA

• He had surgery He had surgery later that weeklater that week

• Went home in Went home in good condition 2 good condition 2 weeks laterweeks later


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Questions?Questions?

Documents

Nov 2007 ACoRN © 2006-07 Cardiovascular Sequence Case Two