Obstetric Emergencies, Stabilization & Transport Considerations

Yvette Gonzalez, MS, RN, C-NPT, C-EFM, RMH High Risk Obstetric & Neonatal Transport Clinical Manager

Objectives

• Review normal physiologic changes in pregnancy and assessment of obstetric patients

• Review HROB clinical presentations, pre-transport & transport clinical considerations

• Review HROB transport case studies and apply principles of maternal-fetal physiology through selection of clinical interventions appropriate for the clinical scenario.

• Review HROB peri-transport stabilization priorities

• Review in-utero resuscitation measures for pre-transport and transport application

• Review neonatal peri-transport stabilization priorities

This outreach education presentation is intended as an overview of basic concepts surrounding assessment of the

pregnant patient, OB complications and stabilization priorities for maternal patients.

Follow designated county protocols, policies and guidelines for actual care of obstetric and newborn patients.

60% of Maternal Deaths

PREVENTABLEhttps://www.youtube.com/watch?v=I5Dsn4obCa4&feature=youtu.be

Source: Maternal Mortality Review. https://www.cdcfoundation.org/sites/default/files/files/ReportFromNineMMRCs.pdf. Accessed March 2018.

Causes Of PREVENTABLE Mortality & Severe Morbidity

Failed CommunicationLack Of Recognizing Signs & Symptoms

Misdiagnosis & Ineffective TreatmentFailure In Care Systems & Processes

https://www.youtube.com/watch?v=URJfczEUA78 questions pertaining to Neo/HROB.

Sources:1. Maternal Mortality Review. https://www.cdcfoundation.org/sites/default/files/files/ReportFromNineMMRCs.pdf. Accessed March 2018.2. Preventing Maternal Death. TJC Sentinel Event Alert. Sentinel Events. https://www.jointcommission.org/assets/1/18/SEA_44.PDF. Accessed March 20183. Near Miss Mothers. NPR. https://www.youtube.com/watch?v=I5Dsn4obCa4&feature=youtu.be. Accessed May 2018

For every American woman who dies from childbirth, 70 nearly die

US Maternal Morbidity & MortalityLeading Causes & Regions

Louisiana, Georgia, Indiana, Arkansas, New Jersey, Missouri, Texas

Source: 1. National Vital Statistics Maternal Morbidity. https://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_04.pdf. Accessed March 2018.2. Meeting the Challenges of Measuring and Preventing Maternal Mortality in the United States. https://www.cdc.gov/grand-rounds/pp/2017/20171114-maternal-mortality.html. Accessed April 2018. 3. Sentinel Event Alert: Preventing Maternal Death. TJC. https://www.jointcommission.org/assets/1/18/SEA_44.PDF. Accessed April 2018

Causes of Arrest-Near Arest in OB Patients

B –E –A –U –C –H –O –P –S

Bleeding-DIC, Embolism, Anesthetic complications, Uterine atony, Cardiac

disease, Hypertensive disease, Other, Placental, Sepsis

Other Considerations: Peripartum Cardiomyopathy, & Vascular Dissections,

Source:1. The American Heart Association 2010 Guidelines for the Management of Cardiac Arrest in Pregnancy: Consensus Recommendations on Implementation Strategies. http://www.jogc.com/article/S1701-2163(16)34991-X/pdf . 2. American Heart Association: AHA. Maternal Cardiac Arrest. http://circ.ahajournals.org/content/132/18/1747. Accessed March 20173. Direct Causes of Maternal Mortality. Dartmouth.edu. Countdown to 2015 Decade Report (2000-2010), World Health Organization (2010).

OB Case Study

• Scene call: CC pelvic pressure/cramping, “leaking”

• Transport time: 35 minutes

• 28 y/o G5P2T1P1A2L1

• 25.3 weeks

• Maternal VS: HR 118, RR 20, sp02 97%, 105/70, temp 100.9 F

• FHR-EFM tracing: FHR 170, minimal variability, no decels or accels

What are clinical priorities---what would/can you do to stabilize?

Tick Tock...Every Minute Matters

Preterm Labor &

Preterm Premature Rupture of Membranes

• Primary Impression?, Consult, & Pre-transport Stabilization

• Optimize Tocolysis: Nifedipine, Indomethacin, Terbutaline, Magnesium

• Fetal Protection: Magnesium Sulfate, Antenatal Steroids & Antibiotics

• Evaluate Progression Of Labor PTD: Cervical Exam & UC evaluation

• Transfer To Higher Level Of OB & Neonatal Care: if able Source:1. Society For Maternal Fetal Medicine. Implementation of the Use of Antenatal Corticosteroids in the Late Preterm Birth Period in Women at Risk for Preterm Delivery. August 2016. Accessed March 2017. 2. ACOG. Management of Preterm Labor. https://www.acog.org/Womens-Health/Preterm-Premature-Labor-and-Birth. October 2016. Accessed March 2017 3. The American College of Obstetricians and Gynecologists Committee on Obstetric Practice Society for Maternal-Fetal Medicine. Magnesium Sulfate In Obstetrics. January 2016. https://www.acog.org/-/media/Committee-Opinions/Committee-on-Obstetric-Practice/co652.pdf?dmc=1&ts=20171212T2253317113. Accessed August 2017.

Normal Physiologic Changes In Pregnancy

Cardiovascular • Influence of Hormones, Hemodynamics & Vital Signs

Hematologic • Increased Circulating Blood Volume & Coagulation

Respiratory• Compensated Respiratory Alkalosis: pH 7.4-7.45 & PaCO2 27-32

• O2 Consumption, MV, & Tv

• Delayed gastric emptying---risk for aspiration!

Sources:1. Hayes, Meghan; Larson, Lucia (2012). "Chapter 220. Overview of Physiologic Changes of Pregnancy". Principles and Practice of Hospital Medicine The McGraw-Hill Companies.

https://accessmedicine.mhmedical.com/content.aspx?bookid=496&sectionid=41304210 March 20182. Cardiac Arrest In Pregnancy. AHA Scientific Statement. https://doi.org/10.1161/CIR.0000000000000300 Circulation. 2015;CIR.0000000000000300. Accessed March 2018. Originally published October 6, 2015

Pregnancy Vital Signs & Labs

Normal Pregnant VS

• HR: 85

• SBP: 114

• DBP: 70

• MAP > 70 &/or SBP >90

• Goal: vital organ perfusion

• If Hypotensive: ensure adequate preload before initiating vasoactive drugs

Normal Labs

• Hct 34

• Platelets > 150

• AST & ALT ~ 35

• Creatinine < 1.0

• WBC < 16

Source: Hayes, Meghan; Larson, Lucia (2012). "Chapter 220. Overview of Physiologic Changes of Pregnancy". Principles and Practice of Hospital Medicine The McGraw-Hill Companies. https://accessmedicine.mhmedical.com/content.aspx?bookid=496&sectionid=41304210 Accessed March 2018

Common HROB MedicationsMagnesium Sulfate:

• Preterm labor & fetal neuro protection

• Preeclampsia/HELLP seizure prophylaxis

• Eclamptic seizure treatment

Tocolytics: Nifedepine, Indomethacin (NSAID)& Terbutaline

Fetal Protection: Steroids, Magnesium Sulfate & Antibiotics

OB Hypertension-Antihypertensives:

• Labetalol vs. Hydralazine-- Goal not to normalize BP---achieve a range of 140-160/90-100mmHg

Eclamapsia-Anticonvulsants: Magnesium, Ativan, Versed, Diazepam, Phenytoin, Keppra

Uterotonic: Pitocin after delivery of placenta with fundal massage.

Fundal Height, How Many Weeks & Viable Fetus?

> 23 weeks?

Estimated Fetal Weight Based On Weeks of Pregnancy

600 grams 1Kg 2Kg 3Kg 4Kg

Source:1. NEJM. Survival and Neurodevelopmental Outcomes among Periviable Infants. February 2017. Accessed May 2017. 2. ACOG & Society For Maternal-Fetal Medicine. Periviable Birth. https://www.acog.org/Resources-And-Publications/Obstetric-Care-Consensus-Series/Periviable-Birth. October 2017. Accessed November 2017.

Rapid OB Assessment Primary Impression, CC & Priorities?

Prenatal care, history & current condition?• GPTPAL?

• How many weeks is she?

• Complications with this pregnancy?

• Complications with past pregnancies?

• Medical History? Medications?

• Vaginal bleeding? Leaking fluid?

• Pain: location, continuous or rhythmic?

• Injured: MOI?

• Ultrasound Findings: Placental pathology & location?

What about the fetus??• Does she feel fetal movement (typically present by 20 weeks)?

• Doppler or EFM FHR (normal 110-160)?Source: ASTNA, Patient Transport: Principles & Practice. 4th Edition

Peri-Transport Optimal Maternal Positioning

Lateral Uterine Displacement Improves Maternal CO &

Fetal Perfusion!

Source: Aortocaval Compression Conundrum in Obstetrics. https://journals.lww.com/anesthesia-analgesia/Citation/2017/12000/The_Aortocaval_Compression_Conundrum.7.aspx. Accessed March 2018.

OB Care Priorities: Stabilization & TransportABCs

Lateral Positioning: ~ 15 degrees

Vascular Access & Fluid Bolus • If indicated: LR or NS

Treat Mom To Treat Fetus!!• Uteroplacental Unit-New “End-Organ”

During Transport: • Ensure stability of mother and fetus during transport• Obtain frequent maternal vital signs & fetal assessment

• Fetal movement? Doppler FHR? Vaginal bleeding present?

Source: Trauma in the Obstetric Patient. American College of Emergency Physicians. https://www.acep.org/Clinical---Practice-Management/Trauma-in-the-Obstetric-Patient--A-Bedside-Tool/. Accessed March 2018.

Uteroplacental Blood Flow & Risk For Bleeding During Pregnancy

Source: 1. ACOG. Bleeding During Pregnancy. https://www.acog.org/Patients/FAQs/Bleeding-During-Pregnancy. Accessed March 2017.2. https://www.acog.org/-/media/Districts/District-II/Public/SMI/v2/he-06b-AF-140516-HemChecklist-Binder.pdf?dmc=1&ts=20171212T2152159656. Accessed March 2017.

She’s Pregnant & Bleeding….Placental Abruption??

Does she have any Risk Factors?

Abruption = Placental Detachment• May present with dark red & painful bleeding, OR

• Bleeding may be occult, rigid abdomen with severe pain !!

Source: Bleeding During Pregnancy. ACOG. https://www.acog.org/Patients/FAQs/Bleeding-During-Pregnancy. Accessed March 2018

She’s Pregnant & Bleeding: Abnormal Placental Implantation??

• Previa: Bright red, painless bleeding with or without UC’s

• Invasive Placental Implantation: C/S & Hemorrhage Risk

•Rapid transport to surgical & MTP capability center

Source: Placenta Previa-Obstetric Risk Factors & Pregnancy Outcome. https://www.ncbi.nlm.nih.gov/pubmed/11798453. Accessed March 2018

#1Cause of Maternal Death: OB Trauma

Primary Causes: MVA, Intimate Partner Violence Abuse, & Falls• Risk of abdominal trauma & hemorrhage

Physiologic Changes Can Mask Signs of Shock• Increased blood volume, cardiac output, mild tachycardia

Uteroplacental Unit Compromise: Increases risk for Maternal Fetal Hemorrhage & Fetal Compromise

Source: Trauma In The Obstetric Patient. American College of Emergency Physicians. https://www.acep.org/Clinical---Practice-Management/Trauma-in-the-Obstetric-Patient--A-Bedside-Tool/. Accessed March 2018

OB Trauma: Stabilization, Assessment & Transport

• Coms w/Receving : Trauma Center, OB & Neonatal Teams: Prepare For 2+ Patients

• OB Assessment • Primary & Secondary Survey

• ABCDE

• MOI

• Fetal Assessment: FHR – FetalMovement?

• Vaginal Bleeding?

• Rigid Abdomen?

• EDD? Viability?

• Labs & Diagnostics: • KB, Rh & FAST Scan-Ultrasound

1. ACOG. Bleeding During Pregnancy. https://www.acog.org/Patients/FAQs/Bleeding-During-Pregnancy. Accessed March 20172. High Risk & Critical Care Obstetrics. N. Troiano, C. Harvey, B. Flood Chez. AWHONN 2013, 3rd Edition.

Intrauterine Resuscitation MeasuresNormal Fetal Heart Rate: 110 – 160

Lateral Positioning• Optimize perfusion to uteroplacental unit

IV Fluid Bolus: Based on clinical condition

• Correction of maternal hypotension is essential!!

Oxygen Supplementation :• May optimize maternal oxygenation status and fetal oxygen delivery.

Reduction of Uterine Activity: Tocolysis (if needed/able)

Source: Maternal Oxygen Administration As An IntraUterine Resuscitation Measure During Labor. Simpson, Kathleen Rice. MCN: The American Journal of Maternal/Child Nursing: March/April 2015 - Volume 40 - Issue 2 - p 136http://www.sfnmjournal.com/article/S1744-165X(08)00061-9/abstract. Accessed March 2018.

OB Cardiac Arrest & Perimortum Cesarean Delivery

Recognition, CRM, & Teamwork

BLS, ACLS & ATLS

Positioning• Laterally to improve preload & CO

Primary Impression & Delivery• Every Minute Matters

• Rapid Assessment: Is Fetus Viable & Alive?

• Maternal Death Imminent?

• Prepare for Delivery & NRPSource: 1. Aortocaval Compression Conundrum in Obstetrics. https://journals.lww.com/anesthesia-analgesia/Citation/2017/12000/The_Aortocaval_Compression_Conundrum.7.aspx. Accessed March 2018.2. Cardiac Arrest In Pregnancy. AHA Scientific Statement. https://doi.org/10.1161/CIR.0000000000000300 Circulation. 2015;CIR.0000000000000300. Accessed March 2018. Originally published October 6, 20153. Preparing For Clinical Emergencies In Obstetrics. ACOG. https://www.acog.org/-/media/Committee-Opinions/Committee-on-Patient-Safety-and-Quality-Improvement/co590.pdf?dmc=1&ts=20180426T2325399798. Accessed March 2018

OB Case Study

Dispatch: IFT ED to regional OB center25y/o G1PO, 23 weeks, primary impression uterine contractions/PTL Transport time/Flight time 1:15

Maternal/fetal condition upon TT arrival: Maternal HR 86, Sp02 94%, RR20, B/P 209/104, temp 98, Cx 1.5cm/100%/-1, UC’s Q 3-5 (2/10), FHR 150+ IV MIVF @ 150ml/hr, HA X 3 days, RUQ pain

The Pressure Is On…..OB Hypertensive Emergencies

Defined: SBP >160mmHg, or DBP > 100mmHg, acute-onset, & persistent (>15 min)

Severe systolic hypertension--most important predictor of cerebral hemorrhage in OB patients• Goal B/P: Range of 140-160/90-100 mmHg to preserve fetal perfusion!!• Severe hypertension can occur antepartum, intrapartum or post-partum (6 wks)

Stabilization: • Magnesium Sulfate bolus & infusion, Antihypertensives-control B/P, Transport & Delivery• Be prepared to treat eclamptic seizures

Source:1. California Maternal Quality Care Collaborative: CMQCC. https://www.cmqcc.org/. Accessed August 20172. ACOG. Emergent Therapy for Acute-Onset, Severe Hypertension During Pregnancy and the Postpartum Period. April 2017. https://www.acog.org/-/media/Committee-Opinions/Committee-on-Obstetric-Practice/co692.pdf?dmc=1&ts=20171212T2343034025.

Accessed May 2017

Image Source: https://www.thirdstopontheright.com/may-is-preeclampsia-awareness-month-do-you-know-the-signs-and-symptoms/. Accessed April 2018

https://www.youtube.com/watch?v=URJfczEUA78 questions

Preeclampsia, HELLP & Eclampsia

Cerebral Effects Cardiac/Vascular

Pulmonary Liver Renal Fetal

Occurance: Up to 6 weeks PP

Labs: Obtain Hct, Platelets, LFT’s, Cr, Coags

Preeclampsia Assessment

Treatment-Stabilization: Magnesium Sulfate, Antihypertensives, Anticonvulsants, Delivery

Source: 1. California Maternal Quality Care Collaborative: CMQCC. https://www.cmqcc.org/. Accessed August 20172. https://www.propublica.org/article/die-in-childbirth-maternal-death-rate-health-care-system. Accessed December 2017

HELLP Syndrome: Severe Form Of Preeclampsia & State of Coagulopathy

Variant of severe preeclampsia

Presentation similar to pre-eclampsia with or without hypertension

Diagnosis determined by laboratory confirmation of: • Hemolysis• Elevated Liver Enzymes• Low Platelets

Treated similar to PEC with addition of blood products (as needed): • PRBC’s and Platelets• Antihypertensive Medications: Labetalol or Hydralazine (as needed)• Magnesium Sulfate infusion

Source: 1. California Maternal Quality Care Collaborative: CMQCC. https://www.cmqcc.org/. Accessed August 2017

Eclampsia: Onset of Seizures With PEC• Initiate Magnesium Sulfate: Bolus then continuous infusion

• Rebolus Magnesium if seizure continues

• Lorazepam or Versed

• Other options: Diazepam, Phenytoin, & Keppra

• Maintain ABC’s and protect patient

• Difficult to obtain EFM tracing during maternal seizuresSource: 1. California Maternal Quality Care Collaborative: CMQCC. https://www.cmqcc.org/. Accessed August 20172. https://www.propublica.org/article/die-in-childbirth-maternal-death-rate-health-care-system. Accessed December 2017

Delivery Outside Of OB Unit : Now What??• Supplies: OB Kit & Neo Ventilation Device

• Place infant on mothers abdomen after birth

• Clamp cord 8-10 inches from baby• Use 2 clamps several inches apart: cut between clamps

• Delayed Cord Clamping X 30-60 seconds IF VIGOROUS

• Immediate Cord Clamping IF NONVIGOROUS

• Provide basic newborn care• Clear Airway & Optimal Airway Positioning

• Dry Thoroughly & Provide Warmth

• Continuous assessment of ABC’s

• Thermoregulation & Blood Glucose

Source: Neonatal Resuscitation Program. AAP. 7th Edition

Tiny Ones: Preterm Delivery

Delayed Cord Clamping:

IF vigorous DCC reduction of IVH

IF NONVIGOROUS immediate umbilical cord clamping & NRP

Thermoregulation & Neuroprotection:

Warming mattress, isolation bag, hat, nesting, & head alignment with gentle handling

NRP Guidelines:

Sp02 & ECG, CPAP, PPV, airway & perfusion support, careful fluid administration, glycemic control, early activation of neonatal & transport teams!

Source:1. AAP. Neonatal Resuscitation Program. 7th Edition.

Delivery of Placenta: Now What?

Anticipate within 20 min after delivery• Do not pull on cord

Normal blood loss ~ 500ml

Provide vigorous fundal massage!!

• Support lower uterine segment

• Ensure uterus stays contracted-firm

• Uterotonics: as needed/if able

Source: ACOG Guidelines For Management Of Hemorrage. https://www.aafp.org/afp/2007/0401/p1101.html. Accessed 3/2018.

Leading Causes of Postpartum Hemorrhage: 4 T’s

•Tone• Uterine Atony = Inability of the uterus to contract

• Over-distension, muscle exhaustion-long labor, infection,

•Trauma• Lacerations, rupture, inversion

•Tissue• Retained tissue, clots, placental implantation

•Thrombin• Coagulopathy

Causes Of PP Hemorrhage

Atony Tissue Trauma Thrombin

Uterine Atony80%

Uterine Atony & Postpartum Hemorrhage Clinical Priority #1: Provide Vigorous Continuous Fundal MassageGoal: uterus remains contracted & firm

Ongoing Clinical Priorities:• Adequate Vascular Access• Continuous Fundal Massage• Uterotonics: Pitocin-dose & rate• Consider TXA: Consult • Rapid Transport To Surgical/Regional Center• D&C -- Removal of Placental Parts (if needed)• OR --- Looking For Bleeders• Activate Massive Hemorrhage Protocol

Source: OB Hemorrhage V2 Toolkithttps://www.cmqcc.org/resources-tool-kits/toolkits/ob-hemorrhage-toolkit. CMQCC. California Maternal Quality Care Collaborative. Accessed 3/20/2018

Image Source: dailymom.com

Thank You & Questions

Neonatal Resuscitation & Pre-Transport Stabilization

Yvette Gonzalez, MS, RN, C-NPT, C-EFM, RMH High Risk Obstetric & Neonatal Transport Clinical Manager

Objectives

• Review rapid assessment of neonatal patients

• Review differences between NRP and PALS

• Review neonatal clinical presentations, pre-transport & transport clinical considerations

• Review neonatal case studies and apply principles of NRP & STABLE through selection of clinical interventions appropriate for the clinical scenario.

• Review neonatal peri-transport stabilization priorities

• Review neonatal airway management, vascular access options, warming measures, & glycemic control

This outreach education presentation is intended as an overview of basic concepts surrounding assessment of the

pregnant patient, OB complications and stabilization priorities for maternal and newborn patients.

Follow your designated hospital and county protocols, policies and guidelines for actual care of obstetric and newborn patients.

Case Study: EMS Dispatch Female With Abdominal Pain

You Arrive On-Scene: Unexpected Newborn Delivery ~ 26 weeksRapid Newborn Assessment: Apnic, Dusky, HR palpable ~ 80bpm

What Are Your Clinical Priorities?

Delivery Outside Of OB Unit : Now What??• Supplies: OB Kit & Neo Ventilation Device

• Place infant on mothers abdomen after birth

• Clamp cord 8-10 inches from baby• Use 2 clamps several inches apart: cut between clamps

• Delayed Cord Clamping X 30-60 seconds IF VIGOROUS

• Immediate Cord Clamping IF NONVIGOROUS

• Provide basic newborn care• Clear Airway & Optimal Airway Positioning

• Dry Thoroughly & Provide Warmth

• Continuous assessment of ABC’s

• Thermoregulation & Blood Glucose

Source: Neonatal Resuscitation Program. AAP. 7th Edition

Tiny Ones: Preterm Delivery Priorities

Delayed Cord Clamping:

IF vigorous DCC reduction of IVH

IF NONVIGOROUS immediate umbilical cord clamping & NRP

Thermoregulation & Neuroprotection: Keep em’ warm & handle gently

Warming mattress, isolation bag, hat, nesting, & head alignment with gentle handling

NRP Guidelines: ABC, ensure chest rise and correct PPV/BVM rate

Sp02 & ECG, CPAP, PPV, airway & perfusion support, careful fluid administration, glycemic control, early activation of neonatal & transport teams!

Source:1. AAP. Neonatal Resuscitation Program. 7th Edition.

Neonatal Resuscitation & Stabilization Priorities

•NRP: A, B, C versus PALS• Airway, Airway, Airway• Ventilation Rate Adequate? Do You Have Slight Chest Rise?

• Stabilization Measures: The S.T.A.B.L.E. Program

• Glycemic Control• Thermoregulation• Perfusion Support• Preparation For Transport • Transfer to higher level of care

Source: http://www.abclawcenters.com/wp-content/uploads/2014/11/original_resuscitation_with_bagging_and_chest_compressions.jpg. Accessed August 2017.

Neonatal Airway Management: Babies are different…..• Anatomical Challenges• Ventilation Device Options• Establishing Effective Ventilation

• Ensure Adequate Rate: 40-60• Slight Chest Rise

• Oxygenation

• Ongoing Airway Support modalities• Alternative Airway Needed?• Vt’s of newborns compared to adult?• Common ventilation support: BVM Rate & Pressures?

Source1. AAP. Neonatal Resuscitation Program. 7th Edition2. The S.T.A.B.L.E. Program. 6th Edition

Neonatal Vascular Access Emergent UVC: o18-20 gauge IV catheter: Prep—Tie—Cut--Cannulateo Single lumen UVC catheter 3-5 cm, obtain blood return o <1500 Grams/30 weeks 3.5 F and >1500 Grams/30 weeks 5.0 F

PIV Placement • 24g

IO Placement• Proximal Tibia & Distal Femur

• EZ IO >3kg• Manual IO <3kg

Fluid Resuscitation • NRP versus PALS

Source1. AAP. Neonatal Resuscitation Program. 7th Edition2. The S.T.A.B.L.E. Program. 6th Edition

Neonatal Fluid ResuscitationIndication?

• Not responding to resuscitation• Appears in “shock” hypo-perfused• History of blood loss

DOSE: 10 ml/kg

SOLUTION: Normal Saline or O Rh- negative PRBC’s (if indicated)

ROUTE: PIV, UVC or IO (proximal tibia or distal femur)

RATE: Over 5-10 min. Preterm precautions

Total neonatal circulating blood volume: • 80-90ml/kg

Source:1. AAP. Neonatal Resuscitation Program. 7th Edition.

Neonatal EZ IO Insertion Sites

Neonatal IO Insertion Sites

• EZIO > 3kg: Distal Tibia, Proximal Tibia & Distal Femur

• Manual IO < 3kg: Proximal Tibia

Image Source: https://www.teleflex.com/global/clinical-resources/ez-io/8082_Rev_02_-_FDA_Intraosseous_Infusion_System_IFU_ATH_v2_-_PRESS.pdf. Accessed 6/14/19.

Keep Em’ Dry, Warm & SweetThermoregulation Measures & Blood Glucose Surveillance

Case Study: ED Admit37.5 weeks, 5do, 3.1kg difficulty breathing, hypothermia Clinical Priorities?

Tachypnea: Respiratory Rate 70-80

Increased WOB Grunting Retractions: Moderate/Severe

Hypoxemia: sp02 low 90’s

Hypoglycemia: BG 41

Hypothermia: 35.9 C

Hypotonic: decreased responsiveness

I/O’s: Decreased PO Intake X 1day & 3 diapers in the last 24 hours (consider eating is a newborn vital sign)https://www.youtube.com/watch?v=NBA9iigiDgk

CXR Findings In The ED: Suspected Pneumonia

Birth History Risk Factors?Before & During Birth

PPROM &/or Prolonged Rupture of Membranes> 18 hours?PTD maternal administration of antibiotics?

Maternal Chorioamnionitis?Maternal fever/ infectionFetal tachycardiaFoul smelling amniotic fluidDid MOB receive antibiotics during labor >4 hrs before

birth?

Meconium aspirationSources:1. https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Intrapartum-Management-of-Intraamniotic-Infection. Intrapartum Management Of Intraamniotic Infection. ACOG. Number 217, August 2017. Accessed

Neonatal Sepsis Clinical Priorities

• Rapid Consult, Stabilization & Transport to Regional Center

• NRP then STABLE

• Airway Support: noninvasive and/or invasive

• Perfusion Support: • Volume resuscitation/bolus: assess perfusion parameters & liver margin

• Pressor support (ensure adequate preload)

• Glycemic Control: Glucose bolus (as needed) + MIVF

• Thermoregulation: Goal temp 36.5C-37.5C

• Sepsis screen: CBC w/differential and Blood Cultures

• Early initiation of antibiotics: Ampicillin & Gentamycin • Consider/discuss antivirals if neuro assessment abnormal

Source1. AAP. Neonatal Resuscitation Program. 7th Edition2. The S.T.A.B.L.E. Program. 6th Edition3. https://pediatrics.aappublications.org/content/129/5/1006. Management of Newborns With Suspected or Proven Early Onset Bacterial Sepsis. AAP 2016. Accessed January 15, 2019.

Case Study:ED, born @ term, 3.9 kg, 22 d/o

• Tachycardic: HR 170’s

• Labored Breathing

• Compromised Perfusion

• Acidotic

• Tender, distended abdomen

• Bilious vomiting

• Bloody stools

• Stopped eating

• Fussy all day

Suspected Bowel ObstructionClinical Priorities

• Rapid Consult, Stabilization & Transport to Pediatric Surgical Center

• Airway & Oxygenation Support

• Perfusion Support

• Gastric Decompression: Orogastric Tube 8F or 10F

• Glycemic Control: Glucose bolus (as needed) + MIVF = D10W

• Thermoregulation: initiate warming measures

• Comfort Measures

• Rapid Transport: Potential Surgical Emergency & Time Sensitive Source1. AAP. Neonatal Resuscitation Program. 7th Edition2. The S.T.A.B.L.E. Program. 6th Edition

3. Journal of Obstetric Gynecologic and Neonatal Nursing. JOGNN. Lockridge, Caldwell, Jason (2003). Neonatal Surgical Emergencies: Stabilization & Management. Volume 31, Number 3.

Free Air On Xray Is A Surgical Emergency

Considerations For Neonatal Altered LOCTHE MISFITS

• T= Trauma

• H= Heart disease or Hypovolemia

• E= Endocrine – Hypoglycemia

• M= Metabolic--Electrolytes

• I= IEM

• S= Sepsis

• F= Formula error

• I= Intestinal catastrophes

• T= Toxins/ Poisons

• S= Seizures

Neonatal Skills Review

• Neonatal Airway Management• Positioning: shoulder roll & sniffing position

• BVM/PPV: Mask size, rate, pressures, & devices

• CPAP

• LMA

• Intubation

• Vascular Access

• Thermoregulation: warming measures

• Glycemic Control: Calculating D10W Bolus & MIVF

Thank You & Questions

Febrile Seizuresand…

My BIG Secret

Jennifer Cochran, RN, BSN, MICN, CFRN

REACH Air Medical Services

Objectives

Review the basics of seizures

Discuss the diagnosis of

complex febrile seizures

Identify signs and symptoms

of complex febrile seizures

Demonstrate the proper

treatment of complex febrile

seizures.

What’s the difference

between school and life?

“In school you’re taught a

lesson and then given a test.

In life, you’re given a test that

teaches you a lesson”

- - - Tom Bodett

As a health care provider,

have you been:

Caught off guard?

Unprepared?

Surprised?

Thrown off?

Confused?

Good!

Now… what did you do about it?

I’ve been a “xxxx” for

“xxx” years….

Quick survey of the room…years of experience

Are you ever done LEARNING??

Are you giving honest advice/guidance… not the

typical cliches

Let’s be Honest

We don’t know everything

We have not SEEN everything

BUT…

Why can’t we share our fears,

shortcomings, lack of

understanding…

Why is it a secret…. ?

We Aren’t Perfect…

So Stop Pretending

Healthcare professionals should share their learnings

Admit your mistakes

Discuss your critical thinking

Share the way you re-directed or corrected the situation

Volunteers…?

How many years experience

and what did you recently

learn?

How many years experience

and what advice would you give

to someone beginning in your

field?

Speaking of kindness…

I have a unique perspective

Every call has unique

challenges

Family

Acuity

Story changes

Poor historian

Scene time is limited

Are you a professional when

speaking with one another?

Radio Reports

Bedside Hand-offs

Admission Reports

Calls to Physicians

Think about your reports

to the floor….

Sit down, get yourself prepared

Not multitasking while on the

phone giving report

Same with EMS

Move the patient

Get full report

Ask questions when finished.

Stop and think…

Don’t judge, you have no idea what they are going through

Could you walk a mile in their shoes?

Criticizing others doesn’t make you better

EMS is a family… definitely dysfunctional… but still family

I’ll Tell you about my

experience…

1345 on a Friday

Launched to rural East County

4 y/o seizure

What are your

thoughts on the

10 minute flight

to the scene?

By the book…

Landing safely

Parents

Initial ABC’s

RSI drugs & doses

Differential Diagnoses

Weather

Destination options

My Actual Thoughts…

eh - probably just a febrile

seizure. No biggie

Parents probably panicked

Child will be awake & crying by

the time I get there

Be Honest..

You totally thought

that too!!

Paramedic AssessmentNPA with BVM by BLS engine company

Clenched jaw after multiple seizures

GCS = 3

Room Air saturation = 35%

ETCO2 = 87

HR = 135, BP = 135/74

Blood Sugar = 176

Temp = 94.9

HPI

Sick, fever & runny nose for past few days

Father witnesses two seizures called 911 and placed

her in cool bath

Engine reports two more seizures lasting 1 minute or

less

NO LUCID INTERVAL….

Paramedic Intervention

Recognized seizure without lucid interval and

respiratory compromise!!

Continue BVM with 100% oxygen

24 ga to left hand

2mg Versed (per LBRT)

Drive patient to LZ

Your Initial Assessment

Seizures continue

Medics giving 2nd dose of Versed (2mg)

GCS = 3

Oxygen saturations = 100%

ETCO2 = 24 with BVM

20kg

YIKES!!

Not what I was

expecting…

#$^&$%!!!!

GOOD OL’ A… B… C’s

Airway: Patent, but NOT maintainable

Breathing: Ineffective

Circulation: So far… so good

Your

Treatment?

Airway: Intubate via RSI

Breathing: BVM until in aircraft

Circulation: Second IV started

RSI

0.3mg/kg Etomidate = 6mg

1mg/kg Rocuronium = 20mg

Tube size = age + 16 = 5.0

Visualized tube through the cords via video laryngoscopy4

Feeling Good??

Load into aircraft

Place on ventilator (pressure, SIMV, rate 24, PS 10, peep 5)

Fentanyl 20mcg

Differential Diagnoses??

Epilepsy

Brain Tumor

Trauma

Atrial-Venous Malformation

Electrolyte Imbalance

Toxins

Bacterial Infection

Meningitis

Something else weird?

Neuro blah blah blah?

On Arrival To ER

GCS = 3, sedated, postictal

Tube confirmed, but a tiny bit too high

CT head

CXR

Labs

Diagnosis:

Complex Febrile Seizure

Actually, I didn’t know it

Seizures are difficult to remember

and assess

I just focused on ABC’s

Don’t you hate not knowing!

But… it’s ok.

“Wow, I’ve never seen that before. How interesting! I am lucky to have

learned something today!”

AND…

Don’t make others feel

incompetent when they

admit they learned

something new!!

Pathogenesis of Fever

Phagocytic cells release

several substances into

the blood stream.

Two types of WBCs are

phagocytic:

Leukocytes (microphages) - small,

appear quickly

Monocytes (macrophages) - large,

appear days later

Pathogenesis of Fever

Phagocytic cells release Cytokines

Cytokines travel via blood to anterior hypothalamus

Cytokines induce an abrupt increase in the synthesis

of prostaglandins

The prostaglandins raise the set-point for body

temperature

Hypothalamus Set-Point

Similar to a thermostat in

your house

Temperature is set

The body responds to

keep in limits

Set-Point is Increased…

Thermoregulatory center recognizes the current

body temp is too low and initiates a series of

events to raise the body temperature

Increases metabolic rate

Increases muscle tone

Decreases heat loss through vasoconstriction

to skin

Quick question ??

We know fever is an integral part

of the inflammatory response.

But…. is a fever harmful or

helpful??

Is it a defense mechanism gone

crazy?

Still Disputed…

Potential Benefits

Slows growth of some

bacteria & viruses

Enhances immunologic

function at moderately

elevated temps

?Play a role in fighting

infection

As temp increases… are

the benefits reduced?

Potential Dangers

Increases:

Metabolic rate

O2 consumption

CO2 production

Demands on cardiac

and pulmonary

systems

Febrile Seizure: Definition

Temp >38 C (100.4 F)

3 months - 6 years (also saw 6 months - 5 yrs)

Absence of central nervous system infection

Absence of metabolic abnormality

No history of previous afebrile seizures

Febrile seizures are not considered a form of

epilepsy

Cause of Febrile Seizure?

Unknown

Likely related to vulnerability of developing nervous

system AND underlying genetic predisposition

Risk factors: fever, viral infection, recent

immunizations & family history of febrile seizures

Other Bits of Knowledge

Maximum height of fever is probably the main

determinant (supported w/research)

Seizure threshold is reduced with certain

medications, water & electrolyte imbalances,

especially hyponatremia.

Viral infections are more commonly associated

with febrile seizures than bacterial.

Febrile Seizure

Most common neurologic disorder <5yrs

Age dependent with strong genetic predisposition

Low risk for future epilepsy

2 types: simple & complex

Simple Febrile Seizure

Most common type

Single generalized seizure lasting <10 - 15min

Most last < 5min

Typically spontaneously resolved

Few require benzodiazepines

Prophylactic antiseizure drugs typically not needed

Complex Febrile Seizure

Focal onset (eg: shaking of a limb or one side of body

Prolonged (>15 min)

Recurrent within 24hrs

25% of febrile seizures

Complex Febrile Seizure

An initial simple febrile seizure may be followed by

complex seizures

An initial complex febrile seizure does not indicate that

all subsequent seizures will be complex.

Febrile Status Epilepticus

Extreme end of complex seizures

Continuous seizure or intermittent seizure without

lucid interval > 30 min

Prospective Study of 119 children (FEBSAT study)

Median duration 68 minutes

2/3 were partial seizures

52% continuous & 48% intermittent

Treatment

Midazolam, Lorazepam or Diazepam

Antipyretics:

Facilitates heat loss

Does not inhibit heat production

Does not lower seizure threshold

Summary

Febrile Seizures

Usually in the setting of

viral or bacterial infection

3mos - 6yrs

Typically on the first day

of illness

Take Home Points

Be suspicious of reports for repeated seizures

Observe closely for focal or partial seizures

Ask about family history

It is SCARY for the parents…

Be Kind…

Respect each other

Admit your learnings

Be prepared

Thank you!

Questions?