PEDIATRIC TRAUMA AND CRITICAL CARE PROVIDES SIX (6) HOURS OF CONTINUING EDUCATION CREDIT AGENDA 0800-0830 Registration 0830-0930 Transport Pearls for the Neonate Patty Duncan, BSN, RNC 0930-0940 Break 0940-1140 Pediatric Airway and Prehospital Golden Hour Dave Duncan, MD 1145-1215 Lunch 1215-1315 State of the Art EMS Protocols are Created, Not Born That Way Paul S. Rostykus, MD, MPH, FAEMS 1315-1325 Break 1325-1525 Pediatric Trauma Heather Summerby, RN 1525-1530 Evaluation Transport Pearls for the Neonate Patty Duncan There are not many careers where your decisions and interactions can positively impact the life of a human for up to 80 plus years. Dr. Stephen Butler PEARLS OF NEONATAL TRANSPORT FROM A 35 YEAR NICU RN PATTY DUNCAN BSN RNC PATTY DUNCAN BSN RNC • ADVANCED LIFE SUPPORT COORDINATOR • ALS NICU TRANSPORT COORDINATOR • ASSISTANT NURSE MANAGER 61 BED LEVEL 3 NICU • STABLE INSTRUCTOR • NRP INSTUCTOR NICU TRANSPORT TEAM • VIA GROUND, FIXED WING AND ROTOR • SERVE 27 COUNTIES IN NORTHERN CA • 3 OUT OF HOUSE TRANPORT ISOLETTE CONTAIN CONV VENT HFJV NITRIC OXIDE ACTIVE COOLING TECOTHERM BCPAP THE NEONATE-WHY THEY ARE SPECIAL • OF, RELATING TO ,OR AFFECTING THE NEWBORN AND ESPECIALLY THE HUMAN INFANT DURING THE FIRST MONTH AFTER BIRTH • MERRIAM-WEBSTER Large surface area compared to size keep them warm (BSA is 3X greater than adult) Correct ventilation is the key to solving most issue be smart Glucose is their energy source - keep them sweet NEONATES: MASTERS OF DISGUISE KEY = TREAT THE SYMPTOM! • Tachypnea: the most common symptom! • Respiratory Distress Syndrome • Transient tachypnea of the newborn, Hyaline Membrane Disease, pneumothorax, pneumonia • Sepsis-bacterial, virus • Cardiac-ductal dependent vs non ductal dependent • Metabolic Acidosis • Hypoglycemia, • Hypothermia TREAT THE SYMPTOMS! THE DIAGNOSIS WILL FOLLOW (MAYBE) S.T.A.B.L.E. PROGRAM • SUGAR • TEMPERATURE • AIRWAY • BLOOD PRESSURE • LABS • EMOTIONAL SUPPORT SUGAR - KEEP THEM SWEET! TIP: D10W IS YOUR FRIEND • Glycogen stores increase dramatically the last few weeks of gestation • Neonates rely on the breakdown of this glycogen to provide energy (ATP) for the first few days of life • Very little energy is supplied in the absence of oxygenation • So ---- assume any infant who is: • Not oxygenating well • Premature (very little glycogen) • Stressed or ill NEEDS A SUPPLY OF GLUCOSE ASAP INFANT’S AT RISK FOR HYPOGLYCEMIA • ILL/STRESSED INFANT Glycogen stores gone • PREMATURE / IUGR / SGA Inadequate Glycogen Stores • HYPERINSULINEMIA Excess Insulin HYPERINSULINEMIA PREMATURE, IUGR, SGA STRESSED/ILL INFANT IV FLUID AND RATE • D10W WITHOUT ELECTROLYTES • 80ML/KG/DAY • WEIGHT IN KG X 80 • DIVIDE BY 24 • EQUALS MLS PER HOUR (RUN VIA AN INFUSION PUMP) BEDSIDE GLUCOSE CHECKS TIP: D10W 2ML/KG IV PUSH • Do with first assessment! • Follow closely - every 30 minutes until stable for 2 hours • Accept a glucose of >50 • Start IV: 10% glucose early • 80mls/kg/hr. to start • If glucose remains below 50-increase to 100ml/kg/hr. • If glucose remains below 50-increase glucose conc. to 12% • Concentrations > D12% require central line. NEONATAL TEMPERATURE RANGE TIP- CHECK TEMP Q 15 MIN • NORMAL RANGE 36.50 – 37.40C for all infants (axillary temp) • The neonatal temperature is monitored per axilla using digital thermometers. • Flank temperatures may be monitored using skin temperature probes. • An infant’s core body temperature will generally be higher than the recorded skin temperature, with a difference of ~0.50C in term infants; the difference may be narrower in very preterm or ill infants. NEONATE’S NEED TO BE TRANSPORTED IN A NEUTRAL THERMAL ENVIRONMENT • SICK OR PREMATURE INFANTS NEED TO BE IN A TRANSPORT ISOLETTE (SERVO CONTROLLED) • INFANTS CAN DROP 1-1.5 DEGREE’S PER MINUTE POST DELIVERY • INFANTS LOSE HEAT 4X FASTER THAN ADULTS • SKIN TEMP DROP OF 1 DEGREE FROM 97.7 (36.5C) INCREASES OXYGEN REQUIREMENT BY 10% • LOW BIRTH WEIGHT INFANTS HAVE LITTLE BODY FAT HOW TO KEEP THEM WARM TIP- NEOWRAP / PLASTIC WRAP • IF NO ISOLETTE: • SKIN TO SKIN • SOME TYPE OF PLASTIC WRAP • HATS-WARM BLANKETS-KEEP INFANT FLEXED/TUCKED • INCREASE TEMP IN AMBULANCE/AIRCRAFT • KEEP THEIR BLOOD SUGAR NORMAL!!! (ENERGY TO PRODUCE HEAT) • KEEP OXYGEN LEVELS NORMAL (SO THEY GET MORE BANG (ATP) FROM THEIR GLYCOGEN (KREBS CYCLE) BENEFITS OF SERVO CONTROL ISOLETTE TIP - WHO IS YOUR CLOSEST NICU TRANSPORT TEAM? • THEY CAN CONTROL TEMPERATURE OF INFANT BY FEEDBACK TEMP PROBE • IF COLD-ABLE TO SET TEMP ONE DEGREE ABOVE SKIN TEMP TO PREVENT WARMING TOO FAST. • VASODILATATION LEADS TO DECREASED BLOOD PRESSURE, INCREASED LACTATE, INCREASED OXYGEN NEED THE BIGGEST BENEFIT IS THAT THE CRITICAL VITAL SIGN TEMPERATURE IS CONSTANTLY VISIBLE – THIS ALLOWS THE TEAM TO FOCUS ON OTHER VITALS WHAT ABOUT THERAPEUTIC HYPOTHERMIA? TIP- COOLING NEEDS TO START WITHIN 6 HOURS OF BIRTH-WHERE IS THE CLOSEST COOLING CENTER?? • ONE OF THE MOST IMPORTANT TREATMENT MODALITIES IN NEONATAL MEDICINE TODAY • SIGNIFICANT IMPROVEMENT IN OUTCOMES OF INFANTS WITH MODERATE TO MILD HYPOXIC ISCHEMIC ENCEPHALOPATHY (HIE) • KNOWN PERINATAL/POSTNATAL HYPOXIC INSULT • INFANT IS >34 WKS, PH, 7.0, LACTATE >12, ABNORMAL NEURO EXAM • INFANT IS COOLED QUICKLY TO 33.5C FOR 72 HOURS IN CONTROLLED COOLING CENTER TRANSPORTS ARE 90% RESPIRATORY! TIP- NOTHING REPLACES YOUR ASSESSMENT SKILL • Number 1 reason for neonatal transport • Difficult to determine exact diagnosis-treat the symptoms • Use every tool you have to guide your treatment • YOUR ASSESSMENT SKILLS • Vital signs • Oximetry - pre ductal / post ductal • Perfusion-cap refill / pulse • ABG / bedside glucose • XRAY AIRWAY- THE LEAST INVASIVE THE BETTER • REDUCE VENTILATOR INDUCED DAMAGE TO THE NEONATAL LUNG • PERMISSIVE HYPERCAPNIA • DECREASED NEED FOR VENTILATION=LESS BRONCHOPULMONARY DYSPLASIA (BPD) • GREATER USE OF BUBBLE CPAP- NCPAP THE CASE FOR BCPAP (BUBBLE CPAP) • USE BCPAP ON THE FIRST BREATH IN THE DELIVERY ROOM • IF YOUR TRANSPORT TEAM DOES NOT USE BCPAP NOW-MOVE TOWARD IT 2008 BPD 38 percentile • HIGH HUMIDITY OR HIGH FLOW NASAL 2009 BPD 25 percentile CANNULA - ok for oxygen needs, but not 2010 BPD 12 percentile effective for consistent peep 2017 BPD 13 percentile NEONATAL BCPAP KEY#INFANT NEEDS TO BE BREATHING • CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) • USED FOR SPONTANEOUSLY BREATHING INFANTS • FOR RDS, TTN, MEC ASPIRATION, APNEA OF PREMATURITY • FLOW OF GAS MAINTAINS EXPIRATORY PRESSURE CONTINOUSLY • CAN BE EASILY USED IN TRANSPORT LMA’S IN NEONATAL RESUSCITATION • Reduction in upper airway obstruction • Improved oxygenation / ventilation • Reduced incidence of tracheal intubation • Reduced amount of expertise required. This Photo by Unknown Author is licensed under CC BY-NC-SA • After positioning, the LMA is quite stable and frees operator’s hands for other tasks. IF YOU MUST INTUBATE TIP- ETT TIP TO LIP-WT PLUS 6 • USE THE LOWEST PIP NEEDED TO MOVE THE CHEST • UTILIZE TCM OR END TIDAL CO2 • ABG FOR CORRELATION • ETT TIP PLACEMENT CRUCIAL- TIP TO LIP • 1KG –ETT TAPED AT 7 LIP • 2KG-ETT TAPED AT 8 ETC.ETC. • PREVENT POOR IMPROVEMENT/PNEUMOTHORAXES FOR R MAIN STEM INTUBATIONS WHAT'S NEW IN NEONATAL INTUBATION • Uncuffed tubes – size: 2.5 - 4.0 • Use a CO2 detector! • Use tip to lip rule-weight plus 6 • Ventilate with minimal pressure to move chest • CXR for placement • Each hand off includes ETT size, where it is taped, cuffed or uncuffed? • Keep CO2 detector handy for evaluations NEONATAL CHEST XRAYS ABDOMEN XRAYS DO NOT BE DECEIVED BY A NORMAL NEONATAL BLOOD PRESSURE • NEONATES HOLD THEIR BLOOD PRESSURE UNTIL THEY HIT THE WALL • BLOOD PRESSURE IS A VITAL SIGN-BUT A NORMAL B/P DOES NOT ELIMINATE THE POTENTIAL OF SHOCK • USE ALL OF YOUR ASSESSMENT SKILLS TO DETERMINE SHOCK • CAPILLARY REFILL TIME >3 SECS • PULSES -WEAK,FULL, THREADY • COLOR-PALE,MOTTLED • HEART RATE>180 • 3 TYPES OF NEONATAL SHOCK • HYPOVOLEMIC, SEPTIC, CARDIAC HYPOVOLEMIC SHOCK • CAUSES OF HYPOVOLEMIC SHOCK • PLACENTAL PREVIA, ABRUPTION, CORD ACCIDENT, ORGAN LACERATION • SKULL BLEEDS-SUBGALEAL HEMORRHAGE • PNEUMOTHORAX • TREATMENT OF HYPOVOLEMIC SHOCK • FILL THE TANK! • SALINE • BLOOD SEPTIC SHOCK •BACTERIAL •VIRAL • SEND BLOOD CULTURES • GIVE ANTIBIOTICS • TREAT SYMPTOMS This Photo by Unknown Author is licensed under CC BY-NC-SA CARDIAC SHOCK TIP- EPINEPHRINE DRIP • CONGENITAL CARDIAC DISEASE • Ductal dependent lesions • Non-ductal dependent lesions • CARDIAC MYOPATHY • Viral infections • Congestive heart failure This Photo by Unknown Author is licensed under CC BY-SA LABS BEFORE TRANSPORT • BEDSIDE GLUCOSE • BLOOD GAS • BLOOD CULTURE • CBC WITH DIFF WHAT IS NEW IN NEONATAL RESUSCITATION- FROM THE MOMENT OF BIRTH • INTUBATION IS A THING OF THE PAST FOR MOST INFANTS • EXCEPTIONS INCLUDE NEONATAL DEPRESSION, EXTREMELY LOW GESTATIONAL AGE, SOME GOOD VENTILATION SURGICAL PATIENTS-EX CDH WITH A BAG AND MASK • USE LMA WHEN YOU DO NOT HAVE COMPETENT WILL INCREASE A STAFF PRESENT FOR INTUBATION-GOES DOWN TO NEONATE’S HEART RATE THE SIZE OF 0.5 (AIRQ) 99% OF THE TIME-MAKE SURE YOU HAVE STAFF • YOU CAN PROVIDE PPV FOR A PROLONGED THAT CAN ADEQUATELY PERIOD OF TIME IF NECESSARY BEFORE HAVING VENTILATE ACCORDING UNQUALIFIED STAFF PERFORM POOR TO NRP GUIDELINES INTUBATIONS • KNOW WHO YOUR SPECIALISTS ARE-ER, ANESTHESIA, NP, NURSE SPECIALIST, RCP’S • DO NOT INTUBATE FOR MECONIUM ONLY • RESUSCITATIONS ARE PERFORMED FROM 22 WEEKS AND UP • DELAYED CORD CLAMPING 90-120 SECS FOR THE PREMATURE INFANT • FETAL THERAPY PERINATAL GROUPS SCHEDULE HIGH RISK FETAL PREGNANCIES TO DELIVER IN TERTIARY CENTERS • MATERNAL TRANSPORTS ARE INCREASING