RTH 226 - Unit 4, Assessment

APGAR 0-3

Depressed infant. Requires Resuscitation.

Nasal flaring

Dilation of nasal opening (infants are nose breathers). An attempt to achieve airway dilation to decrease airway resistance.

Silverman Score

Evaluates the level of respiratory distress in neonates, with the score being 0 - 10, 10 being the worst. Looks for chest movement, Intercostal retraction, Xiphoid retraction, nasal flaring, expiratory grunt.

Urine output

•Related to circulation and perfusion •Normally > 1-2 mL/kg for infants •Fluid overload is best monitored by weighing the baby

Regulation of breathing

•Response to decrease O2 is minimal. •Response to increase CO2 is minimal in premie •Tolerates hypoxia poorly •Apneic spells

Umbilical artery catheters (UAC)

•Tip is best placed just above the aortic bifurcation at the level of L3 - L4 (low position) •Frequent ABG sampling, continuous BP monitoring, infusion of fluids. •Low position: L3-4 •High position: T8 •Best position: T6

Stridor

•Upper airway obstruction, high pitched inspiratory sounds •Subglottic swelling - croup •Supraglottic swelling - epiglottitis •Foreign Body Aspiration

CBG

•Usually preferred for neonates and small infants •Clinical values is highly dependent on arterialization •Careful heating of the site without milking which can lyse cells and alter results •Ph, PcCo2, HCO3 correlates well with ABG but not oxygenation

Pulmonary vessels have increased PVR

•Very sensitive to constriction by hypoxia, acidosis and hypercarbia

Thermo-regulation

•When "cold stressed", infants will use more oxygen •At 35 C they will require 2Xs more oxygen •At 33 C they will require 3Xs more oxygen •Infants who cannot compensate will become hypoxemic, acidosis, and hypothermic •Infants can further develop severe apnea

Decreased breath sounds

HMD, atelectasis, pneumo, pleural effusion.

Bs: Bradycardia

HR< 100/min, regardless of time

Ds: Desaturations (SpO2)

Highly variable. Most clinicians allow for both the severity (<70) and duration (>20 sec). Brief desaturations with spontaneous recovery are seldom reported.

ABG normal values

Hours old •pH: 7.34 (7.33 in premature infants) •PCO2: 35 (47 in premature infants) •PO2: 50-70 newborns Days old •pH: 7.38 •PCO2: 36 •PO2: 60-90 infants, 80-100 children

Radiation

Attempting to warm a cold surface not in contact with skin.

Acrocyanosis

Blue extremities, centrally pink. A sign of peripheral vasoconstriction not hypoxia, not associated with respiratory distress.

Appearance

Blue or pale: 0 Acrocyanosis: 1 Pink: 2

Central pulses

Carotid Axillary Brachial Femoral

As: Apneas

Cessation of breathing >20 sec/episode.

Increased breath sounds

Consolidation, lobar pneumonia.

Convection

Cool gas blowing over skin surface.

Targeted Pre-Ductal SpO2 after birth

1 minute: 60-65% 2 minutes: 65-70% 3 minutes: 70-75% 4 minutes: 75-80% 5 minutes: 80-85% 10 minutes: 85-90%

Pulse in term infants

110-160bpm (faster in pre-term infants) Tachycardia: >170 bpm Bradycardia: <100 bpm

Cyanosis

5 grams of desaturated hemoglobin per 100 mL of blood. Usually from hypoxemia caused by shunting, V/Q mismatch or hypoventilation. To determine true cyanosis, check mucus membranes of the mouth and tongue and nail beds, not the extremities.

Normal pediatric pulse range

80-130 (decreasing with age)

Hypoglycemia

<40 mg/dl •Extremely important in development of newborn brain •Causes: infection, hyperinsulinism secondary to diabetes and inadequate glycogen stores secondary to being small for gestational age, cold stress and resuscitation

Hyperglycemia

>160 mg/dl Most often iatrogenic in origin. Causes: early signs of sepsis in infants, cord compression, stress before birth.

Head Bobbing

A sign of impending respiratory failure.

Grunting

A sound heard at the end of exhalation just before a rapid inhalation. Used to attempt to increase lung volume.

Delivery room bedside assessment

APGAR scores History- family, mother, pregnancy, delivery Gestational Age Weight General Appearance- color, chest configuration Breath sounds

Coarctation of the aorta

Absent pulses in legs.

Pulse

Absent: 0 <100: 1 >100: 2

Respirations

Absent: 0 Slow, irregular, weak crying: 1 Strong Cry, vigorous breathing: 2

Short apnea

Apnea for 10-20 sec; may be normal.

Respiratory pause

Apnea for 5-10 sec; normal.

Long apnea

Apnea for more than 20 secs; always abnormal.

APGAR

Appearance Pulse Grimace Activity Respiration Typically scored at 1 and 5 minutes.

5 minute APGAR score

Identifies how successful our efforts were.

1 minute APGAR score

Identifies how well the infant tolerated delivery.

Fine rales (crepitant)

In the alveoli.

APGAR 4-6

Indicates infant needs some assistance - warm, stimulate, give O2.

Absent breath sounds

Infants may be due to small thoracic cage; in pediatrics, may be due to pneumothorax.

Retractions

Intercostal Subcostal Substernal Supraclavicular Suprasternal

Activity (muscle tone)

Limp:0 Some flexion: 1 Active: 2

Evaporation

Liquid evaporating from skin surface.

Coarse rales (rhonchi)

Low pitches in large airways.

More anterior and cephalad larynx

Makes intubation more difficult

Medium rales

Middle airways.

Relatively large and U shaped epiglottis

More susceptible to trauma and forms more acute angle with vocal cord.

Relatively large head

Moving head forward (flexion) may cause airway obstruction.

Abnormal transition

PVR remains higher than SVR so shunts continue. This leads to hypoxemia. Nitric Oxide can help with oxygenation due to pulmonary hypertension.

Electrolytes (newborn values only)

Na+ = 133-149 mEq/L Cl- = 87-114 mEq/L K+ = 5.3-6.4 mEq/L (very important in neonates) HCO3/total CO2 content = 19-22 mEq/L

Relatively large tongue

Neck extension may not effectively relieve obstruction.

Grimace

No response: 0 Grimace: 1 Cry, cough, sneeze: 2

Unequal breath sounds

Pneumothorax, pleural effusion, pneumonia and atelectasis.

Obligatory nasal breather

Poor tolerance to obstruction. Treatment should be focused on nasal application (unless invasive). At birth suction mouth first, then nose

Peripheral pulses

Radial Posterior tibial Dorsalis pedis

APGAR 7-10

Routine care.

During normal transition

SVR becomes greater than PVR. Shunts resolve and that leads to normal gas exchange.

Neonatal Vitals

Temperature •36.5-37.0 C HR •110-160 bpm •100 when asleep •180 irregular when crying RR •30-60 breaths/min BP •60-80 mmHg (systolic) •40-45 mmHg (diastolic) SpO2 •95% preterm- 97% (full term), maintaining at roughly 90-95 % in preterm infants.

Blood glucose

The most frequent blood determination made in newborns Normal Values (mg/dl): •Preterm > 20 mg/dL •Term - 30-100 •Child - 60-105 •Thereafter - 70-110

Conduction

Touching cold or wet object.

As, Bs, Ds

While informal, it is common practice to refer to them in the NICU. It can be valuable form of reporting key events during hand off.

Rhonchi

Vibration heard during exhalation that clears with coughing or suctioning.

Assessment of x-rays

•Reasonable inspiratory effort places the diaphragmatic apex at the 6th anterior rib Et tube/trach •Optimum placement •T2-t5 •Head in neutral position Nasogastric tubes •Below the level of T9-T10 Chest tubes •To drain air: anterior portion of the chest, second intercostal space, midclavicular line •To drain fluid: between 4th and 5th intercostal space, midclavicular line

Vernix (commonly found on premature infants)

•A white fatty lipid substance •Acts to insulate and warm the infant

Scoring systems for assessing infant distress

•APGAR Score •Silverman Anderson system •New Ballard Score or Dubowitz

Dysmorphic features

•Abnormal weight, length, or head circumference and malformations •Congenital abnormalities usually occur in groups •Check chromosomes, heart disease, respiratory distress

Secondary apnea

•Associated with bradycardia or hypotension •Does not respond to oxygen and simple stimulation •Requires bag mask ventilation

Capillary refill

•Blanching the infants skin to see how long it takes for normal color to return •Longer than 3 secs may indicate decreased cardiac output

Palpating pulses on infants

•Brachial pulse infants <1 year because the radial is too small •Umbilical is easiest for palpation during delivery •Essential to palpate brachial and femoral pulses when suspecting cardiac defects •An infant can only increase their cardiac output by increasing their heart rate •Carotid pulse for infants >1 year •Both central and peripheral pulses should be palpated •Heart rate and rhythm should be assessed in context of the child's activity level, clinical condition, and underlying pathologies •Exaggerated difference between central and peripheral pulses suggest shock •Vasoconstriction causes peripheral pulses to become weaker •Weak central pulses require rapid intervention to prevent cardiac arrest

Initial care

•Clear the airway with a bulb syringe •Mouth first, then nose •Dry and keep warm

Scaphoid abdomen

•Consistent with diaphragmatic hernia •Resulting from bowel in the chest cavity causing a hollow or concave abdomen

VBG

•Drawing venous blood can often be done from existing catheterization but provides limited information •Assess perfusion of the site (temperature, color etc..) as drawing to ensure adequately correlated results.

Primary apnea

•Due to hypoxia •Improves with Oxygen and/or stimulation

Modified Dubowitz Score

•Estimates gestational age in very low birth weight infants •Scoring system uses 7 physical signs and 6 neurological findings to determine gestational age •Normal score of 40 corresponds to 40 weeks

Dubowitz Score

•Evaluates gestational age •Important to determine between a premature infant and one that is small for gestational age •Uses a combination of 7 physical and 6 neurological findings •The higher the score, the older the gestational age •Normal is 40, corresponding to 40 weeks •Higher is post term •Lower is preterm

Wheeze: bronchospasm

•Hyaline Membrane Disease (HMD) •Bronchopulmonary Dysplasia (BPD) •Asthma •Treat with bronchodilator (wheezing may increase with increased flow) •Watch for unilateral wheezing, may indicate foreign body

Causes of tachycardia in infants

•Hyperthermia •Heart disease •Pain •Crying •Drugs

Causes of tachypnea in infants

•Hypoxemia •Metabolic and respiratory acidosis •Congenital heart disease •Anxiety •Fear

Causes of bradycardia in infants

•Hypoxia •Heart Disease •Valsalva maneuver •Drugs

Pre and Post-ductal blood gas

•If a right to left shunt occurs through the ductus arteriosus, the PaO2 levels from the right arm (pre-ductal) often exceeds the PaO2 taken from the umbilical artery or a lower extremity •PaO2 differences greater than 15mmHG indicates right to left shunt across the ductus arteriosus

Umbilical vein catheters (UVC)

•Immediate access for an emergency situation, continuous infusion of medications, fluids •Best position: 0.5-1 cm above the diaphragm •Avoid placement in the right atrium

Alveoli: Increase closing capacity

•Increase air trapping and decrease collateral circulation of air •No pores of Kohn •Without surfactant, alveoli will collapse because they will have high surface tension thus lung compliance is low

Chest wall

•Increase compliance due to weak rib cage •Increase A-P diameter •Ribs horizontal •Breathing is all diaphragmatic, FRC determined solely by elastic recoil of lungs •Chest wall collapses with negative pressure

Cricoid is the narrowest portion of airway

•Increased resistance with airway edema or infection •Acts as a "cuff" during tracheal intubation

Trachea: small diameter (6mm)

•Increased resistance with airway edema or infection, collapses easily with neck hyperflexion or hypertension •High compliance

Work of breathing

•Increases at lower rates •Weak respiratory muscles •Increased RR equals early sign of respiratory distress

Transillumination

•Indicated when an infant exhibits asymmetrical chest movement with respiratory distress and decreased breath sounds •A bright fiberoptic light is placed against the infant's chest in a darkened room •Normally a lighted "halo" is seen around the point of contact •A pneumothorax or pneumomediastinum will cause the entire thorax to light up (brightly illuminated) •A decrease in illumination may indicate diaphragmatic hernia, an absent hemidiaphragm or consolidation

Seesaw respirations

•Inspiration: chest retracts, abdomen expands •Expiration: chest expands, abdomen retracts •In neonate: some are normal.

Causes of bradypnea in infants

•Medications (narcotics) •Hypothermia •CNS disease •Lung disease

Temperature

•Normal 36.5 C •Infants lose heat quickly •Often must be kept warm using incubators and radiant warmers •Servo controllers use sensors placed on the infant's skin to automatically adjust the temperature

Respiration rates

•Normal for term: 30-60 b/min •Normal for child: 16-25 b/min •Adolescent +12 years: 12-20 b/min •Bradypnea in infants: <30/min •Tachypnea in infants: >60/min •A RR < 10 and > 60 in any child is abnormal and requires assessment •An irregular breathing pattern doesn't always indicate a problem •Periodic breathing: common finding with premature babies characterized by intermittent respiratory pause >5 seconds

Birth weight

•Normal term infant- >3000gms •28 weeks - 1000 gms •The lower the birth weight, the higher the risk of respiratory problems

Blood pressure

•Preterm infant- 50/30 mm/Hg •Normal term infant- 60/40 mmHg •Infant- 9060 mmHg •Child: 100/60 mmHg •Increases with stress, hypoxia, sepsis •Decreases with shock, severe stress, severe sepsis

Lab data

•RBC - 3.8-7.1 million/cu mm •Hb - 11-18 g/dl •HCT - 35-54% •WBC - 5,000 - 30,000 per cu mm •COOMB'S test- used only in neonates to evaluate blood type compatibility (Rh+ or Rh-)