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#54 Not In My Box!


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#41 onearmwonder

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Posted 09 June 2011 - 03:15 PM

Sean does she have a pulse with the rhythm and rate change?
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#42 SerendepitySaki

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Posted 09 June 2011 - 03:37 PM

thanks YSU! important thing about labs, physical assesment, etc... ALWAYS ALWAYS ALWAYS know BASELINE for your patient!

and you're right, it just aint gonna matter in terms of what you do for this lady.....(maybe later, we'll talk about BNP and the circumstances under which that is elevated!)


and speaking of good BLS before ALS onearm...

no, she does NOT have a pulse and is back in V-FIB on the monitor... but yeppers.... i WOULD have merrily let y'all go down the wrong algorithm if you had NOT cycled the cuff, checked a pulse, whatever..... B)


we now return you to your regularly scheduled scenarios....



mom in pulseless arrest, presumably from an MI, and meconium stained baby half in / half out with 360 nuchal cord....


and in terms of post-ROSC management, assuming you get that far.... of course, there is at least one other resource, y'all might want to be asking about/mobilizing...

.
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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#43 ysumedic05

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Posted 09 June 2011 - 04:21 PM

Ok let me see if I can take a swing at this. First lets go over baby: Follow NRP at this point, attempt to remove cord from around neck without stimulating too much, have intubation equipment, meconium aspirator, suction, umbilical catheter kit, epi and all that good stuff by the warmer. After taking care of the nuchal cord help baby out the rest of the way. Do some tracheal suctioning until meconium is cleared out then stimulate baby. Now onto mom: Defib 200J biphasic, start compressions, make sure IV access is established, intubate, 300 mg Amiodarone IVP, rhythm check in 2 minutes. If we do happen to get ROSC we need to think about therapeutic hypothermia if our destination facility is so equipped.
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Justin Koper FP-C, NREMT-P

#44 MSDeltaFlt

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Posted 10 June 2011 - 03:44 AM

Unless Sean gives us evidence otherwise I'm going to say this is walking like a duck and sounding like a duck so I'm going to call this a duck.

First off, get junior out of there and make sure he/she is all there is during CPR. Sounds like Momma just through an amniotic/muconium embolus. It also sounds like it might be somewhere high up in the cardiac vasculature judging from the back and forth rhythm changes. If we don't get her back soon I doubt we will get her back at all.

Just my thoughts so far.
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Mike Hester, RRT/NRP/FP-C
Courage is resistance to fear, mastery of fear - not absence of fear -- Mark Twain

#45 pureadrenalin

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Posted 10 June 2011 - 06:13 AM

thanks for beating me to the punch ysumed...I was just a little slow to respond. Posted Image
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#46 SerendepitySaki

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Posted 11 June 2011 - 11:47 AM

plenty of love for everyone PA... you can handle the BNP/ cardiac "enzyme" issue for later if you want...especially in peripartum cardiomyopathy really just for information purposes only... probably not going to significantly change YOUR mgt... but, the potential dx itself IS well worth considering in terms of post ROSC mgt...

Mike! so very good to hear from you! evidence as to "duckiness" (or lack thereof .....B) ) will be forthcoming... and as always, excellent leap on the EKG...

Justin, just curious...is there some reason you went straight to amio, vs. giving epi? rocking the NRP... how do we "take care of the nuchal cord"?
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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#47 FlyingScot

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Posted 11 June 2011 - 09:03 PM

So what does the kiddo look like once he/she's out?
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#48 SerendepitySaki

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Posted 11 June 2011 - 09:17 PM

scot, he's an FLK... in the middle of tutoring session... probably update in detail tomorrow.... ask me more better questions for more better answers (typical NRP assessment questions anyone?)
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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#49 FlyingScot

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Posted 12 June 2011 - 02:58 AM

OK, is the nuchal cord tight or short and/or impeding the delivery in anyway? Most of the time the infant can be delivered without doing anything. If the cord is tight or impeding delivery and depending how many loops are involved you can either slip it over the baby's head or clamp and cut. If you go the clamp and cut route you must deliver the baby immediately. The baby is meconium stained is it thick or thin? Is it really meconium or is it bile? Thin meconium or bile does not require intubation for suctioning. Thick meconium does. If tracheal suctioning is necessary try not to stimulate the baby until you have done this particularly because there was no time to suction on the perineum. Is there a heart rate or respiratory effort. Grunting, flaring, retracting? Initial APGAR? I figured there was going to be some sort of congenital issue with the history of polyhydramnios. FLK isn't specific. What kind of abnormalities are we seeing. Are there mid-line anomalies, any extremity anomalies, is the abdominal wall closed? How about the cranium? Are the anomalies compatible with life? How big is the kid? SGA,LGA or IUGR? How is he responding to stimulation? What is his color (under the green)? Tone?
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#50 SerendepitySaki

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Posted 13 June 2011 - 01:42 AM

excellently well stated, sir (or ma'am)...not that you needed me to tell you that... I just like for these case studies to serve as reviews and references, so i prefer things spelled out and where appropriate, referenced... thank you for taking the time to type out those superb thought processes! freaking AWESOME!


will answer all of these and more tomorrow....
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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#51 SerendepitySaki

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Posted 13 June 2011 - 08:56 PM

to get you started:

A. team splits...mama being coded per current ACLS algorithms...

1. You easily resolve 360 nuchal cord by gentle manipulation of infant and cord. (if anyone who does NOT know pros and cons of clamping and cutting nuchal cords and wishes to discuss, feel free to ask and/or discuss...otherwise, we will review in after action debrief...not necessarily an issue in this case)

FOR NOW, cord remains intact...current time is seconds after assisted delivery....

2. Thick mec/REAL mec

3. obviously microcephalic

4. APGAR:
Appearance...global pallor/ central cyanosis difficult to assess, secondary to inherent infant skin tone
Pulse............aprox 80
Grimace........only upon stimulation... weak
Activity.........minimal...floppy, by and large does not pull back...
Respirations...Irregular, Few, Weak and Gasping
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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#52 MSDeltaFlt

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Posted 13 June 2011 - 10:25 PM

to get you started:

A. team splits...mama being coded per current ACLS algorithms...

1. You easily resolve 360 nuchal cord by gentle manipulation of infant and cord. (if anyone who does NOT know pros and cons of clamping and cutting nuchal cords and wishes to discuss, feel free to ask and/or discuss...otherwise, we will review in after action debrief...not necessarily an issue in this case)

FOR NOW, cord remains intact...current time is seconds after assisted delivery....

2. Thick mec/REAL mec

3. obviously microcephalic

4. APGAR:
Appearance...global pallor/ central cyanosis difficult to assess, secondary to inherent infant skin tone
Pulse............aprox 80
Grimace........only upon stimulation... weak
Activity.........minimal...floppy, by and large does not pull back...
Respirations...Irregular, Few, Weak and Gasping


I was going to ask how tight the cord was and if it had a pulse and what color was the head and body, but that's now moot.

Break out the broslow tape (or equivalent) and grab a tube for suctioning with meconium aspirator. I'm betting it'll be a 2.5 maybe a 2.0. Suction that out with CPR then intubate and bag. Dry vigorously and get a UVC line. A UAC might not be a bad idea if junior pops back. If and when he/she/it (if hermafaditic ?sp?) We'll discuss vent settings.
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Mike Hester, RRT/NRP/FP-C
Courage is resistance to fear, mastery of fear - not absence of fear -- Mark Twain

#53 FlyingScot

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Posted 14 June 2011 - 01:32 AM

Serendipity, need an approximate weight on this kid for further interventions. MS not sure a 2.0 is gonna do it for thick mec. I haven't seen one used for anything (airway or mec) even on ELBW babies since the late 80's. Down and dirty UVC: use an 18 gauge angio WITHOUT the stylet. Also, is the microcephaly an isolated anomaly? Once an airway/ventilation is established the heart rate will likely stabilize. We're lucky the kiddo was born with a rate of 80. No heart rate would have made this much uglier.
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#54 SerendepitySaki

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Posted 14 June 2011 - 01:37 AM

~ 2kgs...and remember...that was the IMMEDIATE presentation...further anomolies may or may not be revealed and 80 was by palp...past performance is no guarantee of future results.....getting slower by the second...
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Sean G. Smith, RN-Alphabet Soup

#55 ST RN/PM

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Posted 15 June 2011 - 12:53 PM

Sean,
Great case! I believe I owe you a phone call or two......had more questions and forgot to call back.........
Anyway, seeing how things go, I have begun to think about which congenital heart defect you are gonna throw our way..... but as Scot says, ventilate.....observe heart rate/color/Sp02/Capno if you can get a wave.....the heart rate should come up after suctioning and effective ventilation. MS..... compressions during airway/ventilation procedures or after these attempts are ineffective? NRP would have you do one before the other.... no? (Go easy, litle ones just aint my bag, baby)....oxygenation depends on the plumbing of this child, microcephaly has me extremely concerned for a heart defect as well.....Scot, an 18 g angio without the needle as a UVC...... niiiiice. Effective?
Mom is not oxygenating well during her ALCS algorithmic code, is she? Awesome case and review esp. for those of us that do primarily adult patients. Thanks for all responses.......Mike Mac would be proud. Steve
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Steve T. RN, PM

#56 SerendepitySaki

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Posted 15 June 2011 - 01:38 PM

steve! i wondered what happened to you... new #, so e-mail...as always, a pleasure and very much looking forward to talking with you...


speaking of assessment... anyone want to tell me HOW you're monitoring mum during resus and what you're looking for interms of wave forms, numbers, etc.... both to assess quality of CPR and ROSC? and, please tell me relative to YOUR equipment...that you carry...

meanwhile, neo is cleaned up/ warm dry suck stim in appropriate order... activity improves briefly in response to stimulation... before you get monitoring attached, while you're setting up to drop a tube, the baby appears to begin choking on their own secretions...
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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#57 FlyingScot

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Posted 15 June 2011 - 10:13 PM

And the zebra has arrived. Try to pass an OG down the babe...bet it doesn't pass more than a few centimeters. Measure how far it's in secure it and put it to continuous suction because unless I've gone stupid we have ourselves a tracheo-esophageal fistula (mid-line anomaly anyone?). Are the kid's hands on straight and where is the PMI?
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#58 SerendepitySaki

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Posted 15 June 2011 - 11:48 PM

sooooooo..... we didn't even have to make it to persistent gastric insufflation...

along with mgt of momma, who wants to discuss types of tracheo-esophageal fistulas in _________ Syndrome?

as well as some possibilities with regards to emergent airway management...

also, in terms of vascular access on this little guy, for the record, i'd like someone to please spell it out, step by step....

anyone want to chime in on Flying Scot's assessment questions, along with your thought processes?


THE zebra? as in ONLY one? can't you hear the hoofbeats?....stand by.... after y'all definitely nail airway mgt, etc there's more certification exam review to come! B) (besides...the polyhydramnios and the microencephaly make them less zebra-ish and more of a "horsey" certainty....)
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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#59 FlyingScot

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Posted 15 June 2011 - 11:57 PM

Don't have time to post much and don't want to hog all the space but the syndrome you're looking at is likely VATER or sometimes called VACTERL syndrome. I'll let ya'll google that but suffice it to say these kids are messed up...however they are typically normal intelligence although this kid is microcephalic which doesn't bode well for his future. As far as airway, very frequently the cords are extremely anterior in these kids which can make them a beast to intubate.Anyone else want to play?
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#60 SerendepitySaki

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Posted 16 June 2011 - 12:19 AM

yeppers.... i discarded feingold syndrome as too easy for y'all... have fun getting all google-liscious folks! B)

just the basics of ACLS capnography and NRP, + advanced airway mgt critical thinking should be a good start....

before we get into a little CHD, etc........
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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup