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#56 Carpe Diem!


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#1 SerendepitySaki

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Posted 16 June 2012 - 04:29 PM

You are called to the ER for a readmitted 4 day old newborn ...Complaint of depressed mental status, irregular respirations, possible seizure activity. Patient reportedly unresponsive to initial dose of rectal benzodiazepine.
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Sean G. Smith, RN-Alphabet Soup

#2 Sue

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Posted 16 June 2012 - 08:29 PM

You are called to the ER for a readmitted 4 day old newborn ...Complaint of depressed mental status, irregular respirations, possible seizure activity. Patient reportedly unresponsive to initial dose of rectal benzodiazepine.


Sean,

This is wide open territory here and since newborns are not my favorite, I say live and learn and take the beatings as they come.
First, start with the simple stuff- like managing baby's airway and circulatory status. What does he look like centrally and peripherally?
What was Mom's pregnancy history? Any infections, illnesses, medications (legal or not) used during pregnancy.
Was baby early or late?
Could we consider other benzos?
What are baby's electrolytes like? Draw blood when we get line.
Things to consider...trauma, infection, drug withdrawal, genetic issues, hemorrhage?
I will stop there.

Sue
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Sue Toberman, RN

#3 SerendepitySaki

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Posted 16 June 2012 - 08:39 PM

Airway: patent.

Breathing: uncoordinated, poor air movement, CTAB throughout.

Circulation: central/distal pulses intact and =, cap refill 2 sec, periorbital edema

Disability: actively seizing

Exposure: skin clear and intact throughout. trunk /extremities mildly cool....

Pertinent Medical Hx:

- full term child of non-English speaking migrant worker first time single mother....
- does not appear syndromic and ER staff tells you mom delivered here 4 days ago...
- no Hx maternal drug use.

how would you like to rule in/out trauma, infection, hemorrhage?
how would you like to consider other benzos?
how would like to obtain electrolytes?
how would you like to establish access?
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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#4 Sue

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Posted 16 June 2012 - 09:25 PM

Airway: patent.

Breathing: uncoordinated, poor air movement, CTAB throughout.

Circulation: central/distal pulses intact and =, cap refill 2 sec, periorbital edema

Disability: actively seizing

Exposure: skin clear and intact throughout. trunk /extremities mildly cool....

Pertinent Medical Hx:

- full term child of non-English speaking migrant worker first time single mother....
- does not appear syndromic and ER staff tells you mom delivered here 4 days ago...
- no Hx maternal drug use.

how would you like to rule in/out trauma, infection, hemorrhage?
how would you like to consider other benzos?
how would like to obtain electrolytes?
how would you like to establish access?


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Sue Toberman, RN

#5 Sue

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Posted 16 June 2012 - 09:38 PM

Okay. First and foremost- let's assist baby's airway and breathing with BVM and 100% O2 since it sounds like he is not ventilating well. If we cannot establish a peripheral or scalp line suddenly, I would elect for the EZ IO. I would then consider Ativan at 0.05-0.10 mg/kg IV to stop sz activity. I may consider Versed as an alternative at 0.05-0.10 mg/kg IV, too. I would also be prepared to intubate once I got access, as well.
I would at the least do a glucose stick. If I get peripheral access I would consider Chemistry, CBC, ABG, etc.
First priority is maintaining the airway and arresting the seizures. Once I get that stopped. I would start looking for my zebras.
I will throw this out as well, how about phenobarbitol, Dilantin or phosphenytoin? Not 100% sure of the dosages, so I need to look those up.
Will come back for more in a bit.
What is his temperature?
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Sue Toberman, RN

#6 SerendepitySaki

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Posted 16 June 2012 - 09:54 PM

euglycemic and normothermic

while you're looking those up and setting up your EZ-IO, we'll pause for station identification and give the other kids a chance to play....
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#7 TexRNmedic

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Posted 17 June 2012 - 12:34 AM

I like Sue's tx so far.

To recap plus my $0.02

O2 by infant BVM. Broslow tape out.
Keep the kiddo euthermic.
Monitor- ECG, SPO2, NIBP, ETCO2
Vascular access. PIV if quick. I prefer an Illinois bone needle IO for kiddo this size and age. BGL and iSTAT CG8 (this is what I would usually have immediately available). VBG and lactate if available at the sending facility quickly.
Accurate patient weight and since it is probably available, patient's discharge weight.
Benzos- ativan 0.1mg/kg first dose, 0.05mg/kg additional doses- caution if benzyl alcohol but we are about to intubate.
Atropine and fentanyl. ETT per Broslow.
Based on presentation (color, mottling, vital signs) consider IVF bolus.
Reassess interventions to this point.
H&P- Fontanels, description of seizure activity, head to toe exam looking for infected scalp monitor site, umbilicus, rash, or trauma. Abdomen assessment, especially liver palpation.
PO intake history, diaper count and stool consistency.
MOM'S GBS STATUS AND ANY TREATMENT?!!!!!!
If I am really feeling frisky- pre and post ductal SPO2. May play with the Sonosite in a bit if something raises my CV suspicion.
Phone call to the attending back home regarding anticonvulsants and abx tx.
Another reassessment to this point, vital signs and start packing for the road.
DDX- Meningitis/sepsis with GBS high on the list. Atypical cardiac presentation. Some sort of congenital neurological disorder/ malformation or metabolic disorder. Trauma. Toxic exposure.

Transfer modality and travel time to tertiary care? That should get a pretty good start at stabilizing.
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Wes Seale
Houston , TX

#8 SerendepitySaki

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Posted 17 June 2012 - 12:45 AM

nothing freaky deaky y'all, just good ole review of basics.... this one's short and schweet.... (no pun intended...kid's euglycemic and stays that way.... ) B)
everything more or less spot on so far...

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

#9 SerendepitySaki

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Posted 17 June 2012 - 11:12 AM

While we give other folks a chance to chime in....here's a little con-ed....

Reduction in Red Blood Cell Transfusions Using a Bedside Analyzer

http://www.nature.co...s/7211201a.html


and for those that haven't found it yet,

some VERY good technical Information about how each test works on an iStat, what will confound it, etc.....

http://www.abbottpoi...nfo-Sheets.aspx
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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#10 SerendepitySaki

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Posted 18 June 2012 - 02:35 PM

wes and sue... i'm going to go w/ the hypothesis that y'alls dynamic duo is so awesome that you scared everyone else off....:P


Na+ 115 mEq/L....

WHY?

What might your other lab values be and why? (in general)

What NOW?

as always, where appropriate, please reference your answers and thanks for playing! B)


anyone else want to chime in?
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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#11 TexRNmedic

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Posted 18 June 2012 - 02:47 PM

More in depth answer later. Best guess this kiddo is formula fed and mom is cutting it with extra water. Hyponatremic sz. More thoughts when I have a full keyboard.
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Wes Seale
Houston , TX

#12 Sue

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Posted 19 June 2012 - 12:43 AM

[quote name='SerendepitySaki' date='18 June 2012 - 10:35 AM' timestamp='1340030100' post='29471']
wes and sue... i'm going to go w/ the hypothesis that y'alls dynamic duo is so awesome that you scared everyone else off....:P


Na+ 115 mEq/L....

WHY?

What might your other lab values be and why? (in general)

What NOW?

as always, where appropriate, please reference your answers and thanks for playing! B)


anyone else want to chime in?

I just chimed in because I see the itty bitties so rarely. I am with Wes, and by the way, we can be partners anytime! Baby is hyponatremic with too much water on board. I am going to do some research and hope that some of my peers across the scope of this forum decide to ring in.

Sue
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Sue Toberman, RN

#13 STPEMTP

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Posted 19 June 2012 - 01:24 AM

Sorry for getting in late, computer has been on vacation pending retirement........ ugh....

History requested: Any problems with pregnancy? Any other children? (if so, any problems with them?)

Initial assessment: agreeing with Sue and Wes's treatments so far. (Wes: pre and post ductal SPo2? assuming R and L hand SPo2 readings?)

NA of 115....
thinking hyponatremic strong possibility cerebral edema additional problem here.

DDx: Shaken baby, Inborn error of metabolism (? impaired glucose metabolism. specific disorder escapes me at moment), 2nd hand recreational drug use

I'll try to post more tomorrow. Off to the books to review the little ones to give better answers.......
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#14 SerendepitySaki

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Posted 19 June 2012 - 01:12 PM

maternal and neonatal hx otherwise unremarkable and noncontributory...up to this point...

strong work by all and nice additions by STEMTP... keep working it, y'all...


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

#15 TexRNmedic

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Posted 19 June 2012 - 04:28 PM

[Quote name='STPEMTP' date='18 June 2012 - 08:24 PM' timestamp='1340069069' post='29479']

Initial assessment: agreeing with Sue and Wes's treatments so far. (Wes: pre and post ductal SPo2? assuming R and L hand SPo2 readings?)

NA of 115....
thinking hyponatremic strong possibility cerebral edema additional problem here.


Pre and post ductal spO2 is a cheap and easy way to evaluate for right to left shunting thanks to a PFO or PDA. >3% different is reliably significant for r->l shunt. Right arm and a lower extremity site should be used. Valuable as a spot check but much more useful as a trend when titrating FiO2 levels and monitoring changes in r->l shunt. Ever seen a kid turn blue while crying? And here is a more elaborate explanation of neonatal spO2 monitoring. http://www.rtmagazin.../1998-04_04.asp

So hyponatremia- we need to determine the kiddo's fluid volume status to decide on management and to aide us in determining the etiology. I think the most important concept in correcting lytes is if it was slow to break (hours or days) we should be relatively slow to fix it. So this kiddos Na should be corrected at rate of about 10 meq a day, so tomorrow his Na should be around 125ish.

So if this kiddo looks dry (on only the fourth day of life) is it from GI loss or renal loss. Isotonic fluid correction with a dextrose including IVF. We know the glucose is normal, but hyperglycemia may lead to big fluid and lyte loss.


If the kiddo is euvolemic- water intoxication from formula dilution, adrenal insufficiency, hypothyroid, SIADH. Water restriction to maintain euvolemia and correction of the underlying pathology. Hypertonic Na, but I'm going to leave that to a nephrologist or intensivist to manage in an ICU setting.

Hypervolemia- This is why I was asking about the possibility of heart failure or some sort of CV abnormality (pre and post ductal spO2 and a quick peek with the sonosite if I suspected cardiac etiology). Also why I was interested in a careful palpation of the liver looking for hepatic disease or a fluid overload creating a large liver. Renal disease is also a consideration.

So with my CG8 results in hand I would call my intensivist back home and let them make the decision regarding IVFs, manitol, or hypertonic Na.

Serum and urine osmo and Na would be a big help for ICU management, but my goal right now is life support and getting them to the ICU with limited brain injury from seizures or worsening cerebral edema.

BTW foley cath with a urometer needs to be done soon if not already done.

Here is a cool hypo- na algorythm I found on a quick search of the web.

http://www.cleveland...yponatremia.htm
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Wes Seale
Houston , TX

#16 BrianACNP

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Posted 19 June 2012 - 04:55 PM

[quote name='TexRNmedic' date='19 June 2012 - 12:28 PM' timestamp='1340123327' post='29481']
[Quote name='STPEMTP' date='18 June 2012 - 08:24 PM' timestamp='1340069069' post='29479']

Initial assessment: agreeing with Sue and Wes's treatments so far. (Wes: pre and post ductal SPo2? assuming R and L hand SPo2 readings?)

NA of 115....
thinking hyponatremic strong possibility cerebral edema additional problem here.


Pre and post ductal spO2 is a cheap and easy way to evaluate for right to left shunting thanks to a PFO or PDA. >3% different is reliably significant for r->l shunt. Right arm and a lower extremity site should be used. Valuable as a spot check but much more useful as a trend when titrating FiO2 levels and monitoring changes in r->l shunt. Ever seen a kid turn blue while crying? And here is a more elaborate explanation of neonatal spO2 monitoring. http://www.rtmagazin.../1998-04_04.asp

So hyponatremia- we need to determine the kiddo's fluid volume status to decide on management and to aide us in determining the etiology. I think the most important concept in correcting lytes is if it was slow to break (hours or days) we should be relatively slow to fix it. So this kiddos Na should be corrected at rate of about 10 meq a day, so tomorrow his Na should be around 125ish.

So if this kiddo looks dry (on only the fourth day of life) is it from GI loss or renal loss. Isotonic fluid correction with a dextrose including IVF. We know the glucose is normal, but hyperglycemia may lead to big fluid and lyte loss.


If the kiddo is euvolemic- water intoxication from formula dilution, adrenal insufficiency, hypothyroid, SIADH. Water restriction to maintain euvolemia and correction of the underlying pathology. Hypertonic Na, but I'm going to leave that to a nephrologist or intensivist to manage in an ICU setting.

Hypervolemia- This is why I was asking about the possibility of heart failure or some sort of CV abnormality (pre and post ductal spO2 and a quick peek with the sonosite if I suspected cardiac etiology). Also why I was interested in a careful palpation of the liver looking for hepatic disease or a fluid overload creating a large liver. Renal disease is also a consideration.

So with my CG8 results in hand I would call my intensivist back home and let them make the decision regarding IVFs, manitol, or hypertonic Na.

Serum and urine osmo and Na would be a big help for ICU management, but my goal right now is life support and getting them to the ICU with limited brain injury from seizures or worsening cerebral edema.

BTW foley cath with a urometer needs to be done soon if not already done.

Here is a cool hypo- na algorythm I found on a quick search of the web.

http://www.cleveland...yponatremia.htm
[/quote]

It is important to ascertain the reason for the hyponatremia as to whether or not it's acute vs chronic as the rate of correction is slower for chronic hyponatremia with central pontine myelinolysis as a catastrophic consequence of too rapid a correction. That said, remember that the threshold for seizures is lowered once the Na+ falls below ~ 120. So, regardless of the etiology for hyponatremia, the Na+ needs to be repleted more rapidly if the patient has serious mental status changes related to the hyponatremia. The more rapid correction occurs until the neurologic sympotoms improve, then you slow the rate of correction and go through the algorithmic process of determining the etiology for hyponatremia....in this case, I would increase the Na+ to stop the seizure activity....or at least take Na+ out of the equation for the etiology of seizures. And how do you raise the Na+ acutely? Likely hypertonic NS, at least in the adult world. I may be corrected for the peds world, but the key is to give Na+, not fluid restrict, etc.

Had a similar case like this back in my RW days of a mother who diluted formula w/ free water. The Na+ was 116 w/ an actively seizing child...seizure refractory to benzos, anti-epilectics, etc. What stopped the seizure? Raising the Na+ to a level that raised the threshold for seizures, which most texts I believe will say around 120(ish).

Other lesson for this post: For actively seizing patients (both adult and peds), know what your electrolytes look like. In my snipet above, the referring institution didn't appear to have an idea that the Na+ was low. The referral folks likely raised the Na+ with all of the NS pushes with the med administrations b/c the patient was seizing when I got there.

Sorry, Sean! Back to the scenario!

Food for thought.

Brian
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Brian, MSN, ACNP, CCRN

#17 TexRNmedic

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Posted 19 June 2012 - 06:17 PM

So hyponatremia- we need to determine the kiddo's fluid volume status to decide on management and to aide us in determining the etiology. I think the most important concept in correcting lytes is if it was slow to break (hours or days) we should be relatively slow to fix it. So this kiddos Na should be corrected at rate of about 10 meq a day, so tomorrow his Na should be around 125ish.

So if this kiddo looks dry (on only the fourth day of life) is it from GI loss or renal loss. Isotonic fluid correction with a dextrose including IVF. We know the glucose is normal, but hyperglycemia may lead to big fluid and lyte loss.



Good points B. Dosing hypertonic Na in a kiddo is far beyond my realm of expertise and experience. Hence the phone call to the experts. Betting K, Mag, & Ca are likely out of whack too (but not need as emergent of correction).

To clarify my statement above, after rereading it may be misleading. Hyperglycemia, as in DKA or HHNK, would lead to fluid and lyte loss. This neonate needs IV glucose as kiddos this age have poor glucose/glycogen stores and will quickly become hypoglycemic. ADD- had two thoughts going at the same time.
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Wes Seale
Houston , TX

#18 BrianACNP

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Posted 19 June 2012 - 06:59 PM

Good points B. Dosing hypertonic Na in a kiddo is far beyond my realm of expertise and experience. Hence the phone call to the experts. Betting K, Mag, & Ca are likely out of whack too (but not need as emergent of correction).

To clarify my statement above, after rereading it may be misleading. Hyperglycemia, as in DKA or HHNK, would lead to fluid and lyte loss. This neonate needs IV glucose as kiddos this age have poor glucose/glycogen stores and will quickly become hypoglycemic. ADD- had two thoughts going at the same time.


I should emphasize while I'm thinking about it.....the correction for ACUTE hyponatremia without neurologic deterioration is about 8-10 mmol/day....and some may be a little more conservative than that....I recall a case where an individual was appropriately replaced at ~ 10mmol/24hr and still suffered CPM as a catastrophic consequence...and folks, that is a permanent problem!

For chronic hyponatremia, the rate of correction in asympomatic individuals is roughly half of the correction for acute hyponatremia.

No one here is really going to worry about figuring out how to correct a hyponatremia unless you plan to be with that patient for quite a while...it's usually done in an ICU. You may not have all the resources (and perhaps time) to do it....but you do need to intervene when the Na+ is critically low. Even if it's not the underlying etiology for the baby's presentation, that piece will need to be managed as it's critially low.


Brian
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Brian, MSN, ACNP, CCRN

#19 SerendepitySaki

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Posted 20 June 2012 - 12:16 AM

running and gunning folks....more than a little gratified by the quality of conversation on this one.... STRONG work!

here is some additional germane food for thought:

http://pediatricneur...lfonso/pg42.htm








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

#20 onearmwonder

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Posted 20 June 2012 - 03:41 PM

Even though the glucose is normal, we still don't know physical features of the kiddo. Also think about other differentials i.e. Adrenal problems.... Congenital Adrenal Hyperplasia and so on... Just a thought...

Matt
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