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# 58 Bitty Baby


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#1 SerendepitySaki

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Posted 03 August 2012 - 09:49 PM

In honor of my Neonatal-Transport Certification (C-NPT) review text (vol I) coming out later this month,

(and co-authored NPS review text on track for 1st quarter 2013)...

let's do a bitty baby!

(and yes, this case IS an artificial construct to illustrate MULTIPLE specific items directly from the C-NPT blueprint....)

Lead In:
You get the following report from dispatch…2 w/o VLBW (1.4 kg) delivered at 28weeks, hx of RSI at birth, enteral feeds. To be transported for transient apnic and bradycardic spells. Vital Signs currently within normal limits.

ROE: you can have anything you want, you just have to ask... and yeppers, there will be at least two or more follow-on questions that reinforce specific C-NPT blueprint items...
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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#2 Northtoalaska

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Posted 04 August 2012 - 03:58 AM

Meds? Oxygen requirements?
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#3 neorn606

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Posted 04 August 2012 - 05:08 PM

I'll start with the initial response......here's what I want.......

Team: neonatal transport team (either specialty team or specifically trained for these itty-bittys).
Isolette (fully loaded): capability to maintain neutral thermal temp range (insulating cover in colder climes, sun shield in the desert regions).
Cardiac/Resp/NIBP/Temp/InvBP monitor capable of opperating all parameters in NEO mode, appropriate size BP cuffs (prob #2).
Gel Mattress: preheated in isolette, to help with positioning, dampen vibration/motion
Fully stocked neo response bag, these item in particular: Premie nasal cannula, RAM cannula (can deliver NC, nCPAP and niVent), syringe pumps (infant most likey on TPN, maybe on early light tube feedings)
Security: reliable method to contact Medical Director (neonatologist preferably)

Would like to know infant's history, at 2 weeks old at this size is probably significant....

Maternal facts: GP or GTPAL even better, complications of pregnancy, labor or delivery, method of delivery (vag or csec), location of the delivery (tertiary center, I hope, could have been community hosp L&D, ED in hospital with no OB, clinic, highway or home), infections?, nutrition choice(breast or bottle)
Birth history: weight, APGARS, resuscitation needs at birth, inital course and support
Present Condition: O2 support needed, frequency of A's and B's (with or without desats), reqiure spontaneously or need stimulation or bagging to recover, on any meds (caffeine - set up the Coffee Bar!), results of head US (head clean of intraventricular bleeds, ventricles normal size, any other significant findings contributing to CNS status)), any other meds, IV access, NPO or feedings methods and amount, blood sugar (recent and current), why can't this infant be taken care of where is he currently?, why is transport needed?, medical necessity or elective (mom delivered away from home, wants to return closer to home), what's the length of our transport? Any family riding along?

OK I am prepared. What's next?
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#4 neorn606

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Posted 04 August 2012 - 10:40 PM

For those of you that missed the "Coffee Bar" comment.........[url="http://www.youtube.c...?v=Hg0w2bJ7YaU"[/url]
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#5 SerendepitySaki

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Posted 04 August 2012 - 10:47 PM

B)
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LET THE WILD RUMPUS BEGIN !!!!!!
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#6 SerendepitySaki

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Posted 08 August 2012 - 08:29 PM

anyone have anything to add to neoRN606 and northtoalaska?
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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#7 SerendepitySaki

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Posted 10 August 2012 - 01:47 PM

With exception of mild tachycardia, VitalSigns currently within normal limits. Labs significant for leukocytosis, thrombocytopenia, and slight metabolic acidosis. Currentlypresents with lethargy, and abdominal distension.
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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#8 FlyingScot

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Posted 10 August 2012 - 11:50 PM

Babygram! Babygram! Babygram! AP and lateral decubitus please!
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#9 SerendepitySaki

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Posted 11 August 2012 - 12:00 AM

because it's YOU, FS,.... i'll even give you a little extra... positive guaiac, and please see attached....

Attached Files


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

#10 neorn606

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Posted 11 August 2012 - 04:44 PM

S.S. - I am unable to open the file - even when logged in. What am I missing?

For this itty-bitty with symptoms described....
NPO
Place a 5 or 8 fr OG feeding tube for gastric decompression.
Measure abdominal circumfernce - compare with previous from sending facility if available.
Xray - expect to see dialated loops of bowel, don't want to but may see signs of pneumotosis intestinalis (air in small or large bowel wall) :(
Assess for signs of shock, already tachycardic and lethargic - BP, quality of pulses and peripheral perfusion, urine output? May need a volume support (NS 10 ml/kg over 15-20 min)
Consider antibiotics sooner than later - not waiting unitil arrival at receiving facility
Assess for need for supplemental O2 - if frequent A's and B's - maybe just a low flow NC (0.2-0.5 L) to maintain sats 90-95%
Assume we are heading to a NICU with GI surgery capabilites?
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#11 SerendepitySaki

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Posted 11 August 2012 - 04:59 PM

SPOT-ON....your assessment, interventions and assumption are correct seven ways from sun down. (of course...never any doubt w/ with you and Flying Scot) Pneumatosis intestinalis is indeed what the X-Ray shows...

will give Flying Scot and others a chance to buff and puff, chime in, etc before I introduce the next round of FP-C/CFRN and C-NPT review questions....


to you and Flying Scot, the diagnosis literally leaps out from across the room... let's see what the others have to say...

S.S. - I am unable to open the file - even when logged in. What am I missing?
For this itty-bitty with symptoms described....
NPO
Place a 5 or 8 fr OG feeding tube for gastric decompression.
Measure abdominal circumfernce - compare with previous from sending facility if available.
Xray - expect to see dialated loops of bowel, don't want to but may see signs of pneumotosis intestinalis (air in small or large bowel wall) :(
Assess for signs of shock, already tachycardic and lethargic - BP, quality of pulses and peripheral perfusion, urine output? May need a volume support (NS 10 ml/kg over 15-20 min)
Consider antibiotics sooner than later - not waiting unitil arrival at receiving facility
Assess for need for supplemental O2 - if frequent A's and B's - maybe just a low flow NC (0.2-0.5 L) to maintain sats 90-95%
Assume we are heading to a NICU with GI surgery capabilites?


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

#12 FlyingScot

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Posted 12 August 2012 - 12:05 AM

Agree with most of NeoRN606's plan. Two things I might do differently. I'd drop a 10fr Andersen OG for better gastric emptying and would just go ahead with the antibiotics prior to transport. I would consider blood cultures first if baby's condition and venous access allows. Also would consider how long the trip back is going to be. If it's more than say an hour I'm going to have fluid boluses and pressors mixed up and ready to go. I hate it when those nasty cells lyse. Also what does this kid look like? Is he mottled? Cap refill? Does he have that look on his face that says "I'm going to die". I've seen it even on preemies and it makes my blood run cold. I know it sounds stupid but my experience is they get this haunted look in their eyes that makes them look like little old wizened men and although awake and even alert they are very... quiet. It is very specific to this disease.
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#13 SerendepitySaki

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Posted 12 August 2012 - 12:57 AM

food for thought:

A. does anyone have a probable dx?

1. discuss at two gas laws that may affect this child in airborne transport

2. given VLBW, discuss at least two variables (in ADDITION to those in #1.) you may need to proactively manage

3. what other system often displays abnormalities in conjunction w/ this disease process and how might that (in theory) impact your management of this patient's hemodynamic status?...
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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#14 FlyingScot

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Posted 12 August 2012 - 10:59 PM

I know the answers but I want to give someone else a chance to stretch their wings. Come on....somebody out there must have some ideas. Give it a shot. SS doesn't bite and neither do we.
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#15 SerendepitySaki

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Posted 13 August 2012 - 12:27 AM

http://www.youtube.c...h?v=f4zyjLyBp64



I know the answers but I want to give someone else a chance to stretch their wings. Come on....somebody out there must have some ideas. Give it a shot. SS doesn't bite and neither do we.


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

#16 SerendepitySaki

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Posted 13 August 2012 - 09:12 PM

a little something to get y'all started....slightly dated, but should get the ball rolling.... (not mention, give you an AWESOME radiology resource, if you haven't already found it on my free clinical resource page!)

http://www.learningr.../neccorrect.htm


http://www3.ha.org.h...colitis_NEC.pdf
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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#17 FlyingScot

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Posted 13 August 2012 - 11:46 PM

http://www.youtube.c...h?v=A9peZ5WOtL0
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#18 SerendepitySaki

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Posted 15 August 2012 - 08:26 PM

hmmmmmmmmmm?

NEC, boyle's, dalton's, thermoregulation, nutrition, cardiac.

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

#19 ittbrian

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Posted 28 September 2012 - 01:05 AM

food for thought:

A. does anyone have a probable dx?

1. discuss at two gas laws that may affect this child in airborne transport

2. given VLBW, discuss at least two variables (in ADDITION to those in #1.) you may need to proactively manage

3. what other system often displays abnormalities in conjunction w/ this disease process and how might that (in theory) impact your management of this patient's hemodynamic status?...


Hi there, new to this forum. My training coordinator recommended this thread. I'll add my 2 cents...

A. A tentative Dx of NEC is supported by:
- increased girth (suspicious for intra-intestinal gas)
- history of enteral feeds (predispose the baby to NEC due to an immature gut which will not absorb and metabolize feeds well)
- As and Bs (secondary to acidosis, sepsis, hypoxia, hypoglycemia...)
- thrombocytopenia (possible bleeding which may lead to DIC)
- leukocytosis (fighting the infection)
- lethargy (hypoglycemia)
- pneumatosis intestinalis

1. Boyles' Law defines one risk to the patient where the increasing altitude can be associated with decreased atmopsheric pressure, which at a given temperature results in expansion of the gas. Gas in the patient's gut can expand, causing pain, upward movement of the diaphragm (reduced lung volume) and perforation.

Charles' Law defines another theoretical risk to the patient. At a given pressure, the volume of a gas is directly proportional to the absolute temperature. If the temperature of the gas in the gut increases (ie unheated oxygen administration) then the volume will also increase, with the same consequences as per Boyles' law.

2. Being VLBW, thermal instability is a high risk with the premie's inability to properly regulate temperature and insufficient insulation. Another problem is the poor autoregulation of cerebral blood flow. If there are any hemodynamic pressure changes associated with gravity and flight, or fluctuating PaO2/SaO2 causing cerebral vascular tone changes then CBF will vary raising the risk for IVH.

3. This baby is at risk for DIC due to the physiological attempt to manage bleeding, infection and tissue necrosis. Eating up platelets as indicated in the lab results will lead to an attempt to increase platelet production and other clotting factors, ultimately leading to exhaustion of this mechanism and loss of clotting factors.

My thoughts

brian





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Brian Thornburn
Maternal-Pediatric Critical Care Paramedic Student
British Columbia Ambulance Service Infant Transport Team
Affiliated with the Children's and Women's Health Centre of British Columbia in Vancouver, BC

#20 SerendepitySaki

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Posted 28 September 2012 - 05:45 AM

strong work, sir! your time and attention is MUCH appreciated!
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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup