The crew and Dr. Olicker continue the conversation of undersstanding the neonatal patient, equipment, protocols and emotions. They start to wrap up the discussion in Part 3 as they prepare for the live podcast!
Prehospital Paradigm Podcast
Understanding the Neonatal Patients for EMS - Part 3
(upbeat music) - The question that I was formulating there while you were talking is you were talking about the high pulmonary pressures. All right, so that translates into us in the field. We got this kid who's just refusing to oxygenate despite us bagging them and increasing the FiO2, the oxygen concentration, is peep appropriate for the newborn or is that something that we should only be thinking about in our kiddos and our adults? - So all newborns should have peep. And if you think of CPAP-- - That's my thing. - You think of CPAP, CPAP is just peep, right? - Of course. - We can increase it some. We don't tend to increase it a lot. So we usually start with bagging with something like 20 over five. When you're having difficulties with ventilation and you will know that by your heart rate, not coming up and by not having good chest rise, that's when we start to go up on our pip. If you're having respiratory distress, so a baby is retracting quite a bit or you're having some difficulties with oxygenation, we'll tweak our people a little bit in the delivery room. We'll tweak it up to six usually. I've never thought of it in terms of overcoming your pulmonary pressure, but you can definitely help with oxygenation by increasing your peep. I think a lot of that has to do with recruitment and having more open L-V-L-I in order to exchange gas through and along with low compliance that wants to collapse in on itself. But-- - Okay. I think to kind of restate that simply would be, you can start your cessation, you can start bagging, not necessarily needing, needing peep. - Right. - And then if you're not improving, adding people to one of those steps. - But you always need peep. - You should always peep. - So you're always going to have, you're always going to have some degree of peep when you're bagging. So, and we start at five. - I'm talking about putting peep valves on the bags. - There are always, we always have peep. - Okay. - There you go. - Yeah. - Always peep. - Absolutely, yes. Always peep. (laughs) - That is, sadly, I put it on the floor here. - There's one up there too. - I said. - All the time makes great progress. - Here we go. It took so long. Often in the initial resuscitation of the adult. - We don't have peep to our best. - Often not peep. And that's where he's got his pet peeves he talks about. I always somehow figure out a way to slide somebody peep valve in there. - So remember, the newborn lung is going to come out completely deflated, right? And you have to, you have to inflate it. And what you're doing with your initial breathing for the baby, so what you're doing initially, is first starting to help the baby develop their FRC, or their functional residual capacity, so that amount of air that is always going to be in the lung, even at the end of exhalation. And that's that initial inflation of your lung. And babies have lungs with very high resistance, or not high resistance. They have lungs with very low compliance. And so what that lung wants to do is collapse in on itself. And peep is going to be the measure that helps get that lung open and keep it keeping. And as soon as you take, so if you have a baby on CPAP, or as soon as you take away your peep, that lung is just going to collapse down. You have to do the work to re-inflate it all by it, all over again. - And we talk about that in the adults too, that once you break that mask seal, if you're doing BVM, you've not lost your peep, you can re-recruit your out of your eye by keeping that mask seal on, and be able to keep that peep in place. Always peep, got it. - Always peep. - Always peep. Makes me happy. Now if we can just get everybody to stay, you know. - So in your world of pediatrics, where is the best, is it intriosis or vascular access? - I was getting to access that. - What is your best options? - Drug, we've got drugs and access to talk about here. - So certainly you couldn't put in an intravenous lung. If you are doing initial newborn resuscitation, your best bet is always going to be umbilical access. So we brought my little umbilical cord, but your best bet's always gonna be umbilical access. So if you have moved past, so you've started with bag mass ventilation, and your heart rate is still low, so you've moved on to intubation, and you're doing now, or a supragwadic airway, but you've moved into artificial airway, and you know you have effective ventilation for 60 seconds, and your heart rate is still low, then your next move is going to be to compressions. And if you are doing compressions with effective ventilation and your heart rate is still low, your next move is going to be talking meds epinephrine, and NRP is gonna be simpler than any of the other resuscitation programs. So NRP, we only have one medication. So if you think you've had something like blood loss, like acute blood loss, so you've had an eruption, then you can fluid resuscitate, so the next step is gonna be fluid resuscitation with either crystalloid, if that's the easiest thing to get to you, so normal saline bolus, or blood, and while you are, so in order to do that, you're gonna need vascular access, and in order to give epinephrine, you can give it two ways, you can give it down the tube, or you can give it through a UBC, or umbilical venous line. So in NRP, these are things you're going to want to do quickly, and so you're gonna want to get quick, easy, secure access, and in these babies that are first born, not having, and they're down, you're not gonna be able to get peripheral access quickly or easily. And so what you're gonna wanna do is take something. If you have umbilical tape, that's great. If you have something else you can use to kind of tie around, so you're just going to tie around, if you put it here. It fits in here. So if you imagine your cord sticking on your baby, and this is kind of a lot of it, and you have a clamp on this end, you kind of bated on quickly, tie, so tie at the bottom, so once you cut off your clamp, it doesn't bleed everywhere. Cut, and then when you look at it, you should have three vessel steering you in the face. Some cords will have two vessels steering you in the face, but you'll have three vessels steering you in the face, two small vessels that have thick walls, and one big vessel with a thin wall. And the big vessel with a thin wall, especially in a baby that is sick, is usually gaping open right at you. And that's gonna be your best source of venous access. So if you have access to an umbilical venous catheter, you put it in just to blood return, and then you can use it, make sure that anything you're putting in there, make sure it's flushed. It's always a good rule. - I think that's important to say, 'cause when we put in drop central lines, they're always flushed and we've got fluid in them. When they're inserting IVs, they're never pre-flush. - Pre-flush, yeah. - So I think that's important to say to flush it with saline. - It's charged the catheter with. - So we don't do an air bolus. - Yep, an air embolus. - Yeah, I just remember this is a big central vessel. (laughs) - Yeah. - So you literally just, this is an angiocath, but you literally just put it in, and if you have a longer catheter, you put it in, you pull back to the get blood return, and then you can go straight through it. It is sometimes, it is easiest, you put a stopcock on it. But if you don't have a stopcock on it, you can just kind of pinch off as you're changing things and do it that way. - They should have J-loops, which should have-- - The clung stops, okay, with the valves on them. - Oh, and always just when you're changing things, pull back on it, make the air come back out of it, and then you can make the air come back out, it'll rise up to the top, and you can flush through it again. So that's where you can put in your fluid bolus, that's where you can put in your blood, that's where you can put in your epinephrine. So that's in a code situation, or in an RP situation, going to be your source of vascular access. - Okay. - If for some reason you cannot get a UVC, say you have a baby who's not directly, this isn't, you're not doing an RP, well, you'd still be doing an RP. Say if a baby who's not a brand newborn, so a baby who has been home, say, or a baby who's more than a few days old and her core's not there, or just an older baby in general. If you have a baby where you can't get peripheral access, your next line is going to be doing an I/O. And unlike an older children and adults, we actually use the medial tibial plateau for our I/Os. So you're not going to want to do the humeral head like you do in older people, it's always going to be in the tibia. - All right, so always tibia, no humeral heads. Can it be a powered I/O, or is this something we should finesse by hand? - We have the drill. - You have the drill? No, I mean, that's all I needed to hear, right? Didn't know if there was a preference to, you know, even taking the same, it's the same needle, right? And then just, you know, hand working that in, or-- - So you could, and that's-- - Of course you could, but-- - So that's the size you're going to be using for our babies, and it makes sense, right? So you're either working it in, or once you're using the drill, you just use the drill until you don't feel a resistance, and then you stop. - I think it's important to say that you don't want to put pressure on it, you just want to-- - Hold it down, but have the drill do the work, and once you feel that resistance, you stop. - Stop, yep. - And leave it in place, and that's as deep as it needs to go. - The resistance will just go away. - Yeah. - That's true, neonates, children, or even adults. We don't need to drill it all the way in, down to the skin, as long as soon as you lose resistance, it's in the right place. - Yeah, we've certainly covered that before, on some of the other talks. The point here that we really haven't touched on is glycemic management, or glucose management, of the neonate. I guess let's just get right to the point. Are the values the same, or am I looking for-- - They're much different. - Much different. (laughing) - So you're telling me that an infant's not a little adult, a little adult? - It doesn't come out with 80, 100 BGL, so. It probably comes out with 80 to 100 BGL, but it's going to drop fairly quickly. - It kind of shows it quickly. - So after about half an hour, this is something you're going to want to check. And the reason it's coming out with normal glucose is when it's born, is because it's getting continuous glucose and fusion from placenta. But once a baby is born, they have an acute cutoff of that continuous glucose infusion, and they're pancreas is still used to seeing that, and so babies are born in a relative state of hyperinsulanism. - Okay. - And there are genetic reasons for prolonged hyperinsulanism, and there are some kind of environmental, or some fetal environmental, so diabetes reasons for hyperinsulanism. But even in a normal baby, you're going to be in a state of relative hyperinsulanism, because you've been getting a continuous glucose and fusion through your pregnancy. - So after about half an hour, you're going to want to start checking your glucose. The target that we're using for glucose is actually 40. - 40. - You may want to write that a little higher just in the field and in EMS, just to give yourself some wiggle room. - Just padding it. - Yeah, so shooting for 50, 60, just to pad it. So a baby with a glucose of 45, who is otherwise well, nothing to worry about. If you have a baby who is sick or who has needed resuscitation, those are always going to mean babies who need continuous glucose and fusion anyway. - Got it. - But the question's really going to be, do I just want to start continuous glucose and fusion, or do I need to correct? And so if I'm less than 40, I'm going to want to correct. And the way to do that is going to be with D10 boluses. - That's our traditional two MLs per K. - Exactly, two MLs per Kilo. And you're never going to want to use anything more concentrated than D10 in a peripheral baby vein. - Can you be given them billically? - Yeah, anything you can give peripherally, you can give through a UBC. The opposite is not true. (laughing) Normal, so we talk in neonatology about glucose and fusion rates, or we call it GIR. So it's thinking about the amount of glucose that a baby needs, the language of glucose and a neonate is going to be the glucose and fusion rate, which is milligrams per kilogram per minute of IV ductus and fusion. A typical neonate's need for glucose and fusion is going to be four to six milligrams per kilogram per minute. So when we're talking about starting IV fluids just to meet their regular metabolic demands, you'll hear us talk about in a newborn starting at 80 MLs per Kilo of D10. And it's the magic of D10 and usually water in a newborn, but the magic of D10 water at 80 milligrams per kilogram, at 80 MLs per kilo per day. So the magic of D10 water at 80 MLs per kilo per day is going to be your kilograms is going to cancel out as you're dividing this. So D10 water at 80 milligrams. D10 water. - It's a word so, but it's okay. - Oh, my God. The magic of D10 at 80, or at 80 MLs per kilo per day, is going to be D10, 10% ductus at 80 MLs per kilo per day, is always going to be a glucose infusion rate of 5.5 milligrams per kilogram per minute. - Per minute, okay. - And so you're hitting toward the higher end of that four to six milligrams per kilogram per minute of normal metabolism in a newborn. So you figure your fluid needs are about 80 MLs per kilo per day, and your glucose needs are going to be four to six milligrams per kilogram per minute. And you reach the happy medium of D10 to meet five and a half milligrams per kilogram per minute at 80 MLs per kilo per day. - It's almost like we could do that. I think something worth pointing out that with the babies and the land sets, you're probably not going to want to use a finger. - You beat me, just do it. - Do they feel sticks? - Yes. - We were talking off camera about using things in a pinch in the resuscitation, more so for the EMS side of things where we might not have a whole cart full of or a whole room full of - Hypnotable sized things. - Purposely sized things. And what you had shown us earlier was you just using an angio. - Yeah. - Just using the catheter, not the catheter, not the needle and catheter. - Do not use the needle. - Yeah, I was, oop, I'm going to stab somebody with that. - This was the 16? - 14? - This is a 14, but yeah. - Yeah. - Using the catheter part of that sterile, not gloving it like I just would have, but. - So it's going to be a little tight in here because you've got plastic on plastic, but you can put, you can prime this and you can put a syringe on the end. You can't even put a stop clock on the end, but so prime. - Prime that with saline or? - And so you beta-dined and you tied and you've cut and now you're inserting your UBC. So you're putting it into the thin walled big open vessel and you just slide it in while pulling back until you see blood return. And once you see blood return, then you can use this for all of your resuscitation. You can use it for fluid resuscitation. You can use it for epinephrine. You can use it to run blood. You can use it to run your IV fluid. You can use it for antibiotics. This is a central line, nice. - For how long? - I mean, obviously we're not gonna, it'll be very acutely for us, but. - So we will, when you bring a baby in with a UBC that you've placed in the field, no matter how sterile you've tried to do it, we will assume that it is not sterile. - Sure. - And so we will pull it out and replace it. Also, you're not gonna wanna use, so this is what we would call a low-lying UBC. So this is gonna be a UBC that is going in just to blood return. It's going to be sitting below the liver and anything that you're putting in it is going to be going up, and in addition to going into systemic venous circulation, it's also gonna go into portal circulation. - That's a good point. - And so, in order for us to use it as a true central line, we like to get it through the ductus phonosis, which again is part of fetal circulation, but through the ductus phonosis, up through the liver and have it sitting just above the diaphragm. And we'll use a line like that for, I mean, in a pinch, if we've not had anything else or babies unstable, we've used them for longer. We've used them for as long as, generally we like to use them for no longer than seven days, but we've used them. - That's longer than I intended. - It's longer than I expected, yeah. - We've used them a little bit longer if we've had to. If we anticipate needing it for longer than that, then we'll usually put in a pick line and pull out our umbilical line. - And some other things we've been talking about off camera is in a pinch as we may. I would hope this day and age, most ambulances have an infant bag valve mask, but I can at least pretty much assure we would have a pediatric size. Do we want to talk about bagging in general? - Yeah. - So it's always going to be easier to hold your bag with two hands and have somebody else, or hold your mask with two hands, excuse me and have somebody else bag for you. You want to get your baby into a good sniffing position, so not hyper-extended, but not flexed either. And a flexed chin is going to be a closed airway. So a nice sniffing position. Babies can be on the floppier side and sometimes you're helped by a shoulder roll. If you don't have a shoulder roll, I often like to use my middle and pink, or my regular pinky fingers to make my own shoulder roll. - Over here, yeah, you're using it as a ramp. - Yep, so I'm making my own shoulder roll there and you want to kind of, rather than pushing the mask onto the face, try and pull the head up toward the mask. So you get a good seal and, so NRP talks about the C and the E. So I don't have a seal, I just felt to come out that way. NRP talks about the C and the E, so the way you hold the mask, if you see it, there's the C and there's the E. So one finger under the chin and your index finger and your thumb on the mask. So once I have a good seal, yeah, if you want to put some air into there, I still don't have a good seal. This is a good example. So you put in a little, yep, so you see you have trust rise there. So you're going to want to do it when you don't have a manometer. You want to do it just to trust rise. What you were saying before though, so I'm having a hard time getting a seal. Sometimes if your face is just the wrong shape for your mask, your mask is too big for your face. One of the things you can try is turning it around. I still have a link. There we go. - I think it's important to say, like to have that communication between who's back, who's back. - Yeah, exactly. I feel like you're finally-- - I still have a link. - I'm doing repositioning, yeah. Small, finite. - Yeah. - And we don't want to cause barotrap. - If you only have an adult mask, it's not ideal to have the eyes inside your mask, but if your choices are eyes inside your mask are unable to ventilate, then you can put the mask over the whole face and it'll take a little bit of manipulation, but... Okay, you can see it down there, I'm going to try that. - And if you're having just a hard time with the masks you have, it's a little slow, so it's kind of a practice that, but we can do it through something where you can see. If you're having a hard time with the masks you have, you don't have anything small enough and you have the ability to put in a super-glotical way. - Super-glotical. - You can put in your super-glotical way. So, this is your eye gel, but just literally just push it into place. Put on your mask or put on your bag and see, there's your chest rise. So then you're going to want to breathe at the speed of 40 to 60 breaths a minute, so breathe, two, three, breathe, two, three, breathe, two, three, breathe, two, three, breathe, two, three. Good. It's interesting having people coming from the adult world 'cause usually when I see in the delivery room, it's people going. - That's how it usually goes. - Honestly, that rate seems what... - Like a heart rate? - No, it's, it's, no, it seems like what I'm coaching myself down from in the adult population, right? It's like, it's what I would naturally go to. I didn't know that it actually hurt people, hurt adults, you know? - How important are fontanels to you? - Very? - It's a lot of clients. - So, why? - So, baby should definitely have them. (laughing) - Okay, let me rephrase this. - The assessment of what do fontanels tell you about the patient's condition or lack of? - So, in a newborn, fontanels tell you most about fluid status. So, just to think about the baby skull for a second or think about anybody's skull, but the skull is made of a few different bones. So, you have your frontal bone in the front, your frontal bones in the front, your parietal bones, your occipital bones, okay? Your temporal bones are there too, I just left them out. So, if your frontal bones, your parietal bones, your temporal bones, and your occipital bones, and they are all, in us, they are fused, with suture lines, in babies, they are open. And the reason for that is that they can slide around and go over each other and overlap to allow the baby to come down through the pelvis and come out. Think about them as the tectonic plates in the earth and how they slide over each other. So, the fontanel is a space between these bones before they have fused, and as the bones fuse eventually, the fontanel will fuse too and go away. But it is a little opening between the bones. There's an anterior one and a posterior one. The anterior one is really easy to feel the posterior one's a little bit more difficult. But I give you a good idea of a baby's fluid status. So, a fontanel, when you feel it, and you know what a normal fontanel feels like, just by feeling a lot of fontanels. But having felt a lot of fontanels, a normal fontanel is going to be soft, so it won't be tense, but it'll be flat. So, when you're feeling the head, so you shouldn't be able to see it, when you're feeling the head, it should look flat. And when you give it a little, not hard press, but when you give it a little pressure, it should be soft. If a fontanel is sunken, that'll tell you that a baby is probably dehydrated. If a fontanel is bulging or tense, that tells you, for some reason, you have increased intracranial pressure. So, that can be from things like hydrocephalus. Sometimes our preterm babies have intraventricular hemorrhages, or they bleed into the spaces in their brain that should contain CSF. Once you've bled into them, you can get obstructive hydrocephalus. And so, it's kind of a good measure of obstruction, and if something needs to be done about it, or at least a screening tool, not really a measure, but it's a screen for obstruction, or a screen for increase intracranial pressure from obstruction or from obstructive hydrocephalus. It can be for meningitis. So, meningitis will give you increased intracranial pressure. It can be from more nefarious things like trauma. So, a bulging fontanel is bad. A sunken fontanel is a sign of fluid loss, or of dehydration. - Yeah, and I love to teach you the point that fluid loss can be not only hemorrhage, but also just diarrhea, or vomiting, respiration. So, you gotta-- - In a newborn, it can just be evaporation. - Yeah, that's a good point. - Excellent, yeah. Going back to your, putting the preemies in a bag, yeah, yeah. In the acute resuscitation parts, or anything else we need to talk about on this episode, we've got a ton of stuff here that is definitely suited for another go around. But anything we didn't hit in the newborn resuscitation, as the high points. - I think one thing we should talk about, 'cause we talked about picking where we're gonna take these kiddos, right, if they were just born and they should go to. And you can get 'em to a NICU center, and that's where they should go. If they're full-term and they're sick, a place that has OB services and will have some level of neonatal care there. When, at what point, or what things should we be looking for, whether it's just a newborn that was just born at home, or were in the field, when should we be calling for a helicopter versus just transporting via ground to the nearest DR? - This may be my own ignorance, but can you get a helicopter in a baby that's born at home, or just the field? - Yes. (laughing) - So I will speak to a recent case where they were reluctant to fly, 'cause they couldn't thermo-regulate the kid. And the kid was term and improving, right, and doing well, and they said, "We're stuck, we're stuck in a hell." And they got on and they went by ground to a local hospital with, well, it's a Geauga, whatever level that Geauga is. - Geauga's a one. - It's a one. - So I-- - They went by ground, and their primary consideration was kids getting better, I can't thermo-regulate them very well in the helicopter. - I would say most babies can be safely transported by ground, especially in-- - I'm sorry, that's a catch. - Thanks. - She's on the pressure. - Especially in our area where we have a relatively high number of hospitals in a relatively small geographical area. And so even if you are going to a freestanding ED without OB services and having to transport from there, it'll be safer to go by ground to where you are, stabilize in a hospital, rather than in the field, and then transport again. - And every ER's got warmers, like we've got, we have the equipment to be prepared for these deliveries, isolates. - We don't have isolates, but we have warmers that we can warm baby up after they arrive, so. - What hospitals, or what helicopters are really good for is decreasing your out of hospital time. They don't necessarily speed up your whole transport. And so, and sometimes they can actually slow down your whole transport. So when you're talking about having to get a helicopter from a place that, from a helicopter pad or from an airport to a place that may not have a pad or to a place that you can land safely, sometimes babies have to be transported, or patients have to be transported by ground to a place where you can take the helicopter, take off with the helicopter, and with our geographical area, there aren't a lot of circumstances where that is going to be faster. So, unless your baby is so ill that you're concerned about really needing to minimize the time that you have the amount of a hospital, around this area, ground is generally going to be a reasonable way to transport, and we're talking about inter-hospital transport around here. We, so our critical care transport team at this moment is using only ground, even with our sickest of babies. As we get the ability, we probably will go to using air when it is available to us. And I think that I'll have a lot to do with the ability to get to babies faster. I don't know that it'll get babies back faster, but it may help us get to babies faster. We have talked before about potentially using it as a resource to get providers to the baby, even if the baby comes back by ground. One thing to be aware of with the helicopter is that a helicopter is not always a good choice, even if it is going to make things make your transport shorter. And the best example I can think of with this is with a baby who has a pneumothorax. So as you use the helicopter, you're increasing an altitude, which is going to decrease pressure and ultimately make your pneumothorax bigger, which could ultimately lead to cardiovascular compromise in the helicopter, which is not something you want to deal with. - Yes, and a tough place to manage it. - Yeah. - I very much so. - So sometimes babies are born with anomalies, and sometimes those are major anomalies that take some consideration for the initial stabilization and for transport. So two important things to think about are going to be open abdominal wall defects and spina bifida or open or closed, but so open abdominal wall defects or defects in your neural tube. So things like spina bifida. The biggest consideration for these is going to be bringing these babies back safely while keeping either your abdominal wall defect or your spina bifida defect moist. So the same way that we covered a preterm baby, so a baby less than 32 weeks, the same way we wrapped them in plastic wrap or we put them into some sort of plastic bag. We in the delivery room at the hospital use what we call a bowel bag, which is literally a sterile bag with a drawstring. And you can put the whole baby up to above the level of the defect into the bag. You want to pour some sterile saline into the bag and just make sure that that stays moist. So as you're driving, if you're driving a longer distance, you may want to open it up and just pour some more saline in there. - I'm feeling more than saline, hopefully. - With a spinal defect, you're not going to want to transport that baby on their back. So you're going to want to transport them on their sides or on their belly with an open abdominal wall defect. So an open one is going to be a gastroschesis, one that's covered with a membrane is going to be an unfaliceal. Unfaliceals can sometimes rupture. And so one that was previously closed can look open. A big consideration is going to be not rupturing the sac, either really an anterior or a posterior sac. So you don't want to rupture an unfaliceal sac or you don't want to rupture a spina bifida sac. And in all of these cases, the easiest thing to do is just put them in the bowel bag or put them in the bag you have, keep it moist. - Okay, and that would go back to your previous statement of in the absence of the perfect tool. Saran wrap or something? - Saran wrap, keep it moist. Do what you can to not compromise the bowel if you have something like gastroschesis or trying to keep it kind of loose and mobile as opposed to make creating kinks that can affect the blood supply. - So loose wrap, but this is what I'm hearing is if I'm improvising with. - Loose plastic wrap, saline. - With all of our episodes, we'll have shown us up on our website. - As always. - We'll have some diagrams up there, some more support materials as well that you guys can go look at at pre-PP.com. - That's right, all right. Doctor, thank you so much for joining us. - Thank you. - This has been great. - Thank you. - This is fun. (dramatic music) (gentle music) (gentle music) (gentle music) (gentle music) (gentle music) (gentle music) (gentle music)