Medical Scenario #3

Disclaimer :

These are hypothetical situations and are not meant to be taken literally. Always follow your hospital's policies, procedures, and guidelines. Your hospital will have specific guidelines that you must follow in each department. These scenarios are purely educational. Always consult with your hospital providers before doing any medical procedure on patients. 

SCENARIO: 

You are a respiratory therapist on duty in the Neonatal Intensive Care Unit (NICU) when an urgent call comes in from the delivery room. A preterm infant, born at 24 weeks' gestation, is being delivered via emergency cesarean section due to placental abruption. The mother experienced severe hypertension throughout her pregnancy, and the baby is anticipated to be at risk for respiratory distress syndrome. Estimated weight is 500g. 

& DISCUSS:  What extra, special equipment may be necessary in this delivery? 

ANSWER:  Since the baby is less than 32 weeks, a warming mattress and plastic bag to wrap the baby are needed. 

ACTION:  Radiant warmer is on. You activate the warming mattress and cover it with a blanket. The baby should never be placed directly on the warming mattress because it can burn their skin. The plastic wrap is ready to be used. 

SITUATION:  That baby is born and immediately given to RN/RT due to floppy appearance, no cry, and cyanosis all over. Baby is placed on warming mattress and covered in plastic wrap. Pulse oximeter is placed on the right wrist. HR is being auscultated with stethoscope. ECG leads are placed on the baby. 

Vital Signs: 

• Heart Rate (HR): 35 

• Respiratory Rate (RR): Absent 

• SpO2: Unreadable 

• Temperature: Not assessed yet 

• Blood Pressure: Not assessed yet 

& DISCUSS:  What interventions are necessary at this time?   What are the 1-minute APGARS? 

ANSWER:  The baby needs PPV since HR is less than 100 bpm. 

APGAR Score at 1 Minute 

Appearance:  0  (cyanosis all over) 

Pulse:  1  (HR was less than 100bpm) 

Grimace: 0 ( no cry when stimulated)) 

Activity: 0 ( no tone) 

Respirations: 0 (no spontaneous breathing) 

Total APGAR Score at 1 minute = 1 

ACTION:  PPV is started at 20 PIP and 5 PEEP.  

SITUATION:  You notice the HR now 30 bpm and there is minimal chest rise when bagging.  

& DISCUSS:  What interventions are necessary at this time? 

ANSWER: MRSOPA should be performed. You reposition the mask and reposition the patient and airway. You continue bagging but still no chest rise. You then suction the airway and open the mouth. You notice there is still no chest rise when providing bag mouth ventilation. You increase your ventilatory pressures to 25-30 cm H20. HR is now 50 bpm. 

& DISCUSS:  What interventions are necessary at this time? 

ANSWER:  The last step of MRSOPA should be performed which is alternate airway. What size ET tube and laryngoscope are needed? Where will the ET tube be placed at the lip? 

SITUATION: The baby is intubated with a size 2.5 mm ET tube using a 00 Miller laryngoscope blade. The ET tube is placed at 6.5 cm at the lip. A good rule of thumb is to add 6 to the baby’s weight in KG. 6 + 0.5kg = 6.5 at lip. Bilateral breath sounds are noted. There is positive color change on the capnometer. After 30 second of effective PPV, the HR is now 55 bpm. 

  & DISCUSS: What interventions are necessary at this time? 

ANSWER: Chest compressions should be started. Current NRP guidelines recommend a chest compression rate of 90 compressions per minute coordinated with 30 ventilations per minute, which equals to 120 events per minute. This is delivered using a 3:1 compression: ventilation (C:V) ratio which comprises of 3 compressions followed by 1 ventilation every 2 seconds. 

ACTION:  Chest compressions and PPV are started. HR is being reassessed every minute.  

SITUATION:  After 1 minute of chest compressions the HR is 45 bpm. 

& DISCUSS:   What intervention should be done now?  

ANSWER: Epinephrine should be given. Once compressions started, someone on the team should start getting equipment necessary for epinephrine administration. ET tube dose is 1.0 ml/kg. IV dose is 0.2 ml/kg. In this case the nurse has already placed a low lying UVC. 

& DISCUSS:  What dosage of epinephrine should be given via IV? 

ANSWER:  0.1 ml of epinephrine will be given.  ( 0.5kg x 0.2 ml/kg = 0.1ml ) 

SITUATION:  0.1 ml of epinephrine is given via IV. HR is reassessed and appears to now be 133 bpm.  

& DISCUSS:   What intervention should be done now? 

ANSWER:  Compressions should be stopped now that HR is greater than 60 bpm. PPV/ CPAP should be continued via ET tube and baby is transferred to NICU for further evaluation. 

Disclaimer:

These are educational situations and are not meant to be taken literally. Always follow your hospital's policies, procedures, and guidelines. Your hospital will have specific guidelines that you must follow in each department. These scenarios are purely educational. Always consult with your hospital providers before doing any medical procedure on patients.