Medical Scenario #5
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Medical Scenario #5
Important Reminder:
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 working in the Neonatal Intensive Care Unit (NICU), and you receive a call to attend to a newborn delivered in the delivery room. The infant, a full-term baby girl, was born via vaginal delivery. The medical team reports concern about the baby's respiratory distress and requests your immediate assistance.
Upon arrival, you find the neonate lying on the resuscitation table, surrounded by the delivery room team. APGAR timer is at 1 minute. The mother had an uneventful pregnancy, but during the final stages of labor, thick meconium-stained amniotic fluid was noted. The infant is limp, cyanotic, and not breathing spontaneously. The heart rate is approximately 80 beats per minute (bpm), and there is no chest movement.
Vital Signs:
Heart Rate (HR): 40 bpm
Respiratory Rate (RR): Absent
SpO2: Centrally and peripherally cyanotic
Temperature: Not assessed yet
Blood Pressure: Not assessed yet
& DISCUSS: What interventions are necessary at this time?
ANSWER: Baby should be warmed, dried, and stimulated. Consider suctioning since thick meconium was present. You notice there is no cry on stimulation. Since HR is less than 100 bpm, PPV should be started. SPO2 should be titrated according to NRP guidelines.
& DISCUSS: What is the APGAR Score for the baby at 1 minute of life?
ANSWER:
1 MINUTE APGAR SCORE
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:
Oxygenation/ Ventilation:
Since the HR is less than 100 the therapist initiates positive pressure ventilation using a T-piece resuscitator or flow inflating bag with 21% oxygen.
Adjusts the oxygen concentration based on continuous pulse oximetry monitoring to target the appropriate range according to NRP guidelines.
Suction: Copious thick secretions suctioned from the mouth.
SITUATION:
You notice the baby's chest is not rising during PPV.
& DISCUSS: What intervention is needed at this time?
ACTION:
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 for a second time and open the mouth. You notice the chest is now rising when providing bag mouth ventilation. MRSOPA has been successful. PPV is continued,
SITUATION:
After 30 seconds of PPV, HR increases to 151 bpm. Breathing is unlabored. The baby is centrally pink, but some peripheral cyanosis is still present. Baby is spontaneously crying and has strong tone.
ACTION:
PPV is discontinued. Monitor the baby for any signs of distress. These vitals stay this way up until the 5-minute mark.
& DISCUSS: What is the APGAR Score for the baby at 5 minutes of life? What intervention should be done now?
ANSWER:
1 MINUTE APGAR SCORE
Appearance: 1 ( peripheral cyanosis )
Pulse: 2 ( HR greater than 100)
Grimace: 2 ( cries on stimulation )
Activity: 2 ( great tone)
Respirations: 2 ( strong cry )
Total APGAR Score at 5 minutes = 9
Always discuss APGAR scores with the other associates who are involved in the resuscitation. APGAR scores can sometimes be subjective, so it is imperative that you all agree on the final scores.
Important Reminder:
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.
