it is the drama performed by single person. they will assume various character on the stage according to the theme.
the number of role assumed by the actor is depends up on the nature of story..
High Risk New Born
Wednesday, February 6, 2013
Saturday, March 24, 2012
RESUSCITATION OF NEW BORN
New Born
Resuscitation
PURPOSE
l The main purpose of resuscitation is to initiate respiration in a newborn, who is asphyxiated or spontaneous breathing
has not been initiated.
What risk factor are associated with the need for
neonatal resuscitation?
1, ANTEPARTUM:
l Maternal Diabetes
l PIH
l Bleeding in second & third trimester
l Post term gestation
l Maternal age less than 16 or more than 35 year.
l Multiple pregnancies
l Severe anemia
l Pervious still birth
l Maternal infection
l Mother on drug therapy (Lithium carbonate)
l Maternal drug abuse
2, INTRAPARTUM:
l Abnormal presentation
l Rupture of membrane more than 24 hrs prior to
delivery.
l Precipitate labour
l Prolapsed cord
l Abruptio placenta
l Meconium stained amniotic fluid
l Premature labour
l Foul smell amniotic fluid
l Prolonged labour either for first or second stage
l Non reasoning fetal heart pattern
l Placenta previa
PREPARATION FOR RESUSCITATION:
l Two trained personnel capable of working together to
perform all aspect of resuscitation but one of the two must be skilled in the
tracheal intubation.
l Sources of heat either radiant warmer or 200 watt
bulb.
l Adequate lighting & place to work.
Indication:
·
Asphyxia.
·
Cardiac
arest
·
respiratory
distress
·
Consider
every birth is at risk
·
All
resuscitation equipment are kept ready in labour room
·
One
person from labour room should be skilled in resuscitation
·
Resuscitation
room will be well lighted and warm
·
Essential
articles should be good working condition
·
And
should be checked by nursing personal at every duty shift.
·
Follow
aseptic precaution
·
Universal
precaution against HIV ALSO MIAINTAINED
EQUIPMENTS:
SUCTION EQUIPMENT:
1.
mucous
aspirator,
2.
meconium aspirator
3.
mechanical
suction apparatus,
4.
suction catheters,
5.
feeding
tube and 20ml syringes
6.
Oxygen
sources,
7.
face mask
INTUBATION EQUIPMENT:
1.
neonatal
laryngoscope,
2.
with
appropriate blade, (no=0 for preterm, no=1 for term)
3.
extyra
bulbs and batteries, e.t tubes,
(SIZE, 2.5, 3, 3.5, 4 MM.DM0)
1.
STYLET
2.
SCISSORS
MEDICATIONS:
1.
Epinephrine
2.
Naloxone
hydrochloride
3.
Normal
saline
4.
Ringer
lactate
5.
Naco2
6.
Albumin
7.
Dextrose(5%,10%)
8.
Sterile
water
9.
Ampule
of injection, dopamine, slow infusion pump.
MISCELLANEOUS:
1.
Watch
with sounds,
2.
Hand
prewarmed linen,
3.
Towel
shoulder roll
4.
Radient
warmer or heat sourses,(bulb 200w)
5.
Stethscope,
syringes (1,2,3,5, 10, 20, 50ml)
6.
Needles,
umbilical cateters, (3.5fg, 5fg)
7.
Three
way stopcocks, gloves, gauze, adhesive tape room thermometer, low radiant
thermometer or tele thermometer
8.
Scalp
vein set, or iv canula, neonatal airway tube, spot light
TABCs OF RESUSCITATION
T- TEMPERATURE:
1.
Provision
of radiant heat sourses
2.
Drying
the baby
3.
Removing
wet linon
A-ESTABLISNMENT OF OPEN AIRWEY
1.
Position
the infant
2.
Suction
the mouth, nose and in some instance the trachea,
3.
ET
tube if necessary
B-INITIATION OF BREATHING
1.
Tactile
stimulation
2.
PPV,
using either bag and mask or bag and ET tube
C. MAINTENANCE OF CIRCULATION
1. Chest compression
2. Medication
Initial
step of resuscitation:
1.
Receive
the baby in prewarmed linen.
2.
Dry
the baby
3.
Position
ther baby (1 inch away from matress, side lying neck slightly extended)
4.
Suctioning(
80mmhg)
5.
Provide
tactile stimulation
6.
Using
free floe oxygen
Evaluate baby:
1.
Heart
rate >100b/m, skin color pink or acrocyanosis, baby need observation and
monitoring only.
2.
Spontaneous
respiration heart rate >100, with cyanosis at lip or tongue then flow oxygen
is administered.
3.
When
no spondaneous respiration PPV is started with bag and mask.
4.
spondaneous respiration and heart rate is
<100 b/m PPV is started.
Bag and mask ventilation:
1.
It
s,b started after tactile stimulation
2.
And
the infant is still apnic and gasping and having spondaneous respiration and
heart rate is <100 b/m
3.
It
s, b done after tracheal suction
4.
Contraindicated
in diaphragmatic hernia
5.
Baby
head s,b slightly elevated to ensure open airwaymask to be place and seal to be
checked by 2 -3 ventilation
6.
Rise
of ches to be observed
7.
Ventilation
should done at the rate of 40-60 breaths/mitfollow a squeeze ‘one’ ‘two’
squeeze sequence
8. After 15-30 sec of ventilation baby s, b again evaluated.
9. Heart rate is avove 100 and spondaneopus respiration present then
provide tactile stimulation monitor heart rate, reap and color.
10. If no breating establishes continue ventilation
11. If heart rate is b/w 60-100 continue ventilation if not increasing
start chest compression
Chest
compression:
1.
It
should be performed always with ventilation and 1005 oxygen
2.
Indicated
with 15-30 sec of PPV with 100%oxygen then heart rate is 60to 80b/m and not
increasinmg
Techniques:
1.
Thumb
techniques
2.
Two
finger techniques
Pressure is applied on lower third of the sternum (1/2 to ¾ inches)
Rate is 90 compression with 30 PPV a total of 120 events
Chest complression is 1.5 sec and ½ sec for ventilatiopn
Then carotid and femoral pulse s,b checked to assess effectiveness of
chest compression.
ET
TUBE INTUBATION:AND MEDICATION:
Medication:
1.
when heart rate is still 80b/m a or above chest compression s, b discontinued, when
100b/m and have spondaneous respiration ventilation is discontinued.
2.
Umbilical
vein is preferable route
3.
No
intracardiac injections are recomended for neonates
4.
No
direct injection into umbilical card
5.
Some
medication given through ET tube
6.
Naco2
is not administetrd still the ventilation is established
7.
.
No respiratory stimulant is needed
8.
8.
Naco2 is diluted 1:1 with water
9.
9.
Metabolic acidosis is corrected with o2 and volume expanders.
Complication
of resuscitation:
l Trauma to the heart
l Trauma to the lungs
l Trauma to the liver
l Broken ribs
l Laceration of liver and pneumothorax.
INTESTINAL MALROTATION
Intestinal malrotation
Incidence :
• 1
in 500 live births.
• Approximately
50%of patient with duodenal atresiaa and 33% patient with jejunoileal atresia
have maalrotation.
• Younger patients have higher rates of
morbidity and mortality.
• Infants
range from 2 to 24%. Male to female ratio is 2:1
• No
sex discrimination seen in patients with older than one year.
• 40%
of malrotattion cases develops during 1st week of life.
• 50%
of cases diagnosed during 1st month of life, 75% in the 1st
year of life. Remaing 25% will be detected during 1 to 18 years of life incase of other surgical procedures
or at atopsy.
• 50%
of cases diagnosed during 1st month of life, 75% in the 1st
year of life. Remaing 25% will be detected during 1 to 18 years of life incase of other surgical procedures
or at atopsy.
A report of 25 years'
experience demonstrated congenital cardiovascular disease in 27.1% of patients
with intestinal malrotation; those patients had a morbidity rate of 61.1% after
intestinal malrotation surgery.2
Causes:
• The
exact causes is unknown.
• It
is not associated with a particular gene, but
there is some evidence of recurring in families.
Clinical features.
• Some
time it is asymptomatic
• Vomitus,
• Crampy
abdominal pain.
• Abdominal
distention.
• Passage
of blood and mucus in the stool
Result of malrotation:
• the
cecum is displaced (from its
usual position in the right lower quadrant)
into the epigastrium -
right hypochondrium
• fibrous
bands (of Ladd) course
over the horizontal part of the duodenum
(DII), causing intestinal
obstruction.
• the
small intestine has
an unusually narrow base, and therefore the midgut is prone to volvulus (a twisting that can
obstruct the mesenteric
blood vessels and cause intestinal ischemia).
Associated conditions
• This
can lead to a number of disease manifestations such as:
• Acute
midgut volvulus
• Chronic
midgut volvulus
• Acute
duodenal obstruction
• Chronic
duodenal obstruction
• Internal
herniation
Diagnostic evaluation:
History
• The
history of present illness varies in patients with intestinal malrotation
according to acute or chronic presentation, as well as according to type of
rotational defect.
Acute midgut volvulus
– Most
patients present in the first year of life.
– The
primary presenting sign of acute midgut volvulus is sudden onset of bilious
emesis.
Chronic midgut volvulus
– Chronic
midgut volvulus is due to intermittent or partial twisting that results in
lymphatic and venous obstruction.
– Multiple
case reports show that 2 of the main presenting features are recurrent
abdominal pain and malabsorption syndrome.
– Several
patients presented with acute midgut volvulus, but further history revealed
they had had chronic symptoms with misdiagnoses.
– Other
clinical features include recurrent bouts of diarrhea alternating with
constipation, intolerance of solid food, obstructive jaundice (1 case),3 and
gastroesophageal reflux.
Acute duodenal obstruction
– This
anomaly is usually recognized in infants and is due to compression or kinking
of the duodenum by peritoneal bands (Ladd bands).
– Patients
present with forceful vomiting, which may or may not be bile-stained, depending
on location of the obstruction with respect to the entrance of the common bile
duct (ampulla of Vater).
Chronic duodenal obstruction
– The
typical age at diagnosis ranges from infancy to preschool-age.
– The
most common symptom is vomiting, which is usually bilious.
– Patients
may also have failure to thrive and intermittent abdominal pain (frequently
diagnosed as colic).
Internal herniation
– Internal
herniation usually has a chronic picture.
– Patients
have recurrent abdominal pain, which may progress from intermittent to
constant.
– They
experience vomiting as well as constipation at times.
– They
are often diagnosed with psychosocial problems.
Physical examination:
• Physical
examination findings may vary depending on the type of rotational defect. Acute
and chronic presentations also differ.
• Acute
midgut volvulus
– Abdominal
distention is frequently present, and the infant appears in acute pain.
– As
vascular compromise persists, intraluminal bleeding may occur, which leads to
blood per rectum and sometimes hematemesis.
– Abdominal
guarding is usually present and prevents palpation of intestinal loops.
– Acute
midgut volvulus conti..
– As
symptoms persist, the infant may develop signs of shock,
including poor perfusion,
decreased urine output, and hypotension.
– Patients
also have signs of peritonitis, including abdominal tenderness and
discoloration of the skin.
Chronic midgut volvulus
– Physical
examination results may be completely normal if the patient presents during a
period when the obstruction is relieved.
– If
partial twisting is present at the time of examination, the patient may have
signs and symptoms equivalent to those of acute midgut volvulus.
– Abdominal
tenderness and guarding is usually present, as well as abdominal distention.
Acute duodenal obstruction
– Abdominal
distention and gastric waves may be present.
– Passage
of meconium or stool can be present.
– These
patients usually do not have signs of peritonitis or shock unless volvulus is
also present distal to the obstruction.
Chronic duodenal obstruction
– Physical
examination results may be completely normal at the time of presentation.
– Abdominal
distention and tenderness may be present.
– Diagnosis
is usually made by history and enough suspicion to obtain radiologic studies;
physical examination findings are very unreliable.
– -Intravenous
(IV) fluids to help prevent dehydration dopamine at an infusion rate of 3
mcg/kg/min intravenously (IV) and continue it postoperatively even if the
patient is not hypotensive.
– -If
the patient is unstable, do not delay surgical intervention for upper GI and
laboratory studies. Quick surgical intervention, not prolonged medical
management, produces the best results if midgut volvulus is suspected
– Your
child may also be given and antibiotics to prevent infection.
Duodenal obstruction
– After
the volvulus is reduced or if no volvulus was present, identify any extrinsic
obstruction to the duodenum.
– If
peritoneal bands crossing the duodenum are found, ligate them with careful
attention to protecting the superior mesenteric vessels. The bands may also
obstruct the ileum or the jejunum and sometimes run to the gallbladder and
liver.
Post operative care and
Consultations
• Pediatric
surgeon: The only definitive treatment for malrotation is surgical in nature.
• Dietary/intravenous
nutrition team: In hospitals where available, include a nutritionist in the
medical team to monitor total parenteral nutrition to ensure optimal levels are
being achieved.
• Physical
therapist
– A
physical therapist can help with range of motion exercises and strength
conditioning while patients are bedridden.
– Frequent
repositioning also helps prevent decubitus pressure and head molding (in
infants).
• Occupational
therapist
• An
occupational therapist also helps with range of motion exercises.
• Occupational
therapists can also assist with splinting of extremities that contain central
lines to prevent contractures.
• Speech
therapist
• A
speech therapist can help with oral stimulation while patients are not being
fed. This stimulation can prevent feeding aversion and dyscoordination when
oral feeds are restarted.
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