VentMedic Posted September 2, 2008 Share Posted September 2, 2008 Lots of assessing to do since there are about 32 different things that can also have similar presentation in neonates that come to mind. "Guessing" is not acceptable in neonates unless you have some assessed data to at least make a more "educated guess". Maternal hx? Nourishment? Baby go to bottle okay? Glucose? Output? Wet diaphers? Breath sounds? Heart sounds? Murmur? Gallop? SpO2 pre and post ductal? Pulse quality and BP in extremities? Peripheral perfusion? Vessels on the cord normal? Link to comment Share on other sites More sharing options...
chbare Posted September 2, 2008 Author Share Posted September 2, 2008 Following the onset of his distress you note the patient becomes very lethargic and will not feed, develops pallor that progresses to cyanosis, develops oliguria with no wet diaper for several hours, pulses are diminished throughout, you note significant respiratory distress, and you also think the patient has developed an enlarged liver upon performing a repeat abdominal exam. I want to hold off on heart tones for just a bit and see what people think with this additional information. Take care, chbare. Link to comment Share on other sites More sharing options...
Mateo_1387 Posted September 2, 2008 Share Posted September 2, 2008 First: What do you think is going on? Does not have to be a specific problem at this point; however, think of broad categories that may fit. I am thinking there is a problem with the heart and related vessels. Some that come to mind are Tetralogy of Fallot, Patent ductus arteriosus, patent foramen ovale, aortic coarctation, and transposed great vessels. I would also want to listen to lung sounds and heart tones. Second: Why do you suspect this problem? I am thinking the problem is related to the circulatory system because of the increased dyspnea of the patient as well as progressive tachycardia presented with cyanosis. Third: Are we dealing with one problem, or could other problems be present? There could be other problems. The baby will not be feeding so it will become weak really fast. The increased workload can make the patient have hypertrophy of the ventricles. With heart and vessels defects, they usually come along with other problems, such as trasposition of vessels often comes with problems such as ventricular septal defects and patent ductus arteriosus. Fourth: Could any of these additional problems actually help in the short term? If the baby is having something such as aortic coarctation, then patent ductus arteriosis is the only means of receding oxygenated blood by the body. Link to comment Share on other sites More sharing options...
p3medic Posted September 2, 2008 Share Posted September 2, 2008 In the ambulance, a good physical exam and maternal hx can be done, pre and post ductal sp02, ekg, glucose, vascular access,etc...What about the remainder of the exam? Lung sounds, heart sounds, ekg, capilary refil? The developing hepatomegaly makes me suspect hepatic congestion secondary to R sided heart failure/RV outflow obstruction given the information we have thus far....standing by awaiting further. Link to comment Share on other sites More sharing options...
chbare Posted September 2, 2008 Author Share Posted September 2, 2008 You appreciate an apical diastolic rumble, a fairly normal first hear sound, and a loud pronounced second heart sound. You have vascular access and the glucose is normal for the patient's age. Maternal history is unremarkable except for G5P5A0. (G6P6A0 now) Denies smoking or drinking. Denies drug use. Obviously, prenatal care is lacking however. EKG indicates right axis deviation, tachycardia, and right ventricular hypertrophy. What do you think is going on and what should we do to treat the problem? Take care, chbare. Link to comment Share on other sites More sharing options...
Arizonaffcep Posted September 3, 2008 Share Posted September 3, 2008 IV, O2, monitor, D-stick etc. Not much else I know of for prehospital. What about VSD? Link to comment Share on other sites More sharing options...
chbare Posted September 3, 2008 Author Share Posted September 3, 2008 VSD is a possibility. First, I think we have identified that the patient has a cyanotic defect. I also think we have identified that the defect is PDA dependent. Good call on realizing that the deterioration of the patient is most likely related to the fact that the DA is closing. So, we have at least two problems a cyanotic and non cyanotic defect. However, the cyanotic defect is the bigger problem, and in fact, we want to keep the PDA patent. What can we do to maintain on open DA? What do the heart sounds suggest? Take care, chbare. Link to comment Share on other sites More sharing options...
fireflymedic Posted September 5, 2008 Share Posted September 5, 2008 Just out of curiousity, since it seems to be my turn to chime in here - mom have gestational diabetes? We mention pre natal care was lacking, and that's a normal heads up during prenatal care, so I'm heading that direction. If that's the case, may have mentioned effects on baby. I'm slightly tired here tongiht, been overworked, but that's my starting point. Cardiac malformations are also in my list, but I'm not going to delve into those just yet tonight. Let me sleep and get back to you in the morning. Link to comment Share on other sites More sharing options...
chbare Posted September 5, 2008 Author Share Posted September 5, 2008 No problems with mom and no history of gestational diabetes. Take care, chbare. Link to comment Share on other sites More sharing options...
ncmedic309 Posted September 5, 2008 Share Posted September 5, 2008 I would be concerned about the patient developing congestive heart failure at this point. In regards to keeping the PDA open, we could look at a Prostaglandin such as Alprostadil to assist with vasodilation. We could also explore the option of administering Digoxin, but with the possibility of renal problems as well, it would be a risky way to go. I guess this also depends on what he available to us in these circumstances. We're behind the eight ball and want to keep this kid alive until they can get more invasive and attempt to correct the problem. Edit: Not that it's not already obvious, but taking this route with treatment - it would be a REALLY progressive EMS system... :wink: Link to comment Share on other sites More sharing options...
Recommended Posts