This Wisconsin Critical Care Paramedic module covers obstetrical, neonatal, and pediatric emergencies as associated with critical care interfacility transports.
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Our ladies who are pregnant
come with a variety of issues,
right?
So we've got pre-existing
medical conditions,
you've got issues that you
could have with the pregnancy,
there could be issues
with the fetus itself.
And again, our physical
assessment techniques
are going to help
us figure out how
to best manage for
this population.
So our goals,
physical assessment
is a big part of it, a
nice thorough assessment.
Form a differential
diagnosis and treatment plan,
and then anticipate
any complications
to provide the
best care possible.
So a couple of key numbers
for pregnant ladies.
Gestation averages about
266 days for a human female.
Feels like a long time when
you're in your 250th day.
So by definition, premature
infants are less than 37 weeks,
and then you're overdue,
or your post mature,
infants have been in
for 42 weeks or longer.
And we know they're
divided into trimesters.
So on physical
assessment, you've
probably seen this
diagram before.
You're looking for that fundus.
Has anyone ever
had the opportunity
to palpate a fundus?
Yes, couple I see a couple nods.
So for those of you who don't,
as your palpating the belly,
you're starting above
the symphysis pubis,
working your way up, and
you're looking, kind of,
for that top of that uterus.
And the picture shows us that,
based on how high or how many,
I believe it's in centimeters,
where you're located,
you can estimate the
weeks that the woman
is based on where
that fundal height is.
So at 20 weeks, it should
be about at the umbilicus,
and then as they
get past 20 weeks,
again, it's going to
proceed above the umbilicus.
In emergent situations, where
the females have complaints,
something's not
going quite right,
we are not asked to do
any type of exam that
involves putting anything
into the vaginal vault.
But we certainly do want to
do parineal visualization so
that we're looking
for things, right?
Looking for a stray
foot, looking for a cord,
looking for bloody show,
looking for hemorrhage.
So again, we're going to
inspect that parineum.
General rule of thumb,
vitals every 15 minutes,
unless the medical condition
indicates quicker or more
often.
Fetal heart tones,
what do you guys
use to– do you measure
fetal heart tones?
Pregnant Ladies?
Anybody in the room trained
to do fetal heart tones?
No?
Fairly simple technique, but
you do need a little– in the ER
we have the little Doppler,
the little handheld Doppler,
and we'll use that.
The diagram just kind of shows
one of the common locations
that your usually
going side to side
in the lower abdomen looking
for fetal heart tones.
The key is to feel moms
pulse at the same time
that you're listening, so
that you can differentiate
between her heart rate
and the fetal heart rate.
But we're looking at a
rate of between 110 and 160
to be expected, to be normal.
Now does anyone
have any other kind
of fetal monitoring
capability in their rigs?
Any of the belts
that do monitoring?
OK, good because that's fine.
I don't need to go into
the science of that.
All right, if we
have a fetus that's
in distress, so the fetal
heart tones would be too low,
again, we have to provide
some emergent care
to try and oxygenate that
infant as best as possible.
So we're going to give 100%
oxygen to preserve mom's blood
flow, or get that blood
returned to her heart,
so that she can
pump it to the baby.
What's the best position
for mom to be in?
It's up there.
Yeah, left lateral recumbent.
What are we taking
pressure off of when
we put mom on her left side?
Inferior vena cava.
Awesome, so that way blood flow
can get back into circulation.
If mom is hypotensive,
we're going
to give repeat fluid
boluses, again,
to bring that pressure up.
We're going to do external
view, but no internal view,
and do you guys transport
moms on oxytocin?
Yea, so you will have
oxy drips going, OK.
So if the– now if you have
oxytocin on board while they're
being transported, do
they have fetal monitoring
on at the same time?
No, so you've got,
all right, so there's
some physical assessment
challenges, there, related
to that.
Cause if that fetus in
the hospital environment,
while they've got the
big belt and the monitor
on, if the fetus's heart
rate drops during an oxytocin
infusion, they may
have to [? DC ?] it,
because the contraction maybe
too strong that it's actually
causing the babe not to get
enough blood circulation.

All right, so let's take a
look at two conditions that
may cause mom, pregnant
mom, to call 911.
So we have the abruptio
placentae and then
the placenta previa.
So definition of abruptio,
the first one on the left.
If you see where
the number one is,
can you see the
hemorrhage that's
happening there
underneath the placenta?
So something has happened
that has caused the placenta
to come away from
the uterine wall,
and we now have hemorrhage
going on underneath.
Can it be minor,
can it be major?
Absolutely, so it just
depends on how much of that
placenta has separated.
With the placenta previa,
that's more the position.
It's where the
placenta has locked
into the inside of that uterus.
And placenta previa
can completely
cover the cervical os, like
you see in this picture,
or it can be a partial covering.
Now symptoms that mom might
experience for each of these
are quite different,
so let's take a look
at how we would
differentiate those.
For the abruptio,
so this is where
we've got the separation
from the placenta
from the uterine wall, most
women, or half of women,
will have some kind
of abdominal pain.
Where the other one,
the previa, is painless.
More than 90% of them will have
uterine contractions triggered
by the separation
of the placenta.
And 90% of them will
have vaginal bleeding,
unless it's all concealed
underneath the placenta where
it's hemorrhaging, and
they may have fetal demise.
So mom might not be feeling
any movement anymore,
and fetal heart tones
would be not present.
Really severe
cases, so we've got
a lot of hemorrhaging going
on inside that uterus,
when you feel that uterus,
it's going to be rigid.
So instead of soft feeling,
like a fluid filled balloon
with the baby inside, now you've
got this rigid, hard ball,
like a bowling
ball, and mom will
present with signs and
symptoms of hemorrhagic shock.
So what would you expect
to see in her vitals?
Tachycardia, low blood
pressure, exactly.
So we'd want to address those.
All right, so management,
let's get her on some oxygen.
Again, get as much oxygen
to that fetus as we can.
If she has airway issues,
we're going to address those.
Assist ventilations,
intubate as necessary
She needs two large
bore IV's, because we're
going to start with
what kind of fluids?
Yeah, we're going to start
with isotonic crystalloids,
and then usually after
how many liters do we
like to switch over, if we
need to do blood replacement?
Yeah, usually about
two liters, and we're
looking at blood,
if it's available.
Foley catheter, if available,
if she's a hospital hospital
transport, and we've got
the Foley catheter in place.
The goal for our urine
output would be what?
How many cc's per hour?
Thirty is your minimum.
Can be a weight based goal, as
well, so looking for a half cc
to 1 cc per kilogram.
These pictures show
the different previas,
so you can see a little
bit of impingement,
all the way to
complete impingement.
These moms will have
bleeding, but it's
painless, bright red bleeding.
Their abdominal
examine, usually benign.
But again, we don't want
to put anything in there,
because if we introduce
anything into the vaginal vault,
we may cause further rupturing
or tearing of that placenta.
For previa, this is
the diagnostic path,
so remember when you're dealing
with one of these charts,
look at the top.
So we're going through
the diagnostic process,
and at the bottom, we see our
end goal, or our end product,
might be cesarean birth.
So why does that happen?
If the baby is
more than 37 weeks,
so they'd be
considered full term,
bleeding continues, or
they have complete previa,
that baby's obviously
not going to be
able to pass through
the vaginal vault,
so we need to get them
out through c-section.
If they have bleeding
stopped, or minimal
and no fetal distress,
the larger box
there talks about
induction of labor
if it's a low-line or marginal.
But if it's a
complete presentation,
then we're going to
anticipate the c-section.
So they'll do a
little more ultrasound
to figure out exactly where
that placenta is located.
If we're less than
37 weeks, of course
our goal is to keep
that baby in if we can,
but it might not be possible.
If bleeding reoccurs,
labor is present,
again, they're going to go
right for the c-section.
If the bleeding
is well controlled
and there's no
contractions, they're
looking at that list
over there, bed rest,
vital signs every four hours,
IV fluids, type and cross-match,
just in case they start to
hemorrhage with observation.
So again, this is the
diagnostic pathway
that they'll follow once
mom is at the hospital.
All right, let's look
at preterm labor,
so might have– have you
had calls from ladies,
think they need to go
to hospital cause their
having contractions?
So how do you know if
they're preterm or not?
What are some of the
clues that you guys use?
Yeah, what's the due date?
Are they ready?
Wait, what did you–
So the water broke.
Yeah, so looking again at
those assessment pieces.
So preterm labor, by
definition, are contractions
that are occurring between
the 20th and the 37th week
of gestation.
Maternal complications
of premature labor,
so if we could have the
endometritis, sepsis,
septic shock, P-R-O-M stands for
premature rupture of membranes,
if you're not familiar,
and chorioamnionitis,
which would be infection
in the amniotic fluid.
Fetal consequences can
be premature birth, cause
they're not supposed to come
quite yet, and unfortunately,
accounts for about 100 deaths
of infants out of every 100,000
in the US annually.
So our assessment,
rupture of membranes.
You mentioned that.
Was it a small bloody
show, was there
a lot of bleeding with it?
Once they get to the hospital
and an appropriate provider can
do that vaginal exam
to look for membranes,
look for dilitation of
the cervix, if we see
drainage coming out,
do you have the ability
to test drainage for pH?

I know, that's a good question.
We do have pH paper in the ER.
It's located in our eye
room, because we do it
for the eye test for
the eye exposures.
But if you needed
to, and again, I
worked at St. Luke's
in those years
when OB transitioned out of the
building over to West Dallas.
And from the ER perspective,
that was really tough,
because we always had
that resource to call,
and they could come down and
deal with these OB emergencies,
if necessary.
But now when the ladies would
show up, it was all on the ER
to do the full work-up
before we determined
if they needed to be transferred
to West Dallas, or Sinai,
as an appropriate location.
So if they would be
leaking amniotic fluid,
a little bit of that
could be collected,
you could test the pH, and
then the Nitrazine paper
it would show less than
6.5, as a measurement.
Or there's the feather
test, a little bit
of the amniotic fluid could
be put on a glass slide.
Again, have to get one
of those from the lab,
we don't have those
in the department.
But put a little bit on,
and then as it dries,
it has a real distinct
feather pattern to it.
And that's also a positive
indication of amniotic fluid.
A little, I've not actually
seen that done in practice,
but available as part
of the assessment.
We want to measure
fundal height, again.
That'll, kind of, help us
estimate when the due date is.
Fetal heart rates, if
possible, and if there's
any contractions.
So our goals for
preterm labor, again
perfuse that infant to
the best of our ability.
So hydrate mom, if necessary.
We're going to give 100% oxygen
and volume replacement, if we
think dehydration,
and then a lot
of the books that I was reading
uses the word tocalytic.
Have you heard that term before?
It was actually
a new term to me,
as long as I've been doing this.
So tocalytic means to stop,
or cease, contractions.
Magnesium sulfate,
the most common.
How does magnesium work to
slow or stop contractions?
What is it known for?
It is a smooth muscle
relaxer, so it's
going to hopefully
relax that uterus
from having those
preterm contractions.

All right, imminent delivery,
uh-oh, you've arrived on scene
and that baby is coming.
Get ready to catch.
Has anyone been part of
an imminent delivery?
A couple.
Yeah, we had one delivered
in a taxicab outside the ER
at St. Luke's on a shift
that I was working.
It's one of my coworkers
caught the baby.
And then another one
delivered– they were coming in,
if you're familiar with the
St. Lukes campus at all,
you know there's
multiple entrances.
She was coming in like
the complete opposite side
of the hospital from the
ER, so she delivered right
in the north building entrance,
right inside the two glass
doors.
So yes, those precipitous
births do happen.
Did either of yours have
any complications at all,
or did they just they
just squirt it out?
[INAUDIBLE]
A breech presentation.
Yeah.
So some synonyms to imminent
delivery, so that baby
that is going to come no matter
what, you may hear the term
emergency childbirth,
precipitous delivery, or birth
on arrival.
They get there
and squirt it out.
All right, so indications,
you guys experienced that.
She's having contractions,
she says it's coming,
it's a good indication.
When you look in the perineum,
you see bulge or crown,
or she may have that
feeling like she
has to defecate or bear down.
Their body's telling her things.
What do you need to do?
Stay calm, in control.
That's what we do well in
our profession, usually.
And don't delay the delivery.
It's going to happen.
That baby's coming whether
we want it to or not.
So we want to do our
best, as that baby
is being born, to kind
of control the expulsion,
without stopping
it from coming out.
We just don't want it
to come all the way out
without some kind of
control, cause, of course,
the baby who was born in a
taxi cab outside or our ER
at Luke's at the time, slipped
and went to the ground.
So it landed on its
head and it's shoulder.
It was OK, but
again, gave the staff
quite the fright, reasonably so.
So we want to, not only do
we want to catch the baby,
but things that can happen to
mom, you know, she can tear.
She can have quite some pretty
significant perineal tearing,
lacerations, and
damage to the urethra.
So again, kind of control the
rate so that doesn't happen,
to the best of our ability.
If mom is walking or in
a chair and there's not
time to place her on
a stretcher, of course
we might need to
go to the floor.
We want to keep fingers
out of the vagina,
so we're not introducing
any type of bacteria.
This is considered a clean
procedure, it's not sterile.
The only thing
that– the sterile
pack that we have in
the ED, do you guys
have a delivery pack on the
rigs that has the scissors?
Those items are all sterile,
but the actual prepping of mom,
she's not in a sterile field.
We'll drape her, protect her
modesty, put some kind of pad
down, if we can.
I mean babies come,
and it's not always
easy to get a full
history on mom.
There's a lot more
questions that you can ask,
but of course
these are some key.
When's your due date, so we
know if this baby's full term
or not.
Did she have any complications
identified in the pregnancy?
Should we expect more
the one to pop out?
Are there multiple
births inside there?
Rupture of membranes,
did it happen?
Does she remember when?
What was the color of
the amniotic fluid?
Why is that important?
Yeah, does she have
meconium staining?
Is that baby– can we anticipate
any distress as a result
of that, and did she have any
vaginal bleeding prior to this?
So be prepared to give
firm, calm instructions.
You guys are all
excellent at that.
Contractions that occur
every one to two minutes,
and last about a minute
to a minute and a half,
are indicative
that she's probably
ready to start pushing.
And do remember that it's
not a teaching moment.
There's a little too much stress
going on for mom right there.
Ask her if she took
a breathing class.
Do you have any
breathing exercises
that you can implement right
now, put them into place.
Or just teach her inhale
through the mouth,
and exhale through pursed lips.

For positioning, dorsal
recombinant, so laying back
is fine with knees bent.
Left side-lying is also
an option with knees bent.
Get your equipment,
absorbent pad, towels,
whatever you have available.
Drape underneath, if you can.
If you have time
permitting, they usually
do wash the perineum with
some kind of antiseptic soap,
so just kind of wash the area.
Do you have anything on the
rig that would suit that?
All right, just get
ready to catch then.

All right, so there's some
pictures on the next few slides
to just, kind of, show the
process of the baby coming out.
Infants usually can
deliver themselves.
They follow a natural
progression out
of the vaginal vault,
and they will turn.
It's when we run into
some of the problems
that you guys researched that we
have to do more interventions.
So if mom pants as the
head is being delivered,
that helps control the
rate of the delivery,
kind of helps slow it down.
The picture, here,
shows the assistant
supporting the perineum,
again, so the perineum doesn't
have a tendency to bulge or rip.
So we're holding that
tissue to allow–
we're not keeping the
baby in, we're just
controlling the
rate of delivery.

Again, you can see more
support of the perineal area.
Then we have the
hand on the head
as the baby starts to emerge to,
again, help guide the baby out.
We want to avoid that rapid
expulsion and support the head.
It's going to rotate
naturally as it comes down.
Once the head out,
if you see– we're
going to look at that
head and the face.
Moms membranes might
be still intact,
so the baby will come
up kind of looking
like they're in a balloon.
What are we going to do?
Take yep, take
some gauze finger.
We're going to clean
those membranes away
for the baby's face
to open that up.
Then we want to check
for umbilical cord,
so you're going to feel down
around the chin, the neck area,
looking for the umbilical cord.
|f we can address it, procedures
to attempt to slide it over
the head to get out of the way.

As baby comes out, looking at
suctioning in the mouth first,
nares second.
Suctioning the nose
usually causes the gasps.
Kind of stimulates
the respiratory,
so that's why we're going
for the mouth first.
And it also helps them
prevent any of them
from aspirating anything
in to the oral pharynx.
If we don't have a bulb
syringe available just,
a glove, gauze over a glove
finger works, as well.
If we see meconium, we want
to suction sooner than later
because as soon as they start
to take those first breaths,
they might aspirate
that content.
I love this picture.
It looks like they're
pulling them out, doesn't it?
Twisting that baby
out, again, they're
just, kind of,
help guiding them.
Have you seen a physician
to deliver a baby?
Yep, you see them, kind
of, do that manipulation
where they're working on it?

Yeah, I have not
done it myself, so I
don't know what it
feels like, but I've
seen both a vaginal
and a c-section birth.
Quite interesting
to participate in.
All right, so once we've
got the shoulders clear,
infants going to squirt out.
So again, we want to
support that body, catch it.
Note the time of
delivery, and then
how do we manage
the umbilical clamp?
Where are we going to clamp it?
Couple inches above,
it's about three inches
above the baby's abdomen.
Second clamp two to three
inches away from that.
Sterile scissors to
cut between the two.
If we don't have sterile
equipment available,
it is recommended
not to cut the cord.
But how would we position
the baby with mom, then?

Yeah, so we're going to put
baby on moms, kind of dry baby
off, put them on moms
tummy, at the level of mom
or below, so we don't cause
blood, abnormal blood flow.
Do you guys measure apgars?
It was in the book,
OK, so we've got
scoring at one
minute, five minutes,
and then if there
are low scores,
it should be an
ongoing assessment
for 20 total minutes.

If we need to actively
resuscitated our babe,
the picture shows different
ways of stimulating.
So again, stimulating that
foot, slapping that foot,
rubbing the belly vigorously,
rubbing the chest and belly.
Again, we need to,
usually the drying process
is enough to get babe to wake,
and it also prevents heat loss
and stimulates.
So this comes out of the
PALS, one of the PALS manuals.
Just, kind of, shows most normal
babies, normal births babies,
don't require anything.
Then less frequently
you do have to do
a little bit of positioning,
clearing the airway,
sometimes they need
ventilation, bag and mask,
some babies need
chest compressions,
and even more rare is the
administration of medications.
So again, the majority of
births are non-traumatic.

Vital signs, so we want to
know what to expect at birth.
So we're looking
for that heart rate.
Again, should be the same
as the fetal heart tones,
at this point, so we're
looking in that 100,
to 150, to 160 range
for that birth.

If we have to open
the airway, you know,
baby's got those big heads, we
need to position appropriate.
If we have meconium
that's present,
that the baby is vigorous,
meaning that, you know,
they're kind of fighting it, and
they've got some muscle tone,
we're going to do
suctioning, what we can.
And a vigorous baby has
respiratory efforts,
they have decent muscle tone,
and a heart rate over 100.
So we're just going to look
to clean things out, and see
if we can protect them.
If the baby's not
vigorous, so showing
signs of limp, poor
respiratory effort,
we're going to get some oxygen
on board, intubate if possible,
and suction trachea
before ventilating,
because again, they probably
have meconium in that airway,
so we want to get
it out of there.

If their heart rate
is less than 60
after 30 seconds of
ventilation, according
to PALS, that's when we
restart compressions, right?
Get on the chest.
It's a 90 compressions,
30 breaths per minute,
two thumb technique, so we
practice that in our CPR.

Once we have a
heart rate over 60,
we can stop chest compressions
and spontaneous respirations.

We'll continue to ventilate
until that heart rate has
improved to over 100, cause
that's our goal, target goal.
If drugs are required,
Epi, Narcan, you know,
if the situation
warrants it, mom
might have that
narcotic on board.

And then keep in mind,
glucose requirements.
Very high metabolism, so check
in that blood sugar, where
if infant needs excess
supplementation of glucose.
All right, so after birth,
stick that maybe on the breast.
Stimulates the
oxytocin, promotes
contractions of the uterus.
So now we're back to
mom's body making sure
that we finish up this
birthing process appropriately.
The placenta comes out
about 20 to 30 minutes
after the baby is born.
You can tell that it's about to
come out when the cord starts
to lengthen, cause it's starting
to move within that uterus,
so the chord lengthens.
We just don't want to tug on it.
We want little gentle
traction to ease it out,
but we don't want to pull it and
cause any premature separation.
We don't want to
put any pressure
on the fundus at that time.
Again, we just want to let
it naturally birth itself.
Placenta should be
kept with mom until she
is delivered to her destination.

Oxytocin may be
delivered, if they
need to firm up the uterus.
If it's firm, once
it's firm, they'll
decrease the drip
if remains boggy,
she has a risk for
hemorrhage, so they
may increase the oxytocin drip.
This diagram just
kind of showing
how that uterus can be palpated.
Should be about the
size of a grapefruit.
That's our goal.
Firmness is checked
about every five minutes,
looking for appropriateness.
It is massaged if it's not
firm to prevent hemorrhage.

We want to monitor vital signs
until stable, so usually five
minutes every cup for the first
period of time after birth.

And massaging and
feeling that uterus
to see if it's returning
to its– returning
to that grapefruit
size that we expect.
Because if we have
that boggy uterus,
and we start to get a
steady flow of blood,
now we're concerned about
the obviously concerned
about this hemorrhage.
So watching for signs of shock.
Provide that high flow
too if this is the case.
Here we might use
modified Trendelenburg.
What does that mean?
What is modified Trendelenburg?

Head and upper body
supine, legs elevated.
In one of my emergency
nursing resources,
there was a little article,
reference to an article,
about the dangers of
Trendelenburg in and of itself,
when you have the
patient with their head
lower than the
rest of their body.
So [INAUDIBLE]
receptor stimulated,
thinks the blood
pressure's high,
so you don't get the
appropriate response.
It can also increase
intercranial pressure too,
which may decrease your
cerebral profusion.
So yes, Trendelenburg itself
is not necessarily good,
so modified is recommended here.
Infant to the breast,
because again,
that can stimulate the
uterus to firm up and slow
the flow of the hemorrhage.
Just like a trauma patient,
she'll need those large bore,
two large bore IV's.
If she has any
external lacerations,
so if the perineum
lacerated in any way,
and you have blood flowing from
that, we need direct pressure.
And then if we have protocols,
or oxytocin, as prescribed,
that may be initiated, as well.
For amniotic fluid
embolism, I've
not taken care of a woman
who's ever had that.
Has anyone else
experienced this?
So again, I know some
of these emergencies
are kind of academic,
but something
we have to be aware of.
So if mom starts with sudden
respiratory distress and shock,
it's almost like throwing a
PE, they just can't breathe,
they can't get enough air.
So we're going to
need to manage ABC's.
She'll probably
require intubation.
Type and cross will be needed.
She may need blood, and you
may see signs of DIC in this.
So again, it's going
to be supportive care
until we get her
to her destination.
Uterine rupture, so you
have a very pregnant lady
involved in a possible trauma.
And now you have a
uterus that's normally
very pliant and flexible.
But for whatever
reason, the trauma
was enough to cause– you've
got that blunt trauma that
caused a burst.
She may have had
previous surgeries too,
so there was a weaker
spot of the uterus that
just made it more
susceptible to this.
But what these women will
experience, sharp, sudden onset
of pain, hypovolemic
shock, because they
may be bleeding internally.
When you're feeling and
doing that belly assessment,
rebound tenderness,
because now they're
going to have bleeding
into the peritoneum,
and they're going to
have peritoneal signs.
Distension, the
weirdest part about it
is that when you're palpating,
you can feel the baby.
You don't feel the
nice round uterus,
you actually feel
the baby parts.
You can feel the arm, you can
feel the head, feel the foot,
and we shouldn't normally
be able to feel them
to that degree.
But the uterus is no
longer enveloping the baby
with fluid inside of it.

So management, the
only thing that's
going to save mom at
this point is surgery.
So again, getting her
to that nearest facility
for surgical repair.
Our immediate goal,
preserve those ABC's,
so if mom needs
airway protection,
we're going to do it.
And we want to provide as much
uteroplacental perfusion, so
left lateral recumbent,
again, will be recommended.
100% oxygen by non-rebreather.
She'll need IV, and then if
we have the luxury of a Foley
catheter, making sure
that we are resuscitating
with fluid appropriately to
get the right urine output.
Magnesium sulfate may
be indicated, as well,
to stop contractions to control
hemorrhage and loss of fluid.
Pregnancy hypertension,
we may get a call
for a fairly pregnant
woman who has a seizure.
What condition does
that happen in?
Is it pre-eclampsia with a
seizure, or is it eclampsia?
It's eclampsia.
Once they have the seizure,
they are fully eclamptic.
So pre-eclampsia is when
you have findings present,
so what are the positive
findings in pre-eclampsia?
So blood pressure, pitting
edema, protein in the urine,
so we've got a
variety of big things.
Mom might not feel or look
all that well, generally,
but once they have the seizure,
they are fully eclamptic.
So they might need a
magnesium sulfate infusion
to manage those seizures.
Morphine, they might
develop pulmonary edema,
so they might need
drugs for that.
And then antihypertensives
for severe elevations
would be part of the management.
All right, let's
look at our kiddos.
A lot of you guys have
the kiddo emergencies.
Well he's just not
a happy little baby.

All right, so pulmonary
just, kind of, overview.
I mean you guys have
had PALS, right?
So what's the number one
cause of kids having arrest?
It's pulmonary based, right?
They're not the ones
usually with the cardiac.
We have some cardiac conditions
out here that we research,
but most normal kids do
not have cardiac issues,
so we're dealing with a
lot of respiratory issues.
So things that
could be presenting.
Airway obstruction,
which we'll hear
about, foreign bodies,
edema, bronchospasm, trauma,
infection, congenital
heart defects.

When the kid is having
respiratory distress,
our kids– have you seen
kids in respiratory distress?
They clip along with their
compensatory mechanisms pretty
darn well for a long
period of time, right?
Then once those compensatory
mechanisms have failed,
what happens?
They just plummet.
They are gone.
All their reserves
are absolutely gone,
so our goal, of course, is basic
and advanced life support to,
hopefully, prevent
complete failure.
So we're all familiar
with different kinds
of respiratory findings that
we might have in our sick kids.
Particularly looking
at nasal flaring.
You know little ones
don't have, they
don't have as much musculature
control of the nose,
so you'll see a lot
of nasal flaring
to help get extra air in.
You don't see that in adults.
Retractions, you can see some
pretty significant retractions.
Grunting, that's the
infants body's way
of doing its own
PEEP, so you might
hear those grunting
respirations.
So you want to be real good
to describe that if you can.

And respiratory
failure, baby's not
responding as we would expect.
They're flaccid,
poor color, modeling.
So one of them has increased
pulmonary blood flow
because the heart defect, one
of them has decreased blood flow
and then the third one has
obstructive blood flow.
So let's hear a little
bit more about those.
The first one increases
pulmonary blood flow,
and that's our PDA.
So that's a very
high level overview.
You guys did a great job.
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