Neonatal/Pediatric Tips for the Less Experienced Neonatal/Pediatric Care Provider
Non-Accidental Trauma, Sepsis, and Congenital Heart Disease
Introduction: Pediatric patients less than a month old are typically labeled as neonatal. This category of patient can cause anxiety to medical care providers, especially when most primary training for this age of patient is minimal. Unless a provider has spent significant time (3-5 years) caring only for this age patient, proficiency of care (let alone confidence) has probably not been established. The term “high acuity, low volume” is typically reserved to describe certain procedures such as thoracotomies, tracheostomy, or in some circles regular intubation. However it could be used in relation to a whole patient demographic such as the neonatal population. Some of the most unassuming signs or symptoms in the neonatal patient can be significant, while others, when observed in the older patient seeming significant, are not in the neonate.
Three diagnoses that imitate each other in the neonatal population are Non-Accidental Trauma (NAT, specifically abusive head trauma or AHT), Sepsis, and Congenital Heart Disease. Each of these conditions are complicated by themselves, and unfortunately, can happen simultaneously. This can happen in pairs, or all three, with other multi-system involvement. To break this down, each diagnosis will be presented separately as a series. This will be followed by a final essay that will compare and contrast them to assist the care provider in prioritization of tasks and management of this patient. These are written by a Registered Nurse with 18 years experience in pediatrics and 10 years of pediatric/neonatal transport experience with a certificate in pediatric critical care nursing from the AACN. The information here should be considered to be simply informational, experiential little tidbits or nuggets of advice.
Abusive Head Trauma: Now, on to Abusive Head Trauma (AHT). AHT is lumped into a multitude of injuries that fall under the umbrella of non-accidental trauma (NAT), others could include burns, long bone fractures, hard organ lacerations, mucosal fissures etc. The Center for Disease Control defines abusive head trauma as “preventable and severe form of physical child abuse that results in an injury to the brain of a child. AHT often happens when a parent or caregiver becomes angry or frustrated because of a child’s crying. It is caused by violent shaking and/or with blunt impact. The resulting injury can cause bleeding around the brain or on the inside back layer of the eyes”. The experience of AHT to babies is fatal in 25% of cases. The injuries sustained by AHT vs. accidental trauma are far more severe, as evidenced by the treatment modalities required to care for these patients. (1)
The cycle of transportation of a patient with AHT (like most other patients) follows a pattern of 1. History gathering, 2. Exam and Stabilization 3. Packaging 4. Transport 5. Re-evaluation (which occurs throughout this process) 6. Arrival and handoff. Anyone with transport experience knows that this is a very fluid situation and multiple steps can be happening at once. Those of us in transport don’t strictly follow the Primary/Secondary exam acronyms and structure. We’re usually transporting via interfacility, so these types of exams should have been completed multiple times by the time the CCT team makes contact with the patient. This is not to say the points in those surveys are not to be re-evaluated continuously by the transport team. The evaluation of a patient from the standpoint of a critical care transport professional is often fraught with the dichotomy of expert evaluation and treatment versus the urge to “not delay transport” to a regional tertiary specialty healthcare center. The time taken to obtain key information at the referral facility depends on what has been obtained prior to the team’s arrival. Key information includes: the initial physicians exam findings and treatments, history taken directly from the parent or provider, physical exam, lab results and imaging results read by a radiologist experienced in the neonatal population.
Something I always try to obtain with most patients is the details provided to the referral physician by the parent or caregiver if/when I receive a report from said physician or caregiver. This allows me to compare/contrast the report I get directly from the parent/caregiver to see if anything changes.
Here starts the primary exam of which I will not go into detail (general impression, mental status, airway, breathing, circulation). Of course one notes the above and prioritizes care based on that. One of the things I note upon entering the patient room is if the patient is cervically immobilized. For a neonate this isn’t necessarily for protection of the spinal cord from fractures, but mostly of the ability to maintain the head at midline, to help with venous return to assist with lowering IntraCranial Pressure (ICP). Neonates have weak neck muscles and very cartilaginous bone structure, mostly they cannot hold their heads in place. Given that the mechanism of injury with this type of injury stems from a shaking motion with the infant’s head forcefully moving forward and backward, muscular and ligamentous injury could also be present. Cervical immobilization may not be initially done by the referral facility, but this should be done by the transport team to prevent movement and pain. There are also many facilities that do not stock cervical collars for this size patient. Many times the referral facility will state that the c-spine has been cleared, acknowledge this and move on, with the full intention of immobilizing the cervical spine until the patient receives tertiary care. (3)
The secondary exam then begins and again I won’t go into details of it’s points. Think head to toe. Speaking of head, one of the helpful anatomical differences in infants is the lack of a complete osseous closure of the skull bones which provide fontanelles (anterior and posterior) for swelling (or depression) should there be any. The fontanelles allow the provider some extra minutes needed to obtain the differential diagnosis (if not already confirmed). These also provide valuable assessment findings which relate to cardiovascular fluid status (dehydration will show sunken fontanelles) or intracranial pressure (bulging with elevation of ICP). Pupillary response can sometimes be difficult to obtain in neonates, but it absolutely must be evaluated. Look into the mouth and note the state of the frenulum connecting the tongue to the bottom of the mouth. Examination of the whole body in a neonate, while smaller, is sometimes more time consuming depending on the situation when the provider walks in. If the patient is bundled up and being held by a defensive parent, it will take longer to simply get the patient in a position to examine. Once this is allowable, it won’t take long, take the patients hat off and check the fontanelles and scalp for bruising, check the rib cage for bruising, the limbs for mobility and swelling, look closely at the diaper area and document anything unusual, even if they say it’s “just a rash”.
Just as with an older patient, when the provider finds something that must be treated immediately, one should do so. Signs of elevated ICP would include a bulging fontanelle, pupillary discrepancies (lack of reaction, unilateral reaction, and/or very large pupils that are sluggish), lethargy, high pitched cry, bradycardia, hypertension and possibly tachypnea. Note that a normal heart rate for a typical one month old is 100-180, typical systolic blood pressure is 65-100, normal respiratory rate is 30-50. One practice that has fallen out of favor is for medical practitioners to hyperventilate patients with elevated ICP. The thought was to lower serum carbon dioxide, in turn lowering the volume of blood flowing into the head, in turn lowering ICP. This is no longer common, or correct practice in the first 24 hours of injury. Our program uses 3-5 ml/kg of 3% Saline over 20-30 minutes with a maximum of 250 ml to treat elevated ICP of all etiologies (trauma or cerebral edema from rapid glucose changes). Some places use Mannitol and the typical dose for that is 0.5 grams per kilogram. You’ll want to have a urinary catheter in place for this as it produces diuresis. (5)
Other injuries should be also treated, splinting of broken limbs etc. But let’s not forget pain. These patients feel pain even though they cannot express the words “my head hurts”. Pain is assessed differently in the young neonate. There are pain scales specifically formulated for such demographics utilizing behavioral observation pain ratings. A popular and commonly referred to scale is the FLACC which stands for Face, Legs, Activity, Cry and Consolability. We use Fentanyl 1 mcg/kg, diluted and then pushed slowly every 5 minutes as needed for moderate or severe pain. Exceptions include hypotension and a significantly altered level of consciousness without a secured airway in place. The intranasal route can also be used, however the dosages change (usually increased to allow for mucosal absorption). We use an atomizer hooked up to the syringe.
When packaging a neonatal patient, a pediatric/neonatal team will typically arrive to transport the patient in an isolette that has an enclosed and warmed compartment. Normothermia is the goal with the AHT patient for transport. With an isolette, only slight elevation of the patient can be achieved for transport. However the typical team will have a patient cot and some form of pediatric/neonatal transport device that interfaces with the adult sized cot. This allows for more aggressive elevation of the head. The standard for our program is a 30 degree head elevation hinged at the hips. This can be difficult with a neonatal patient. A neonate’s head is large in proportion to their body. Also, they cannot hold it up. In order to have the patient’s head elevated to 30 degress one can place a pad underneath the neonate’s bottom and back up to their neck with baby blankets or towels, but do not pad behind the head, this prevents the patient from having their chin tucked to their chest. Make sure they are bending at the hips, not the lumbo-thoracic area. Our program typically removes backboards. Take measures to maintain normothermia in the neonatal patient by obtaining warmed blankets and possibly a hat for transport.
Generalized Care: During transport, monitor vital signs at a minimum every 15 minutes. If a blood glucose was not obtained earlier, this is a good time to obtain one and treat it if the patient is hypoglycemic (2 ml/kg of D10). Remember a normal serum glucose range for a neonatal patient (less than 30 days old) is 40-99. Maintenance IV fluid should contain some form of dextrose after initial resuscitation of normal saline if it was needed. A patient on NICU transport will receive D10 as a maintenance fluid. Typically when a patient is going to be admitted into a general pediatric floor or pediatric ICU, their maintenance fluid is D5 .9 or D5 .45 with or without potassium depending on levels. We carry D10 and D5.9 without potassium depending on whether the patient will go to the NICU or PICU respectively.
To calculate IV fluid rates, in the pediatric population we use the 4-2-1 rule. 4 ml/kg/hr for the first 10 kg (this should be all you need for neonates, I cannot remember a child less than 30 days weighing more than 10 kg). So, given a 3.3 kg patient, 3.3 x 4 = 13.2 ml/hr. Most people outside the NICU will not criticize you for rounding. Speaking of the NICU, not only is the fluid rate weight based but the calculations are time based as well. For instance this same patient would get 60-80 ml/kg/day of fluid. So 3.3 x 70 = 231 ml over 24 hours. 231 ml divided by 24 hours = 9.625 ml/hr. I’d give 9.6 ml/hr. They will accept D10 for transport, but prefer D5 .2 or D5 .45 for larger neonates (greater than 1 kg) and older than 48 hours when possible. If possible, have continuous temperature monitoring placed on the patient. Use blankets, patient compartment heating to warm the patient. We have an IV fluid warming cartridge available to us, but neonatal fluid rates are much slower, so fluid can cool off by the time it reaches the patient.
Re-evaluate the patient continuously throughout transport and intervene if needed. Keep in mind, a wise transport nurse I look up to (now retired) once said “just because you can do it, doesn’t always mean you should”. In the transport world we are given training above and beyond our representative disciplines scope of practice, especially from a nurses’ perspective. Conservative treatment in the transport world is a safe place to stay for your patient. There are many variables that are uncontrollable and many resources that are unavailable in the back of an aircraft or ambulance. Sometimes intervention is unable to be avoided, this takes calm minds and well thought out decisions. Pediatric patients are remarkably good at compensation, and in the adult patient we’d consider this by maintaining blood pressure. In the pediatric population, this sign is not much of an indicator. Pediatric patients can maintain normotensive status when losing 30% of their intravascular volume. This will be covered in further essays but sometimes all they need is some prompt and aggressive fluid resuscitation. Very aggressive unneeded treatment, such as intubation, can lead to unintended decompensation. (4)
When arriving at the accepting facility, it’s good to give a concise, comprehensive report of all you know of the patient. We do this before unloading the patient, when all disciplines arrive, the physicians, nurses, respiratory therapists, etc. When all is communicated, then the transport team leads in placing the patient into the bed/crib/warmer. Respiratory adjuncts are confirmed again as well as any infusing intravenous site. A final set of vital signs are obtained from the receiving facility before the team departs after obtaining signatures from the receiving staff. I’ve included the following algorithm to assist in differentiating non-accidental trauma from accidental trauma.
Andy Bullock, BSN, RN, CCRN-P is a neonatal and pediatric critical care nurse that works for a large hospital-based transport company in the midwest. He has been a nurse for a total of 18 years; 4 years in general pediatrics, 4 years in pediatric intensive care, and the last 10 years in critical care transport. Andy has lived in central Indiana since 1989. He enjoys spending his time with his wife of 20 years with 3 children on 7 peaceful rolling acres of land in rural Morgan County.
1. Non-accidental trauma in pediatric patients: a review of epidemiology, pathophysiology, diagnosis and treatment. Alexandra R. Paul and Matthew A. Adamo. Translational Pediatrics, July 2014.
2. Update in Pediatric Emergency Medicine: Pediatric Resuscitation, Pediatric Sepsis, Interfacility Transport of the Pediatric Patient, Pain and sedation in the Emergency Department, Pediatric Trauma, Guest Editor (s): Shalea Piteau, Tania Principi, 2 Deborah Schonfeld, M.D., F.R.C.P.C.,2 Laura Weingarten,3 Suzan Schneeweiss, M.D., M.Ed., F.R.C.P.C.,2 Daniel Rosenfield,2 Genevieve Ernst, M.D., F.R.C.P.C.,2 Suzanne Schuh, M.D., F.R.C.P.(C.), F.A.A.P., 4 and Dennis Scolnik, F.R.C.P.(C.), D.C.H., M.Sc.5,6
3. Peter E. Fischer, Debra G. Parina, Theodore R. Delbridge, Mary E. Fallat, Jeffrey P. Salamone, Jim Dodd, Eileen M. Bulger & Mark L. Gestring (2018): Spinal Motion Restriction in the Trauma Patient – A Joint Position Statement, Prehospital Emergency Care, DOI: 10.1080/10903127.2018.1481476
4. Pediatric Hypovolemic Shock, Michael J. Hobson and Ranjit S. Chima, The Open Pediatric Medicine Journal, 2013, 7, (Suppl 1: M3) 10-15
5. Godoy, D. A., Seifi, A., Garza, D., Lubillo-Montenegro, S., & Murillo-Cabezas, F. (2017). Hyperventilation Therapy for Control of Posttraumatic Intracranial Hypertension. Frontiers in neurology, 8, 250. https://doi.org/10.3389/fneur.2017.00250