Neonatal Pediatric Transport – Rationale Samples

Neonatal Question

A 34 week gestational age preterm neonate currently being maintained on a conventional ventilator following vigorous resuscitation efforts at birth is being referred to a tertiary center. The transport team notes stable vital signs and laboratory findings at the time of departure. Approximately 15 minutes into the ground transport, the infant becomes irritable and experiences a sudden drop in heart rate and onset of cyanosis. Equipment function and presence of exhaled CO2 is confirmed. Based upon the history and clinical findings, the infant's current status is indicative of

  • developing tension pneumothorax
  • partial plugging of the endotracheal tube
  • worsening of the underlying respiratory condition

Rationale

Infants at increased risk for the development of air leaks fall into 3 specific categories: healthy term infants, neonates with pulmonary diseases, and neonates receiving positive-pressure support (CPAP and IMV). A tension pneumothorax causes a sudden and severe deterioration in the clinical course, characterized by profound cyanosis, bradycardia, air hunger including gasping and anxious facies, diminished or shifted breath sounds, and diminished, shifted or muffled heart sounds. In this case, the infant's clinical presentation matches the classic signs of a tension pneumothorax. The equipment function was checked and the CO2 detector confirmed proper ET tube placement.

Pediatrics Question

Which of the following is the most common cardiac rhythm pattern observed in cases of asphyxial arrest?

  • Bradycardia with wide QRS complexes
  • Third degree block followed by a pulseless state
  • Ventricular tachycardia preceding ventricular fibrillation

Rationale

In contrast to adults, cardiac arrest in infants and children does not usually result from a primary cardiac cause. More often it is the terminal result of progressive respiratory failure or shock, also called an asphyxial arrest. Once CPR has been established, a child's cardiac rhythm should be determined from the ECG or, if an AED is being used, the device will tell you whether the rhythm is "shockable" (eg, ventricular fibrillation (VF) or rapid ventricular tachycardia) or "not shockable" (eg, asystole or pulseless electrical activity: PEA). Asystole and bradycardia with a wide QRS are most commonly seen in asphyxial arrest. Ventricular fibrillation (VF) and PEA are less common but VF is more likely to be present in older children with sudden witnessed arrest.

Core Question

Maintaining appropriate temperature is particularly important in the pediatric or neonatal patient because of a predisposition to heat loss due to

  • increased norepinephrine production
  • large body surface area to weight ratio
  • rapid depletion of fat stores

Rationale

Compared to adults, neonates and pediatric patients have a very large surface area to body mass ratio and therefore have a relatively large area exposed to the environment from which heat can be lost. More mature infants may try to minimize their surface area by changing positions and flexing the trunk and extremities, to decrease exposed surface area when faced with a cold stimulus but this is not as effective as in an adult. They also have little subcutaneous fat tissue which acts as insulation to help prevent heat loss.