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NICU guideline identifier

Collapsed ventilated infant in Newborn Services

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Situation

You are called to see the small ventilated premature baby with RDS. The baby has suddenly collapsed, is cyanosed, pale, with a falling BP, falling HR. How does one deal with this situation?

Strategy

  • Have a systematic checklist to rapidly ascertain the problem and then treat it appropriately. 
  • Aim to achieve adequate oxygenation. If any delay in diagnosis or management remember to maintain CPR basics. 
  • Don't hesitate in calling the consultant if you anticipate major problems that require expertise beyond your abilities. 

Delivery

Problem Action
System fault, i.e. interruption of gas supply to ventilator. 
Loss of desired ventilation from machine to ETT. 
Reconnect or change to adequate gas supply. 
Check ventilator settings and tubing circuit integrity.

ET Tube Problems

Problem Action
Extubation
poor chest movement, poor air entry 'blowing bubbles'.

Remove ETT, bag, reintubate.
Tube placement
e.g. right main bronchus
Directly visualise ET tube and check position.
Withdraw 0.5-1cm.
Check CXR.
Blockage
poor chest movement, poor air entry, copious secretions, difficulty passing suction catheter
no flow on respiratory function graphics

Remove ETT, bag, reintubate.

Ectopic Air

Problem Action
Pneumothorax
decreased chest movement and/or decreased air entry, that may
transilluminate with a cold light.

Aspirate with fine gauge butterfly needle, 3-way tap and syringe.

If free air proceed to insertion of intercostal drain.
Pneumopericardium
present on previous CXR
signs of tamponade - loss of cardiac output with no heart sounds
heard but normal complexes on ECG.

Aspirate with fine gauge butterfly needle, 3-way tap and syringe
via subxiphisternal space.

If air recollects consider drain insertion.

NB: In both situations, consider obtaining a chest radiograph if time allows to confirm diagnosis

Acute Blood Loss

Problem Action
Revealed
From arterial line, umbilical vessels, GI tract, renal tract or up ETT
Control bleeding if possible.
Give volume, FFP, blood promptly.
Check clotting.
Concealed
Pulmonary, GI tract bleeds and also IVH/PVH.
Give volume , FFP, blood promptly.
Check clotting.
Arrange CXRs, cerebral USS.

Neurological

Problem Action
Convulsions
Associated abnormal limb truncal, facial movements
Consider Brainz monitoring
Administer anticonvulsant - Phenobarbitone 20-25 mg/kg load is usual.
Correct any predisposing factors.
Arrange cerebral USS, and consider follow up MRI


Other occasional causes of acute cardio-respiratory collapse

Problem Action
Septicaemia Maintain optimal cardiovascular support with colloid and inotropic agents.Obtain microbiological samples if stable.
Check FBC, clotting.
Commence on antibiotics.
Metabolic disturbances
e.g. Hypoglycaemia


Hypocalcaemia


Hypokalaemia

Administer 2ml/kg of 10% Glucose as bolus, increase rate of maintenance Glucose infusion and recheck blood glucose in 30 minutes.

Administer 1ml/kg of 10% Calcium Gluconate, increase maintenance infusion and recheck serum calcium in 30 minutes.

Administer 1ml/kg of 10% Calcium Gluconate and consider further treatment depending on degree of hyperkalaemia. e.g. Resonium, Glucose and Insulin.
Congenital Cardiac Disease
With heart failure commonest lesions presenting in first week of life:
Hypoplasia of the left heart
Coarctation of the aorta syndrome.

With severe cyanosis:
Transposition of the great arteries.
Pulmonary atresia or severe pulmonary valve stenosis.
Maintain optimal oxygenation and cardiac output.
Arrange urgent CXR, ECG and ECHO.
Treatment dependent on diagnosis and in consultation with Paediatric Cardiologist.
In the absence of a rapidly accessible Echocardiogram or Cardiology assessment, a prostaglandin infusion may be life-saving.
Pulmonary Hypertension
Commonly a problem in known term baby with PPHN.
However, significant R to L shunting may cause acute collapse in the ventilated premature baby.
Pulmonary vasculature is PO2 and pH sensitive.
Keep optimal oxygenation.
Keep pH high using base +/- hyperventilation.
Maintain adequate systemic blood pressure with colloid and inotropes.
Consider inhaled Nitric Oxide.

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Document Control

  • Date last published: 24 October 2012
  • Document type: Clinical Guideline
  • Services responsible: Neonatology
  • Owner: Newborn Services Clinical Practice Committee
  • Editor: Sarah Bellhouse
  • Review frequency: 2 years