1. Nov 2007 ACoRN © 2006-07 Cardiovascular Sequence Case Two

2. Nov 2007 ACoRN © 2006-07 Ethan

3. Nov 2007 ACoRN © 2006-07 Breathing is easy and regularBreathing is easy and regular HR is 140 bpmHR is 140 bpm Colour …Colour … What do you do?What do you do? Ethan

4. Nov 2007 ACoRN © 2006-07

5. Nov 2007 ACoRN © 2006-07

6. Nov 2007 ACoRN © 2006-07

7. Nov 2007 ACoRN © 2006-07 You now observe Regular respirations, RR 55Regular respirations, RR 55 Heart rate 140/minHeart rate 140/min Remains dusky despite oxygen administrationRemains dusky despite oxygen administration You leave the Resuscitation Sequence to complete the Primary Survey.You leave the Resuscitation Sequence to complete the Primary Survey. Ethan

8. Nov 2007 ACoRN © 2006-07 SpO 2 is 75% on 70% oxygen administered via oxygen hood – colour remains cyanoticSpO 2 is 75% on 70% oxygen administered via oxygen hood – colour remains cyanotic Breathing remains easy, breath sounds are heard bilaterallyBreathing remains easy, breath sounds are heard bilaterally HR120/minHR120/min BP 59/32, M 43 mmHgBP 59/32, M 43 mmHg Tone flexedTone flexed Temperature 36.7°CTemperature 36.7°C Complete the Primary Survey. Complete the Primary Survey. Ethan

9. Nov 2007 ACoRN © 2006-07

10. Nov 2007 ACoRN © 2006-07

11. Nov 2007 ACoRN © 2006-07 Organization of Care

12. Nov 2007 ACoRN © 2006-07 Response

13. Nov 2007 ACoRN © 2006-07 As close to 100% oxygen as possible is administered for 15 to 20 minutes.As close to 100% oxygen as possible is administered for 15 to 20 minutes. What response are you looking for? What response are you looking for? Ethan

14. Nov 2007 ACoRN © 2006-07 Next Steps

15. Nov 2007 ACoRN © 2006-07 Mother is 32 years old, G1P0.Mother is 32 years old, G1P0. Pregnancy has been uneventful.Pregnancy has been uneventful. Antenatal scan at 19 weeks was normal.Antenatal scan at 19 weeks was normal. Labour was spontaneous at 39 weeks gestation.Labour was spontaneous at 39 weeks gestation. No evidence of fetal distress.No evidence of fetal distress. Ethan was born in good condition.Ethan was born in good condition. Ethan

16. Nov 2007 ACoRN © 2006-07 The focused cardiovascular examination is unremarkable, other than for cyanosis.The focused cardiovascular examination is unremarkable, other than for cyanosis. SpO 2 remains 75% during the hyperoxia test.SpO 2 remains 75% during the hyperoxia test. Can Ethan tolerate this degree of cyanosis? Would you wean the oxygen? Ethan

17. Nov 2007 ACoRN © 2006-07 Next Steps Cyanotic heart disease?

18. Nov 2007 ACoRN © 2006-07 Consult! Transport! Cyanotic heart disease!

19. Nov 2007 ACoRN © 2006-07 The team has quickly completed the Fluid & Glucose, Thermoregulation and Infection Sequences.The team has quickly completed the Fluid & Glucose, Thermoregulation and Infection Sequences. A blood culture was not done - nor were ampicillin and gentamicin ordered.A blood culture was not done - nor were ampicillin and gentamicin ordered. An assessment was done of the resources needed to look after this baby.An assessment was done of the resources needed to look after this baby. The chest radiograph and blood gas results have returned. The hgb is 180.The chest radiograph and blood gas results have returned. The hgb is 180. You re-enter the Cardiovascular Sequence to complete Specific Diagnosis and Specific Management.You re-enter the Cardiovascular Sequence to complete Specific Diagnosis and Specific Management. Ethan

20. Nov 2007 ACoRN © 2006-07 Ethan

21. Nov 2007 ACoRN © 2006-07 Normal radiograph for comparison

22. Nov 2007 ACoRN © 2006-07 Specific Diagnosis

23. Nov 2007 ACoRN © 2006-07 Specific Management

24. Nov 2007 ACoRN © 2006-07 Arterial blood gas:Arterial blood gas: –pH 7.35 –pCO 2 35 mmHg –BD 2 mmol/L –HCO 3 22 mmol/L –pO 2 40 mmHg Interpret the blood gas. How would this affect your management plan? Ethan base acid pH

25. Nov 2007 ACoRN © 2006-07 Would you initiate Prostaglandin E 1 ?Would you initiate Prostaglandin E 1 ?

26. Nov 2007 ACoRN © 2006-07 On arrival of the transport team, Ethan was stableOn arrival of the transport team, Ethan was stable He was transported to the level III center without incidentHe was transported to the level III center without incident 12 hours later, the physician from the level III center calls you to report on Ethan’s condition …12 hours later, the physician from the level III center calls you to report on Ethan’s condition … Ethan

27. Nov 2007 ACoRN © 2006-07 Ethan Ethan had TGAEthan had TGA He had surgery later that weekHe had surgery later that week Went home in good condition 2 weeks laterWent home in good condition 2 weeks later

28. Nov 2007 ACoRN © 2006-07 Questions?