NCCP Quiz

Shoulder dystocia: a birth complication where the baby's shoulders cannot pass beyond the mother's pubic symphysis, causing the head to deliver but retract back into the perineum.

"Turtle sign": a term used to describe shoulder dystocia where the baby's head delivers but the body does not.

Management of shoulder dystocia:

• McRoberts maneuver: a technique to help deliver the baby where the buttocks are moved off the end of the bed and thighs are flexed upward, applying pressure above the pubic symphysis.
• Transport immediately: regardless of the success or failure of the delivery attempt.

Nuchal cord: a condition where the umbilical cord is around the neck of the baby, commonly found during delivery and rarely associated with adverse outcomes.

Management of nuchal cord:

• Attempt to slip the cord over the infant’s head.
• If unable to slip the cord, clamp and carefully cut it.

Magnesium sulfate: a medication used to treat eclampsia and hypertension in pregnancy, but not recommended for pre-eclampsia. It can cause toxicity and result in cardiac arrest.

Benefits of intramuscular (IM) drug administration over the subcutaneous (SQ) route: IM administration is more consistent in the prehospital setting, especially for obese patients and pediatrics. More predictable absorption in critical patients.

Intranasal delivery of medications:

• A method that delivers medication as a fine aerosol into the nose, resulting in a broader distribution and increased bioavailability.
• Not all medications can be delivered intranasally, and medications that can include fentanyl, midazolam, naloxone, ketamine, and glucagon.

Pharmacological interventions for pain management: most commonly used agents include narcotics, ketamine, nitrous oxide, nalbuphine, and NSAIDS.

Monitoring and documentation before and after analgesic administration: documenting the patient's clinical status before and after analgesic administration is required, including vital signs, any significant changes, and corrective actions taken.

Quality improvement and medical oversight: systems with established quality improvement programs have better compliance to pain management protocols.

Acute vs. chronic pain management: perform a thorough pain assessment prior to providing treatment, pain management should depend on objective clinical decision making, and pain is individualized with each patient.

Sedation monitoring: use of analgesia and sedation in the out-of-hospital setting, including the use of NSAIDs, acetaminophen, fentanyl, midazolam, and ketamine.

Pediatric pain management: optimizing the environment, assessing pain, using non-invasive methods, and utilizing local and regional anesthesia.

Neonatal pain management: physiologic awareness of medication use in neonates, and non-pharmacologic pain management.

Oxygen therapy may worsen tissue damage in Acute Coronary Syndrome (ACS) and stroke patients due to the production of "free radicals."

• Free radicals are toxic byproducts of metabolism that damage membranes and increase local tissue damage.
• Reintroducing high concentrations of oxygen to cells that have been functioning anaerobically can increase free radical production and cause membrane damage and tissue death.

In cardiac arrest patients, Return of Spontaneous Circulation (ROSC) can be recognized by:

• A sudden increase of ETCO2 level
• The presence of a pulse after an organized rhythm is observed
• The patient breathing
• Patient movement

Post-cardiac arrest patients require optimal ventilation and oxygenation:

• Maintain an SpO2 of greater than or equal to 94%
• Avoid excessive ventilation
• Maintain ETCO2 between 35-40mm/Hg

Hemodynamic instability in the post-cardiac arrest patient should be monitored and managed:

• Vital signs
• Vascular access
• Cardiac hemodynamics
• Hypotension: treated with fluid bolus and vasopressors
• Arrhythmias: treated as required

Potential causes of cardiac arrest include:

• Obtaining and interpreting a 12-lead EKG
• Considering and managing reversible causes

Airway management during cardiac arrest includes:

• BVM (Bagu-valve mask): use 2-Rescuer technique
• Endotracheal tube (ETT) placement: compressions should not be interrupted
• Supraglottic airways: acceptable during CPR

Capnography should be attached to airways and monitored for signs of ROSC.

Pediatric cardiac arrest may be caused by various factors including "Hs and Ts" and other underlying conditions.

CHF may be caused by increased peripheral vascular resistance, ventricular failure, or fluid overload.

CHF presentation/signs/symptoms include distended neck veins, peripheral edema, and difficulty breathing.

CHF treatment includes Continuous Positive Airway Pressure (CPAP), nitroglycerin, and other medications.

CPAP contraindications include inability to maintain own airway, hypotension, and recent esophageal surgery.

Nitroglycerin use includes peripheral venodilation, reduction of oxygen demand in the heart, and dilation of coronary arteries, with contraindications for hypotension and use of phosphodiesterase inhibitors in the past 24-48 hours.

Minimal equipment required for intubation (iii) has disadvantages:

• Contraindicated for patients with a gag reflex
• Some devices not suitable for patients at risk for regurgitation (e.g., LMA™)
• Misplacement can occur without recognition
• Additional contraindications may apply per local protocol

Endotracheal Tubes (ETT) have advantages and disadvantages:

• Keeps airway patent and protects from aspiration
• Allows suctioning of deep airway secretions and potential drug administration
• Difficult initial training, requires frequent practice, and may cause trauma to the oropharynx
• Prolonged intubation attempts may cause hypoxemia
• Adverse outcomes common for inexperienced providers and inadequate monitoring

Suctioning the airway in newborns:

• Can cause bradycardia and should be avoided unless necessary
• Should not be done immediately after birth unless an obstruction is present or positive pressure ventilation is required
• Presence of meconium does not always indicate a need for suctioning

End tidal CO₂ (ETCO₂) measurement:

• Utilized to measure ventilation in patients
• Measures partial pressure (mmHg) or volume (% vol) of exhaled CO₂
• Reflects changes in ventilation within 10 seconds
• Breath-to-breath measurement provides information within seconds
• Not affected by motion artifact, poor perfusion, or dysrhythmias

Physiology of CO₂:

• Carbon dioxide can be measured in arterial blood gas, mixed venous blood gas, and exhaled CO₂
• Normal ranges for PaCO₂, PvCO₂, and ETCO₂

Measuring ventilation in intubated patients:

• Provides information on ET tube placement, tube displacement, chest compressions, ROSC, and probability of successful resuscitation

Measuring ventilation in non-intubated patients:

• Objectively assesses acute respiratory disorders (asthma, COPD, hypoventilation, congestive heart failure, sedation and analgesia, stroke, head injury, and perfusion status)

Interpreting ETCO₂ and capnography waveform:

• Normal waveform consists of five phases: dead space ventilation, ascending phase, alveolar plateau, end-tidal, and descending phase
• AHA Guidelines recommend oxygen administration for patients with suspected acute coronary syndrome or stroke based on SpO₂ levels and specific conditions.

Oxygenation of chest pain and stroke patients:

• 2 L/min via nasal cannulas for patients with dyspnea, signs and symptoms of shock, or heart failure, or an SpO₂ of less than 94% on room air
• Titrate oxygen to maintain an SpO₂ of at least 94%