The Collapsed Ventilated Infant
Aids to Diagnosis and Treatment

Reviewed by Simon Rowley

December
2000

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.

PROBLEM		ACTION
Delivery	System fault, i.e. interruption of gas supply to ventilator.	Reconnect or change to adequate gas supply.
Delivery	Loss of desired ventilation from machine to ETT.	Check ventilator settings and tubing circuit integrity.
ET Tube Problems	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.	Remove ETT, bag, reintubate.
Ectopic Air	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.
	In both situations, consider obtaining a chest radiograph if time allows to confirm diagnosis
Acute Blood Loss	Revealed From arterial line, umbilical vessels, GI tract, renal tract or up ETT.	Control bleeding if possible. Give volume, FFP, blood promptly. Check clotting.
Acute Blood Loss	Concealed Pulmonary, GI tract bleeds and also IVH/PVH.	Give volume , FFP, blood promptly. Check clotting. Arrange CXRs, cerebral USS.
Neurological	Convulsions associated abnormal limb truncal, facial movements	Administer anticonvulsant – Phenobarbitone 20-25 mg/kg load is usual. Correct any predisposing factors. Arrange cerebral USS.
Other occasional causes of acute cardio-respiratory collapse.	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	Administer 2ml/kg of 10% Dextrose as bolus, increase rate of maintenance Dextrose infusion and recheck blood glucose in 30 minutes.
	Hypocalcaemia	Administer 1ml/kg of 10% Calcium Gluconate, increase maintenance infusion and recheck serum calcium in 30 minutes.
	Hyperkalaemia	Administer 1ml/kg of 10% Calcium Gluconate and consider further treatment depending on degree of hyperkalaemia. e.g. Resonium, Dextrose 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.