How do you initiate management?
You assess that this baby is critically unwell and shocked. It is impossible to determine the exact cause at this stage. Initial resuscitation follows an ABCD+DUCT approach. Do not be afraid to use oxygen liberally during this early phase.
A saturation probe is applied to the right hand to obtain a pre-ductal saturation reading and to either foot for a post-ductal comparison. Titrate oxygen to preductal saturations as this is what the brain will receive and accept saturations above 75%. Post-ductal saturations are normally slightly lower due to mixing of pulmonary blood but a difference of greater than 3% on the feet may indicate underlying duct dependent congenital heart disease.
Saturations may be tricky to pick up in the shocked neonate due to poor peripheral perfusion. Trying the probe on the earlobe might help.
Access is obtained intravenously (remembering scalp and external jugular veins) but if difficult then use a 15mm intraosseous needle (“paediatric pink” EZ-IOÒ) placed in the proximal tibia. Umbilical venous access is another option, and a feeding tube or central line can be used here.
5ml/kg crystalloid boluses are given and titrated to heart rate and blood pressure remembering that hypotension is a late sign.