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Neo/peds
chp 6-8 & 15
| Question | Answer |
|---|---|
| Core temp maintained at | 37 degrees |
| Brown fat cells appear around | 26 to 30 weeks |
| Where is brown fat stored? | Around great vessels, kidneys, scapula, axilla & nape of neck |
| Term for when brown fat is broken down to produce heat | Nonshivering thermogenesis |
| What is ITG? What does it mean? | Internal Thermal Gradient = temp difference between body core and skin |
| How does ITG heat travel thru body? | from warmer internal structures to cooler skin |
| What factors effect ITG? | metabolic rate, fat present, surface area, distance from body core to skin |
| What is ETG? What does it mean? | External Thermal Gradient = Temp difference between skin and environment |
| How does ETG heat travel thru body? | from skin to the cooler environment |
| What are the four factors effecting ETG? | Radiant heat loss, conduction, convection & evaporation |
| What are four types of heat loss? | Radiant, conduction, convection, & evaporation |
| Radiant heat loss | loss of heat from neonate to cooler objects surrounding it, but not in direct contact of |
| Conduction | transfer of heat from skin to cooler surface in contact with neonate |
| Convection | loss of heat from skin to air current passing over neonate |
| Evaporation | release of heat due to water changing from liquid to gas |
| Evaporation - insensible | from skin and respiratory tract |
| Evaporation - sensible | from sweating from skin |
| Hypothermia | peripheral vasoconstriction shunting blood away from skin |
| Results of hypothermia | hypoxemia and acidosis due to anaerobic metabolism |
| What does hypothermia trigger? | Nonshivering thermogenesis which results in hypoglycemia |
| Hyperthermia | peripheral vasodilation to help release heat |
| Results of hyperthermia | increases metabolism and O2 consumption |
| What are causes of hyperthermia? | Infection, dehydration. Also malfunctioning incubators, radiant warmers, humidifiers, and phototherapy (equipment malfunction) |
| Thermoregulation in delivery room | Prevention of Evaporative heat loss, radiant heat loss, and convective & conductive heat loss |
| Prevention of Evaporative heat loss at delivery | Completely dry neonate with pre-warmed blanket/towel; most important head and face |
| Prevention of Radiant heat loss at delivery | Place under warmer, wrap in warm blanket, place cap on head |
| Prevention of convective & conductive heat loss at delivery | Keep neonate covered, small preemies placed on warming mattress and prewarmed incubators |
| Thermoregulation in Nursery | Incubators and Open warmers |
| Incubators | Adv = controlled thermal environment; temp reg by servo-control, skin temp increases/decreases heat in incubator, skin probe secured to skin |
| Open Warmers | Adv = access to pt; Keep wrapped up, use shields and plastic sheets, don't place on cold surface |
| Behavioral based care | times pt stimulation based on sleep/wake state, activity level, approachability, and O2 status |
| Sleep/Wake state | Only stimulate when baby is awake |
| Risk Factors for Neonate for Upper Airway Occlusion | Tongue large, lymphoid tissue in pharynx, epiglottis large, trachea small and/or short, swelling, & diaphragmatic breathing |
| 3 factors for low reserve | heart enlarged, no stability of ribs/sternum, large abdominal contents cause diaphragm not to flatten |
| Obstetrical history needed | Gravida - #of pregnancies, Para - # of deliveries, Previous pregnancies ie: high/low risks & previous premies |
| PARA stands for | P=total prior preg, A=Total premature dlvrs, R=total abortions/miscarriages, A=Total live births |
| Prenatal & intrapartum history needed | Length of stages, fetal pres, Vaginal vs. C-section, Fetal hr, anesthetic or tocolytic used, NST or ST, PROM b4 37 wks, maternal steroids, placenta problems |
| Used for Gestational Age | Naegele's Rule, Dubowitz, Ballard Score, Fetal ultrasound |
| Naegele's Rule | Subtract 3 months + 7 days from 1st day of last menstrual cycle |
| Dubowitz | (Objective & reproducible)11 physical and 10 neurological findings; higher score = longer gestation; score of 40= 40 weeks |
| Ballard score | Uses 6 physical and 6 neurological findings |
| Fetal ultrasound | Age determined by measurement of fetal head or femur diameter |
| Classifications of neonate | AGA, SGA, LGA |
| AGA | Average for gestational age |
| SGA | Small for gestational age |
| LGA | Large for gestational age |
| Quiet Examination | Visual observances of color, skin, activity, inspect, and respirations |
| QE Color | Central cyanosis, acrocyanosis, or jaundice |
| QE Skin | Edema, diaphoresis, and/or flushing |
| QE Activity | Anxiety & irritable - suggests hypoxia / increased RR; ↓SpO2 during handling - suggests intolerance or cardiac anomaly |
| QE Inspect | chest deformity, abnormality, asymmetry |
| QE Respirations | look for 3 cardinal signs of Resp distress; nasal flaring, grunting, and retractions |
| Cardinal signs of Respiratory Distress | Silverman-Anderson scoring, retractions, nasal flaring & grunting |
| Silverman-Anderson scoring system | Pic chart used to grade severity of retractions & grunting |
| Retractions (3 types) | Substernal/subcostal (center)= lung disease, Intercostal (sides) = heart disease, Intrasternal/Marked substernal (center) = ETT obstruction |
| Nasal flaring | an attempt to get airway dilation to ↓ airway resistance and ↑ gas flow and volume |
| Grunting | sound used at end expiration to ↑ lung volume |
| Hands-on exam | vital signs, chest, and abdomen |
| HOE Chest | Look for asymmetry and auscultate for murmurs |
| HOE Abdomen | Distended, Scaphoid, Omphalocele, Gastroschisis |
| Distended abdomen | Marked inflation of abdomen = suggests over-ventilation or fluid |
| Scaphoid abdomen | hollow concave abdomen (guts in chest) -- bowel sounds in chest which suggests diaphragmatic hernia |
| Omphalocele | protruding intestines covered with membrane |
| gastroschiss | protruding intestines not covered with membrane |
| Vital signs should include | RR, apnea exam, pulse, temp, SpO2, BP |
| Normal RR | 30 to 60 bpm |
| Apnea | absence of breathing > 20 secs; due to aspiration, asphyxia, maternal drug use |
| Normal Pulse | 100 to 160 bpm; Evaluate both brachial and femoral; if bounding = suspect cardiac anomaly; poor pulse = suspect coarctation of aorta |
| Normal temp | 36-37 degrees |
| SpO2 | 84-94% |
| BP | 50/30 for 1,000g, 60/35 for 2,000g, 65/40 for 3,000g |
| Pulse < 100 | bradycardia; caused by hypoxia, heart disease, valsalva maneuver, drugs |
| Pulse > 200 | tachycardia; caused by hyperthermia, heart disease, pain, crying, drugs |
| Pre-ductal ABG | from R arm; if PaO2 more than 15 mm Hg> than Postductal = right to left shunt; suspect PDA or congenital heart defect |
| Post-ductal ABG | from UAC; If PaO2 on pre-ductal is more than 15 > than postductal = right to left shunt; suspect PDA or CGD |
| Na+ for term | 130 - 150 |
| Cl- for term | 87-114 |
| K+ for term | 5-6 |
| HCO3 | 20-24 |
| WBC's | 7,000 -14,000 |
| Urine output | 2cc/kg per hour |
| BUN | 4 - 17 |
| Creatinine | .11 - .68 g per 24 hr |
| Glucose | 55-115 mg/dl; Hyperglycemia > 160 = septicemia, cord compression, stress ; Hypoglycemia < 40 = infection, SGA, IDM, cold stress |
| Bilirubin | Term = < 6 @ 0-1 day old Preemie = <8 Hyperbilirubinemia is due to Rh and ABO blood incompatibility |
| ABG Norm for Neonate | Ph=7.34-7.35, PCO2=26-40, PO2=50-70, HCO3=17-23, BE=+/- 2 to -10 |
| ABG Norm for Infant | Ph=7.34-7.46, PCO2=30-45, PO2=85-100. HCO3=20-28, BE=+/-2 to -4 |
| Asymmetrical chest movement may be due to | Pneumothorax, atlectasis, Improper ETT, pneumonia, diaphragmatic hernia or paralysis, phrenic nerve palsy |
| transillumination of chest | bright fiber optic light; normal=forms a "halo"; abnormal=entire hemithorax lights up b/c of free air |
| indications for transillumination | asymmetrical chest w/resp distress, ↓ breath sounds, and/or absent heart sounds, with trachea or mediastinum shift away |
| Neonatal reflex tests | rooting, suck, grasp, moro |
| rooting reflex | stroke corner of mouth, baby should turn that direction |
| Suck reflex | place finger in mouth and baby should suck immediately |
| Grasp reflex | place index finger in palm, baby should grasp; place thumb over fingers and should be able to pull baby towards sitting position |
| Moro reflex | slowly lie baby back down (after grasp) and just b4 head touches, remove fingers. Baby should extend arms up and out |
| Physical exam to determine preterm baby | Vernix=thick & all over, skin=thin, transparent, nails=short, sole=few creases, ears=flat, soft, little cartilage |
| Physical exam to determine term baby | Vernix=very little, skin=pale, few visible vessels, nails=normal, sole=creases over 2/3, ears=firm, recoil easy |
| Physical exam to determine post-term baby | No Vernix, Skin=thick, soft, may crack/peel, nails=long, sole=creases on entire sole, ears=firm, recoil easily |
| Acrocyanosis | Arms and legs are blue but core is pink |
| acyanotic | pink all over |
| cyanotic | blue; worse condition--more critical immediately |
| 4 Acyanotic CHD's that ↑ pulmonary blood flow | ASD, VSD, AVCD, and PDA |
| ASD | Atrial Septal Defect = L to R shunt thru opening in atrial septum; causes extra blood R heart; ↑ pulm BF (CHF); give lasix for CHF & perform surgical repair |
| VSD | Ventricular Septal Defect = L to R shunt thru opening in vent septum; causes extra blood R heart, ↑ pulm BF(CHF); give lasix for CHF & do surgical repair |
| AVCD or AVC | Atrioventricular Canal Defect = L to R shunt thru ASD, VSD; deformed mitral & tricuspid; causes CHF; give lasix & do surgery |
| PDA | Patent Ductus Arteriosus = common in premies, more common in males, failure of ductus arteriosus to close; L to R shunt into pulm arts; ↑ pulm BF (CHF); give indocin and perform PDA ligation surgery |
| 2 Acyanotic CHD's with NORMAL blood flow | coarctation of the aorta and aortic stenosis "all systemic" |
| Coarctation of the Aorta | Severe narrowing of aortic lumen; PDA present-keep open; give PGE to ↓ PVR due to extrapulm BF; Good pulse upper, weak pulse lower; perform surgery |
| Aortic Stenosis | Narrowing of aorta causes blood backup into lungs; no shunts; give lasix for CHF; give PGE to vasodilate; perform surgery |
| Common Cyanotic CHD's with ↑ pulmonary blood flow | TGA, Tricuspid Atresia, truncus arteriosus, TAPVR |
| TGA | Transposition of the Great Arteries = BF from R vent to aorta, & L vent to pulm arts; has PDA & ASD and/or VSD for mixing; Give PGE until surgery |
| Tricuspid Atresia | Tricuspid valve not developed, no entry to R vent from R atrium. ASD & VSD must be present to survive. Blood shunts from R to L thru ASD then from L vent thru VSD to pulm system |
| Truncus Arteriosus | The two great vessels (pulm & aorta) are formed into one vessel. Blood shunts from L to R if VSD present |
| TAPVR | Total Anomalous Pulmonary Venous Return = Pulm veins dump blood from lungs into R atrium, IVC or SVC. ASD must be present. |
| Common Cyanotic CHD's with ↓ pulm blood flow | Tetralogy of Fallot = TET or TOF |
| Tetralogy of Fallot | 4 heart defects=overriding aorta, pulm art stenosis, VSD, & R vent hypertrophy; poss ASD; Cyanosis w/crying & feeding; ↑ PVR and ↓ pulm BF causing R to L shunt; perform surgery |
| Increased O2 | ↓ PVR = ↑ Pulm BF |
| Decreased O2 | ↑ PVR = ↓ pulm BF |
| Increased CO2 | (Hypoventilation) ↑ PVR = ↓ pulm BF = ↑ CBF (cerebral) |
| Decreased CO2 | (Hyperventilation) ↓ PVR = ↑ pulm BF = ↓ CBF (cerebral) |
| Nitric Oxide (NO) | vasodialates and ↓ PVR (doesn't systemically vasodilate due to short half life) |
| Prostaglandin (PGE) | vasodilates and ↓ PVR |
| Viagra | vasodilates and ↓ PVR |
| Ribavarin | Used for RSV & dlvd via SPAG |
| Atropine | used for brady; dosage .01-.03 mg/kg IV over 1 min |
| epinephrine | used for brady & hypotension; dosage .1-.3 ml/kg |
| digoxin | used for CHF; dosage 20-30 mcg/kg IV |
| indocin | used to close PDA; dosage .1-.2 mg/kg IV given 12 hrs |
| prostaglandin | maintain PDA until surgery; dosage .1 mcg/kg/min UAC |
| dopamine | ++ CO; dosage 2-20 mcg/kg/min IV |
| tolazoline | treats PPHN that is refractory O2 and vent; dosage 1-2 mg/kg/hr |
| lasix | used for fluid overload, symptomatic PDA & PPHN; dosage 1 mg/kg then 2 mg/kg > 2hrs |
| aldactone | for BPD & CHF; dosage 1-3 mg/kg/24hr PO |
| Corticosteroids | for BPD & asthma; also given to Mom in premature labor to induce fetal lung maturity |
| types of steroids given by MDI | beclomethasone (Vanceril), aerobid, dexamethasone, azmicort |
| Primary steroid given to Neonate for BPD & edema | Dexamethasone (decadron); dosage .2-.5 mg/kg IV loading dose, then .1-.4 mg/kg/day IV |
| Cromolyn Sodium (Intal) | prevent the release of asthma mediators; dosage DPI 20 mg |
| Theophylline or Caffeine | to treat neonatal apnea, acute & chronic bronchospasm |
| Nitric Oxide (NO) | treats PPHN |
| Artificial surfactant | Prophylactically for infants <1350g at birth; and for infants >1350g with lung immaturity |
| types of surfactant | Exosurf, survanta, infasurf |
| RDS | aka hyaline membrane disease=scar-like tissue replaces normal alveolar tissue; usually at birth or soon after |
| Signs/Symptoms RDS | RR>60, grunting, retractions, nasal flaring, cyanosis, severe edema, flaccid muscles, hypoactivity |
| CXR RDS | ground glass appearance |
| Death RDS | >72 hrs is usually due to 2 degree complications |
| Treatment RDS | prevention, surfactant, low pressures, FiO2 to maintain PaO2 50-80, PCO2 <60 & Ph >7.25; diuretics for edema, monitoring |
| Complications RDS | ICH, Pulm air leaks, DIC, infection and PDA |
| BPD | bronchopulmonary dysplasia |
| BPD causes | O2 toxicity, barotrauma, PDA, and fluid overload |
| BPD CXR | ground glass & blood gas shows chronic lung disease |
| BPD treatment | Prevention, ventilation, resp therapy, Fluid therapy, digoxin, nutrition, and vitamin E |
| Pulmonary Dysmaturity | aka Wilson-Mikity Syn; neonates <1500 g at birth |
| PD CXR | increased density and cysts, but pt not ventilated |
| Signs/Symptoms PD | hyperpnea, transient cyanosis, retractions, severe resp distress, poor feeding, and vomiting |
| Treatment PD | mech vent for apnea & progressive hypercarbia, O2 for hypoxemia; once pt ventilated, treat as BPD |
| ROP | Retinopathy of Prematurity; formation of scar behind lens of eye caused by high PaO2 |
| Contributing factors to ROP | immaturity, hypoxia, IVH, apnea, infection, hypercarbia, PDA, Vit E def, lactic acid, bright lights, early intubation, hypotension, & NEC |
| Treatment ROP | cryotherapy or laser therapy, vitrectomy, lensectomy, prevention |
| ICH/IVH | Intracranial or intraventricular hemorrhage; bleeding in cranium |
| Subdural or subarachnoid bleeds | more common in term neonates following birth trauma |
| Cerebellar tissue bleeds | common in preterm between 24-32 weeks and/or <1500g |
| Choroid plexus | most common area neonates bleed |
| diagnosis of ICH/IVH | Ct scan or ultrasound |
| treatment ICH/IVH | prevention, avoid wide fluxes in BP, O2, and pH |
| Complications ICH/IVH | PHH caused by blocked CSF flow treated by removing CSF via lumbar puncture |
| 6 types of Pulmonary Air Leaks (PAL) | Pneumothorax, pneumomediastinum, pneumopericardium, PIE (Pulm interstitial Emphysema), Pulmonary air embolism, subcutaneous emphysema |
| PAL Pnuemothorax | Most common, occurs when extra-alveolar air ruptures to external surface of lung into pleural space; must do thoracentesis or chest tube |
| PAL Pneumomediastinum | Occurs when extra-alveolar air dissects thru lung interstitium and ruptures into mediastinum; need lower ventilatory pressures |
| PAL Pneumopericardium | Occurs when air enters the pericardial sac; it compresses the heart impeding CO; must have needle aspiration |
| PAL PIE | Pulm interstitial emphysema=air dissects thruout interstitial tissue of lungs caused by chronic high peep/pip; need lower vent pressures & high frequency vent |
| PAL Pulmonary air embolism | Extremely rare; caused by high pressures used to vent stiff lungs; air enters the pulm vasculature; no effective treatment |
| Subcutaneous emphysema | 2 degrees to other air leaks; occurs when air enters subcutaneous spaces; must fix primary air leak |
| PPHN | Persistent Pulm Hypertension in Newborn; unknown cause; causes persistent pulm vasoconstriction ↑ ptressures & ↓ pulm BF causing persistence in fetal circulation |
| TTN | Transient Tachypnea in Newborn |
| NEC | Idiopathic disorder characterized by ischemia and necrosis of intestine; risk factors are prematurity, asphyxia, & formula feeding |
| 3 main causes of NEC | mucosal wall injury, bacterial invasion into damaged intestinal wall, and formula in the intestine |
| signs/symptoms NEC | guaiac-positive stools, bile in emesis, poorly tolerated feedings, lethargy, ↑ FiO2 needs |
| Pulmonary Anomalies | Tracheoesophageal anomalies, choanal atresia, diaphragmatic hernia, Pierre-Robin Syn aka Micrognathia |
| Respiratory Care for Cardiac defect ↓ BF | Tetralogy of Fallot, tricuspid atresia; causes lung compliance to increase; use low pressures & increased frequencies |
| Respiratory Care for Cardiac defect ↑ BF | VSD, PDA, Coarctation of Aorta; causes lung compliance to ↓; use higher pressures & Peep to maintain adequate V/Q ratio |
| Infections causes of persistent perinatal illness | Bacteria, Virus, Protazoa |
| Treatment of persistent perinatal illness | Isolation, Identify antigen, aseptic technique, fetal immunity |
| Five classes of fetal immunity | IgA, IgD, IgE, IgG, IgM |
| IgA immunity | Found in tears, saliva, bronchial & intestinal secretions, breast milk; Breast fed neos get IgA from breast milk |
| IgD immunity | Found in serum tissue, unknown role, increases in presence of allergic reactions to milk, penicillin, insulin, & toxins |
| IgE immunity | Found in lungs, skin, & cells of mucous membranes; provides primary defense against environment |
| IgG immunity | only one thru placenta; protects neo up to 1st 3 months for any immunity Mother has |
| IgM immunity | Produced by fetus @ 30 wks; used to test for infection; unreliable for early detection |
| Goals of mechanical ventilation | normalize ABG's, prevent iatrogenic complications, support pts respiratory needs |
| Neonatal Ventilation | Normally time cycled/pressure limited |
| Pediatric Ventilation | Normally Volume cycled |
| Initial PIP | set to achieve good chest excursion |
| Excessive PIP | causes hyperinflation, barotrauma; ie: pneumo's, & BPD) |
| When you increase PIP | ↑ PIP, ↑ PaO2 & ↓ PaCO2, by ↑ Ve, also ↑ MAP; doesn't affect I:E or I-time |
| PEEP | highest for neos 6-8 cm H2O; prevents alveoli collapse and ↑ FRC; Improves Oxygenation & compliance; ↑ PEEP ↓ Vt |
| Frequency (Rate) on mech vent | RR directly affects Ve, PaCO2, MAP (Paw); ↑RR = ↑Ve; ↑RR = ↓PaCO2; ↑RR = ↑ Paw (MAP) |
| Inspiratory Time on mech vent | Itime directly affects MAP (Paw), Plateau press, intrapleural press; ↑Itime=↑MAP; ↑Itime=affect hemo press & venous return |
| MAP or Paw on mech vent | Average press in airways; Most powerful influence on O2, as ↑MAP=↑PaO2; MAP adjusts by changing PEEP, PIP, Itime, RR, Flow; MAP<14cm H2O; ↓etime=↑Paw (MAP) |
| Tidal Volume on mech vent | In time cycled/pressure limited Vt not set; Vt directly affected by PIP & PEEP; ↑ PIP & not PEEP= ↑Vt; ↑PEEP & not PIP=↓Vt; ↑PIP & PEEP=↑Vt |
| Inspiratory flow rate | amt of speed to dlvr Vt; Directly affects MAP; ↑flows=↑vent & reverse atelectasis |
| Opening and driving pressures | amt of press to keep alveoli open; "recruitment maneuver"=high level PEEP moving down to normal in short time |
| Driving Pressure | Difference between PIP and PEEP |
| Indications for Neonatal ventilation | Apnea, ICH, Drugs, to Normalize pH; pH<7.20, PaCO2>60, PaO2 <50 ever with O2, SaO2 <88% even with O2 |
| Phase I ventilation | Putting baby on ventilation |
| Phase II ventilation | Monitoring baby on vent |
| Phase III ventilation | Weaning baby off vent |
| Indications for Pediatric Ventilation | Neuromuscular, Pulmonary disease, Post-resuscitation, ventilatory failure = pH <7.30, PaCO2 >50, PaO2 <70 w/O2 |
| Initial vent settings Peds | Vt 6 to 8 ml/kg; RR 12-20; Ve primary factory controlling PaCO2; If PaCO2 ↓, can ↓ RR or Vt |
| Modes of vent | SIMV prefered over AC; PCV recommended when pt needs FiO2 > 60 & PEEP > 15, PIP >50, has RDS; often with inverse I:E |
| 4 ways to assess Oxygenation and ventilation | ABG, Transcutaneous monitor, Pulse Ox, Capnography |
| ABG Analysis -- when do you get it? | Neo in resp distress, neo clinically changed for no reason, within 15-30 mins of changing vent settings, & per MD orders |
| Where do obtain ABG sample? | UAC, Arterial line, Arterial puncture, capillary puncture; UAC is preferred method |
| UAC Samples | Most preferred; can be compared to R radial ABG to see if PDA; disadvantage=UAC's only in place 3-4 wks |
| R arterial sample Vs. UAC sample | R arterial is pre-ductal; UAC is post-ductal. If R artery is higher than UAC, R to L shunt is present |
| Radial Arterial Line Sample | Catheter in radial artery; reflects pre-ductal flow which ais in minimizing risks of IVH & ROP |
| Arterial Puncture Sample | Difficult to obtain; these are done blindly; not suggested unless no UAC |
| Capillary Puncture sample | Used prim after UAC gone; not reliable for PaO2; Must warm heel to puncture |
| ABG Values PaO2 | Neo = 50-70 ; ped = 85-100 |
| ABG Values PaCO2 | Neo / Ped = 35-45 ; if chronic=<60 ok |
| ABG Values pH | Safe = 7.35-7.45; Acceptable = 7.25-7.50 for acute/chronic |
| ABG Values BE | Neo / Ped = +/- 4 |
| Alveolar Ventilation determined by | Ve - Vd (Min vent - deadspace volume |
| Acidosis may result because of | CO2 retention, Excessive H+ ions, removal of HCO3 |
| Alkalosis may result because of | Removal of CO2, Excessive loss of H+ ions, addition of HCO3 |
| Transcutaneous using Clark | noninvasively monitor O2, must changed frequently, PtcO2 can be lower than PaO2 by 2-3. ↓PtcO2 w/ N PaO2 = circulatory failure; ↓PtcO2 w/↓PaO2 = respiratory failure |
| Transcutaneous using Servinghaus | PtcCO2 levels closely relate to PaCO2 levels, non invasively monitoring CO2 levels |
| Pulse Ox | Neo = around foot or palm; Ped = toe, finger, ear; SpO2 withing 2-3 of SaO2; preemie alarms set 85-95 |
| Capnography | Noninvasive for CO2; determines end tidal PaCO2 (PetCO2); placed on ET tube or catheter in nose; trends are important with this, however inaccurate with severe resp distress |
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Beccaboop
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