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Neonatal Resuscitation

Neonatal Resuscitation

Information Covered:

1. Introduction
   1. Newborn
      1. A recently born infant; usually considered the first few hours of life
   2. Neonate
      1. Considered the first 28 days of life
2. General pathophysiology, assessment and management
   1. Epidemiology
      1. Incidence
         1. Approximately 6% of deliveries require life support
         2. Incidence of complications increases as birth weight decreases
      2. Morbidity/ mortality
         1. Neonatal mortality risk can be determined via graphs based on birth weight and gestational age
         2. Resuscitation is required for about 80% of the 30,000 babies who weigh less than 1500 grams at birth
      3. Risk factors
         1. Antepartum factors
            1. multiple gestation
            2. inadequate prenatal care
            3. mother’s age <16 or >35
            4. history of perinatal morbidity or mortality
            5. post-term gestation
            6. drugs/ medications
            7. toxemia, hypertension, diabetes
            8. perinatal infections
            9. known fetal malformations/“high risk” OB patient
         2. Intrapartum factors
            1. premature labor
            2. meconium-stained amniotic fluid
            3. rupture of membranes greater than 18 hours prior to delivery
            4. use of narcotics within four hours of delivery
            5. abnormal presentation
            6. prolonged labor or precipitous delivery
            7. prolapsed cord
            8. bleeding
      4. Treatment strategies
         1. Preparation of resuscitation equipment
         2. Determine appropriate destination
   2. Pathophysiology
      1. Transition from fetal to neonatal circulation
      2. Respiratory system must suddenly initiate and maintain oxygenation
      3. Infants are very sensitive to hypoxia
      4. Permanent brain damage will occur with hypoxemia
      5. Apnea in newborns
         1. Primary
         2. Secondary
      6. Congenital anomalies
         1. diaphragmatic hernia
         2. choanal atresia
         3. Pierre Robin syndrome
         4. Cleft lip
         5. Other craniofacial Defects
         6. Spina bifida
         7. Exposed abdominal contents
            1. Intact omphalocele
            2. Non intact omphalocele
         8. Other common conditions
   3. Assessment of the newborn
      1. Time of delivery
      2. Normal/ abnormal vital signs
      3. Airway and ventilation
         1. Respiratory rate
         2. Respiratory effort
      4. Circulation
         1. Heart rate
         2. Color/ cyanosis
            1. normal
            2. central versus peripheral
            3. mucosal membranes
         3. End organ perfusion
            1. compare strength of central pulses versus peripheral
            2. capillary refill
      5. APGAR
         1. Appearance - skin color
            1. completely pink - 2
            2. body pink, extremities blue - 1
            3. blue, pale - 0
         2. Pulse rate
            1. above 100 - 2
            2. below 100 - 1
            3. absent - 0
         3. Grimace - irritability
            1. cries - 2
            2. grimaces - 1
            3. no response - 0
         4. Activity - muscle tone
            1. active motion - 2
            2. some flexion of extremities - 1
            3. limp - 0
         5. Respiratory - effort
            1. strong cry - 2
            2. slow and irregular - 1
            3. absent - 0
   4. Treatment
      1. Prior to delivery, prepare environment and equipment
      2. During delivery, suction mouth and nose as head delivers
      3. After delivery
         1. Airway and ventilation
            1. drying
               1. head and face
               2. body
            2. warming
               1. appropriate techniques
               2. minimize heat loss via head
            3. position
            4. suction
               1. technique
                  1. mouth first, than nares
                  2. nasal suctioning is a stimulus to breathe
               2. equipment
                  1. bulb suction
                  2. suction catheters
                  3. meconium aspirator
            5. stimulation
               1. flicking soles of feet
               2. stroking back
            6. blow-by oxygen
               1. never withhold oxygen
               2. oxygen should be warmed
               3. use when
                  1. newborn is cyanotic and
                  2. heart rate > 100 and
                  3. adequate respiratory rate and effort
               4. 5 liters/ minute maximum
                  1. complications due to hypothermia
                  2. direct rather than tangential flow on face
               5. appropriate techniques
            7. oral airways - rarely used for neonates
               1. necessary to keep mouth open for ventilation
               2. bilateral choanal atresia
               3. Pierre Robin syndrome
               4. macroglossia
               5. craniofacial defects affecting airway
            8. bag-valve-mask
               1. mask characteristics
                  1. appropriate size
                  2. minimize dead-space
               2. bag characteristics
                  1. pop-off valve should be disabled
                  2. risk of pneumothorax with excessive pressures
                  3. initial breath may require high pressures
               3. use when
                  1. apneic
                  2. inadequate respiratory rate or effort
                  3. heart rate less than 100
               4. technique
                  1. initial ventilations require higher pressure to expand lungs
                  2. rate
            9. intubation
               1. indications
                  1. prolonged positive pressure ventilation
                  2. bag and mask ventilations ineffective
                  3. tracheal suctioning required
                  4. diaphragmatic hernia suspected
                  5. craniofacial defects that impede ability to maintain adequate airway.
               2. technique
                  1. suction equipment
                  2. laryngoscope
                  3. blades-straight
                  4. endotracheal tubes -- 2.5 to 4.0 mm id
               3. confirmation
               4. PEEP
            10. gastric decompression
                1. abdominal distention is impeding ventilation
                2. presence of diaphragmatic hernia
                3. tracheo-esophageal fistula
         2. Circulation
            1. vascular access
               1. indications
                  1. to administer fluids
                  2. to administer medications
               2. peripheral vein cannulation
               3. intraosseous cannulation
            2. chest compression (in addition to assisted ventilation with BVM) Refer to current ILCOR/AHA guidelines
         3. Pharmacological
            1. bradycardia
            2. low blood volume
            3. respiration depression secondary to narcotics
            4. metabolic acidosis
            5. hypoglycemia
         4. Non-pharmacological
            1. temperature control
            2. positioning
         5. Transport consideration
            1. rapid transportation of the distressed infant
            2. position newborn on their side to prevent aspiration
            3. adequate securing of ETT
         6. Psychological support/ communication strategies
3. Specific situations
   1. Meconium stained amniotic fluid
      1. Epidemiology
         1. Incidence
            1. may occur either in utero or intrapartum
            2. mostly in post-term and small-for-gestational-age newborns
         2. Morbidity/ mortality
            1. high mortality
            2. hypoxemia
            3. aspiration pneumonia
            4. pneumothorax
            5. pulmonary hypertension
         3. Risk factors
            1. fetal distress during labor and delivery
            2. post-term infants
            3. thin particulate meconium versus thick
      2. Anatomy and physiology review
      3. Pathophysiology
         1. Hypoxia or physiologic cause
         2. Aspiration of meconium stained amniotic fluid
            1. Complete airway obstruction
               1. Atelectasis
               2. right-to-left shunt across the foramen ovale
            2. Incomplete airway obstruction
               1. Ball valve type obstruction
               2. developing pneumothorax
               3. chemical pneumonitis
         3. Patient deterioration
            1. hypoxia
            2. hypercapnia
            3. acidosis
      4. Assessment findings
         1. Thin and watery
         2. Thick and particulate
      5. Management considerations for thick or particulate meconium
         1. Airway and ventilation
            1. do not stimulate the infant to breathe
            2. tracheal suction under direct visualization
               1. airway is clear
               2. infant breathes on own
               3. bradycardia
            3. ventilate with 100% oxygen
         2. Circulation
         3. Pharmacological
         4. Non-pharmacological
            1. needle decompression may be required
            2. hypothermia prevention
         5. Transport consideration
            1. identify facility to handle high-risk newborn
         6. Psychological support/ communication strategies
            1. do not discuss "chances of survival" with family
            2. explain what is being done for the newborn
   2. Apnea in the neonate
      1. Epidemiology
         1. Incidence
         2. Morbidity/ mortality
         3. Risk factors
            1. prematurity
            2. in newborn, prolonged or difficult labor and delivery
            3. drug exposure
            4. maternal Infection
      2. Anatomy and physiology review
      3. Pathophysiology
         1. Usually due to hypoxia or hypothermia
         2. May be due to other causes
            1. narcotics or central nervous system depressant
            2. airway and respiratory muscle weakness
            3. oxyhemoglobin dissociation curve shift
            4. septicemia
            5. metabolic disorder
            6. central nervous system disorders
      4. Assessment findings
         1. Failure to breathe spontaneously after stimulation
         2. Respiratory pauses greater than 20 seconds
      5. Management considerations
         1. Airway and ventilation
            1. stimulate the baby to breathe
               1. flicking the soles of the feet
               2. rubbing the back
            2. ventilate with BVM
               1. disable pop-off valve
               2. subsequent ventilations with minimal pressure to cause chest rise
            3. suction as needed
            4. intubation
               1. indications
               2. complications
                  1. tube dislodgement
                  2. tube occlusion by mucous or meconium
         2. Circulation
         3. Incidence
         4. Morbidity/ mortality
         5. Risk factors
      6. Anatomy and physiology review
      7. Pathophysiology
         1. Abdominal contents are displaced into the thorax
         2. Heart may be displaced
      8. Assessment findings
         1. Little to severe distress
         2. May have cyanosis unresponsive to ventilations
            1. may be difficult to ventilate at “normal” airway pressures
            2. may have associated hypoplastic lung on involved side.
            3. if significant prenatal shift in mediastinum, may have some degree pulmonary hypoplasia on contralateral side.
         3. Scaphoid (flat) abdomen
         4. Bowel sounds heard in chest
         5. Heart sounds displaced to right
      9. Management considerations
         1. Airway and ventilation
            1. assure adequate oxygen
            2. place an orogastric tube and apply low, intermittent suction
            3. endotracheal intubation may be necessary
            4. exercise caution if needle decompression
         2. Circulation -- monitor heart rate continuously
         3. Pharmacological -- none indicated for primary problem
         4. Non-pharmacological -- surgical repair required
         5. Transport consideration -- identify facility to handle high-risk newborn
         6. Psychological support/ communication strategies
   3. Bradycardia in the neonate
      1. Epidemiology
         1. Incidence
         2. Morbidity/ mortality
         3. Risk factors
      2. Anatomy and physiology review
      3. Pathophysiology -- Primarily caused by hypoxia
      4. Assessment findings
         1. Assess upper airway for obstruction
            1. secretions
            2. tongue and soft tissue positioning
            3. foreign body
         2. Assess patient for hypoventilation
         3. Palpate umbilical stump or brachial artery
      5. Management considerations
         1. Airway and ventilation
            1. suction
            2. positive pressure ventilation with 100% oxygen
            3. endotracheal intubation
         2. Circulation
            1. heart rate less than 100 -- BVM ventilation with 100% oxygen and reassess
            2. heart rate less that 60 -- begin chest compressions
            3. heart rate between 60 and 80 but not responding to assisted ventilations with BVM -- begin chest compressions
            4. discontinue chest compressions when heart rate reaches 100
         3. Pharmacological -- epinephrine
         4. Non-pharmacological -- maintain temperature
         5. Transport consideration -- identify facility to handle high-risk newborn
         6. Psychological support/ communication strategies
   4. Premature infants
      1. Epidemiology
         1. Incidence
            1. born prior to 37 weeks gestation
            2. weight ranges from .6-2.2 kg
            3. often related to comorbidity
         2. Morbidity/ mortality
            1. healthy premature infants weighing greater than 1700 g have a survivability and outcome approximately that of full-term infants
            2. respiratory suppression
            3. hypothermia risk
            4. head/ brain injury
         3. Risk factors
      2. Anatomy and physiology review
      3. Pathophysiology (retinopathy of prematurity)
         1. result of long term oxygen use
         2. extreme prematurity
         3. should not be a factor in short term management
         4. hypoxemia causes irreparable brain damage
      4. Assessment findings
         1. Degree of immaturity determines the physical characteristics
         2. Generally a large trunk and short extremities
         3. Skin is transparent and less wrinkles
         4. Less subcutaneous fat
      5. Management considerations
         1. Attempt resuscitation if the infant has any sign of life
         2. Airway and ventilation
         3. Circulation -- chest compressions if indicated
         4. Pharmacological -- epinephrine
         5. Non-pharmacological -- maintain body temperature
         6. Transport consideration -- transport to a facility with special services for low birth weight newborns
         7. Psychological support/ communication strategies
   5. Respiratory distress/ cyanosis in the neonate
      1. Epidemiology
      2. Anatomy and physiology review
      3. Pathophysiology
      4. Assessment findings
      5. Management considerations
   6. Seizures in the neonate
      1. Epidemiology
         1. Incidence -- occur in a very small percentage of all newborns
         2. Morbidity/ mortality -- represent relative medical emergencies as they are usually a sign of an underlying abnormality
         3. Risk factors -- prolonged and frequent multiple seizures may result in metabolic changes and cardiopulmonary difficulties
      2. Anatomy and physiology review
         1. Degree of myelinization will affect manner of seizure presentation/observed clinical signs
      3. Pathophysiology
         1. Types of seizures
            1. subtle seizure
               1. eye deviation
               2. blinking
               3. sucking
               4. swimming movements of the arms
               5. pedaling movements of the legs
               6. apnea
            2. tonic seizure
               1. tonic extension of the limbs
               2. less commonly, flexion of the upper extremities and extension of the lower extremities
               3. more common in premature infants, especially in those with intraventricular hemorrhage
            3. multi focal seizure
               1. clonic activity in one extremity
               2. randomly migrates to another area of the body
               3. occur primarily in full-term infants
            4. focal clonic seizure
               1. clonic localized jerking
               2. occur in both full-term and premature infants
            5. myoclonic seizure
               1. flexion jerks of the upper or lower extremities
               2. may occur singly or in a series of repetitive jerks
         2. Causes
      4. Assessment findings
         1. Decreased level of consciousness
         2. Seizure activity
         3. Apnea/bradycardia
      5. Management considerations
         1. Airway and ventilation
         2. Circulation
         3. Pharmacological
            1. consider D10 for hypoglycemia
            2. consider anticonvulsant
            3. consider benzodiazepine for status epilepticus
         4. Non-pharmacological -- maintain normal body temperature
         5. Transport consideration -- identify facility to handle high-risk newborn
         6. Psychological support/ communication strategies
   7. Fever in the neonate
      1. Epidemiology
         1. Incidence
         2. Morbidity/ mortality
         3. Risk factors
      2. Anatomy and physiology review
      3. Pathophysiology
      4. Assessment findings
      5. Management considerations
   8. Hypothermia in the neonate
      1. Epidemiology
         1. Incidence -- body temperature drops below 35 degrees C
         2. Morbidity/ mortality -- infants may die of cold exposure at temperatures adults find comfortable
         3. Risk factors (need to be controlled)
            1. Evaporation
            2. Conduction
            3. Convection
            4. Radiation
      2. Anatomy and physiology review
      3. Pathophysiology -- Increased surface-to-volume relation makes newborns extremely sensitive to environmental conditions, especially when wet after delivery
      4. Assessment findings
      5. Management considerations
   9. Hypoglycemia in the neonate
      1. Epidemiology
         1. Incidence
         2. Morbidity/ mortality
         3. Risk factors
      2. Anatomy and physiology review
      3. Pathophysiology
      4. Assessment findings
      5. Management considerations
   10. Vomiting in the neonate
       1. Epidemiology
          1. Incidence
          2. Morbidity/ mortality
          3. Risk factors
             1. aspiration of vomitus can cause respiratory insufficiencies or obstruction of the airway
             2. fluid and electrolyte imbalances due to vomiting
       2. Anatomy and physiology review
       3. Pathophysiology
       4. Assessment findings
       5. Management considerations
          1. Airway and ventilation
          2. Circulation -- bradycardia may be caused by vagal stimulus
          3. Pharmacological -- fluid administration may be required
          4. Non-pharmacological
          5. Transport consideration
       6. Psychological support/ communication strategies
   11. Diarrhea in the neonate
       1. Epidemiology
          1. Incidence
          2. Morbidity/ mortality
          3. Risk factors
       2. Anatomy and physiology review
       3. Pathophysiology
       4. Assessment findings
       5. Management considerations
          1. Airway and ventilation
          2. Circulation
          3. Pharmacological -- fluid therapy may be indicated
          4. Transport consideration -- identify facility to handle high-risk newborn
          5. Psychological support/ communication strategies
   12. Common birth injuries in the newborn
       1. Epidemiology
          1. Incidence
          2. Morbidity/ mortality
             1. birth trauma
             2. anoxic injuries
          3. Risk factors
             1. precipitous delivery
             2. shoulder dystocia
             3. breech delivery
       2. Anatomy and physiology review
       3. Pathophysiology
       4. Assessment findings
       5. Management considerations

Content Creator: Ariel Wai

CAPCE Course Number: 20-EMTP-F3-5201

Total CE Hours: 1

Level: Advanced

EMT-CE uses the NEMSES guidelines as the foundation for every course outline.