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