Download Chapter 42: Neonatology

Neonatal Assessment
Provincial Reciprocity Attainment Program
The Need for Resuscitation
 Most term newborns require no
resuscitation beyond maintenance of
temperature, suctioning of the airway,
and mild stimulation
 Approximately 6% of deliveries require
life support
 Incidence of complications increases as
birth weight decreases
The Need for Resuscitation
 Antepartum (before labor and delivery) and
intrapartum (during labor and delivery) risk
factors may affect the need for resuscitation
 When any of these risk factors are present
during delivery or imminent delivery, prepare
equipment and drugs that may be required for
neonatal resuscitation
 Medical direction should also be advised of the
situation so that the appropriate destination
hospital can be determined.
Antepartum Risk Factors
 Multiple gestation
 Inadequate prenatal care
 Mother’s age
 Less than age 16 or more than 35
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History of perinatal morbidity or mortality
Post-term gestation
Drugs/medications
Toxemia, hypertension, diabetes
Intrapartum Risk Factors
 Premature labor
 Meconium-stained amniotic fluid
 Rupture of membranes greater than 24
hours before delivery
 Use of narcotics within 4 hours of delivery
 Abnormal presentation
 Prolonged labor or precipitous delivery
 Prolapsed cord
 Bleeding
The Premature Infant
 Refers to a baby born before 37 weeks gestation
 The weight of these newborns is often between 0.6 to 2.2
kg [1.5 to 5 pounds]
 Premature infants have an increased risk for:
 Respiratory depression
 Hypothermia
 Head and brain injury
 Resuscitation should be attempted if the infant has
any signs of life
Congenital Anomalies
 Choanal atresia
 A bony or membranous occlusion that
blocks the passageway between the nose
and pharynx
 Can result in serious ventilation problems
in the neonate
 Cleft lip
 One or more fissures that originate in the
embryo
 A vertical, usually off-center split in the
upper lip that may extend up to the nose
Congenital Anomalies
 Cleft palate
 A fissure in the roof of the mouth that runs
along its midline
 May extend through both the hard and soft
palates into the nasal cavities
 Pierre Robin syndrome
 A complex of anomalies including:
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A small mandible
Cleft lip
Cleft palate
Other craniofacial abnormalities
Defects of the eyes and ears
Diaphragmatic Hernia
 Protrusion of a part of the
stomach through an opening in
the diaphragm
 Risk factors
 Bag and mask ventilation can
worsen condition
 Pathophysiology
 Abdominal contents are displaced
into the thorax
 Heart may be displaced
 Respiratory compromise
Physiological Adaptations at
Birth
 At birth, newborns make three major
physiological adaptations necessary
for survival
 Emptying fluids from their lungs and
beginning ventilation
 Changing their circulatory pattern
 Maintaining body temperature
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
Causes of Hypoxia
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Compression of the cord
Difficult labor and delivery
Maternal hemorrhage
Airway obstruction
Hypothermia
Newborn blood loss
Immature lungs in the premature
newborn
Hypothermia
 Newborns are at great risk for rapidly-developing
hypothermia because of:
 Their larger body surface area
 Decreased tissue insulation
 Immature temperature regulatory mechanisms
 Newborns attempt to conserve body heat through
vasoconstriction and increasing their metabolism,
placing them at risk for:
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Hypoxemia
Acidosis
Bradycardia
Hypoglycemia
Assessment and Management
 Initial steps of neonatal resuscitation
(except infants born through
meconium):
1. Prevent heat loss
2. Clear the airway by positioning and
suctioning
3. Provide tactile stimulation and initiate
breathing if necessary
4. Further evaluate the infant
Prevention of Heat Loss
 Immediately after delivery
 Dry the infant's head and body
 Remove any wet coverings from the
infant
 Cover with dry wrappings
 Cover the newborn's head
 Accounts for 20% of the newborn’s BSA
Opening the Airway
 Position
 Suction
 Technique
 Mouth first, than nares
 Nasal suctioning is a stimulus to breathe
 Equipment
 Bulb suction
 Suction catheters
Provision of Tactile Stimulation
 If drying and suctioning do not induce
respirations, provide additional tactile
stimulation
 Two safe and appropriate methods are:
 Slapping or flicking the soles of the feet
 Rubbing the infant's back
 If the infant remains apneic after a brief
period (5 to 10 seconds) of stimulation:
 Immediately initiate positive-pressure ventilation
with a pediatric bag-valve device and
supplemental oxygen (40 to 60 ventilations/min)
Evaluation of the Infant
 Observe and evaluate the infant's respirations
 Evaluate the infant's heart rate by stethoscope, or
by palpating the pulse in the umbilical cord or
brachial artery
 HR < 100
 Provide ventilation via BVM for 30 seconds and
reassess
 HR < 60
 Provide ventilation via BVM for 30 seconds and
reassess
 If not resolved begin CPR (a rate of > 100)
Evaluation of the Infant
 Evaluate the infant's color
 If Central cyanosis, bradycardia and other signs of distress
are present in an infant with spontaneous respirations and
an adequate heart rate, administer free-flow oxygen at 5
LPM
 A maximum oxygen concentration of about 80% can be
achieved when the tube is one-half inch from the infant's
nose
 Peripheral cyanosis is common in newborns and should
resolve
Apgar Score
 Enables rapid evaluation of a newborn’s condition at
specific intervals after birth
 Routinely assessed at 1 and 5 minutes of age
Sign
0
1
2
Appearance (Skin
Color)
Central cyanosis, pale
Peripheral cyanosis
Pink
HR
Absent
< 100 bpm
> 100 bpm
Grimace (Irritability)
No response
Grimace
Cough, sneeze, cry
Muscle tone
Limp
Some flexion
Active motion
Respiratory Effort
Absent
Slow, irregular
Good, crying
Resuscitation of the
Distressed Newborn
Risk factors associated with the need
for resuscitation include:
Premature delivery
Maternal health problems
Complicated pregnancies
Delivery complications
Reevaluating components of the
resuscitation process
Resuscitation
Neonatal Transport
 During transport of the neonate:
 Maintain body temperature
 Oxygen administration
 Ventilatory support
 In the prehospital phase of care, transport
strategies are usually limited to:
 Providing a warm ambulance
 Free-flow oxygen administration
 Warm blankets
Specific Situations
Respiratory Disorders
 Respiratory insufficiency in the neonate is
generally managed by:
Stimulation and positioning of the airway
Prevention of heat loss
Oxygenation and ventilation
Suction
Ventilatory support (if needed)
Apnea
 Respiratory pauses that exceed 20 seconds
Common finding in preterm infants, and if
prolonged, can lead to hypoxemia and
bradycardia
Primary apnea
 self-limited condition (controlled by pCO2 levels) that is
common immediately after birth
Secondary apnea
 describes respirations that are absent and that do not
begin again spontaneously
Apnea
 Risk factors
 Hypoxia
 Hypothermia
 Narcotic or CNS depressants
 Airway or respiratory muscle weakness
 Oxyhemoglobin dissociation curve shift
 Septicemia
 Metabolic Disorders
 CNS Disorders
Respiratory Distress and
Cyanosis
 Prematurity is the single most common factor
for respiratory distress and cyanosis in the
neonate
Occurs most frequently in infants less than 1200
g (2.5 pounds) and 30 weeks gestation
Risk factors (see next slide):
 Can lead to cardiac arrest
 Requires immediate intervention to support respirations
Other Risk Factors
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Lung or heart disease
Primary pulmonary HTN
CNS Disorders
Mucous obstruction of
nasal passages
 Spontaneous
pneumothorax
 Choanal atresia
 Meconium aspiration
syndrome
 Amniotic fluid aspiration
 Lung immaturity
 Pneumonia
 Shock and Sepsis
 Metabolic acidosis
 Diaphragmatic hernia
Dyspnea and Cyanosis
 S/S may include
Tachypnea
Tachycardia
Paradoxical breathing
Intercostal retractions
Nasal flaring
Expiratory grunting
Central cyanosis
Cardiovascular Disorders
 All neonates with cardiovascular disorders should
be assessed for treatable causes of hypoventilation
 Bradycardia
 A heart rate of less than100 beats/min
 Causes
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Hypoxia (most common)
Increased intracranial pressure
Hypothyroidism
Acidosis
 Considered a minimal risk to life in neonates if corrected
quickly
Cardiac Arrest
 Incidence is rare
 Risk factors
Intrauterine asphyxia
CNS depressants or other drugs taken by Mom
Congenital neuromuscular disorder
Congenital deformities
Intrapartum Hypoxia
 Arrest protocols are covered in Pediatrics
Hypovolemia
 May result from:
Dehydration
Hemorrhage
Trauma
Sepsis
 May be associated with myocardial
dysfunction
Hypovolemia
 Signs and symptoms
Mottled or pale skin
Cool
Tachycardia
Diminished peripheral pulses
Delayed cap refill
Pressure is not a good indicator
 Prehospital care
Airway
Fluid @ 10 ml/kg over 5 - 10 minutes (ALS)
Gastrointestinal Disorders
Occasional vomiting or diarrhea is not
unusual in the neonate
Vomiting mucus (that may occasionally be
blood streaked) is common in the first few
hours of life
5 to 6 stools per day is considered normal,
especially if the infant is breast feeding.
Persistent vomiting and/or diarrhea should
be considered warning signs of serious
illness
Seizures
 Are usually fragmented and not sustained
 Subtle seizures may include
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Eye deviation
Blinking
Sucking
Swimming movement of arms and peddling of the legs
Apnea
 Causes
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Hypoglycemia
Hypoxic ischemia encephalopathy
Intracranial hemorrhage
Metabolic disturbances
Meningitis or encephalopathy
Development abnormalities
Drug withdrawal
Fever
 Rectal temperature > 38ºC
 Often a response to an acute viral or
bacterial infection
May also be result of
 Lack of internal temperature control
 Dehydration
 May lead to metabolic acidosis
From ↑ O2 demand and ↑ glucose metabolism
Fever
Assessment may include
ALOC
Irritable
Somnolence
History of decreased intake or not feeding
at all
Warm or hot skin
Treatments are supportive only
Hypothermia
 Body temperature drops below 35 º C
 BSA and surface to volume ratio makes them
susceptible
 Infants may die of cold exposure at
temperatures adults find comfortable
 Increased metabolic demand may cause
metabolic acidosis, pulmonary HTN, and
hypoxemia
Hypothermia
 Assessment may include
Pale skin
Cool (especially in the extremities)
Respiratory distress
Apnea
Bradycardia
Central cyanosis
Irritability progressing to lethargic
Absence of shivering
 Treatment
Hypoglycemia
A blood glucose screening test less
than 4 mmol/L indicates hypoglycemia
Risk factors
Asphyxia
Toxemia
Being smaller twin
CNS hemorrhage
Sepsis
Hypoglycemia
 S/S
 Twitching or seizure
 Limpness
 Lethargy
 Eye rolling
 High pitched cry
 Apnea
 Irregular respirations
 Cyanosis possibly
 Treatment
 1.0 cc/kg D50 IV (D10 or D25 preferred) – Requires ALS
Common Birth Injuries
 2 - 7 % out of 1000 births results in an injury
 Risk factors include uncontrolled explosive
delivery
 Types of injuries seen:
Cranial injuries
 Molding of head and overriding of parietal bones
 Soft tissue from forceps
 Subconjunctival and retinal hemorrhage
 Skull fracture
Common Birth Injuries
Intracranial hemorrhage
Spine or spinal cord injury
Peripheral nerve damage
Liver or spleen or kidney
Clavicle or extremity fracture
Hypoxia ischemia
 Prehospital care
Support vital functions
Rapidly transport to an appropriate medical
facility for definitive care
Psychological
and Emotional Support
Be aware of the normal feelings and
reactions of parents, siblings, other
family members, and caregivers while
providing emergency care to an ill or
injured child
These events also are often highly
charged and emotional for the EMS crew
Psychological
and Emotional Support
 As a rule, emergency responders should:
Never discuss the infant’s chances of survival
with a parent or family member
Not give “false hope” about the infant’s condition
Assure the family that everything that can be
done for the child is being done
Assure the family that their baby will receive the
best possible care during transport and while at
the emergency department