Download Neonatal Resuscitation July 2016

Care of the Newborn
Neo-natal Resuscitation
Presence Regional EMS
July 2016 CE
Objectives
 Review
the anatomy and physiology of the
neonate, concentrating on the
cardio/respiratory changes that occur at
birth.
 Outline the assessment of the new born
infant
 Discuss
the use of the “Inverted Triangle”
for organizing resuscitation of the neonate,
including how much time should be spent
on the activities of each level
 Using a variety of scenarios, demonstrate
the resuscitation of the distressed
newborn.

The Dramatic Trauma of Birth
 The
moving of an infant from the warm
water bath of the uterus into the “cold cruel
world” and be dramatic and traumatic.
 But it has to be in order for the new infant
to survive.
 While
in the uterus the fetus is totally
dependent on the placenta to leech
oxygen and nutrients from the mother’s
circulation
 Essentially
the fetus’s lungs and GI tract
are non functional.
 The lungs are full of fluid.
 Blood is bypassed from these areas
 Blood fresh from the placenta full of
oxygen and nutrients enters the fetal body
via the umbilical vein at the ductus venous
in the liver
 At
the heart, blood bypasses
the lungs via two
short cuts


The foramen ovale
between the atria
in the heart
The ductus arteriosis
connecting the
pulmonary
artery and the aorta
At Birth
 Several
things happen to make the lungs
functional:


Compression of the infant’s chest during
delivery through the vagina pushes out 1/3 of
fluid
Blood flow through the umbilical cord slows in
preparation for separation
First Breath Stimulated by
 Hypothermia
(20+ degree drop from
uterus to outside world)
 Hypoxia (decrease in blood flow from
placenta = decrease in oxygen)
 Drop in blood pH
 Initiation of stretch receptors in lung
 As
infant gasps with change in
temperature and hypoxia breathing begins
As lungs fill with air
 Remaining
fluid in lung is displaced
 Pulmonary arterioles and capillaries open
and resistance to blood flow decreases so
lung vessels fill with blood
 Change in pressure causes blood to flow
into lungs rather than through “short cuts”
 Ductus
venosis, ductus arteriosis and
foramen ovale are no longer needed
 Increased pressure in right and left
chambers of the heart force
Structures closed
 Blood is diverted away from
these structures.
 “Slam shut” Structures close
and transition into ligaments
Temperature
 In
addition to the dramatic drop in
temperature during delivery
 Infants have poorly developed
thermoregulation
 Infants have a difficult time maintaining a
constant body temperature
 Keep the newborn WARM
Healthy Newborn
 Not
necessarily NORMAL
Healthy Newborn
A






Healthy Newborn should:
Be wet and slippery (be careful)
Respiratory rate 40-60 per minute
Heart rate 130-180 per minute
Pink skin of head, chest and abdomen
Cyanosis of arms and legs
Oxygen saturation of 70-80% but rises rapidly
Use APCAR score to
document
assessment
The APGAR Score
 Standard
scoring system used to assess
the status of a newborn
 Assigns
a number value to five areas:

Appearance

Pulse

Grimace or irritability

Activity or muscle tone

Respirations
The APGAR Score
The APGAR Score
 Appearance



If the skin of the newborn’s entire body is
blue (cyanotic) or pale, award 0 points.
If the newborn has blue hands and feet with
pink skin at the core of the body, award 1
point
If the skin of the extremities as well as the
trunk is pink, award 2 points.
The APGAR Score


Pulse
Heart rate is one of the most important signs of
whether oxygen is reaching the newborn’s
tissues following birth.



Count the heart rate for at least 30 seconds,
preferably with a stethoscope. If you do not have a
stethoscope, feel the pulse of the umbilical cord
where it joins the abdomen or at the brachial artery.
If no pulse is present, award 0 points.
If the heart rate is under 100 (also a serious
finding), award 1 point.
 If the heart rate is over 100, award 2 points.
The APGAR Score

Grimace (reflex irritability)


Gently flick the soles of the newborn’s feet, or
observe the facial expressions during suctioning.
If the newborn displays no reflexive activity to
your stimulation, award 0 points.
 If the newborn displays only some facial
grimace, award 1 point
 If your stimulation causes the newborn to
grimace and cough, sneeze, or cry, award 2
points.

Activity


The APGAR Score
This score refers to extremity reflexes/movement, or
the degree of flexion of the arms and legs and the
resistance to straightening them. The normal
newborn’s elbows, knees, and hips are flexed, and
you should encounter some degree of resistance
when you try to extend them.
If during your assessment, the newborn is limp
and displays no extremity movement, award 0
points.
 If the newborn only displays some flexion
without active movement, award 1 point.
 If the newborn is actively moving around, award
2 points.
The APGAR Score

Respiration


Another important assessment sign is the newborn’s
breathing effort. The newborn should have regular
respirations and a vigorous cry. Distress is indicated
by irregular, shallow, gasping, or absent respirations.
If the newborn displays no respiratory effort,
award 0 points
 If the newborn displays only a slow or irregular
breathing effort with a weak cry, award 1 point
 If the newborn displays good respirations and a
strong cry, award 2 points.
The APGAR Score
 The
total of the five numbers is the Apgar
score.


A perfect score is 10.
Calculate the Apgar score at 1 minute and 5
minutes after birth.
The APGAR Score
 7–10
points—The newborn should be
active and vigorous. Provide routine care.
 4–6 points—The newborn is moderately
depressed. Provide stimulation and
oxygen.
 0–3 points—The newborn is severely
depressed. You will probably need to
provide extensive care including oxygen
with bag-valve-mask ventilations and
CPR.
Resuscitation of the
Newborn: Give every
chance
Neonatal Assessment and
Resuscitation
 Follow
standard precautions.
 Always
put on gloves before handling a
newborn.
 Protecting
is critical!
the newborn against heat loss
Neonatal Assessment and
Resuscitation
 Newborn
should begin breathing
spontaneously within 15 to 30 seconds
after birth
 Also assure that the airway is clear of all
secretion or birth fluids. Perform
additional suctioning as needed
 Heart
rate should be 100 beats/min or
higher
 If you do not observe these responses:


Gently tap or flick the soles of the feet or rub
the back.
Begin resuscitation efforts.
Neonatal Assessment and
Resuscitation
 Most
newborns (80% +) require no
resuscitation beyond temperature
maintenance, mild stimulation, and
suctioning.
 A minority of the newborns will be so
depressed that they also will need chest
compressions or resuscitative
medications.
Signs of Severely Depressed
Newborn






Respiratory rate over
60 per minute
Diminished breath
sounds
Heart rate over 180
per minute or under
100 per minute
Obvious signs of
trauma from the
delivery process
Poor or absent
skeletal muscle tone
Respiratory arrest, or
severe distress






Heavy meconium
staining of amniotic
fluid
Weak pulses
Cyanotic body (core
and extremities)
Poor peripheral
perfusion
Lack of or poor
response to
stimulation
APGAR score under 4
Meconium
 Fetal
fecal matter
 Greenish black and sticky
 Presence in amniotic fluid
or on newborn infant =
Sign of fetal distress
Neonatal Resuscitation
 To
keep straight what needs to be done
for the newborn in what order. . .Don’t
panic!!!
 Follow the inverted pyramid
The Inverted Pyramid of
Newborn Resuscitation
Management Priorities: Immediate
Care of the Newly Born
 Dry,
warm, position, suction, and stimulate
the infant.
 Clear the airway.
 Assess breathing.
 Assess heart rate.
 Assess color.
Post Delivery Care
 Aggressively
dry off the infant and wrap in
a blanket or towel.
 Place
the infant on one side, with the head
slightly lower than the rest of the body.
 Wrap
the infant so only the face is
exposed.
 Keep
the blanket or towel warm.
Management Priorities: Vaginal
Delivery
 While
drying and warming the baby.
 Clear the airway by suctioning if necessary
 Check for spontaneous breathing (crying)
 If the baby is not breathing/crying well
 Begin resuscitation of the baby as needed.
 Delivery of placenta is non-emergent.
Neonatal Assessment and
Resuscitation
 Observe
the newborn for spontaneous
respirations, skin color, and movement of
the extremities for APGAR Score
 Evaluate
the heart rate at the base of the
umbilical cord or the brachial artery.

The heart rate is the most important
measure in determining the need for further
resuscitation.
Neonatal Assessment and
Resuscitation
 If
cyanosis is present but breathing and
heart rate are adequate, provide blow-by
oxygen
Neonatal Assessment and
Resuscitation

Provide ventilations by bag-valve-mask with
supplemental oxygen at the rate of 40–60 per
minute if the newborn displays any of the
following:
 The infant’s breathing is shallow, slow,
gasping, or absent following brief stimulation.
 The infant’s heart rate is less than 100 beats
per minute.
 The infant’s core body remains cyanotic
(blue) despite provision of blow-by oxygen.
Management Priorities:
Bag-Mask Ventilation
 Extend
the head
slightly on the
neck.
 Position hands in
“EC-clamp.”
 Ventilate at 40–60
breaths per minute.
Courtesy of David J. Burchfield, MD
Neonatal Assessment and
Resuscitation

Reassess after 30
seconds of
ventilation.
 If the breathing has
not improved and the
heart rate is less than
100/minute, continue
ventilations and
reassess every 30
seconds.
Management Priorities:
Assess Heart Rate

Palpate a pulse at the
base of the umbilical
cord.


Count for 6 seconds
and multiply by 10.
If cord pulse cannot
be palpated, listen for
heartbeat with a
stethoscope.
Management Priorities:
Newborn Resuscitation
 If
the heart rate remains <60 beats/min,
after 30 seconds of bag-mask ventilation,
begin chest compressions.
 3:1 compression to ventilation ratio
 90 compressions and 30 breaths/min
(120 “events” per minute)
 Reassess heart rate after 30 seconds
Neonatal Assessment and
Resuscitation


Use either the handencircling technique or
the two-finger technique.
Coordinate chest
compressions with
ventilations at a ratio of
3:1.
Neonatal Assessment and
Resuscitation: Review
Key Concept: The Inverted
Pyramid: If Chest Compressions not
affective, need ALS care and medications
Neonatal Assessment and
Resuscitation
ALS
 If
heart rate is < 60 beats/min after another
30 seconds CPR, consider intubation.
 Prepare epinephrine dose of 0.01 to 0.03
mg/kg (0.1 to 0.3 mL/kg of the 1:10,000
solution) ET/IV/IO.
Neonatal Resuscitation
BLS Shock Treatment
 The
newborn may be in shock due to
fluid loss.
 Shock symptoms:



Poor perfusion
Weak pulses
Poor response to resuscitation.
 Shock

treatment:
Rapid transport.
Neonatal Resuscitation
ALS Shock Treatment

Assure adequate oxygenation and ventilation.
 Obtain intravenous access:
 Intravenous: first choice
 Intraosseous: second choice
 Umbilical venous: if trained and equipped
 10–20 mL/kg normal saline or Ringer’s lactate
ALS Check Blood Glucose
 Infants
have poor glucose reserves
 The stress of delivery may deplete glucose
stores
 Give 2-4 ml/kg (1-2 ml/pound) of 10%
dextrose IV/IO for low blood glucose
Key Concepts: Newborn
Resuscitation
 Oxygen
therapy :Not appropriate to give
supplemental oxygen to all infants only
those in distress
 Monitoring: After resuscitation, reassess
infant status throughout transport.
 Hypothermia: Keep the baby warm during
transport.--Cover head with a knit cap.
 Newborn hypoglycemia: Assess blood
glucose after 30 minutes.
Once infant is
stable or at first
opportunity
Post Delivery Care
 Clamp
 Wait
and cut the umbilical cord
until pulsation of cord stops




Place 2 clamps
First clamp approximately 7 inches
from baby.
Second clamp approximately 2-3
inches from first
Cut with sterile scissors.
Clamp and Cut the Cord
 Monitor
ends for bleeding, if bleeding
occurs place another clamp proximal
to the initial clamp.
Neonatal Resuscitation Pearls
of Wisdom
 Good
assessments and care in first 15
minutes of life
 Keep your head
 Follow the triangle.
Review

Answer the following questions as a group.
 If doing this CE individually, please e-mail your
answers to:
[email protected]
 Use “July 2016 CE” in subject box.
 You will receive an e-mail confirmation. Print
this confirmation for your records, and document
the CE in your PREMSS CE record book.
Review
Scenario 1: You and your partner are
dispatched to the local shopping mall for a
17 year old female with severe abdominal
pain. When you arrive you find your
patient lying on the floor of the bathroom
and discover that she has just given birth.
The newborn is face down on the
bathroom floor. The mother is stable.
Review
The infant is a 31 week gestation baby girl .
You dry, warm, position, suction and
stimulate the infant but despite these
interventions the infant remains flaccid
with irregular respiratory effort and a weak
cry. Central cyanosis is also present and
the heart rate is 40.
Review
1.
2.
3.
4.
Calculate the AGPAR score of this
newborn infant.
What are the BLS treatment priorities
for this newborn infant?
If the respirations don’t improve in heart
rate doesn’t go up in 30-45 seconds,
what must be done?
The infants heart rate has not improve,
now what will you do?
Review
5. What is the appropriate rate of
compressions and the compressions to
ventilations ratio during CPR for the
newborn?
6. Resuscitation is taking priority with this
infant, but you think the umbilical cord
should be secured. Where should the
clamps be placed? Where should the cord
be cut?
7. The infant’s heart rate does not
improve. ALS providers decide to gain
vascular access. What are the choices for
this?
8. The infant appears to weigh about 4
pounds. How much of what concentration of
epinephrine should be considered by ALS
providers?
9. The infant has a low blood sugar of 40.
What are the options for this problem?
10.
The infant is now crying. Her
respirations are spontaneous at a rate of
44. Her pulse has improved to 140.
Her head and chest are pink but her
arms and legs are still cyanotic.
She is moving her arms and legs
weakly. What is her APCAR score now?
Answers
1.
2.
3.
4.
APGAR Score is 2
Position head down. Continue to dry,
suction and stimulate, apply blow by
oxygen.
Being ventilations with Bag-valve-mask at
a rate of 40-60
Begin chest compressions
5. 3:1 compression to ventilation ratio
90 compressions and 30 breaths/min
(120 “events” per minute)
6. Once the cord has stopped pulsating,
place the first clamp 7 inches from infant.
Second clamp goes 2-3 inches from the first.
Cut between the clamps.
7. IV or IO or ET (if intubated)
8. 0.01 to 0.03 mg/kg (0.1 to 0.3 mL/kg) of
Epinephrine 1:10,000 solution ET/IV/IO.
This is .02 mg or 0.2 ml for this child.
9. Give 10% dextrose IV/IO at 1-2 ml/pound.
This is 4-8 ml for this child.
10. APCAR is 8