Download 2016 EMS REFRESHER Care of the Newly Born And Neonate 2015 AHA Update

2016 EMS REFRESHER
Care of the Newly Born
And Neonate
2015 AHA Update
January 31st, 2016
Andrew Walter MD
Introduction
 The likelihood of serious neurologic injury or even
death is higher when delivery occurs in the nondelivery room setting.
 Decisions made in the first few minutes after
delivery will carry life-long consequences.
 We will begin with a review of newborn physiology,
and resuscitation guidelines, with attention to the
2015 AHA guidelines for neonatal resuscittion,
followed by non-resuscitation emergencies, and
case studies.
Epidemiology
 6% of field deliveries require life support
 As the birth weight goes down, the
incidence of complications increase
 80% of infants 3lbs 5 oz require some type
of resuscitation
 Only 1% of all newborns will require cardiac
compression/meds
Preparation for Delivery




Resuscitation-Oriented History
1) Are there twins??
2) When are you due??
3) What is the color of the amniotic fluid??
Delivery Assessment
 Term gestation?
 Good tone?
 Breathing and crying?
Preparation of Equipment
 Although most newly born infants will
require no specific care, assume the infant
will be depressed.
 At a minimum, equipment should include:

Neonatal resuscitator (< 750 ml)

Term and pre-term masks

Suction equipment

Laryngoscope and ET tubes/O2 source
Preparation of Equipment
 Provision of a warm environment
 Ideally, a preheated radiant warmer
 Practically, a supply of towels, thermal wrap
or mother’s abdomen
 Thermal mattress, hat, or plastic bag to the
preemie’s neck
 As the newborn’s body temperature drops,
its’ oxygen requirements raise exponentially
Preparation
 The key to successful resuscitation is
anticipation
 At least two personnel are needed for the
resuscitation of the severely depressed and
asphyxiated newborn
 On person for ventilation, and if necessary,
intubation. Another for monitoring heart
rate, and if necessary, chest compressions
APGAR Score
 Traditionally, assigned at 1 and 5 minutes
 Gives shorthand information about the
newborn’s condition, changes in its’ status,
and is a general predictor of outcome
 Has limitations
 Should not be used as a guide to
resuscitative efforts
 Keys to resuscitation include heart rate, and
respiratory status
APGAR Score
APGAR Score
Transition
 Birth process single most dangerous event
that most of us will ever go through
 Transition from fetal circulation to neonatal
circulation
Fetal/Neonatal Physiology
Fetal Physiology
Immediate Care of the Newborn
 Most full-term newborns are healthy and
require no specific treatment, other than
drying and keeping warm
 However, initial steps in caring for the newly
born can prevent secondary and avoidable
complications in an otherwise healthy
newborn
 These steps provide a beginning point for
resuscitation
Dry and Warm the Baby
Dry and Warm the Baby
 The newly born can lose tremendous
amounts of heat through evaporation and
radiation, unless rapidly dried
 Drying is important, even if the baby is
depressed/asphyxiated, and in need of
immediate resuscitation
 Warming the newly born will dramatically
reduce tissue oxygen requirements
Positioning the Newborn
Positioning the Newborn
Positioning the Newborn
Positioning the Newborn
 The newborn’s head is disproportionately
large when compared to the older child and
adult
 This will lead to flexion of the neck when the
newborn is in the supine position and lead to
airway compromise
Clearing the Airway
 Newborns are born with copious airway
(amniotic) fluid, and even in a vigorous
baby, may cause airway compromise
 Fetal lungs are not really ‘collapsed,’ but
filled with fluid
 Most of this fluid is literally ‘squeezed’ out
during the passage through the birth control
Clearing the Airway
Clearing the Airway
Assess Breathing
 Most newborns will be crying lustily as proof of
their breathing. The heart rate will be over 100
beats/min
 A newly born who is not breathing may be in either
primary or secondary apnea
 In primary apnea, drying and stimulation will cause
a start-up in breathing
 In secondary apnea, spontaneous ventilation will
only start with the use of positive pressure
ventilation
Primary vs. Secondary Apnea
 When apnea is discovered following the
initial steps of positioning, drying and
suctioning, always assume the newborn is in
secondary apnea, and proceed to bag-mask
ventilation
 When the HR is less than 100 beats/min,
proceed to PPV
Primary Apnea
 Primary Apnea: When the fetus/newborn is
asphyxiated, there will be an initial increase
in respiratory effort and heart rate. This will
be followed by an episode of apnea. At this
time, simple stimulation will result in
resumption of breathing, as in the act of
drying and positioning
Secondary Apnea
 When asphyxia is allowed to continue after
primary apnea, the infant responds with
gasping respirations, falling heart rate and
blood pressure
 The infant then takes a ‘last breath’ and
enters into secondary apnea
 Death will ensue unless resuscitation is
begun immediately
Primary vs. Secondary Apnea
Assessing Heart Rate
 In the newly born, a low heart rate is a sign of
hypoxia, NOT intrinsic heart disease
 Even if the newly born appears to be breathing,
the adequacy of ventilation is assessed by
evaluating the heart rate
 If the heart rate is <100/min, the respiratory efforts
are inadequate, and positive pressure ventilation
should be started
Assessing the Heart Rate
Assess Color
 Until the newly born has established regular
ventilation, central cyanosis should be
expected
 If the newborn is breathing regularly and has
a heart rate >100/min, and continues to be
centrally cyanotic, blow-by O2 may be
given, with O2 tubing or a face mask
application
 Peripheral cyanosis requires no treatment
Central Cyanosis
Peripheral Cyanosis
Pink
Pink and Warm
Special Considerations





Meconium aspiration syndrome
Asphyxia
Diaphragmatic Hernia
Pneumothorax
Hypoventilation due to low ventilatory
pressure
 B-strep pneumonia/sepsis
 Congenital anomalies
Meconium Aspiration Syndrome
 The management of meconium stained fluid
has changed over time.
 Routine De-Lee suctioning on the perineum
no longer recommended
 Routine intubation is no longer
recommended in the lusty, crying infant
 Routine intubation not even recommended
in the depressed infant, prior to PPV
Meconium
Meconium Aspiration Syndrome
Asphyxia
 EMS dispatch to home of 17 y/o with severe
abdominal pain
 On arrival, patient in advanced labor, and is
crowning on exam
 Resuscitation oriented history
 Imminent delivery of term infant, with clear
amniotic fluid
Depressed Newly Born
 Upon delivery, newborn is apneic with a
heart rate <100/min
 Most newborns who require resuscitation
have been faced with ongoing hypoxia and
acidosis
 This is reversed with positive pressure
ventilation
Indications for Assisted Ventilation
 Apnea unresponsive to drying, stimulation,
and suctioning
 Always assume apnea in the newborn is
secondary apnea, and begin positive
pressure ventilation
 Heart rate <100 beats per minute
 Persistent central cyanosis with 100% O2
Self Inflating Bag
Flow vs. Self Inflating Bags
Ventilation Masks
Positioning of Airway
Jaw Thrust Maneuver in Newborn
Positive Pressure Ventilation
Positive Pressure Ventilation
 After positioning and rapidly drying the
infant, the mask is placed firmly over the
face, avoiding the eyes
 Begin ventilating with the
‘breathe……two……three’ approach,
delivering about 40 to 60 breaths per minute
 Verify chest rise
 Re-evaluate every 30 seconds
Newly Born’s First Breath
 Pressures needed for the initial breath may
be a many as three times the pressure of
subsequent breaths
 Initial pressures may need to be 60 cm of
water pressure to overcome the resistance
of retained lung fluid
 Another approach with a flow inflating bag is
deliverance of 5 seconds of prolonged
pressure
Indications for Intubation
 Ineffective bag-mask ventilation
 Meconium stained amniotic fluid in the face
of a depressed newborn
 Need for prolonged positive-pressure
ventilation
Intubation
Intubation
Severe Asphyxia
 EMS dispatch to a ‘term delivery in the toilet’
 Upon arrival, we find an apneic and cyanotic
term newborn, heart rate of 40
 Application of positive pressure ventilation
for 30 seconds does not improve the heart
rate
Indications for Chest Compression
 Heart rate <60/min
Chest Compressions
Chest Compressions
 If using bag valve mask ventilation, one should
coordinate ventilation with compressions
 Deliver 3 compressions, then a pause for a
ventilation
 Assume 120 events per minute of CPR, 90
compressions and 30 breaths
 Continue CPR until heart rate is over 60 and rising
 Continue ventilation until heart rate is >100/min
and newborn is breathing spontaneously
Indications for Medications
 Heart rate <60 beats per minute despite
adequate ventilation with 100% O2 for 30
seconds, and another 30 seconds of chest
compression
 Epinephrine is the drug of choice
 IV administration is recommended, but may
be problematic in the newly born
Golden Minute
 60 seconds to complete initial steps, evaluating
condition, and beginning ventilations if needed.
 Important not to cause delay.
 Assess respirations (apnea, gasping or labored
breathing) and heart rate less than 100/min.
 The MOST SENSITIVE indicator of a successful
response to each intervention is an increase in
heart rate.
Newborn Resuscitation
First 30 seconds: should have provided warmth,
positioning of infant, clearing of the airway, drying,
stimulating and reposition the infant
O2 may be given as necessary
In the first 30 seconds, should already have come to
some idea if further intervention is needed
Is there meconium, is the infant crying, vigorous and
pink??
Newborn Resuscitation
 During the next 30 seconds, evaluate
respirations, heart rate and color
 Apnea is treated with positive pressure
ventilation
 HR <100 is treated with positive pressure
ventilation
Newborn Resuscitation
 After another 30 seconds, begin chest
compressions if HR is <60/min (one minute
after birth)
 After another 30 seconds of CPR, consider
epinephrine if HR remains <60/min
 Epinephrine (1:10,000 or 0.1 mg/ml) in a
dose of 0.01-0.03 mg/kg (0.1-0.3ml/kg)
 ET dose: 0.3-1ml/kg
Volume Expansion
 Given with poor response to resuscitation
 Given with concerns about blood loss or
hypovolemia
 Crystalloid preferred
 10ml/kg given over ? 10 minutes
PALS/NRP Inverted Pyramid
 Always needed: Dry, warm, position, suction and
stimulation
 Rarely needed: Chest compressions and
medications
 In the middle is 02 and the need for positive
pressure ventilation
 Of 100 newborns, only 10% will require some type
of extra assistance
 Of the same 100 newborns, only 1% will require
resuscitation
Special Considerations
 EMS dispatch to tier with volunteer service
 They had been called for precipitous
delivery of term newborn
 On arrival infant is tachypneic, tachycardic
and cyanotic despite blow by O2
 One side of the chest appears enlarged and
the abdomen is concave
Diaphragmatic Hernia
Diaphragmatic Hernia
Special Considerations
 EMS unit returning to base after
successfully resuscitating newborn infant
 Infant had required several minutes of
positive pressure ventilation, but no chest
compressions
 Infant crying and pink initially, but now
sudden deterioration with cyanosis,
respiratory distress and falling heart rate
Sudden Deterioration in Newly Born
having needed Initial Resuscitation
Special Considerations
Special Considerations
Special Considerations
 EMS dispatch to home delivery gone awry
 On arrival, term infant is apneic, cyanotic.
Begins to receive positive pressure
ventilation with an appropriate sized Ambu
bag
 No chest rise is noted
 What is your initial approach??
Hypoventilation due to Low
Ventilatory Pressure
 Recall first breath may require 3X as much
pressure as subsequent breaths
 And lungs will not ‘open’ unless this
pressure is delivered
Difficulties with Ventilation
Special Considerations
Special Considerations
Special Considerations
 EMS called to transport newborn from small
outlying hospital
 Recurrent episodes of cyanosis and apnea
 Nursery nurse states ‘strangest
thing………is fine when he is crying, but
when he quiets down, turns blue and stops
breathing’
 ‘So we just kept him crying’
Chonal Atresia
Choanal Atresia
Neonatal Transport
 Called to transfer one month old from small
community hospital with respiratory distress
 Presented with difficulty feeding and
sweating
 On exam, tachycardic and tachypneic
 Requiring supplemental O2 to maintain sats
 Murmur noted on exam, harsh and
holosystolic
Ventricular Septal Defect
EMS Call
 Called to home of pre-term infant, home
from the NICU for only a couple of weeks
 Trouble with breathing, tachycardic and
tachypneic
 Murmur also noted, to and fro type murmur,
a machinery type murmur
EMS Call
 Called to home of 3 week old,
 ‘Not acting right’ per mom. Poor feeding,
and possible apneic event
 Siblings with respiratory ‘colds’
 Infant with weak cry, limp and poor capillary
refill
RSV Bronchiolitis/Pneumonia/Shock
2015 AHA GUIDELINES
Newborn Resuscitation
DCC or delayed cord clamping

Continued emphasis on maintaining
temperature, as admission temp is a direct
predictor of mortality and all things bad

In hypothermic infant, no preference of
fast vs slow rewarming

In meconium staining, routine intubation
and suctioning no longer advised
2015 GUIDELINES
 Heart rate determination: three lead ECG monitor
preferred over pulse ox, and both preferred over
clinical assessment
 Room air resuscitation in term infants
 In preterm, no apparent benefit/detriment with O2
vs RA resuscitation
 Initial breaths requiring increased pressure, shown
in animal, but not human models
 LMA use in 34 weeks and greater gestation, but
med usage and use with compressions has not
been studied
2015 GUIDELINES
 CPAP has been shown to avoid intubation
and the need for PPV
 Chest Compressions: OK to increase to
100% O2
 Low glucose levels associated with poorer
outcomes, and elevated glucose levels
seem to be neuro-protective, but no
recommendations have been made
CESSATION OF EFFORTS
 Apgar 0 at 10 minutes
 Malformation incompatible with life