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RESP 5017 > 10. Neonatal Resuscitation Program (NRP) > Flashcards

10. Neonatal Resuscitation Program (NRP) Flashcards

1
Q

What is the most important action in NR?

A

effective ventilation

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2
Q

List the components of pre-resuscitation team briefing.

A

assess perinatal risk factors, identify a team leader, delegate tasks, identify who will document, determine what supples/equipment needed, identify how to call for additional help

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3
Q

List the resuscitation attendance at a delivery with minimal risk factors.

A

1 person capable of performing PPV (sole responsibility is to newborn), can call for help if needed
routine care of the infant born with no risk factors…typically no RT

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4
Q

List the resuscitation attendance at a delivery with anticipated need for resuscitation or has risk factors.

A

minimum of 2 people, RT/RN, RT/RN/MD/NNP

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5
Q

Prior to delivery, what questions should you ask relevant to obstetrical history?

A
  1. what is the expected gestational age?
  2. is the amniotic fluid clear?
  3. how many babies are expected?
  4. are there any additional risk factors?
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6
Q

List some antepartum risk factors (26)

A

gestational age < 36 weeks, gestational age > 41 weeks, preclampsia/eclampsia, maternal hypertension, multiple gestation, fetal anemia, significant fetal malformations or anomalies, polyhydramnios, oligohydramnios, fetal hydrops, fetal macrosomia, intrauterine growth restriction, no prenatal care, emergency c-section, forceps/vacuum-assisted delivery, breech/other normal presentation, fetal heart rate abnormality, maternal general anesthesia, maternal magnesium therapy, placental abruption, intrapartum bleeding, chorioamnionitis, narcotics administered to mother within 4 hours of delivery, shoulder dystocia, meconium-stained amniotic fluid, prolapsed umbilical cord

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7
Q

List the equipment needed to WARM.

A

preheated warmer, plastic bag/wrap, warm towels/blankets

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8
Q

List the equipment needed to CLEAR AIRWAY.

A

8/10 Fr suction catheter with suction pressure set at 80-100mmHg, meconium aspirator

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9
Q

List the equipment needed to provide OXYGEN.

A

mask, tubing, flow-inflating bag/T-piece, oxygen/air blender, pulse oximeter probe (detached from oximeter until needed), pulse oximeter

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10
Q

List the equipment needed to VENTILATE.

A

PPV device/CPAP (flow-inflating, T-piece, self-inflating), various size masks

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11
Q

List the equipment needed to INTUBATE.

A

laryngoscope size 00/0/1 straight blade, ETT: 2.5,3 3.0, 3.5 (2 each), Stylette Fr 6, ETCO2 detector, LMA size 1 and 5ml syringe

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12
Q

List the equipment required for MEDICATION.

A

preloaded 1:10,000 epi, 1/3/10ml syringe, stopcock, normal saline, umbilical catheter, resuscitation record

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13
Q

List any other important equipment required for NRP.

A

5 or 8 Fr feeding tube and 10 ml syringe, IO needle, cardiac monitor

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14
Q

When should the cord be clamped immediately vs. delayed? What are the benefits of delayed cord clamping?

A

immediate: placental circulation is not intact after birth
delayed: 30-60s for vigorous term or preterm
benefits: neurodevelopmental, decreased anemia, increased blood volume and improved cardiopulmonary transition, increased levels of stem cells, improved outcomes for preterm infants

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15
Q

At the time of birth, what 3 questions should you ask yourself?
What happens with the infant if all 3 answers are yes?

A
  1. does the baby appear to be term?
  2. does the baby have good muscle tone?
  3. is the baby breathing or crying?

infant stays with mother for routine care: warm and maintain normal temp, position a/w, clear secretions if needed, dry, ongoing evaluation

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16
Q

What is routine care for newborns? What % of newborns are vigorous term babies with no risk factors?

A

thermoregulation (can be provided by placing the infant directly on the mother’s chest and providing stimulation and drying with towel), warmth is provided by direct skin-to-skin contact with mother, clearing of secretions (can be provided by wiping them from babies mouth)
90%

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17
Q

How do you properly dry and warm after delivery?

A

pre-heat the radiant warmer, use warm towels to dry the body and head and remove wet linen

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18
Q

How can you stimulate a newborn?

A

drying and clearing a/w may be enough

slapping/flicking soles of the feet, gently rubbing back, trunk, or extremities

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19
Q

When will stimulation of newborn not help?

A

secondary apnea, PPV is needed

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20
Q

How can you clear the a/w? Proper order? Suction pressures?

A

wiping the nose/mouth with towel or suction
mouth before nose
80-100mmHg (> 32 weeks = 10 Fr, < 32 weeks = 8 Fr)

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21
Q

How can you properly position the a/w?

A

sniffing position, towel under shoulders, avoid hyperextending

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22
Q

How will you evaluate the infant?

A

HR and respirations (gasping respirations are ineffective/require the same intervention as apnea)

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23
Q

Describe proper technique for determining HR. What else should be applied?

A

felt at the base of the umbilical or heard with a stethoscope of apex of heart (count # of beats in 6 seconds x 10)
SpO2 probe + ECG leads

24
Q

List some indications to provide PPV and SPO2 probe.

A

apnea, gasping, HR < 100, O2 saturation below target range despite free-flow oxygen or CPAP

25
Q

During ventilation:

BPM? PEEP? PIP?

A

40-60 BPM (slightly less than 1 breath per second)
5-6 cmH2O
20-25 cmH2O (should be adjusted to lowest pressure to produce chest rise) (higher PIP may be needed for the first few breaths to open the lungs)

26
Q

Describe the two methods for applying the mask.

A
  1. chin first (may pull the mouth closed during application of the mask over the nose)
  2. nose first method (allows for mouth to be kept open when applying mask over chin)
27
Q

List the advantages and disadvantages of a self-inflating bag.

A

advantages: does not require a compressed gas source, will always refill after being squeezed, ease of use, pressure release valve
disadvantages: will inflate even is there is not a seal between the mask and the patients face, requires oxygen reservoir to provide high concentration of oxygen, cannot be used to deliver free flow oxygen, requires an external pressure manometer to monitor PIP/PEEP, difficult to maintain constant PIP, cannot be used to deliver CPAP, can only deliver PEEP when an external PEEP valve is being used

28
Q

List the advantages and disadvantages of a flow-inflating bag.

A

advantages: can deliver a variable % oxygen when attached to a blender, easy to determine when there is a seal on the patient’s face, can be used to deliver free-flow oxygen at variable concentrations, can be used to deliver CPAP, can “feel” the compliance of the lungs
disadvantages: requires a tight seal between the mask and the patients face to remain inflated, requires a compressed gas source, requires use of a pressure gauge to monitor pressure being delivered with each breath, requires operator technique

29
Q

List the advantages and disadvantages of a T-piece resuscitator.

A

advantages: reliable control of PIP and PEEP, can deliver a variable % oxygen if attached to a blender, operator does not become fatigued from bagging, can administer free flow or CPAP
disadvantages: requires a gas source, requires pressures to be set prior to use, risk of prolonged inspiratory time

30
Q

List the 5 steps of setting up a T-piece.

A
  1. set up flowmeter from oxygen blender at 10 LPM
  2. set the oxygen concentration on the oxygen blender
  3. set the maximum pressure relief at 30 cmH2O
  4. set the inspiratory pressure control (PIP)
  5. set the PEEP to 5-6 cmH2O
31
Q

How do you provide PPV using a T-piece resuscitator?

A

good seal, occlude PEEP cap briefly to deliver breath (amount of time finger covers PEEP cap determines Ti)
observe for adequate chest rise

32
Q

How do you administer CPAP using a T-piece resuscitator?

A

good seal, DO NOT occlude the PEEP cap, CPAP pressure can be seen by looking at the pressure manometer

33
Q

How do you administer free flow oxygen using a T-piece resuscitator?

A

hold mask close to face without obtaining a seal, occlude PEEP cap so that all flow is being directed toward the patient

34
Q

How do you assess for adequate ventilation? Improvement is indicated by?

A

*should occur within 15 seconds of starting
rising HR (most important indicator), improvement in vital signs (HR, RR, colour, tone), bilateral chest rise, air entry on auscultation
increasing HR, improving colour, spontaneous breathing, improving muscle tone

35
Q

How do you know when it is appropriate to discontinue PPV?

A

when infants HR > 100 and they are breathing spontaneously, wean BVM rate
*may continue with CPAP is respiratory distress is present or free-flow if oxygen is needed

36
Q

What is the Targeted preductal SpO2 after birth for 1 min? 2 min? 3 min? 4 min? 5 min? 10 min?

A 
60-65%
65-70%
70-75%
75-80%
80-85%
85-95%
37
Q

What FO2 should be used if the infant is < 35 weeks gestation?

A

21-30%

38
Q

When is pre-ductal SpO2 monitoring indicated?

A

central cyanosis present, administrating oxygen therapy, providing PPV, anticipated resuscitation

39
Q

Where should a pre-ductal SpO2 monitoring prove be placed on the body? How is oxygen titrated? if providing chest compressions, what FiO2 should be used?

A

right hand, wrist
based on SpO2 table
100% or 1

40
Q

When is CPAP administered? What is transitional CPAP? Appropriate pressures?

A

HR > 100 and laboured breathing and/or persistent central cyanosis
only on CPAP for 5-10 mins in order to open up a/w before they improve
CPAP 5-6 cmH2O (with T-piece of flow-inflating bag)

41
Q

When there is no improvement from PPV or inadequate PPV is being delivered, work through what acronym? What do each other the letters mean? How often are 6 PPV breaths delivered?

A 
MP SOPA
M - mask adjustment
R - repositions airway
S - suction mouth and nose
O - open mouth
P - pressure increase
A - airway alternative 
M-R = 6 breaths
S-O = 6 breaths
P = 6 breaths
A = 6 breaths
42
Q

What are the indications for intubation?

A

can be performed anytime during the resuscitation sequence, helpful to ensure adequate ventilation, will facilitate the coordination of ventilation and chest compressions, delivery of medication (epi, surfactant via ETT), extreme prematurity, CDH

43
Q

Intubation equipment (ETT size, laryngoscope blade) and gestation age (weeks) for infants < 1000g, 1000-2000g, > 2000G

A
  1. 5, 00 or 0, < 28 weeks
  2. 0, 0, 28-34 weeks
  3. 5, 0-1, > 34 weeks

all uncuffed tubes

44
Q

How do you determine ETT depth?

A

Oral: 6 + weight in Kg
Nasal: 7 + weight in Kg

or nasal septum to ear tragus - measure from middle of the nasal septum to the ear tragus

oral: add 1 cm to measurement
nasal: add 2 cm to measurement

45
Q

What does meconium increase the risk of? What is routine practice in response to meconium stained fluid?

A

baby will require resuscitation after birth (team should be present at birth)
regular steps of NRP, clear mouth and nose of secretions (routine intubation not suggested)

46
Q

An infant born through meconium stained amniotic fluid may require what? why?

A

suctioning of meconium from below the cords

meconium may be obstructing the a/w and preventing effective ventilation

47
Q

What is the DOPE mnemonic?

A

D - displaced ETT
O - obstructed ETT
P - pneumo
E - equipment failure

48
Q

What are the indications for am LMA?

A

failure to achieve effective ventilation with PPV, unsuccessful intubation, congential anomalies involving mouth/lip/palate making ventilation difficult, anomalies with the mouth/tongue/pharynx/neck making intubation difficult, small mandible such as pier robin syndrome

49
Q

Size 1 is appropriate for what weight range?
Can an LMA be used to suction meconium below the vocal cords?
High ventilating pressure may cause?
Can an LMA be used to administer medications?

A

2.5 - 5 Kg (may work for 1500-2500g)
no
leak and inadequate lung inflation and over inflation of stomach
no

50
Q

What are the indication for chest compressions? Appropriate FiO2?
Cycle of events?

A

HR < 60, only after 30 seconds of effective PPV (chest rise)
100%
3 compressions to 1 breath, 120 events in 1 minute (90 compressions & 30 breaths)

51
Q

Proper location for chest compressions? Depth? Method? How often to reassess?

A

just below nipple line
1/3 AP diameter
2 thumb method
every 60 seconds

52
Q

When is epinephrine indicated? Dose via ETT? Max dose? Draw up in __mL syringe?

Dose via UVC/IV/IO? Draw up in __ml syringe? Follow with __-__ml flush N/S?

give epi every _____ minutes while doing chest compressions, check HR every __ seconds

A

HR < 60 bpm after (1) at least 30 seconds of PPV that inflates the lungs (2) another 60 seconds of chest compressions coordinated with PPV using 100% oxygen
0.1mg/kg (1ml/kg) of 1:10,000
3 ml

0.01 mk/kg (0.1ml/kg) of 1:10,000
1ml
0.5-1 flush

3-5 min, 60 seconds

53
Q

What can prolonged PPV by bag mask cause?

What can be done to prevent this?

A

stomach distension, inhibition of full expansion of lungs, possible aspiration of gastric contents
insertion of NG/OG

54
Q

Proper sizing for NG/OG>
How is it measured?
How is placement confirmed?

A

5, 6, or 8 Fr
NG: nose to ear to halfway between xiphoid and umbilicus
OG: mouth to ear lobe to halfway between the xiphoid and umbilicus
aspiration of gastric content + pop heard

55
Q

What are some special consideration of NRP?

A

Premature (plastic bag < 32 weeks, do not dry, intubate for surfactant admin), CDH (avoid BVM, intubate, large NG/OG), meconium stained amniotic fluid, choanal atresia, pneumothorax

56
Q

How are APGARS scored for children? What is a normal score? What score might require from resuscitative measures? What score might require immediate resuscitation?

A

score given for each sign at one minute and five minutes after birth
if there are any problems with the baby an additional score is given at 10 minutes and every 5 min until a score of 7 is reached

score of 7-10 normal
4-6
3 and below

57
Q

What does each letter of APGAR stand for? What does a score of 0 for each? 1 point? 2 points?

A 
A - activity, muscle tone
P - pulse, HR
G - grimace reflex irritability
A - appearance, skin colour
R - respiration

0 points: A - absent, limp, P - arms/legs flexed, G - no response, A - blue, gray, pale all over, R - absent, gasping

1 point: A - arms/legs flexed, P - < 100, G - grimace, A - pink body, blue extremities, R - slow, irregular

2 points: A - active movement, P - > 100, G - sneeze, cough pulls away, A - entire body pink, R - good, crying

RESP 5017 (19 decks)

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