EM Pedia 11: Neonatal Resuscitation

Question 1

remarks on delayed cord clamping

Answer 1

at least 1-3 mins after birth
benefits:
-reduces the need for blood transfusion
-increases neonatal iron stores
-may decrease the risk of requiring treatment for hyperbilirubinemia

*for newborns requiring immediate intervention, the cord should be clamped and cut to allow for initiation of therapy

Question 2

most important in neonatal resuscitation

Answer 2

“Most important is the rapid establishment of effective ventilation and determining the heart rate before inititating CPR.”

Question 3

Initial steps in the first 30 seconds

Answer 3

1. If the infant is not breathing initially, dry and provide stimulation by rubbing the back 2-3x
2. if there’s no response, open the airway using jaw thrust and towels beneath the shoulders to provide a sniffing position
3. If there appearss to be obstruction from amniotic fluid, gently suction the nose and throat with a bulb or 8F catheter
4. After these initial steps, assess the respiratory effort and heart rate

Question 4

remarks on tracheal suctioning in the newborn

Answer 4

no longer recommended bec it can cause reflex bradycardia and apnea

Question 5

target O2 saturation

Answer 5

make sure preductal (right radial / hand

1 min: 60-65%
2 mins: 65-70%
3 mins: 70-75%
4 mins: 75-80%
5 mins: 80-85%
10 mins: 85-90%

Question 6

30-60 seconda:
if the heart rate is >100 bpm, but there’s persistent cyanosis or labored breathing, what to do

Answer 6

1. open the airway and suction the nose and mouth if there’s a visible obstruction
2. attach pulse oxmetry to the right hand/wrist (preductal) and apply supplemental oxygen to ahchieve targeted preductal O2 sats

Question 7

30-60 seconds:
What if heart rate <100 bpm or those who are gasping or remain apenic after initial steps of resus

Answer 7

begin PPV using a bag and mask and room air

Question 8

remarks on chest compression in neonatal resus

Answer 8

“Bradycardia, even extreme, is typically the result of respiratory failure, and chest compressions or medications should not be intitiated until EFFECTIVE VENTILATIONS have been provided.”

Question 9

remarks on ventilation

Answer 9

40-60 breaths/min

bests indicators of effective ventilation
1. good chest rise
2. an increase in heart rate (usually within 5-10 breaths)

Question 10

steps to ensure effective ventilation prior to further resuscitation measures

Answer 10

“MR SOPA”

Mask (adjust to improve seal)
Reposition the head to open the airway

Suction the mouth then nose
Open the mouth with a jaw thrust, and increase the
Pressure until chest rise is noted (max peak ins pressure, 40 cm H20), and if none of these is effective, proceed to definitive
Airway control (endotracheal intubation)

Question 11

indication for enotracheal intubation in the neonates

Answer 11

1. absence of improvement with bag-mask ventilation
2. concomitant need for chest compressions (i.e., HR <60 bpm)
3. administration of endotracheal medications
4. known or suspected congenital diaphargmatic hernia (to avoid inflating stomach/bowel situated in the chest)

Question 12

remarks on chest compressions

Answer 12

1. done at “60-90 seconds”
2. ratio of 3 chets compressions to 1 breath for a total of 90 compressions and 30 breaths/min
3. two-thumb technique seems to be suprior in generating greater peak systolic pressures
4. two-finger technique may be more practical if a colleague is simultaneously attempting umbilical vessel catheterization
5. stop chest compressions when the heart rate exceeds 60 bpm
6. increase ventilation rate to 40-60 bpm once compression are stopped

Question 13

volume expansion in neonates

Answer 13

administer 10 mL/kg of NSS or O-negative blood when there’s known or suspected blood loss (pallor poor perfusion, or weak pulses)

Question 14

remarks on glucose levels in neonates

Answer 14

“Hypoglycemia in neonates is associated with adverse outcomes following birth asphyxia, whereas hyperglycemia is not.”

Question 15

The most readily available site for venous access in the newborn is

Answer 15

the umbilical vein

Question 16

remarks regarding discontinuing neonatal resuscitation

Answer 16

Newborns with no sign of life after 10 mins of continuous and active resuscitation are virtually certain to suffer severe morbidity and/or mortality if continued resuscitation is successfull in restoring vital signs.

Therefore, it is justified to cease resuscitative efforts after 10 mins and, certainly, after 15 mins of asystole

Question 17

remarks on acrocyanosis

Answer 17

a normal finding in the first few days of life secondary to vasomotor instability and requires no specific evaluation or intervention

Question 18

persistent pulmonary hypertension of the newborn vs coarctation of the aorta

Answer 18

PPHN - the postductal PaO2 (lower extremity) is significantly lower than the preductal (right radial) PaO2

COA - reduced femoral pulses

Question 19

Hyperoxia test

Answer 19

Place the newborn in 100% hood for 10 mins

Cyanotic newborns with a pulmonary disorder can increase their PaO2 to >100 mm Hg (or SpO2 by >20%)

Question 20

If, after initial exam and testing, cyanotic heart disease cannot be ruled out, begin what?

Answer 20

an infusion of prostaglanding E1 starting at 0.05 mcg/kg/min, and titrate to the lowest effective dose to maintain ductal patency

Question 21

Treat hypoglycemia with

Answer 21

10% dextrose in water, 2mL/kg iV bolus, or 3.3 mL/kg/hour

Question 22

treatment of pneumothorax in the newborn

Answer 22

nontension:
nitrogen washout technique:
placing the baby in a 100% oxygen hood for 6-12 hours may accelerate clearance of the airleak
-this is CONTRAINDICATED in preterm newborns due to concerns of O2 toxicity to the lungs and retinas

TENSION:
1. 18- or 20- gauge 1-inch percutaneous catheter
2. local anethetic
3. elevate the neonate’s affected side with towels under the back
4. insert catheter into the 4th ICS at AAL (nipple line)

Question 23

remarks on congenital diaphragmatic hernia

Answer 23

m/c: posterolaterally through the foramen of Bochdalek

restrosternal foramen of Morgagni

most are left-sided

Question 24

ultimate moridity and mortality in CDH is determined by

Answer 24

both the extent of hypoplasia of the contralateral lung and wheter or not the liver is located in the thorax and associated anomalies

total lung volumes >45% of normal are predictive of survival

Question 25

characteristic respiratory pattern in CDH

Answer 25

“seesaw” side-to-side respiratory pattern

Question 26

IVF in omphalocoele

Answer 26

IV 10% dextrose in water at 1.5x maintenance (i.e., 5-6 mL/kg/hour or 120-150 mL/kg/24 hours) to compenstae for the additional insensible water loss

Question 27

IVF in gastroschisis

Answer 27

IV 10% dextrose in water at 6-7 mL/kg/hour (150 mL/kg/24h)

Question 28

antibiotics in omphalocoele and gastroschisis

Answer 28

ampicillin 50-100 mg/kg IV
gentamicin 4-5 mg/kg IV

Question 29

VACTERRL

Answer 29

Vertebral anomalies
Anal atresia
Cardiac anomalies
Tracheo
Esophageal fistula
Radial anomlies
Renal anomalies
Limb anomalies

Question 30

treatment of tracheoesophageal fistula

Answer 30

1. reverse Trendelenburg (head-up) to help prevent passage of gastric contents through the TEF into lungs
2. placeing the NGT into the esophageal puch on low intermittent suction to prevent buildup and possible aspiration of oral secretions
3. NPO. D10W are best

Question 31

management in congenital diaphragmatic hernia (CDH)

Answer 31

1.) rapid endotracheal intubation is the treatment of choice with a rate of 40-50 breaths per min and lowest peak inspiratory pressures that allow for normal chest rise

2.) gentle hyperventilation to a PCO2 between 30 and 35 mmHg may help lower pulmonary vasculature resistance and allow for an easier stabilization phase before surgical correctionn.

bag-mask ventilation will inflate the GI contents in the chest and will further compromise ventilation