EM Pedia 11: Neonatal Resuscitation Flashcards
remarks on delayed cord clamping
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
most important in neonatal resuscitation
“Most important is the rapid establishment of effective ventilation and determining the heart rate before inititating CPR.”
Initial steps in the first 30 seconds
- If the infant is not breathing initially, dry and provide stimulation by rubbing the back 2-3x
- if there’s no response, open the airway using jaw thrust and towels beneath the shoulders to provide a sniffing position
- If there appearss to be obstruction from amniotic fluid, gently suction the nose and throat with a bulb or 8F catheter
- After these initial steps, assess the respiratory effort and heart rate
remarks on tracheal suctioning in the newborn
no longer recommended bec it can cause reflex bradycardia and apnea
target O2 saturation
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%
30-60 seconda:
if the heart rate is >100 bpm, but there’s persistent cyanosis or labored breathing, what to do
- open the airway and suction the nose and mouth if there’s a visible obstruction
- attach pulse oxmetry to the right hand/wrist (preductal) and apply supplemental oxygen to ahchieve targeted preductal O2 sats
30-60 seconds:
What if heart rate <100 bpm or those who are gasping or remain apenic after initial steps of resus
begin PPV using a bag and mask and room air
remarks on chest compression in neonatal resus
“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.”
remarks on ventilation
40-60 breaths/min
bests indicators of effective ventilation
1. good chest rise
2. an increase in heart rate (usually within 5-10 breaths)
steps to ensure effective ventilation prior to further resuscitation measures
“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)
indication for enotracheal intubation in the neonates
- absence of improvement with bag-mask ventilation
- concomitant need for chest compressions (i.e., HR <60 bpm)
- administration of endotracheal medications
- known or suspected congenital diaphargmatic hernia (to avoid inflating stomach/bowel situated in the chest)
remarks on chest compressions
- done at “60-90 seconds”
- ratio of 3 chets compressions to 1 breath for a total of 90 compressions and 30 breaths/min
- two-thumb technique seems to be suprior in generating greater peak systolic pressures
- two-finger technique may be more practical if a colleague is simultaneously attempting umbilical vessel catheterization
- stop chest compressions when the heart rate exceeds 60 bpm
- increase ventilation rate to 40-60 bpm once compression are stopped
volume expansion in neonates
administer 10 mL/kg of NSS or O-negative blood when there’s known or suspected blood loss (pallor poor perfusion, or weak pulses)
remarks on glucose levels in neonates
“Hypoglycemia in neonates is associated with adverse outcomes following birth asphyxia, whereas hyperglycemia is not.”
The most readily available site for venous access in the newborn is
the umbilical vein
remarks regarding discontinuing neonatal resuscitation
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
remarks on acrocyanosis
a normal finding in the first few days of life secondary to vasomotor instability and requires no specific evaluation or intervention
persistent pulmonary hypertension of the newborn vs coarctation of the aorta
PPHN - the postductal PaO2 (lower extremity) is significantly lower than the preductal (right radial) PaO2
COA - reduced femoral pulses
Hyperoxia test
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%)
If, after initial exam and testing, cyanotic heart disease cannot be ruled out, begin what?
an infusion of prostaglanding E1 starting at 0.05 mcg/kg/min, and titrate to the lowest effective dose to maintain ductal patency
Treat hypoglycemia with
10% dextrose in water, 2mL/kg iV bolus, or 3.3 mL/kg/hour
treatment of pneumothorax in the newborn
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)
remarks on congenital diaphragmatic hernia
m/c: posterolaterally through the foramen of Bochdalek
restrosternal foramen of Morgagni
most are left-sided
ultimate moridity and mortality in CDH is determined by
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
characteristic respiratory pattern in CDH
“seesaw” side-to-side respiratory pattern
IVF in omphalocoele
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
IVF in gastroschisis
IV 10% dextrose in water at 6-7 mL/kg/hour (150 mL/kg/24h)
antibiotics in omphalocoele and gastroschisis
ampicillin 50-100 mg/kg IV
gentamicin 4-5 mg/kg IV
VACTERRL
Vertebral anomalies
Anal atresia
Cardiac anomalies
Tracheo
Esophageal fistula
Radial anomlies
Renal anomalies
Limb anomalies
treatment of tracheoesophageal fistula
- reverse Trendelenburg (head-up) to help prevent passage of gastric contents through the TEF into lungs
- placeing the NGT into the esophageal puch on low intermittent suction to prevent buildup and possible aspiration of oral secretions
- NPO. D10W are best
management in congenital diaphragmatic hernia (CDH)
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
