Neonatal Resus

Question 1

What changes occur from fetal to extrauterine life?

Answer 1

SVR increases when umbilical cord clamped
Pulmonary VR decreases with first breaths (pH and PaO2 increase)
Increased Pulmonary blood
Blood flow reverses direction through the ductus arteriosus (15h) and foramen ovale - they close

Question 2

Why does persistent pulmonary hypertension occur?

Answer 2

Because the pulmonary vascular resistance did not fall adequately

Question 3

What to do in case of an emergency delivery in the ED?

Answer 3

Have a plan
Assemble the most qualified people for the mom and baby
Quick Hx to prep for known RF
Meds and equipment for NRP easily accessible
Periodic inspection of this equipment

Question 4

List equipment/meds needed for NRP

Answer 4

PPE
Warm blankets/towels
Suction catheter (sizes 5-10F)
Meconium aspirator
Face masks (prem, newborn, infant)
Oral airways
Bagger/Flow-inflating bag
Laryngoscope
ETT (sizes 2.5, 3.0, 3.5, 4.0) and stylet
LMA
Umbilical catheters (3.5 and 5 F)
3-way stopcock
NG tubes (8 and 10F)
Chest tubes (8 and 10 F)
Needles and syringes
Monitors, pulse oximeter, ETCO2 
Meds - Epi 1:10,000, Naloxone, NS, D10

Question 5

5 components of the APGAR score and assigned scores

Answer 5

Heart Rate
Respirations
Muscle tone
Reflex irritability (suction nares)
Color

Heart Rate
0 - Absent 1 - < 100 bpm 2 - > 100bpm

Respirations
0 - Absent 1 - slow, irregular 2 - good, crying

Muscle tone
0 - Limp 1 - some flexion 2 - active motion

Reflex irritability (suction nares)
0 - no response   1 - grimace           2 - cough, sneeze

Color
0 - blue/pale 1 - pink body/blue extrem
2 - completely pink

Question 6

Key Points for Neonatal Resuscitation

Answer 6

Prevent Hypothermia
Intrapartum routine suctioning of newborn’s nose/mouth is not recommended
Color of newborn is not used as indicator of oxygenation or effectiveness of resuscitation
Start resusc with blended O2 to meet sat targets
Can use LMA in NRP
2 thumb encircling method for chest compressions
Depth 1/2 AP diameter of chest
Use IO if UVC not possible
Give Epi if HR < 60 after 30 secs of adequate ventilation and chest compressions

Question 7

Methods to warm newborns

Answer 7

Radiant heater
Drying and swaddling in blankets
If <29 weeks or < 1500g place if plastic bag

Question 8

Indications to initiate PPV?

Answer 8

Gasping breaths
Apnea
HR < 100 bpm

Question 9

Newborn O2 sat targets

Answer 9

60-65% at 1 min, increases by increments of 5% (ie 65-70) each minute to 85-95 at 10 min

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

Question 10

Ventilation approach in NRP

Answer 10

40-60 breaths a minute 
30 breaths/min if chest compressions
20 cm H20 inflation pressure
Ensure proper mask fit
MRSOPA

Question 11

Indications for intubation in a neonate

Answer 11

Not responding to PPV
Extremely low birth weight (ELBW)
Requires chest compressions
Needs tracheal administration of medications
Special circumstances (diaphragmatic hernia)

Question 12

Size and depth of ETT for neonate

Answer 12

ETT = GA (weeks) / 10

Depth at lip (cm) = Weight (kg) + 6 cm

Question 13

Indications for chest compressions

Answer 13

PPV has been started
HR < or = 60 after 30s of PPV

3:1 ratio
2 thumb encircling technique
lower 1/3 sternum
1/3 compression of AP diameter of chest
RA every 30 seconds

Question 14

3 questions to ask for NRP

Answer 14

Term gestation
Breathing or crying
Good tone

Question 15

What other ventilation support can be used for neonates

Answer 15

CPAP

If HR > 100, no gasping or apnea
But laboured breathing or persistent cyanosis

Question 16

When to intubate and suction for mec-stained amniotic fluid?

Answer 16

Only if baby is nonvigorous or depressed
Ie. decreased tone, absent or depressed respiration or HR < 100 bpm

Repeat until mec stained fluid gone

If HR < 60 leave ETT in place and start PPV

Question 17

What meds are used in NRP? Which ones are not recommended

Answer 17

Epi 0.01 mg/kg to 0.03 mg/kg of 1:10,000
- if HR < 60 bpm despite adequate ventilation, 100% O2 and 30s of chest compressions

Fluids - NS - 10 ml/kg - if signs of hypovolemia (pallor, weak pulses, poor response to resusc)

Not recommended in initial resus
Atropine
Naloxone
NaBiarb - cannot give by ETT

Question 18

Circumstances to not initiate resus for neonate

Answer 18

Difficult in ED - incomplete Hx often, no rapport with parents

Follow NICU Guidelines
Ex. < 23 weeks, < 400g BW, anencephaly, major chromosomal abnormalities incompatible with life

Question 19

When to suspend resus efforts in a neonate

Answer 19

No HR detected after 10 mins of resus
Other factors:
Cause of arrest
GA of infant
Presence of complications
Parent's wishes