Neonatal Resuscitation Flashcards
Birth occurs. What are the 3 very first things to evaluate in the algorithm to determine if baby is fine to stay with the mother for routine care?
If the baby does all 3 of these, he can stay with mom for routine care:
1) Term? Term gestation or not.
2) Tone? Good or bad
3) Breathing or Crying?
What is “Routine Care” after a normal delivery with healthy baby?
Infant stays with mother and you do the following “routine care”:
- WARM and maintain normal temperature,
- DRY the baby (goes along with “warm”)
- POSITION AIRWAY to relieve obstruction
- CLEAR SECRETIONS if needed
- ONGOING EVALUATION
What do you do if baby is NOT doing any of the initial things ([1] Term gestation, [2] Good tone, and [3] Breathing or Crying)
- STIMULATE!! This is the only difference in this initial treatment vs if baby was totally healthy! Otherwise the others below are the same steps as a healthy baby would have
- WARM and maintain normal temperature,
- DRY the baby (goes along with “warm”)
- POSITION AIRWAY
- CLEAR SECRETIONS if needed
- ONGOING EVALUATION
Baby was either not term, did NOT have good tone, and/or was NOT breathing or Crying after birth. You just did the initial treatment of STIMULATION, warming & drying, positioning airway, and clearing secretions. What are the next two criteria to determine the next branching point for neonatal resuscitation?
1) Apnea or Gasping?
2) HR < 100 bpm?
Still in the first minute of the algorithm here. Good news, there is NO apnea/gasping and HR > 100 after your initial intervention of stimulation + routine care. What are the next questions to ask yourself?
1) LABORED BREATHING or
2) PERSISTENT CYANOSIS?
Still in the first minute. Good news, there is NO apnea/gasping and HR > 100 after your initial intervention of stimulation + routine care. Then more good news that there was NO labored breathing or persistent cyanosis (the next step of the algorithm). What do you do next?
This option actually isn’t part of the algorithm. The algorithm only has an option for if there IS labored breathing or persistent Cyanosis.
It seems very logical that you basically just start doing “Routine Care” at that point, which would include warming and drying, positioning airway, clearing secretions, and ONGOING EVALUATION for need to add STIMULATION or need to take baby away from mother for higher interventions.
Still in the first minute of the algorithm here. Good news, there is NO apnea/gasping and HR > 100. Bad news, there IS labored breathing or persistent cyanosis. What do you do next?
1) Position and clear airway
2) Spo2 monitor
3) AS NEEDED Supplementary O2 as needed
4) CONSIDER CPAP (PPV)
Next step from here on the algorithm isn’t super clear, but basically keep an eye on the HR (< 100 consider PPV at the least, possibly an advanced airway) and for breathing to improve or not.
Notice that definitive CARDIAC monitoring (applying EKG) is NOT necessary here. That would more be Necessary is HR <100 or apnea/gasping and so you were placing an advanced airway.
Still in the first minute of the algorithm here. Bad news, there IS apnea or gasping, and/or HR < 100 bpm. What do you do?
1) PPV - so here CPAP is MANDATORY as opposed to “as needed” if baby just has labored breathing or persistent cyanosis as opposed to full on Apnea or Gasping & HR < 100.
2) SpO2 monitor
3) Consider EKG monitoring - the other subtle difference is the addition of EKG. If just labored breathing or persistent cyanosis you’d just provide respiratory support (supp O2, CPAP, airway positioning) but NO extra cardiac monitoring per se)
Where should you place an SpO2 monitor on a baby?
Pulse oximetry can be used to target a PREDUCTAL oxygen saturation - pulse oximeter is placed on RIGHT upper extremity:
- R finger
- R wrist,
- R medial palmar surface)
Preductal SpO2 provides better assessment of CNS oxygenation.
Recount that the Ductus Arteriosus is a patent fetal connection between the PA and aortic arch. It’s origin on the aorta is usually distal to the 3 main branches off the aorta (brachiocephalic/inominate artery, left common carotid artery, and left subclavian artery), or at least distal to the left common carotid artery. Moderately oxygenated blood in fetus (oxygenated blood starting at Placenta) and POORLY oxygenated blood in newborns (no more placenta, so just purely DE-oxygenated blood) is shunted possibly to the LUE (if PDA is slightly proximal to left subclavian artery) and definitely to both lower extremities via a PDA (patent ductus arteriosus), whereas the RIGHT arm (arterial supply from brachiocephalic/inominate artery) is only well-oxygenated blood from lungs & left heart.
What are the pulse ox (SpO2) target saturation goals within the first 5 min of life?
SpO2 60-65% by 1 minute of life
SpO2 80-85% by 5 minutes of life
SpO2 85-95% by 10 minutes of life
In what duration of time does the bulk of the neonatal resuscitation algorithm occur? Or at least what I would consider to be the hard and nit-picky parts.
First 1 minute of life!
Recount the entirety of the algorithm that occurs in the first 1 min of life. Or at least recount what steps would need to go bad in order to go further than the first 1 minute portion of the neonatal resuscitation algorithm
First 3 questions after birth:
1) Term?
2) Tone?
3) Breathing or Crying?
*If anything but definitive “yes,” you STIMULATE + do “routine care” of warm & dry, position airway, clear secretions
2nd set of two questions to see if stimulation was enough:
1) Apnea or Gasping?
2) HR < 100?
*If either is a “yes,” then the main action point is PPV, along with SpO2 monitoring and a consideration for ECG monitoring.
*If both are “no,” then you assess whether the breathing is LABORED or PERSISTENT CYANOSIS is present (so not full blown apnea or gasping, but still not a great respiratory status). If yes labored breathing or persistent cyanosis, then the main action point is AS NEEDED CPAP (PPV) and SUPPLEMENTAL O2, as well as SpO2 monitoring and re-clearing and positioning airway (would have already done in previous step)
You move past the 1 minute mark by RE-ASKING if HR < 100 bpm!
After all the things you might do in the FIRST MINUTE, which could include nothing but routine care, stimulation, AS NEEDED supplemental O2 and CPAP, or MANDATORY PPV, and SpO2 +- EKG monitoring, WHAT QUESTION bridges you to the next part of the algorithm?
HR < 100 bpm??
It’s now been 1 min and you’ve had a bad baby up until this point such that you’re already giving PPV. Now your HR < 100 bpm still. What do you do?
- ETT or LMA AS NEEDED is the big action step here
- Check Chest movement
- Ventilation Corrective Steps as needed
It’s post-1st minute, your HR is < 100 despite going so far as intubating or placing LMA. What’s the next question?
Is HR < 60 bpm?
Notes on APGAR score
Note, the entire 5 components to the APGAR score aren’t quite considered all at once during the Neonatal resuscitation algorithm. However, it IS encountered piece-meal at the important branching points of the algorithm, and it’s talked about a lot in questions and stuff. The Apgar score can also provide a basis for the uniform assessment of the condition of an infant at specific time periods after birth. It provides a common basis for communication between care providers and may serve as an index of successful adaptation of the fetus to the newborn state. The Apgar score successfully provides a comfortable structure upon which there are established indications for resuscitation and indices for the assessment of the efficiency of resuscitation. The Apgar score has proved to be helpful in identifying the neonatal effects of drugs used during labor, obstetrical interventions, intrauterine asphyxia, and changes in the maternal environment.
As a descriptor of the clinical condition at specific time intervals, the Apgar score is a great success. The score is not a successful predictor of long-term outcome. Apgar scores should not be used to “predict” outcomes or direct termination of care. Lower Apgar scores are simply “correlated” with worse outcomes.
