NRP Flashcards
what are the 5 tests for high risk baby determination?
- US
- Non-stress test
- contraction stress test
- Biophysical profile
- amniocentesis
what is a non-stress test?
fetal US that evaluates the baby’s breathing, body movements, muscle tone and amniotic fluid.
what is a contraction stress test?
How the baby’s HR reacts when the mom’s uterurs contracts
what is a biophysical profile?
Non stress test + contraction stress test
what is amniocentesis?
Takes a sample of the amniotic fluid to screen for developmental abnormalities.
what are the three phases of labour
Latent, Active, Deceleration
LAD
What are two ways to monitor the fetus during L&D?
Fetal heart rate monitoring (FHR) and Fetal scalp blood sampling
What is fetal heart rate monitoring?
Measures the fetus HR and provides trends estimating a fetus’s tolerance to the labour process.
What are accelerations in FHR associated with?
Fetal movement which is a sign of well being
What do early decelerations in FHR mean?
These are benign and represent head compression or changes in baby tone after a brief hypoxic episode.
What do variable decelerations in FHR mean?
These are the most common, and they mean umbilical cord compression
What do late decelerations in FHR mean?
These mean uteroplacento insufficiency (UPI) and if recurrent, this can mean fetal compromise
What is fetal scalp blood sampling
Used during labour when FHR monitoring is non reassuring to determine fetal acid-base status.
Fetal scalp pH >7.25 is reassuring.
Acidotic (pH <7.25) is suggestive to intolerance to labor
Whats a newborns FRC?
25-30 ml/kg
Why do infants/children have a lower FRC than adults?
- Larger heart in comparison to thoracic diameter, imposing the lungs, decreasing lung capacity
- elastic recoil of a child’s lung is less than adult (children have very compliant lungs).
- Increased extra thoracic pressure from proportionally large abdominal contents
How many weeks old is a baby that requires plastic wrapping?
<32 weeks.
4 pre-birth questions
- what is the expected gestational age
- is the amniotic fluid clear
- how many baby
- are there additional risk factors?
What is the benefit of delayed cord clamping for preterm newborns?
Decreased mortality, higher blood pressure and volume.
Decrease need for blood transfusion.
Lower incidence /risk of brain hemorrhage.
Lower risk of necrotizing enterocolitis
What is the benefit of delayed cord clamping in term newborns?
Decreases changes of developing iron-deficiency anemia.
May improve neurodevelopment clamping
what are the three questions for rapid assessment of newborns?
- does the baby appear to be term? - If preterm, bring to warmer
- does the baby have good muscle tone? - is the baby active with flexed extremities vs flaccid, extended extremities.
- is the baby breathing or crying? - crying is an indicator of strong respiratory effort. Gasping is not
CHAT
Answered yes to all Q’s - baby can go to mom
Baby is not vigorous and is preterm, what are your next steps?
Provide warmth Position head and neck. Clear secretions (mouth b4 nose) Dry - wet skin increases evaporation heat loss. Stimulate .
What suction pressure do you use for nares/mouth?
80-100 mmHg
Baby is apneic, gasping and HR <100 bpm, what do you do?
Start PPV (1 and 2 and 3 and breathe), put SpO2 monitor on and ECG hooked up.
Baby is having laboured breathing (grunting), what do you do?
Position a/w.
SpO2 monitor on.
CPAP!
Baby has persistent cyanosis, what do you do?
Position a/w.
SpO2 monitor on.
Supplemental O2
What is central cyanosis?
Lips, tongue, torso have blue hue.
What is acrocyanosis?
Hands and feet are blue but trunk is pink.
Why the right hand or wrist for pulse oximetry placement?
This will provide the pre ductal oximetry reading (b4 the ductus arterioles) and a more reliable reading of the blood sats that reach the brain and heart!
Postductal (i.e. left arm or legs) receives blood from the aorta after if mixes with venous blood from the ductus arteriosus.
What does APGAR stand for?
Appearance Pulse Grimace Activity Respirations
When are APGAR scores assigned?
a 1 minute, 5 minutes and repeated every 5 minutes until an APGAR of 7 is achieved.
What is primary apnea?
Stimulation results in resumption of breathing
What is secondary apnea
no amount of stimulation will restart breathing.
PPV is needed
What are the advantages of self-inflating bags?
- does not need compressed gas source
- fills spontaneously with fresh gas after being squeezed
- pop-off valve present
what’s the function of the pop off valve on the self inflating bag and at what pressure does it release?
Limits the peak inspiratory pressures and prevents barotrauma and overinflation. 30-40 cmH2O
What are the disadvantages of self-inflating bags?
- challenging to determine good seal
- reservoir attachment required if need to deliver 100% O2.
- requires PEEP valve
what are the advantages of flow inflating bags?
- easier to assess seal of mask
- ability to “feel” the patient’s compliance
- ability to provide free flow O2.
- ability to provide reliable FIO2 (because it’s coming from a direct gas source)
What are the disadvantages of flow-inflating bags?
- requires access to compressed gas source
- requires a tight seal
- does not have a pop off valve (but has the max insp pressure control valve)
- requires flow between 5-10 lpm to aide with inflating the bag in-between breaths delivered.
What are the advantages of a t-piece resuscitator?
- mechanical device designed to deliver manual breaths at set flow
- provides consistent PIPs
- provides consistent PEEP
- reliable FiO2
What are the disadvantages of T-piece resuscitators?
- having to preset PIP and PEEP prior to use
- challenge to change PIP and PEEP during active resuscitation
- need a gas source to operate.
What are the indications of PPV for newborns?
Apnea
Gasping
HR < 100 bpm
O2 saturation below target range
What FiO2 do you start at when delivering PPV?
0.21
Increase to 0.30 if < 35 weeks GA
what rate should you deliver breaths at?
40-60 breaths per min.
Breathe, two, three, breathe, two, three
What PIP and PEEP should you use?
PIP 20-25 cmH2O
PEEP 5cmH2O
*look for adequate chest rise and fall
You are providing PPV but there is not chest rise, what do you do?
MR SOPA
What does MR SOPA stand for?
Mask adjustment Reposition a/w *try PPV and reassess chest movement* Suction mouth and nose Open mouth and lift jaw forward *try PPV and reassess chest movement* Pressure increase - by 5-10 cmH2O increments. Max of 40 cmH2O. *try PPV and reassess chest movement* Alternate a/w *try PPV and reassess chest movement*
When do you use CPAP?
If baby is spontaneously breathing with a HR > 100 bpm but still showing laboured breathing or low O2 saturation despite free flow O2.
What devices can deliver CPAP?
Flow inflating and T-piece.
How does CPAP help the baby?
It reduces the WOB and optimizes FRC by recruiting alveoli, improving oxygenation.
useful for preterm babies who are deficient in surfactant.
What is one thing you should consider adding when providing PPV or CPAP for several minutes?
OG tube because of gastric insufflation.
Use the OG tube to aspirate any air that enters the stomach, because if you don’t then this can reduce lung volumes.
Why is the ETT uncuffed?
the cricoid cartilage is the narrowest portion of the airway in neonates, so having it cuffed poses submucosal damage to this area that can lead to subglottic stenosis.
No cuff also allows us to use the largest tube possible
What size tube should a <28 week, <1000 gram baby have?
2.5 cm
What size ETT should a 28-34 week, 1000-2000 gram baby have?
3.0 cm
what size ETT should a 24-38 week, 2000-3000 gram baby have?
3.5 cm
What size ETT should a >38 weeks, >3000 gram baby have?
3.5-4.0 cm
What are the two ways to determine ETT insertion depth?
- NTL = distance from nasal septum to ear tragus. NTL + 1 cm.
- Based on gestational age (pg 135)
How do you determine ETT size in peadiatrics (>1 yoa)?
ETT size = (age/4) + 4 for uncuffed tube (croup and neonates), (age/4) + 3.5 for cuffed tube (peds)
ETT depth = ID x 3 (for a tube >3)
How should you confirm ETT placement?
- visualize it go through cords.
- Auscultate for bilateral a/e
- Look for bilateral chest rise
- CO2 detector
- CXR
What are the two types of CO2 detectors?
- Easy cap - changes colour in the presence of CO2. Give you a QUALITATIVE measurement. GOLD YOU’RE GOLDEN.
- Emma - portable end tidal that gives you QUANTITATIVE measurement with a wave form
What are the false negative for Easy cap?
So the tube is in the trachea, but no colour change.
- Inadequate ventilatory pressures
- Collapsed lung
- Low HR or CO
what are the false positives for Each Cap?
Tube is not in the trachea but you have colour change.
- defective device changed colour in package before you
- Epinephrine contamination
where should the ETT be on CXR?
T2-T3 (as per Jonathan paediatric a/w lecture)
1-2 cm above the carina
Where is the carina on CXR?
T3-T4
What does DOPE stand for?
A mnemonic that can help you remember potential problems that can occur if a baby’s condition worsens.
Displaced ETT.
Obstructed ETT (blood, secretions, meconium)
Pneumo
Equipment failure
What should the suction pressure be set at for infants? For children?
Infants = 80-100 mmHg Children = 80-120 mmHg
What size suction catheter would a 2.5 ETT need?
5F or 6F
What size suction catheter would a 3 ETT need?
6F or 8F
What size suction catheter would a 3.5 ETT need?
8F
When do you start chest compressions?
If HR <60 bpm after at least 30 seconds of effective PPV.
Turn FiO2 to 100%.
3:1 (compressions:breaths) - 90 compressions and 30 breaths per minute
When do you give medications during NRP?
when HR is still <60 bpm after at least 30 seconds of effective PPV AND another 60 seconds of compressions on 100% O2.
When do you use volume expanders?
when newborn is showing signs of shock (from fetal trauma, cord disruption, severe cord compression
What concentration of Epinephrine?
1:10,000 (0.1 mg/mL)
What are the effects of Epi?
Has both cardiac and vascular effects - vasoconstriction to increase BF into coronary arteries, as well as inotropic and chronotropic.
What are the doses for Epi via IV and OETT?
IV = 0.1 to 0.3 mL/kg OETT = 0.5 to 1 ml/kg
Why is IV preferred over endotracheal administration of Epinephrine?
Umbilical venous catheter or interosseous needles ensures entry into the central venous system quickly and uses a lower range of dosage.
*peripheral IV is not recommended because it will not get to the heart in enough time.
When would you administer Epi via OETT?
While the umbilical venous catheter is being stabilized .
Should be followed by a saline flush of 0.5-1 mL and PPV to promote optimal distribution.
T/F: compressions don’t need to stop with OETT administration of Epi?
F - they do need to stop due to the change in thoracic pressure during compression as this may hinder Epi administrations. Provide 6 breaths before compressions can start again.
Compressions do not have to stop with IV.
What is the dose for volume expanders?
10 ml/kg normal saline via umbilical venous catheter or IO and delivered at a steady infusion over 5-10 min.
Why is delivering volume expanders too quickly dangerous for the baby?
Places the baby at risk of intracranial hemorrhage.
List 4 reasons why preterm babies present with higher risk and much more vulnerable complications after birth.
Primarily due to their anatomic and physiologic immaturity.
- thin skin with decreased subcutaneous fat –> prone to rapid heat loss.
- Immature lungs requiring artificial support
- Immature immune system –> vulnerable to infection
- Immature blood vessels –> high risk for cranial bleeds –> avoid excessive PPV pressures and avoid rapid administration of fluid and infusions.
What is the make-up of surfactant
- 90% phospholipid, 10% protein.
- primarily phospholipid
What is the primary phospholipid in surfactant?
Dipalmitoylphosphatidychoine (DPPC); aka lecithin.
Other phospholipid = sphingomyelin
what is the function of surfactant?
To reduce surface tension of the alveolar fluid so that lung can inflate easier.
what cells produce surfactant?
Type II pneumocytes
What is SRT?
Surfactant replacement therapy.
It involves the instillation of artificially derived surfactant directly into the lungs to improve lung compliance, FRC and VT
What is the dose of surfactant?
5ml/kg - 2x for BLES
2.5 ml/kg - 1x for Curoserf
T/F - suction right after administering surfactant
False! - avoid suctioning after SRT for at least 1 hr (unless absolutely necessary).
What does LISA stand for?
What is it?
Less invasive surfactant administration.
Uses a feeding tube to deliver BLES (aka SRT).
Do not have to intubate baby.
What is used to help diagnose a pneumo?
Transillumination - light shined on the side where the pneumo is suspected.
If the pneumo is there, the light will spread further and be brighter.
CXR for definitive diagnosis.
What is Robin Sequence?
How should you position baby?
How would you intubate baby?
When the mandible is small in relation to the upper jaw, therefore the tongue is pushed back and prone to obstructing airway.
Position baby in prone position.
Nasal intubation over oral.
What is choanal atresia?
when the nasal a/w is obstructed by bone or tissue.
Use a modified pacifier (McGovern Nipple) to temporarily alleviate the obstruction.
What is CDH?
Congenital Diaphragmatic hernia.
Occurs when the diaphragm does not form appropriately and abdominal contents enter the chest.
Baby will present with an unusually flat abdomen, respiratory distress and hypoxia.
T/F - CHD babies should not receive BVM
TRUE! Prolonged BVM can lead to gastric insufflation with it can worsen this condition!
Immediately intubate and place OG tube to aspirate any air in stomach.
What is pulmonary hypoplasia?
Lungs are incompletely developed from oligohydraminos, CDH or obstruction/absence of both fetal kidneys.
Baby can have deformities of the hands, feet, nose and ears.
High inflating pressures are required but places them at rick for pneumo.
When should you discontinue resuscitation efforts?
When HR remains undetectable for 10 mins.
