Resuscitation - Neonates Flashcards
APGAR Score
1 and 5 mins post birth
Targeted Pre-ductal O2 at birth
1 min 60-75%
2 min 65-85%
3 min 70-90%
4 min 75-90%
5 min 80-90%
10 min 85-90%
Expected BP
Minimum = 70 + (2 x Age in years)
Median = 90 + (2x Age in years)
Neonatal sepsis
Neonate < 28 days + Fever = rectal temp > 38C
Risk factors for Invasive bacterial infection
* Neonates< 21d
* Prematurity
* Ill appearance
* Chronically ill neonate
* Immunocomp
* CV access devices
* Maternal - fever, chorioamnionitis, GBS colonisation
Pathogens
< 2months: E. coli, GBS, Listeria (uncommon), HSV
Older: N meningitidis, Strep. pneumoniae, Staph, GAS
Mx
1. Early recognition/seeking senior help
2. Assess airway and breathing and administer oxygen if required
3. Rapid vascular access
4. Empiric antibiotic therapy - cefotaxime + ampicillin
5. Carefully titrated fluid resuscitation
6. Early initiation of inotropes
7. Early involvement of critical care services
8. Source control
9. Frequent reassessment
Umbilical cord pathologies
Funisitis
- umbilical stump with malodorous d/c
Omphalitis
- abdominal wall cellulitis + peri-umbilical erythema
Omphalitis + sepsis
Omphalitis + fasciitis
- umbilical necrosis + extensive peri-umbilical ecchymosis, crepitus bullae, sup and deep fascia involved
ORGS
MSSA or MRSA
E. coli, Klebsiella, Proteus
Anaerobic - bacteroides fragilis, clost perfringens or tetani
ABx
Flucloxacillin MSSA or Vanc for MRSA
Gentamicin 5-7.5mg/kg
Complications
Nec fasciitis
Sepsis
PV thrombosis
Hepatic abscess
Indications for PPV during resuscitation
- Apnoea for 30seconds
- Gasping breaths
- breaths at a rate of only 6–12 /min.
- involve all accessory muscles in a maximal inspiratory effort
- may persist for up to 20 minutes in a neonate even with severe hypoxia
* Heart rate < 100/min after 30s of stimulation
-improvement in heart rate is the primary marker of response to ventilation
Apnoea
- Apnoea: Absence of breathing for a period of >15 s often associated with a** bradycardia and/or desaturation**
- Neonate: A newborn, up to 28 days of age (post-term)
- Periodic breathing: >/3 periods with no respiratory effort lasting >3s in a 20 second period. This is a normal neonatal breathing pattern and does not involve changes in heart rate or colour.
Classification
1. Central apnoea:(40%) decreased CNS stimuli to respiratory muscles.
2. Obstructive apnoea:(10%) Caused by pharyngeal instability / collapse, neck flexion or nasal obstruction.
3. Mixed apnoea:(50%) Central apnoea is either preceded (usually) or followed by obstructed respiratory effort
Causes
1. Prematurity - most common
2. Airway Obstruction - intrinsic/extrinsic masses, upper airway collapse
3. CVS - anaemia, PDA, Cong heart disease, hypovolaemia
4. CNS - ICH, HIE, NMD, Brainstem infarct, ICH
5. Drugs - sedatives, maternal drugs
6. GI - dec PO feeding, GORD, Perforation
7. Infections - sepsis, NEC, Meningitis
8. Metabolic - hypoglycaemia, hypo Ca/Na, hypothermia,
9. Pain
10. Resp - pneumonia, hypoxia, aspiration, pulm haemorrhage
Management
1. Resus, monitoring
2. Seek and treat underlying cause
3. Stimulate
4. Airway positioning
5. Suction
6. O2 / BVM / NIV / ETT as neded
7. Consider caffeine
8. PICU referral
Neonatal resus algorithm
Sick neonate
Sepsis Antibiotics
NEONATES - all TDS
Cefotaxime 50mg/kg IV
Benpen 60-90mg/kg IV
Aciclovir20mg/kg IV
1-2mo
Cefotaxime 50mg/kg IV QID
Ampicillin 50mg/kg IV QID
Aciclovir 20mg/kg IV TDS
> 2mo
Gentamicin 7.5mg/kg
Ceftriaxone 50mg/kg BD
Acicilovir 10-20mg/kg TDS
Consider Vancomycin 25-30mg IV loading
CAH
1:16,000
Autosomal recessive, gene deletions of 21a hydroxylase enxyme
Deficiency of cortisol + aldosterone
Most cases picked up via newborn screening card
Hx
Poor feeding, vomiting
Wt loss
Lethargy, irritability
Confusion, seizure
Exam
Dehydration
Seizures -> coma
Hyperpigmentation skin creases
Females: ambiguous genitalia
Males: Enlarged penis
Mx
1. Fluid resuscitation 10-20ml/kg 0.9% Saline
2. Seek and treat metabolic distubances
a. Dextrose 10% 2ml/kg
b. Correct hyperkaleamia > 7.0 + ECG changes
i. Calcium gluconate 10% 0.5ml/kg over 3-5mins
ii. Insulin 0.1u/kg
iii. Dextrose 5ml/kg 10% infusion
c. Na correction
d. Hypoglycaemia 10% Dextrose 5ml/kg
3. Rx glucocorticoid deficiency
4. Correct dehyration over 24
5. Antibiotc cover - cefotaxime + ampicillin
6. Endocrine referral
7. Action plan
a. Moderately unwell 3 x steroid dose PO
b. More unwell - 4 x steroid dose PO
c. Vomiting - 2 x steroid dose IM
Examination unwell child
Jaundice
< 24 hr
1. Sepsis
2. Haemolysis
i. Isoimmunisation - ABO or Rh
ii. RBC defects - G6PD, PKD, Hereditary spherocytosis
iii. Haemorrhage - cerbebral, intra-abdominal
iv. Blood extravasation
2d-2weeks
1. Sepsis
2. Physiological
3. Breast milk
4. Dehydration / Poor feeding
5. Birth trauma
Prolonged >2 weeks
1. Unconjugated
a. as above
b. Hypothyrdoism
2. Conjugated
a. Hepatocellular destruction
i. Neonatal hepatitis
ii. Metabolic
iii. Drugs / Parenteral nutrition
b. Biliary obstruction
i. Extra-hepatic - biliary atresia, choledochal cyst
ii. Intra-hepatic - IV nutrition, severe Rh haemolytic disease, CF
iii. Inherited defects Br excretion - Dubin-Johnson Syndrome
Risk factors for neonatal resuscitation
BRUE
Airway: obstruction, inhaled foreign body, laryngospasm, congenital abnormalities, infection
Cardiac: congenital heart disease, vascular ring, arrhythmias, prolonged QT
Abdominal: intussusception, strangulated hernia, testicular torsion
Infection: pertussis, sepsis, pneumonia, meningitis
Metabolic: hypoglycaemia, hypocalcaemia, hypokalaemia, other inborn errors of metabolism
Toxins/Drugs/Ingestions: accidental or non-accidental
NAI
