Resuscitation Of Neonates

Question 1

Evaluate the newborn at 1 and 5 minutes after delivery

Answer 1

heart rate (absent = 0, <100/min = 1, >100/min = 2),

respiratory effort (absent = 0, weak = 1, crying or normal = 2),

muscle tone (limp = 0; some flexion = 1; active, fully flexed = 2),

reflex irritability (no response = 0, grimace = 1, crying or active = 2),

and color (blue or pale = 0, acrocyanosis = 1, completely pink = 2)

Question 2

Do not clamp the umbilical cord of newborns (term or preterm) who

do not require positive-pressure ventilation or immediate resuscitation for

Answer 2

least 1 to 3 minutes after birth.

Question 3

If there appears to be obstruction from amniotic fluid, gently suction the nose and throat with

Answer 3

bulb or 8F catheter.

Question 4

Targeted Pulse Oxygen Levels During Newborn Resuscitation

Answer 4

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

Question 5

for infants with a heart rate of <100 beats/min or who are gasping or remain apneic after the initial steps of newborn resuscitation

Answer 5

Initiate positive-pressure ventilation using a bag and mask

Question 6

Apnea, gasping, or HR <100 beats/min

Answer 6

PPV

Continue PPV for 30 s, taking corrective steps for ventilation if no improvement in HR

Provide PPV with bag-mask ventilation at a rate of 40–60 breaths/min using room air.

Provide 30 cm H2 O pressure for term infants and 20–25 cm H2 O pressure for preterm infants.

Question 7

HR <60 beats/min

Answer 7

Initiate CPR:
3:1 compression-to-ventilation ratio 90:30 compressions and ventilations per minute

Use thumb-encircling technique to provide chest compressions to lower one third of sternum.

Consider intubation prior to chest compressions

Question 8

HR <60 beats/min after appropriate ventilation and CPR

Answer 8

Administer epinephrine

Consider volume expansion if blood loss;

treat hypoglycemia

May be given IO, IV, or through a UV or ETT.

Question 9

potential indications for endotracheal intubation in the newborn

Answer 9

absence of improvement with bag-mask ventilation,

(1) concomitant need for chest compressions,
(2) administration of endotracheal medications, and
(3) known or suspected congenital diaphragmatic hernia (to avoid inflating stomach/bowel situated in the chest)

Question 10

Deliver chest compressions and ventilations in a ratio of

Answer 10

three chest compressions to one breath for a total of 90 compressions and 30 breaths/min

Question 11

The dose of epinephrine

Answer 11

0. 01 to 0.03 milligram/kg IV/IO
1. 1 to 0.3 mL/kg of 1:10,000 solution

Intratracheal dosing is 0.05 to 0.1 milligram/kg

0.5 to 1 mL/kg of 1:10,000 solution

If bradycardia continues despite bag-mask ventilation followed by endotracheal intubation, adequate ventilation with 100% oxygen, and chest compressions for 45 to 60 seconds, then give epinephrine

Question 12

Consider inducing h thermia

Answer 12

33.5°C (92.3°F) for term (36 weeks or greater) neonates requiring extensive resuscitative care

Question 13

most readily available site for venous access in the newborn

Answer 13

umbilical vein

Question 14

not viable

Answer 14

<22 weeks of gestation and weighing <400 grams

22 weeks of gestation, survival ranges from about 10% to 50%; at

23 weeks of gestation, survival is about 35% to 60%; and at

24 weeks of gestation, survival is about 60% to 80%

Question 15

justified to cease resuscitative efforts

Answer 15

10 minutes and, certainly, after 15 minutes of asystole.

Question 16

preductal (e.g., right radial)

postductal (e.g., lower extremity)

Answer 16

postductal PaO 2is s cantly lower than the preductal PaO2

Question 17

new-onset tachypnea and absent femoral pulses later in the first day of life or into the second day of life. Femoral pulses are palpable at birth but disappear after the ductus arteriosus has closed

Answer 17

coarctation of the aorta

Question 18

hyperoxia test

Answer 18

Place the newborn in a 100% hood for 10 minutes. Cyanotic newborns with a pulmonary disorder can increase their PaO 2 to >100 mm Hg (or oxygen saturation >20% as a proxy). Those with a fixed shunt secondary to congenital cyanotic heart disease or the right-to-left shunting of persistent pulmonary hypertension of the newborn cannot do so

Question 19

Treatment

Answer 19

Provide positive-pressure ventilation

Monitor blood gas and pulse oximetry

Establish vascular access and initiate 10% dextrose in water at 3.3 mL/kg/h (80 mL/kg/24 h) if in the first 24 hours of life

Question 20

after initial examination and testing, cyanotic heart disease cannot be ruled out

Answer 20

prostaglandin E 1starting at 0.05 microgram/kg/min, and titrate to the lowest effective dose

Question 21

Steps to Evaluate and Treat Neonatal Central Cyanosis

Answer 21

• Identify breathing pattern to characterize infant into airway obstruction, cardiac pulmonary, or CNS/metabolic pattern.
• Obtain peripheral oxygen saturation pre- and postductal, check pulses in all 4 extremities, and obtain ABG.
• Perform hyperoxia test. Deliver 100% oxygen for 5–10 min. Congenital cyanotic heart disease cannot increase oxygen saturation >20% or raise PaO 2 to 100 mm Hg.
• Obtain stat chest radiograph to identify pneumothorax, congenital diaphragmatic hernia, or pulmonary infiltrates, and assess cardiac size and shape and pulmonary vasculature for clues to congenital heart disease.
• Establish vascular access in umbilical or peripheral vein, obtain POC glucose, CBC, and metabolic panel. Treat hypoglycemia (glucose <40 milligrams/dL [2.22 mmol/L]) with 10% dextrose in water, 2 mL/kg IV bolus, or 3.3 mL/kg/h.
• Institute continuous positive airway pressure or intubate and ventilate if oxygen saturation does not improve with standard methods for oxygen delivery.
• If oxygenation still does not improve, treat as presumptive congenital cardiac disease with prostaglandin E 1 starting at 0.05 microgram/kg/min and titrate to the minimum effective dose.

Question 22

Pneumothorax

Answer 22

Tachycardia, tachypnea, and retractions

breath sounds are decreased on the side of the pneumothorax.

heart sounds and point of maximum impulse may be displaced in the direction away from the pneumothorax

Transillumination of the chest with a bright light is another method to help rapidly establish pneumothorax

Question 23

Confirmation of pneumothorax

Answer 23

Chest radiograph will confirm the diagnosis

Bedside US can also potentially identify pneumothorax

Transillumination of the chest with a bright light is another method to help rapidly establish pneumothorax

Question 24

Pneumothorax treatment

Answer 24

nontension pneumothorax can be observed

In a term or near-term newborn, the nitrogen washout technique, placing the baby in a 100% oxygen hood for 6 to 12 hours,

This technique is contraindicated in preterm newborns due to concerns of oxygen toxicity to the lungs and retinas

Emergency evacuation of a tension pneumothorax may be performed with an 18- or 20-gauge 1-inch percutaneous catheter.

withdraw the needle, and attach the catheter to a three-way stopcock connected to a 10- or 20-mL syringe

A 10F or 12F chest tube or an 8.5F pigtail catheter can then be placed

Question 25

Congenital diaphragmatic hernias diagnostic

Answer 25

diagnosed prenatally with US, which expedites proper initial newborn resuscitation

posterolaterally through the foramen of Bochdalek or, less commonly, through the retrosternal foramen of Morgagni

Question 26

Clinical CONGENITAL DIAPHRAGMATIC HERNIA

Answer 26

clinical hallmark is persistent respiratory distress at birth, often with a characteristic “seesaw” side-to-side respiratory pattern due to the severely hypoplastic ipsilateral lung

abdomen appears scaphoid

Question 27

Treatment for Congenital Diaphragmatic Hernia

Answer 27

Rapid endotracheal intubation is the treatment of choice for respiratory distress

ventilation with a rate of 40 to 50 breaths/min and lowest peak inspiratory pressures

Gentle hyperventilation to a P CO 2 between 30 and 35 mm Hg may help lower pulmonary vasculature resistance

Place a large-bore (10F) orogastric tube set to low continuous suction to minimize further lung compression from overaerated GI contents

Obtain chest and abdominal radiographs and blood gas analysis to confirm the initial diagnosis and guide stabilization and management

Question 28

defect located to the right of the umbilicus fromwhich uncovered intestine is extruded

Answer 28

gastroschisis

Question 29

large, centrally located defect of the abdominal wall containing stomach, intestine, and, frequently, liver that is covered by the mesentery

Answer 29

omphalocele

Question 30

Associated defects in gastroschisis / omphalocele

Answer 30

cardiac defects (such as tetralogy of Fallot), syndromes (BeckwithWiedemann), and chromosomal abnormalities (trisomy 13 and trisomy 18)

Question 31

Treatment omphalocele

Answer 31

Cover the sac with warmed saline gauze wrapped gently around the baby with Kerlix, and then place an additional cover with plastic wrap to help minimize evaporative losses.

Start IV 10% dextrose in water at 1.5 times maintenance (i.e., 5 to 6 mL/kg/h or 120 to 150 mL/kg/24 h) to compensate for the additional insensible water loss

Question 32

Treatment for Gastroschisis

Answer 32

immediately check for dusky or cyanotic intestine, which indicates reduced flow to the affected bowel due to torsion and vascular occlusion

Gently rotate the bowel to relieve torsion if necessary to prevent bowel infarction

If the intestine appears pink, cover with warmed saline gauze, wrap with Kerlix, and further cover with sterile plastic wrap

Therefore, IV 10% dextrose in water should be started at 6 to 7 mL/kg/h (150 mL/kg/24 h)

Check glucose periodically. Antibiotics, usually ampicillin, 50 to 100 milligrams/kg IV, and gentamicin, 4 to 5 milligrams/kg IV,

Question 33

five types of tracheoesophageal fistula

Answer 33

(1) esophageal atresia with a distal t esophageal fistula (88% of cases),
(2) isolated esophageal atresia without tracheoesophageal fistula (7%),
(3) esophageal atresia with proximal tracheoesophageal fistula (1%),
(4) esophageal atresia with proximal and distal tracheoesophageal fistulas (1%), and
(5) H-type fistula without esophageal atresia (3%)

Question 34

several other malformations TEF

Answer 34

vertebral anomalies, 
anal atresia, 
cardiac anomalies, 
tracheoesophageal fistula, 
radial anomaly/renal anomalies, and limb anomalies.

Question 35

Diagnosis TEF

Answer 35

polyhydramnios is usually noted before or at delivery

No air passage will be heard when a 5-mL air bolus is injected into the nasogastric tube.

chest radiograph with a nasogastric tube in place will demonstrate the esophageal pouch

Treatment

placing the child in head-up (reverse Trendelenburg)

Initially, standard 10% dextrose in water IV fluids are best.