Resuscitation Of Neonates Flashcards
Evaluate the newborn at 1 and 5 minutes after delivery
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)
Do not clamp the umbilical cord of newborns (term or preterm) who
do not require positive-pressure ventilation or immediate resuscitation for
least 1 to 3 minutes after birth.
If there appears to be obstruction from amniotic fluid, gently suction the nose and throat with
bulb or 8F catheter.
Targeted Pulse Oxygen Levels During Newborn Resuscitation
1 min - 60- 65% 2 min - 65-70% 3 min - 70-75% 4min 75-80% 5 min 80-85% 10 min 85-90%
for infants with a heart rate of <100 beats/min or who are gasping or remain apneic after the initial steps of newborn resuscitation
Initiate positive-pressure ventilation using a bag and mask
Apnea, gasping, or HR <100 beats/min
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.
HR <60 beats/min
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
HR <60 beats/min after appropriate ventilation and CPR
Administer epinephrine
Consider volume expansion if blood loss;
treat hypoglycemia
May be given IO, IV, or through a UV or ETT.
potential indications for endotracheal intubation in the newborn
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)
Deliver chest compressions and ventilations in a ratio of
three chest compressions to one breath for a total of 90 compressions and 30 breaths/min
The dose of epinephrine
- 01 to 0.03 milligram/kg IV/IO
- 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
Consider inducing h thermia
33.5°C (92.3°F) for term (36 weeks or greater) neonates requiring extensive resuscitative care
most readily available site for venous access in the newborn
umbilical vein
not viable
<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%
justified to cease resuscitative efforts
10 minutes and, certainly, after 15 minutes of asystole.
preductal (e.g., right radial)
postductal (e.g., lower extremity)
postductal PaO 2is s cantly lower than the preductal PaO2
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
coarctation of the aorta
hyperoxia test
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
Treatment
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
after initial examination and testing, cyanotic heart disease cannot be ruled out
prostaglandin E 1starting at 0.05 microgram/kg/min, and titrate to the lowest effective dose
Steps to Evaluate and Treat Neonatal Central Cyanosis
- 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.
Pneumothorax
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
Confirmation of pneumothorax
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
Pneumothorax treatment
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
Congenital diaphragmatic hernias diagnostic
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
Clinical CONGENITAL DIAPHRAGMATIC HERNIA
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
Treatment for Congenital Diaphragmatic Hernia
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
defect located to the right of the umbilicus fromwhich uncovered intestine is extruded
gastroschisis
large, centrally located defect of the abdominal wall containing stomach, intestine, and, frequently, liver that is covered by the mesentery
omphalocele
Associated defects in gastroschisis / omphalocele
cardiac defects (such as tetralogy of Fallot), syndromes (BeckwithWiedemann), and chromosomal abnormalities (trisomy 13 and trisomy 18)
Treatment omphalocele
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
Treatment for Gastroschisis
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,
five types of tracheoesophageal fistula
(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%)
several other malformations TEF
vertebral anomalies, anal atresia, cardiac anomalies, tracheoesophageal fistula, radial anomaly/renal anomalies, and limb anomalies.
Diagnosis TEF
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.
