3. INTRODUCTION Transition from fetal to neonatal life
Before birth, the placenta, not the lungs, is responsible
for providing oxygen and removing carbon dioxide in the
fetus. Fetal lungs are fluid filled. Blood flow through the
fetal lungs is much less than after birth due to
constriction of the arterioles in the lungs.
Major physiological changes occur in the first few
minutes after birth. Regular breathing is established
within 45 seconds. fetal lung fluid is reabsorbed. The
process of labour, which results in a surge in
endogenous steroids and catecholamines, helps to
clear the lungs of fluid. Babies who have poor
respiratory effort or who are apnoeic at birth may not
clear the lung fluid effectively.
4. .
After birth, the blood flow through the lungs increases
from less than 10% to 50% of the biventricular output and
good oxygenation is established.
Key:
RA Right Atrium
MPA Main pulmonary artery
LV Left Ventricle
Ao Aorta
LA Left Atrium
FO Foramen Ovale
IVC Inferior Vena Cava
DV Ductus Venosus
SVC Superior Vena Cava
RV Right Ventricle
PDA Patent Ductus Arteriosus
6. •Definitions:
•Newborn: from birth and while still in delivery room
•Neonate: baby up to 28 days
•Infant: baby from 29 days to 1 year (12 months
7. Check if all equipments are in working order
1.Ensure completeness of the resuscitation trolley
•Bag-valve-mask (BVM)
•Ensure working suction machine!
•Laryngoscope
•ET tubes (sizes 3.5 – 4)
9. 9
3. Prevent heat loss
•Put in radiant warmer
•Towel dry
•Put on dry towel and also cover in dry towel
10. The key to successful neonatal
resuscitation is establishing
adequate ventilation. The majority
of babies can be successfully
resuscitated with bag and mask
ventilation alone, without the need
for intubation or cardiac massage.
11. Scenario 1
A mother arrived at your maternity hospital and
delivered a baby girl as soon as she reached the
labor ward. The placenta followed the baby and
mother was not bleeding.
The baby was pale. He was breathing and heart
rate was 120/min.
What is the Action?
11
14. Message 1
ONLY Routine care is required for a baby who
is crying or breathing normally;
Even routine suctioning is not required for
these normal babies
14
15. Scenario 2
A baby girl is born at your clinic after second stage of 60
minutes. The umbilical cord is short.
You see that the skin is pale .She is not breathing. Heart
rate is over 100/min.
What is the Action?
15
16. Steps of resuscitation
If the baby is not breathing or gasping
Call for help!
Cut cord quickly, transfer to a firm, warm
surface [under a radiant heater]
Inform the mother that baby has difficulty
breathing and you will help the baby to
breathe ( if NVD)
Start newborn resuscitation
16
17. 4. Establish airway (patency)
•Neutral (sniff) position
•Wipe secretions with gauze swab
•Suction secretions (mouth first, then nose)
–Suction pressure ≤ 100mmHg
–Tube length ≤ 5cm
•At this time, usually newborn starts breathing
spontaneously
25. Use the CORRECT size face
mask that covers:
The nose
The mouth
The tip of the chin
but not the eyes
Ventilate
25
26. Fitting a face mask:
A face mask that is too LARGE
Covers the eyes
Extends over the tip of the chin
A face mask that is too SMALL
Does not cover the nose
Does not cover the mouth effectively
Steps of resuscitation
26
27. Squeeze bag with 2 fingers or whole hand,
2-3 times
Observe for rise of chest
IF CHEST IS NOT RISING:
Check seal
Reposition the head
Squeeze harder
Once good seal and chest rising, ventilate
at 40 squeezes per minute
Observe chest rise
Check heart rate after 30 seconds
Steps of resuscitation
Ventilate
27
28. Common mistakes during bag and mask
ventilation
Pushing heavily downwards on the facemask may flex the
baby’s head resulting in closure of the airway. Hold the
facemask firmly on the baby’s face with the thumb and
index finger. Place the middle finger under the baby’s chin
to keep the head in the correct position (EC clamp
technique). Do not press down on the trachea. (Too
Flexed!)
Do not squeeze the bag completely empty. The baby has a
relatively small lung volume and there is a danger of over
expanding the lungs, which can result in a
pneumothorax. (Too Forceful!)
Do not ventilate too fast, as this may cause over distension
of the lungs and does not allow enough time for
expiration. (Too Fast!)
A poor seal either from an inappropriately sized mask, or
bad technique when applying the mask and thereby
resulting in an air leak. (Too Flimsy!)
29. Why am I not managing to ventilate the baby
adequately?
The following points should be checked if the baby is not
responding to bag and mask ventilation:
Make sure that there is an adequate seal between the
facemask and the baby’s face. You can reposition the
baby’s head and apply the facemask again. Remember to
use the ‘EC’ clamp technique of applying the mask to
the face, which will be demonstrated to you on the course.
Make sure that the bag is delivering an adequate
amount of pressure – there may be tears in the bag
itself.
Check that the baby’s airway is clear and that the
head is in the correct position. You may need to
reposition the baby’s head and suction the airway again. It
may help to ventilate the baby with its mouth open. Oral
airways are not often used in neonatal resuscitation.
30. Check that the oxygen supply has not run
out. Make sure that the flow is set at greater
than 5 litres per minute, that the tubing and
connections are working properly and that the
reservoir bag is filling properly. In this case, the
baby’s chest will move with ventilation, but
oxygenation is impaired.
Prolonged bagging (>10 minutes) causes
the stomach to fill with air and prevents
good movement of the diaphragm. A
nasogastric tube should be passed to remove
the air from the baby’s stomach.
The baby may have developed
a pneumothorax. If so, an intercostal drain
needs to be inserted.
32. Chest compression
If the heart is severely affected and the heart rate and
cardiac output do not improve with bag and mask
ventilation, start chest compressions.
Technique
The resuscitator stands to the right side of the baby.
The baby must lie on a flat firm surface. You can feel
the baby’s pulse at the base of the umbilical cord or
you can listen to the baby’s heart with a stethoscope.
Chest compressions are started if the baby’s heart
rate has not improved to more than 60 beats per
minute after 30 seconds of bag and mask ventilation
with supplementary oxygen. Ventilation is the most
effective action in neonatal resuscitation and chest
compressions may interfere with ventilation, so
always make sure that you are ventilating the baby
properly before starting chest compressions. .
33. There are two ways of doing chest compressions
“Hand encircling” technique: Encircle the baby’s
chest with both hands and use both thumbs held at 90
degrees to the baby’s chest. This is the preferred
method as better cardiac output can be achieved.
“Two finger” technique: Using the second and
third fingers held at 90 degrees to the baby’s chest.
This method should be used if an umbilical catheter
needs to be inserted or the resuscitator is on his/her
own.
The Rule of Three: (i) Chest compressions are given to
the lower third of the baby’s sternum, just below the
inter-nipple line. (ii) Compress the chest to 1/3 the
depth of the baby’s chest. A palpable pulse should be
produced
34. . Deliver chest compressions smoothly. Allow
the chest to expand fully between
compressions, but do not remove your
thumbs from the chest. Allow a slightly longer
relaxation time compared to the compression
time when bagging the baby, as this may
improve blood flow in the baby. (iii) Give three
compressions followed by one breath during
a two second cycle (ratio 3:1). This gives an
effective heart rate of 90 beats per minute
and breath rate of 30 per minute.
Compressions are timed together with bag
and mask ventilation. Stop chest
compressions once the baby’s heart rate has
improved to >60 beats per minute.
35. 7. Chest compression (3:1)
•‘Two finger’ technique or ‘two thumb-
encircling hands’ technique
•Just below inter-nipple line in lower 1/3 of the
sternum
•Assess after 30sec for:
–heart rate > 100 beats/min
–centrally pinkness
–spontaneous breathing
36.
37. 8. Drugs ( if need)
•Naloxone: 0.1mg/kg imi or ivi stat
•Adrenalin 0.01mg/kg ivi/ET/imi stat,
repeat every 3-5min until response.
•Naloxone ampule = 400μg/ml
(0.4mg/ml)
38. 1. Hypovolemia (Look For Signs Of
Fluid/Blood Loss. Give Fluid Blolus
And Reassess)
2. Hypoxia (Confirm Chest Rise And
Bilateral Breath Sounds With
Ventilation, Check O2 Source)
3. Hydrogen Ion Acidosis
(Respiratory Acidosis; Provide
Adequate Ventilation But Do Not
Hyperventilate, Metabolic
Acidosis; Give Sodium Bicarb)
4. Hyper/Hypokalemia (For Hyper
Give Calcium Chloride 10 Ml Of
10% Over 5 Minutes, For Hypo
Give Potassium Or Magnesium
5ml Of 50% Solution)
5. Hyper/Hypothermia
6. Hypo/Hyperglycemia (Check
Glucose With Accu-check)
1. Tablets (Drug OD); Find Antidote
Or Reverse Drug, Poison Control.
Always Ask The Family For
Metabolic Or Toxic Causes
During Resuscitation
2. Tamponade (Look For Chest
Trauma, Malignancy, Central
Line Insertion, JVD)
3. Tension Pneumothorax-
Decreased BS, Deviated
Trachea, High Peak Pressures Or
Difficult To Bag, Chest Tube With
Needle Decompression OVER
THE THIRD RIB AT THE
MIDCLAVICULAR LINE
4. Thrombosis- Give Thrombolytics
For Suspected Embolus
5. Trauma- Inspect Body
Completely, Remove Clothing,
Secure Airway, Control Bleeding
And Give Volume With Isotonic
Crystalloids And Blood Products
9. Consider of 6 H’s AND 5 T’s
40. Scenario 4
Mother admitted in maternity unit delivered
a baby boy at 32 week gestation on
bed. The baby is limp and not
breathing.
The baby is pale. He is not breathing and HR is 80/min.
What is the Action?
40
41. Be gentle
Use small size resuscitation bag and give small tidal volumes
to move chest
Avoid 100% oxygen , use blenders and oxygen saturation
monitors
Avoid rapid fluid bolus
May need intubation, chest compression, medications
Keep CPAP back up ready
Steps of resuscitation
Special considerations for preterm
41
42. Message 4
Preterm births need special precautions before and during
resuscitation
The lungs of preterm infants are easily damaged by large
volume inflations so do not use too much pressure when
bagging a preterm infant – this can be assessed by excessive
chest wall movement. Make sure that there is a tight seal
around the mask and no obstruction to the airway before
increasing the pressure. The use of positive end expiratory
pressure (PEEP) ventilation is recommended in the
resuscitation of preterm infants. The use of continuous
positive airway pressure (CPAP) may be useful after
resuscitating a preterm infant.
42
43. Post resuscitation
management
Principles
1. Keeping normal temperature
2. Maintaining oxygenation
3. Maintaining physiological milieu- fluids , glucose
4. Maintaining perfusion
5. Treating seizures
6. Monitoring organ function
43
44. Care after resuscitation
Place baby in skin-to-skin contact with mother
Keep the baby warm
Monitor every 15 minutes
Start breastfeeding as soon as possible
Discuss what has happened with the parents - be positive!
Do not separate the mother and baby unless the baby has
difficult breathing
44
45. Discontinuing resuscitation
The decision to stop efforts at resuscitating a baby is
complex and emotionally difficult.
Always ensure that resuscitation efforts are effective
before considering withdrawal of support. It is
appropriate to consider discontinuing resuscitation
after 10 minutes of Asystole (no heart rate), as this baby
is extremely unlikely to survive. Do not rely on a single
feedback device, e.g. pulse oximeter, to diagnose
asystole. The decision to continue resuscitation beyond
10 minutes of no heart beat is complex and may be
influenced by many factors such as the presumed cause
of the arrest, the gestation of the baby and the presence
or absence of complications.
Prolonged resuscitation of an infant with a heartbeat but
no spontaneous respiratory effort, or an Apgar score of
1 to 3 at 20 minutes, is not indicated. In circumstances
of limited resources, these infants would generally not
be ventilated in NICU and resuscitation should be
discontinued.
46.
47.
48. *** When a patient
experiences a respiratory
arrest, cardiac arrest or
obstructed airway, you
need to act swiftly and
promptly starting with
basic life support skills.***
2.
Pediatric Basic Life Support
49. Basic Life Support, in general, involves a
systematic approach to:
-Initial patient assessment
-Activation of emergency medical services
-Initiation of cardiopulmonary resuscitation
(CPR), including defibrillation
Pediatric Basic Life Support
50.
51.
52.
53. Key Actions in Pediatric BLS
1. Verify scene safety
2. Determine unresponsiveness,
get help, and activate
emergency medical services
(EMS)
3. Assess breathing and brachial
pulse
4. Initiate cardiopulmonary
resuscitation (CPR)
Pedia BLS ---rbt2016---
54. 1. Verify Scene Safety
- Ensure that the scene is safe for the rescuers and the
victim
- e.g. removing the victim from a burning building or
safely retrieving a drowning victim
Pedia BLS ---rbt2016---
55. 2. Determine unresponsiveness, get help, and activate
emergency medical services (EMS)
-If victim is unresponsive, single rescuer should shout for
nearby help and activate emergency medical
response system
-For two or more rescuers, one rescuer continues care
for the victim and a second rescuer activates EMS and
retrieves automated external defibrillator (AED)
56. 3. Assess breathing and
pulse
- Rescuer should
determine if the victim is
breathing or only gasping
while simultaneously
checking for a pulse
within 10 seconds
57. 3.1 No breathing or only gasping and no definite pulse after 10
seconds (SINGLE RESCUER)
-IF THIS IS NOT A WITNESSED SUDDEN COLLAPSE THEN THE RESCUER
SHOULD START CARDIOPULMONARY RESUSCITATION
(COMPRESSIONS-AIRWAY-BREATHING, C-A-B) WITH A RATIO OF 30
COMPRESSIONS TO 2 BREATHS.
-IF THIS IS A WITNESSED SUDDEN COLLAPSE, THEN THE RESCUER
SHOULD ACTIVATE EMS (IF NOT ALREADY DONE) AND RETRIEVE AN
AED, AND THEN USE THE AED.
58. 3.1 No breathing or only gasping and no definite
pulse after 10 seconds (TWO OR MORE RESCUERS)
-RESCUERS SHOULD START CPR (COMPRESSIONS-
AIRWAY-BREATHING,
C-A-B), STARTING WITH A RATIO 15
COMPRESSIONS TO 2 BREATHS.
59.
60. 3.2 No normal breathing but pulse is present (same actions
for single or multiple rescuers)
-START RESCUE BREATHING BY PROVIDING 1 BREATH EVERY 3 TO
5 SECONDS (12 TO 20 BREATHS/MIN).
-ADD COMPRESSIONS IF PULSE REMAINS ≤60/MIN WITH POOR
PERFUSION.
-CONTINUE RESCUE BREATHING. CHECK PULSE EVERY 2 MINUTES.
IF NO PULSE, START CPR (COMPRESSIONS-AIRWAY-BREATHING,
C-A-B)
61.
62.
63. 3.3 Normal breathing and pulse are present
(same actions for single or multiple rescuers)
- MONITOR THE VICTIM UNTIL EMERGENCY
RESPONDERS ARRIVE.
64. 4. Initiate cardiopulmonary resuscitation (CPR)
- THE ACTIONS THAT CONSTITUTE CPR ARE PERFORMING
CHEST COMPRESSIONS, OPENING THE AIRWAY, AND
PROVIDING VENTILATIONS (RESCUE BREATHS) OR C-A-B.
66. CPR sequence of actions for infants and children
1. INITIATE CPR IN AN INFANT OR CHILD WHO IS UNRESPONSIVE, HAS
NO NORMAL BREATHING, AND NO DEFINITE PULSE AFTER 10
SECONDS.
2. START COMPRESSIONS BEFORE PERFORMING AIRWAY OR
BREATHING MANEUVERS (C-A-B).
3. AFTER 30 COMPRESSIONS (15 COMPRESSIONS IF TWO RESCUERS),
OPEN THE AIRWAY AND GIVE 2 RESCUE BREATHS.
4. IF THE PULSE IS ≥60 BEATS PER MINUTE (BPM) AFTER ABOUT 2
MINUTES OF CPR, CONTINUE VENTILATION.
5. APPLY THE AED AND PROCEED BASED ON AED ANALYSIS.
67. Chest Compressions
-THE 2015 INTERNATIONAL RESUSCITATION GUIDELINES
CONTINUE TO EMPHASIZE THE IMPORTANCE OF PROPER
TECHNIQUE WHEN PERFORMING CHEST COMPRESSION,
WITH FULL CHEST RECOIL AND MINIMAL INTERRUPTIONS.
-CHEST COMPRESSIONS SHOULD BE PERFORMED OVER
THE LOWER HALF OF THE STERNUM.
-COMPRESSION OF THE XIPHOID PROCESS CAN CAUSE
TRAUMA TO THE LIVER, SPLEEN, OR STOMACH, AND
MUST BE AVOIDED.
68. THE EFFECTIVENESS OF COMPRESSIONS CAN BE MAXIMIZED BY
ATTENTION TO THE FOLLOWING:
●THE CHEST SHOULD BE DEPRESSED AT LEAST ONE-THIRD OF ITS
ANTERIOR-POSTERIOR DIAMETER WITH EACH COMPRESSION:
-APPROXIMATELY 4 CM [1.5 INCHES] IN MOST INFANTS
-5 CM [2 INCHES] IN MOST CHILDREN
-COMPRESSIONS IN ADOLESCENTS SHOULD ATTAIN THE
RECOMMENDED ADULT DEPTH OF 5 TO 6 CM, BUT SHOULD NOT
EXCEED 6 CM (2.4 INCHES).
●THE OPTIMUM RATE OF COMPRESSIONS IS APPROXIMATELY 100
TO 120 PER MINUTE. EACH COMPRESSION AND
DECOMPRESSION PHASE SHOULD BE OF EQUAL DURATION.
69. CHEST COMPRESSIONS FOR INFANTS (YOUNGER THAN
ONE YEAR)
- MAY BE PERFORMED WITH EITHER TWO FINGERS (FOR
SINGLE RESCUER) OR WITH THE TWO THUMB-
ENCIRCLING HANDS (FOR MULTIPLE RESCUERS)
70. Two fingers technique for
infants’ chest compression
- Compressions are
performed with index and
middle fingers, placed on
the sternum just below the
nipples.
Pedia BLS ---rbt2016---
71. Two thumb-encircling hands
technique for infants’ chest
compression
- The thorax is encircled with
both hands and cardiac
compressions are performed
with thumbs which compress
over the lower half of the
sternum, avoiding the xiphoid
process, while the fingers are
spread around the thorax.
72. Two-handed chest
compressions for children
(from one year until the onset
of puberty)
- Compressions should be
performed over the lower
half of the sternum with either
the heel of one hand or with
two hands.
Pedia BLS ---rbt2016---
74. Ventilation must be provided as follow:
-EACH RESCUE BREATH SHOULD BE DELIVERED OVER 1
SECOND.
-THE VOLUME OF EACH BREATH SHOULD BE SUFFICIENT TO
SEE THE CHEST WALL RISE.
-A CHILD WITH A PULSE ≥60 BPM WHO IS NOT BREATHING
SHOULD RECEIVE 1 BREATH EVERY 3 TO 5 SECONDS (12 TO
20 BREATHS PER MINUTE).
-INFANTS AND CHILDREN WHO REQUIRE CHEST
COMPRESSIONS SHOULD RECEIVE 2 BREATHS PER 30 CHEST
COMPRESSIONS FOR A LONE RESCUER AND 2 BREATHS PER
15 CHEST COMPRESSIONS FOR TWO OR MORE RESCUERS
75. Automated External Defibrillator (AED)
– a portable device that is used extensively to provide prompt
defibrillation to victims in cardiac arrest.
Pedia BLS ---rbt2016---
76. Actions based on AED Analysis:
SHOCKABLE RHYTHM – GIVE 1 SHOCK AND RESUME CPR
IMMEDIATELY FOR ABOUT 2 MINUTES OR UNTIL
PROMPTED BY THE AED. CONTINUE UNTIL ADVANCED
LIFE SUPPORT PROVIDERS TAKE OVER OR THE VICTIM
STARTS TO MOVE.
NO SHOCKABLE RHYTHM – RESUME CPR IMMEDIATELY
FOR ABOUT 2 MINUTES OR UNTIL PROMPTED BY THE AED.
CONTINUE UNTIL ADVANCED LIFE SUPPORT PROVIDERS
TAKE OVER OR THE VICTIM STARTS TO MOVE.
77. 1. Hypovolemia (Look For Signs Of
Fluid/Blood Loss. Give Fluid Blolus
And Reassess)
2. Hypoxia (Confirm Chest Rise And
Bilateral Breath Sounds With
Ventilation, Check O2 Source)
3. Hydrogen Ion Acidosis
(Respiratory Acidosis; Provide
Adequate Ventilation But Do Not
Hyperventilate, Metabolic
Acidosis; Give Sodium Bicarb)
4. Hyper/Hypokalemia (For Hyper
Give Calcium Chloride 10 Ml Of
10% Over 5 Minutes, For Hypo
Give Potassium Or Magnesium
5ml Of 50% Solution)
5. Hyper/Hypothermia
6. Hypo/Hyperglycemia (Check
Glucose With Accu-check)
1. Tablets (Drug OD); Find Antidote
Or Reverse Drug, Poison Control.
Always Ask The Family For
Metabolic Or Toxic Causes
During Resuscitation
2. Tamponade (Look For Chest
Trauma, Malignancy, Central
Line Insertion, JVD)
3. Tension Pneumothorax-
Decreased BS, Deviated
Trachea, High Peak Pressures Or
Difficult To Bag, Chest Tube With
Needle Decompression OVER
THE THIRD RIB AT THE
MIDCLAVICULAR LINE
4. Thrombosis- Give Thrombolytics
For Suspected Embolus
5. Trauma- Inspect Body
Completely, Remove Clothing,
Secure Airway, Control Bleeding
And Give Volume With Isotonic
Crystalloids And Blood Products
Consider of 6 H’s AND 5 T’s
80. References ; south African pediatric association,
prof Daynia ballot
Limpopo initiative for new born care
American heart association 2016
THANK YOU / Ndolivhuwa
