Neonatal Resuscitation, Dr. Wylie 7/17/14

Neonatal Resuscitation
Todd Wylie, M.D.
Department of Emergency Medicine
University of Florida College of Medicine
Jacksonville

Physiology
• Fetal Circulation
– Placenta
• Low vascular
resistance
– Fetal lungs
• High vascular
resistance
2011 UpToDate, Inc.

Physiology
– Right-to-left
shunts
• Foramen ovale
• Ductus
arteriosus
2011 UpToDate, Inc.

Physiology
– From the
placenta…
• Oxygenated
blood…
• Ductus
venosus into
IVC…
• Right atrium…
• Shunted thru
foramen
ovale…
• Into left atrium
2011 UpToDate, Inc.

Physiology
– From the SVC
and IVC…
• Minimal mixing
with oxygenated
blood…
• Right atrium to
right ventricle…
• Shunted through
ductus
arteriosus…
• Into distal aorta
2011 UpToDate, Inc.

Physiology
• Fetal Oxygenation
– Adequate tissue
oxygenation
secondary to:
• Fetal hemoglobin
• Decreased fetal
oxygen
consumption
• Differential blood
flow
2011 UpToDate, Inc.

Physiology
• Changes at Delivery
– Alveolar fluid
clearance
– Lung expansion
– Circulatory changes
2011 UpToDate, Inc.

Physiology
• Difficulties Transitioning
– Risk factors
• Maternal conditions (advanced age, diabetes,
hypertension, substance abuse)
• Fetal conditions (prematurity, postmaturity,
multiple gestation, anomalies)
• Antepartum problems (oligohydramnios,
polyhydramnios, placental anomalies)
• Delivery (breech, transverse, meconium, maternal
narcotics, difficult delivery)

Physiology
• Difficulties Transitioning
– Lack of respiratory effort
– Blockage of the airways
– Impaired lung function
– Persistent pulmonary hypertension
– Cardiac anomalies

Introduction – Multiparous female to ED with severe
contractions; is preterm (28 weeks); precipitous delivery
of pre-term neonate as put into resuscitation bay.
PMH for mother –G6P6, Normal prenatal visits, estimate
gestational age 28 weeks currently, no other issues.
Exam for mother – Awake, alert, stable, can provide
appropriate history as needed
CASE 1

Initial Description of Neonate –
Placed in warmer; is not breathing
or crying; poor muscle tone;
cyanotic; note clear amniotic fluid.
Exam –
Cyanotic neonate, unresponsive,
floppy
No respiratory effort/apneic
Heart rate 50’s
APGAR = 1
CASE 1
Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27

• APGAR Score
– Performed at 1 and 5 minutes
– Evaluate condition after delivery and need for intervention
Component 0 1 2
Appearance Whole body
cyanotic
Cyanotic
extremities
Good color
Pulse No heart rate < 100 BPM > 100 BPM
Grimace No response to
stimulation
Grimace Grimace,
vigorous cry
Activity Limp, no
movement
Some muscle
tone
Active motion
Respiration Not breathing Slow, irregular Cries well
Quick Tangential Point

APGAR Score
“These scores should not be used to dictate appropriate
resuscitative actions, nor should interventions for
depressed newborns be delayed until the 1-minute
assessment.”
Textbook of Neonatal Resuscitation, 6th
Edition; Page 35.

Placed in warmer; is not
breathing or crying; poor
muscle tone; cyanotic; note
clear amniotic fluid.
Exam – Cyanotic neonate,
unresponsive, floppy
Heart rate 50’s
APGAR = 1
CASE 1

• What is the next step?
– “ABCDs”
• Initial steps – provide warmth, suction Airway as necessary,
dry, stimulate
• Reassess
• Positive pressure ventilation (Breathing)
• Reassess
• Ventilation corrective steps (Breathing)
• Reassess
• Chest compressions
• Reassess
• Give Drugs

• Initial steps
– Provide warmth
• Warm towels
• Radiant warmer
– Clear airway as
necessary
– Dry and
stimulate
– Reassess
Term Gestation?
Breathing or crying?
Good tone?
Routine
Care
Warm
Clear airway if needed
Dry
Stimulate
HR less than 100?
Gasping or
Apnea?
No
Yes
30 sec

Reassessment
Patient remains:
Cyanotic
Apneic
Pulse is in the 50s
CASE 1

• Subsequent steps
– Positive-pressure
ventilation (PPV)
• Self-inflating bag
• Position neck in
neutral position
• Suction mouth and
nose
• Ventilate at 40-60
bpm
– SpO2 monitoring
• Right hand or wrist
– Reassess
HR less than 100?
Gasping or
Apnea?
Labored
Breathing
Cyanosis
Positive-Pressure
Ventilation
SpO2 monitoring
HR below 100?
Yes
5-10 breaths
No
Clear airway
SpO2 monitor
CPAP?
Yes

Reassessment
Somewhat improved heart rate
and color
Heart rate increases to 90’s
with continued PPV
Oxygen saturation in the 80’s
CASE 1

• Pulse oximetry
– Attached to preductal location on right upper extremity
– Saturation may normally remain low for several minutes after
delivery
Targeted preductal SpO2 after
delivery
1 min 60-65 percent
2 min 65-70 percent
3 min 70-75 percent
4 min 75-80 percent
5 min 80-85 percent
10 min 85-95 percent

– Heart rate less
than100 BPM
• Ventilation
corrective steps
• Continue BMV
ventilation
HR below 100? Postresus.
care
Ventilation corrective
steps
Yes
No
HR < 60?
No
Continue
ventilation
Yes
HR < 100 but > 60?

• Ventilation Corrective Steps – 3 possible reasons for ineffective
ventilation
– Inadequate mask seal
– Airway is blocked
– Not enough pressure used
Measures to improve positive-pressure ventilation
M Mask adjustment
R Reposition airway
S Suction mouth and nose
O Open mouth
P Pressure increase
A Airway alternative

Reassessment
Heart rate increases to > 100
with continued PPV
Attempts to provide
supplemental oxygen result in
decreasing oxygen saturation
and decreasing heart rate
Obvious inadequate
respiratory effort
CASE 1

Your kind of stuck
here aren’t you…
care
steps
Yes
No
HR < 60?
No
Continue
ventilation
Yes
HR < 100 but > 60?

• Consider placing an
orogastric tube to…
– Suction gastric contents
– Serve as vent for air in
stomach
• Consider endotracheal
intubation for…
– PPV beyond a few minutes
– Meconium and floppy
– Chest compressions
– PPV with inadequate
improvement
– Special circumstances
What to do if positive-pressure ventilation is to be
continued…

Reassessment
Heart rate with PPV remains
above 100
Color improved
Continue to provide respiratory
support (oxygen saturation in
low 90’s)
NICU team present with
warmer
CASE 1

Introduction – Multiparous female to ED in labor; precipitous delivery as
put into resuscitation bay of term neonate. Meconium stained
amniotic fluid.
PMH for mother –G6P6, Normal prenatal visits, due date 2 days from
now, no other issues.
Exam for mother – Awake, alert, stable, can provide appropriate history
as needed
CASE 2

muscle tone; cyanotic;
meconium stained.
Heart rate 50’s (< 60)
APGAR = 1
CASE 2

• Initial steps
– Provide warmth
• Warm towels
• Radiant warmer
– Clear airway as
necessary
– Dry and
stimulate
– Reassess
Term Gestation?
Good tone?
Routine
Care
Warm
Clear airway if needed
Dry
Stimulate
HR less than 100?
Gasping or
Apnea?
No
Yes
30 sec
Hold On!!!

• Meconium is present and
baby is NOT vigorous
– Provide warmth
• Warm towels
• Radiant warmer
– Before drying (!!!)
• Oropharynx and
hypopharynx suctioned
• Trachea suctioned under
direct visualization
– Dry and stimulate
– Reassess
Term Gestation?
Good tone?
Routine
Care
Warm
Direct suctioning of trachea
Dry
Stimulate
HR less than 100?
Gasping or
Apnea?
No
Yes
30 sec

• To suction the
trachea
– Insert a laryngoscope
– Suction mouth and
posterior pharynx
– Insert endotracheal
tube
– Attach to meconium
aspirator
– Suction

Reassessment
No improvement in
respirations (apneic),
heart rate (50’s), or color
(cyanotic)
CASE 2

ventilation (PPV)
neutral position
• Suction mouth and
nose
bpm
– Reassess
HR less than 100?
Gasping or
Apnea?
Labored
Breathing
Cyanosis
Positive-Pressure
Ventilation
SpO2 monitoring
HR below 100?
Yes
5-10 breaths
No
Clear airway
SpO2 monitor
CPAP?
Yes

Reassessment
Neonate with no
improvement (apneic,
heart rate in 50’s, poor
color and tone)
CASE 2

– Heart rate < 60
BPM
• Chest
compressions
(90/min)
• Continue ventilation
at 30 BPM
– Reassess
steps
Chest compressions
Consider intubation
Coordinate with PPV
Yes
HR < 60?
No
Continue
ventilation
Yes
HR < 60?
HR < 100 but > 60?

• Indications for
endotracheal intubation
– PPV beyond a few minutes
– Meconium and floppy
– Chest compressions
– PPV with inadequate
improvement
– Special circumstances
Sondeintubation new.jpg; Author – bigomar2

How do you select the endotracheal tube size?
Weight (grams) Gestational age (wks) Tube size (mm)
< 1,000 < 28 2.5
1,000 – 2,000 28 – 34 3.0
2,000 – 3,000 34 – 38 3.5
> 3,000 > 38 3.5 – 4.0

Reassessment
Neonate with improved
heart rate (is now up to
80’s)
Need to continue PPV
CASE 2

– Heart rate less
than100 BPM
• Continue positive
pressure ventilation
care
steps
Yes
No
HR < 60?
No
Continue
ventilation
Yes
HR < 100 but > 60?

Reassessment
Heart rate improves with
PPV to 100’s
NICU team present with
warmer
CASE 2

Introduction – Young female with history of drug abuse (prescription
pain medications) to ED in labor; precipitous delivery as put into
resuscitation bay of near-term neonate.
PMH for mother – G2P1, drug abuse (prescription pain medications –
is currently abusing), 1 prenatal visit, thinks due date is “a couple
weeks from now.”
Exam for mother – post-partum, speech somewhat slurred
CASE 3

muscle tone; cyanotic; note
clear amniotic fluid.
Heart rate 50’s
APGAR = 1
CASE 3

Reassessment
Remains cyanotic
Apneic
Pulse is 50 BPM
CASE 3

ventilation (PPV)
neutral position
• Suction nose and
mouth
bpm
– Reassess
HR less than 100?
Gasping or
Apnea?
Labored
Breathing
Cyanosis
Positive-Pressure
Ventilation
SpO2 monitoring
HR below 100?
Yes
5-10 breaths
No
Clear airway
SpO2 monitor
CPAP?
Yes

Reassessment
Patient remains cyanotic
Apneic
Pulse is < 60 BPM
CASE 3

– Vascular access
– Drugs
• Epinephrine
• Volume expansion
– Reassess
HR < 60?
According to
condition
Vascular access
IV Epinephrine
(0.01 mg/kg of 1:10,000)
HR < 60
Continue PPV and
Chest compressions
Yes
Every 3-5 min
No
Yes

• Vascular access
– Umbilical vein catheter
• Aseptic technique
• Depth of 2-4 cm

• Epinephrine
– Action – increases heart
rate and myocardial
contractility, causes
peripheral vasoconstriction
– Indication – heart rate < 60
despite adequate
ventilation and chest
compressions
– Dose – 0.01 mg/kg of
1:10,000 solution IV
• Isotonic saline
– Action – increases
intravascular volume
– Indication – hypovolemia
– Dose – 10 ml/kg of 0.9 NS
over 5-10 minutes
Drugs

Reassessment
Heart rate now > 100
Cyanosis resolving
NICU team present
CASE 3

• Summary of resuscitation steps
– Initially provide warmth, clear airway, dry and stimulate infant
– If meconium staining and non-vigorous infant, suction before
stimulation
– If infant continues with poor respiratory effort or HR < 100, start
PPV with BMV, initiate pulse oximetry
– If not improving take ventilation corrective steps
– Intubate if BMV is ineffective or prolonged, or chest
compressions are being performed
– If HR < 60 despite adequate ventilation, start chest
compressions at 90 per minute
– If HR rate < 60 despite adequate ventilation and chest
compressions, administer IV epinephrine

• Suction equipment
– Bulb syringe
– Mechanical suction
– Meconium aspirator
– 8F feeding tube
• Vascular access
– Umbilical vessel
catheterizations supplies
• Intubation equipment
– Laryngoscope with straight
blades
– Face masks (preterm and
term infant sizes)
– Oxygen source
• Medications
– D10 solution
– Epinephrine
– Isotonic solution (0.9 NS)
– Naloxone
• Miscellaneous
– Radiant warmer
– Warm towels
– Cardiac monitor
– Pulse oximeter
– Oropharyngeal airways
Equipment

– Vascular access
– Drugs
• Epinephrine
• Volume expansion
• Sodium
bicarbonate
– Reassess
HR < 60?
According to
condition
Vascular access
IV Epinephrine
(0.01 mg/kg of 1:10,000)
HR < 60
Continue PPV and
Chest compressions
Yes
Every 3-5 min
No
Yes

Neonatal Resuscitation, Dr. Wylie 7/17/14

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