Neonatal Resuscitation, Dr. Wylie 7/17/14

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Neonatal Resuscitation, Dr. Wylie 7/17/14

  1. 1. Neonatal Resuscitation Todd Wylie, M.D. Department of Emergency Medicine University of Florida College of Medicine Jacksonville
  2. 2. Physiology • Fetal Circulation – Placenta • Low vascular resistance – Fetal lungs • High vascular resistance 2011 UpToDate, Inc.
  3. 3. Physiology • Fetal Circulation – Right-to-left shunts • Foramen ovale • Ductus arteriosus 2011 UpToDate, Inc.
  4. 4. Physiology • Fetal Circulation – From the placenta… • Oxygenated blood… • Ductus venosus into IVC… • Right atrium… • Shunted thru foramen ovale… • Into left atrium 2011 UpToDate, Inc.
  5. 5. Physiology • Fetal Circulation – 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.
  6. 6. Physiology • Fetal Oxygenation – Adequate tissue oxygenation secondary to: • Fetal hemoglobin • Decreased fetal oxygen consumption • Differential blood flow 2011 UpToDate, Inc.
  7. 7. Physiology • Changes at Delivery – Alveolar fluid clearance – Lung expansion – Circulatory changes 2011 UpToDate, Inc.
  8. 8. 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)
  9. 9. Physiology • Difficulties Transitioning – Lack of respiratory effort – Blockage of the airways – Impaired lung function – Persistent pulmonary hypertension – Cardiac anomalies
  10. 10. Neonatal Resuscitation 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
  11. 11. Neonatal Resuscitation 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
  12. 12. Neonatal Resuscitation • 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
  13. 13. Neonatal Resuscitation 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. Quick Tangential Point
  14. 14. Neonatal Resuscitation 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
  15. 15. Neonatal Resuscitation • 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
  16. 16. Neonatal Resuscitation • 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
  17. 17. Neonatal Resuscitation Reassessment Patient remains: Cyanotic Apneic Pulse is in the 50s CASE 1 Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
  18. 18. Neonatal Resuscitation • 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
  19. 19. Neonatal Resuscitation Reassessment Somewhat improved heart rate and color Heart rate increases to 90’s with continued PPV Oxygen saturation in the 80’s CASE 1 Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
  20. 20. Neonatal Resuscitation • 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 Quick Tangential Point
  21. 21. Neonatal Resuscitation Reassessment Somewhat improved heart rate and color Heart rate increases to 90’s with continued PPV Oxygen saturation in the 80’s CASE 1 Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
  22. 22. Neonatal Resuscitation • Subsequent steps – 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?
  23. 23. Neonatal Resuscitation • 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 Quick Tangential Point
  24. 24. Neonatal Resuscitation 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 Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
  25. 25. Neonatal Resuscitation Your kind of stuck here aren’t you… HR below 100? Postresus. care Ventilation corrective steps Yes No HR < 60? No Continue ventilation Yes HR < 100 but > 60?
  26. 26. Neonatal Resuscitation • 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…
  27. 27. Neonatal Resuscitation 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 Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
  28. 28. Neonatal Resuscitation 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
  29. 29. Neonatal Resuscitation Initial Description of Neonate – Placed in warmer; is not breathing or crying; poor muscle tone; cyanotic; meconium stained. Exam – Cyanotic neonate, unresponsive, floppy No respiratory effort/apneic Heart rate 50’s (< 60) APGAR = 1 CASE 2 Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
  30. 30. Neonatal Resuscitation • 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 Hold On!!!
  31. 31. Neonatal Resuscitation • 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? Breathing or crying? Good tone? Routine Care Warm Direct suctioning of trachea Dry Stimulate HR less than 100? Gasping or Apnea? No Yes 30 sec
  32. 32. Neonatal Resuscitation • To suction the trachea – Insert a laryngoscope – Suction mouth and posterior pharynx – Insert endotracheal tube – Attach to meconium aspirator – Suction Quick Tangential Point
  33. 33. Neonatal Resuscitation Quick Tangential Point
  34. 34. Neonatal Resuscitation Reassessment No improvement in respirations (apneic), heart rate (50’s), or color (cyanotic) CASE 2 Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
  35. 35. Neonatal Resuscitation • Subsequent steps – Positive-pressure ventilation (PPV) • Self-inflating bag • Position neck in neutral position • Suction mouth and nose • Ventilate at 40-60 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
  36. 36. Neonatal Resuscitation Reassessment Neonate with no improvement (apneic, heart rate in 50’s, poor color and tone) CASE 2 Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
  37. 37. Neonatal Resuscitation • Subsequent steps – 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?
  38. 38. Neonatal Resuscitation Reassessment Neonate with no improvement (apneic, heart rate in 50’s, poor color and tone) CASE 2 Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
  39. 39. Neonatal Resuscitation • Subsequent steps – Heart rate < 60 BPM • Chest compressions (90/min) • Continue ventilation at 30 BPM – Reassess Ventilation corrective steps Chest compressions Consider intubation Coordinate with PPV Yes HR < 60? No Continue ventilation Yes HR < 60? HR < 100 but > 60?
  40. 40. Neonatal Resuscitation • Indications for endotracheal intubation – PPV beyond a few minutes – Meconium and floppy – Chest compressions – PPV with inadequate improvement – Special circumstances Quick Tangential Point Sondeintubation new.jpg; Author – bigomar2
  41. 41. Neonatal Resuscitation 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 Quick Tangential Point
  42. 42. Neonatal Resuscitation Reassessment Neonate with improved heart rate (is now up to 80’s) Need to continue PPV CASE 2 Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
  43. 43. Neonatal Resuscitation • Subsequent steps – Heart rate less than100 BPM • Continue positive pressure ventilation HR below 100? Postresus. care Ventilation corrective steps Yes No HR < 60? No Continue ventilation Yes HR < 100 but > 60?
  44. 44. Neonatal Resuscitation Reassessment Heart rate improves with PPV to 100’s NICU team present with warmer CASE 2 Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
  45. 45. Neonatal Resuscitation 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
  46. 46. Neonatal Resuscitation 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 3 Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
  47. 47. Neonatal Resuscitation • 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
  48. 48. Neonatal Resuscitation Reassessment Remains cyanotic Apneic Pulse is 50 BPM CASE 3 Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
  49. 49. Neonatal Resuscitation • Subsequent steps – Positive-pressure ventilation (PPV) • Self-inflating bag • Position neck in neutral position • Suction nose and mouth • Ventilate at 40-60 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
  50. 50. Neonatal Resuscitation Reassessment Patient remains cyanotic Apneic Pulse is < 60 BPM CASE 3 Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
  51. 51. Neonatal Resuscitation • Subsequent steps – 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?
  52. 52. Neonatal Resuscitation Reassessment Patient remains cyanotic Apneic Pulse is < 60 BPM CASE 3 Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
  53. 53. Neonatal Resuscitation • Subsequent steps – Heart rate < 60 BPM • Chest compressions (90/min) • Continue ventilation at 30 BPM – Reassess Ventilation corrective steps Chest compressions Consider intubation Coordinate with PPV Yes HR < 60? No Continue ventilation Yes HR < 60? HR < 100 but > 60?
  54. 54. Neonatal Resuscitation Reassessment Patient remains cyanotic Apneic Pulse is < 60 BPM CASE 3 Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
  55. 55. Neonatal Resuscitation • Subsequent steps – 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
  56. 56. Neonatal Resuscitation • Vascular access – Umbilical vein catheter • Aseptic technique • Depth of 2-4 cm Quick Tangential Point
  57. 57. Neonatal Resuscitation • 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 Quick Tangential Point Drugs
  58. 58. Neonatal Resuscitation Reassessment Heart rate now > 100 Cyanosis resolving NICU team present CASE 3 Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
  59. 59. Neonatal Resuscitation • 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
  60. 60. Neonatal Resuscitation • 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
  61. 61. Neonatal Resuscitation • Subsequent steps – 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
  62. 62. Neonatal Resuscitation • Subsequent steps – 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

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