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16- Neonatal Resuscitation.ppt
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- 2. Objectives: BLS for infantand child Neonatal resuscitation Pediatric advanced life support
- 4. BLS for infantand child A – B – C Assess for responsiveness Shout for help Open the airway Check for breathing ( look, listen and feel) Give two breaths ( if no breathing) Check for pulse ( carotid or brachial)
- 5. BLS for infantand child Start chest compression and ventilation cycles ( 30:2) or (15:2) ( if no pulse) Finish five cycles of CPR Activate Emergency Medical Services Re-assess pulse If no pulse or pulse less than 60, repeat five cycles of CPR If pulse is present
- 6. BLS for infantand child Check for breathing If no breathing give one breath every 3-5 seconds If breathing is present Place the child or infant on recovery position. Keep monitoring until help arrives.
- 8. Newborn Resuscitation Recommendationsare primarily for neonates transitioning to extrauterine life Also applicable to neonates and infants during the first few weeks to months following birth 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
- 9. Need for Resuscitation Approximately 10% of newborns require additional assistance ◦ 1% requires major resuscitation Resuscitation ◦ Intervene Reassess Intervene Reassess ◦ 30 second intervals
- 11. Initial Steps ofResuscitation Routine Care – If YES to the following questions ◦ Term gestation? ◦ Breathing or crying? ◦ Good muscle tone? Dry Provide warmth (skin-to-skin) Cover Assess color, breathing, activity
- 12. Initial Steps ofResuscitation Resuscitative Care – If NO to the following questions ◦ Term gestation? ◦ Breathing or crying? ◦ Good muscle tone? Provide warmth Position – sniffing position Clear airway (meconium consideration) Dry and stimulate PPV Chest compressions Epinephrine or volume expansion
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- 14. Initial Steps (GoldenMinute) Approximately 60 seconds to complete, reevaluate, and ventilate if necessary ◦ Provide warmth ◦ Clear airway ◦ Dry ◦ Stimulate ◦ Position - sniffing
- 15. Initial Steps (Golden Minute) Decision to proceed beyond initial steps is based on evaluation of: ◦ Respirations Apnea Gasping Labored breathing ◦ Heart rate Less than 100 bpm Auscultation of heart sounds Palpation of umbilical pulse
- 16. Assessment After PPVor Supplemental Oxygenation Evaluate ◦ Heart rate ◦ Respirations ◦ Oxygenation Most sensitive indicator of successful response is an increase in heart rate
- 17. Assessment of OxygenNeed and Oxygen Administration Blood oxygen levels do not reach extrauterine values in uncompromised babies until approximately 10 minutes after birth Cyanosis may appear until that point (10 minutes) Skin color is very poor indicator of oxygen saturation immediately after birth Lack of cyanosis is a very poor indicator state of oxygenation in uncompromised
- 19. Neonatal Pulse Oximetry New pulse oximeters with neonatal probes ◦ Provide reliable readings within 1 to 2 minutes following birth ◦ Must have sufficient cardiac output to skin SpO2 recommended ◦ Resuscitation anticipated ◦ PPV for more than a few breaths ◦ Persistent cyanosis ◦ Supplemental oxygen is administered
- 20. Neonatal Pulse Oximetry Probe location ◦ Right upper extremity Medial surface of the palm Wrist Attach probe to baby prior to device ◦ More rapid acquisition of signal
- 21. PPV and Supplemental Oxygen 100% oxygen administration is not recommended Titrate oxygen to SpO2 range Initiate resuscitation with air if blended oxygen is not available ◦ If bradycardia persists (HR <60 bpm) after 90 seconds, increase oxygen to 100% until HR > 100 bpm
- 22. Targeted SpO2 AfterBirth 1 minute 60 to 65% 2 minutes 65 to 70% 3 minutes 70 to 75% 4 minutes 75 to 80% 5 minutes 80 to 85% 10 minutes 85 to 95%
- 23. Newborn Intervention Triggers Secretions = suction Apnea or gasping respirations = PPV Labored breathing or low SpO2 = oxygen or CPAP HR< 100 bpm = PPV HR< 60 = Chest compressions and PPV Persistent HR< 60 = epinephrine
- 24. Evaluate Respiration, HR, Oxygenation Breathing adequate (rate and effort) ◦ No apnea ◦ No gasping ◦ No labored breathing HR >100 bpm SpO2 in normal range Observe and suction only to keep airway clear
- 25. Evaluate Respiration, HR, Color Breathing adequate HR >100 bpm Core cyanosis is persistent Low SpO2 reading Provide blow by oxygen ◦ Warm and humidify oxygen ◦ 5 lpm ◦ Do not blow directly in eyes
- 26. Evaluate Respiration, HR, Color Breathing adequate HR >100 bpm Acrocyanosis with normal SpO2 No intervention If acrocyanosis with poor SpO2 provide blow-by O2
- 28. Evaluate Respiration, HR, SpO2 Breathing inadequate ◦ Gasping or apnea HR >100 bpm Good pink or normal SpO2 Positive pressure ventilation ◦ Infant size (240 ml) ◦ 5 to 8 ml/kg VT ◦ Disable pop-off (30 to 40 cmH20) ◦ 40 to 60 ventilations/minute ◦ Peak inspiratory pressure 25 cmH2O in full-term ◦ Or use neopuff
- 29. CPAP Breathing spontaneouslybut labored HR> 100 bpm SpO2 normal or low Research lacking – only studied in preterm babies
- 30. Evaluate Respiration, HR, Color Breathing adequate HR <100 bpm SpO2 normal Positive pressure ventilation ◦ Infant size (240 ml) ◦ 5 to 8 ml/kg VT ◦ Disable pop-off (30 to 40 cmH20) ◦ 40 to 60 ventilations/minute ◦ Peak inspiratory pressure 25 mmHg in full-term
- 31. Evaluate Respiration, HR,Color Breathing adequate HR < 60 bpm SpO2 not adequate PPV Chest compressions ◦ Depth 1/3 of anteroposterior diameter of chest ◦ Two thumbs over sternum with hands encircling chest ◦ 3 compressions to one ventilation ◦ Compression rate 120/minute 90 compressions and 30 ventilations in one minute After 30 seconds of compressions and ventilation – consider epinephrine
- 32. Persistent Bradycardia Usuallydue to ◦ Inadequate lung inflation ◦ Profound hypoxemia Primary emergency intervention ◦ Adequate ventilation HR remains < 60 bpm with 100% oxygen Consider epinephrine
- 33. Epinephrine Administration Intravenousroute is recommended only ◦ 0.01 to 0.03 mg/kg ◦ 1:10,000 dilution If ET route is used ◦ 0.05 to 0.1 mg/kg ◦ 1:10,000 dilution
- 34. Volume Expansion Bloodloss known or suspected ◦ Pale skin ◦ Poor perfusion ◦ Weak pulse ◦ HR not responding to other interventions Isotonic crystalloid ◦ 10 mL/kg Avoid rapid infusion in premature infants
- 36. Oral Airways Rarelyused for neonates Use tongue depressor to insert airway
- 37. Respiratory Distress or Inadequacy HR < 100 bpm = hypoxia Periodic breathing (20 second or longer period of apnea) Intercostal retractions Nasal flaring Grunting
- 38. Meconium Stained AmnioticFluid (MSAF) 10 to 15% of deliveries High risk of morbidity Passage may occur before or during delivery More common in post-term infants and neonates small for the gestational age Fetus normally does not pass stool prior to brith
- 39. Meconium Stained Amniotic Fluid Complications if aspirated – Meconium Aspiration Syndrome (MAS) ◦ Atelectasis ◦ Persistent pulmonary hypertension ◦ Pneumonitis ◦ Pneumothorax
- 40. Meconium Stained Amniotic Fluid Determine if fluid is thin and green or thick and particulate If baby is crying vigorously – use standard resuscitation criteria If baby is depressed ◦ DO NOT dry or stimulate ◦ Intubate trachea ◦ Attach a meconium aspirator ◦ Apply suction to endotracheal tube ◦ Dry and stimulate ◦ Continue with standard resuscitation
- 41. Apnea Common ininfants delivered before 32 weeks of gestation Risk factors ◦ Prematurity ◦ Infection ◦ Prolonged or difficult labor and delivery ◦ Drug exposure ◦ CNS abnormalities ◦ Seizures ◦ Metabolic disorders ◦ Gastroesophageal reflux
- 42. Apnea Pathophysiology ◦ Prematuritydue to underdeveloped CNS ◦ Gastroesophageal reflux can trigger a vagal response ◦ Drug-induced from CNS depression Bradycardia is key assessment finding
- 43. Premature and LowBirth Weight Infants Delivered before 37th week of gestation Less than 5.5 lbs or 2,500 grams
- 44. Premature and LowBirth Weight Infants Low birth weight ◦ Chronic maternal HTN ◦ Smoking ◦ Placental anomalies ◦ Chromosomal abnormalities Born <24 weeks and less than 1 lb – poor chance of survival
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- 51. Good Quality CPR •Push hard at least 1/3 of ap diameter of chest. • Push fast at least 100 /min. • Allow complete chest recoil. • Minimize interruption in chest compression. • Avoid excessive ventilation. • Rotate compressor every two minutes. • If no advanced airway 15:2 compression to ventilation ratio. • If advanced airway, 8-10 breaths /min with continuous chest compression.
- 52. Shock energy for defibrillation First shock 2 J/kg. Second shock 4 J/kg. Subsequent shocks more than 4 J/kg Maximum 10 J/kg or adult dose.
- 53. Drug Therapy EpinephrineIO/IV Dose: 0.01 mg/kg (0.1 ml/kg of 1:10 000 concentration) Repeat every 3-5 minutes. If no IV/IO access, may give endotracheal dose: 0.01 mg/kg (0.1 ml/kg of 1:1000 concentration)
- 54. Drug Therapy AmiodoroneIO/IV Dose: 5 mg/kg bolus during cardiac arrest. May repeat up to 2 times for refractory VF/ pulseless VT
- 55. Advanced Airway Endotrachealintubation or supraglotic advanced airway. Waveform capnography to confirm and monitor ET tube placement. Once advanced airway in place give 1 breath every 6-8 seconds (8-10 breaths /minutes)
- 56. Return of spontaneous circulation(ROSC) Pulse and blood pressure Spontaneous arterial pressure waves with intra-arterial monitoring
- 57. Reversible causes Hypovolemia Hypoxia Hydrogen ion (acidosis) Hypoglycemia Hypo-/hyperkalemia Hypothermia
- 58. Reversible Causes Tensionpneumothorax. Temponade, cardiac Toxins Thrombosis, pulmonary Thrombosis, coronary