Resuscitation of a Newborn

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Resuscitation of a Newborn

  1. 1. Resuscitation In Newborns Dr. Kalpana Malla MD Pediatrics Manipal Teaching HospitalDownload more documents and slide shows on The Medical Post [ www.themedicalpost.net ]
  2. 2. Approximately 10% of newborns require some assistance to begin breathing at birth.Approximately 1% require extensive resuscitative measures.
  3. 3. APNEA• Primary – deprivation of oxygen → rapid breathing → resp stop →HR↓ → apnea*** will re- establish breathing with oxygen and stimulation• Secondary –If asphyxia continues →deep gasping resp → HR ↓ & BP ↓ →last gasp →apnea*** unresponsive to oxygen and stimulation →PPV must be started
  4. 4. • Always assume infant has secondary Apnea & commence Resuscitation
  5. 5. Resuscitation Assignments• Team Leader- Airway• Second Rescuer- Pulse Check (HR) Chest Compression• Third Rescuer- Medications Equipment
  6. 6. Core Knowledge and Skills• Airways - Establish Clear Airway• Breathing- Ventilation & Oxygenation• Circulation- Adequate Cardiac Output• Drugs• Environment - Reduce Heat Loss
  7. 7. Steps in Resuscitation - ABCDE• Airway – open & clear airway – Suction mouth and then nose , trachea if needed – No more than 5cms & no longer than 5 secs – Mechanical suction - vacuum does not exceed 100 mmHg (5litres) – Airway tube / ET tube• If nose cleared first the infant may gasp and aspirate secretions in the pharynx
  8. 8. AirwayDO NOT SUCTION IF AIRWAY IS CLEAR – Positioning • Supine or lateral • Head in neutral or slightly extended position - Avoid overextension or flexion
  9. 9. CLEARING THE AIRWAY OF MECONIUMCurrent recommendations No longer advise routine intrapartum oropharyngeal and nasopharyngeal suctioning for infants born to mothers with meconium staining of amniotic fluid
  10. 10. Suction• Suction - Bulb syringe DeLee mucus trap Suction catheters (6F, 8F, 10F) Feeding tube with syringe Meconium aspirator
  11. 11. Steps in Resuscitation - ABCDE• Breathing -Initiate breathing - Tactile stimulation - PPV – bag & mask – bag & ET tube• Assessment of respiratory effort and color
  12. 12. Tactile Stimulation• Drying• Suctioning• Slapping or flicking the soles of the feet• Rubbing the back gently• Do not waste time continuing tactile stimulation if there is no response after 10 - 15 seconds.
  13. 13. Harmful actions• Slapping back• Squeezing rib cage• Forcing thigh onto abdomen• Dilating anal sphincter• Using hot or cold compression or bath• Blowing cold air onto face• Burning placenta
  14. 14. Use of oxygen during neonatal resuscitation• Indications for oxygen administration – Cyanosis – Respiratory distress - Give free flowing oxygen 5L/min• Use – 100% supplemental oxygen• If oxygen unavailable - use room air to deliver positive-pressure ventilation
  15. 15. Steps in Resuscitation - ABCDEIndications for PPV / Bag-Valve-Mask Ventilation• Apnoeic• Gasping respiration• HR < 100 bpm• Persistent central cyanosis despite 100% O2• 40-60 breaths/min• No response
  16. 16. Bag-Valve-Mask Ventilation• NeutralPosition of Head• Tight Mask Seal• Avoid Pressure on Trachea•Assisted rate= 40 to 60 bpm
  17. 17. Bag-Valve-Mask Ventilation• Signs of Adequate Ventilation: - Bilateral Chest Expansion - Bilateral Breath Sounds - Adequate Heart Rate & Color
  18. 18. Bag and mask Ventilate for 30 seconds: Rate: 40-60 /min Pressure: Visible rise and fall of chest HR < 60 HR >100 HR > 100 bpm: Continue ventilation Check for spontaneousInitiate chest compression respirations Consider intubation
  19. 19. Bag and mask the most important tool in newborn resuscitation
  20. 20. ENDOTRACHEAL TUBE PLACEMENT• ET intubation - indicated at several points during neonatal resuscitation:1. Tracheal suctioning for meconium2. Bag-mask ventilation is ineffective / prolonged3.When chest compressions are performed4.When ET administration of medications is required5.Congenital diaphragmatic hernia or extremely low birth weight (<1000 g)
  21. 21. Place a pillow under thehead and neck but NOTunder the shouldersThis allows a straight lineof vision from the mouth tothe vocal cordsThe laryngoscope isintroduced into the righthand side of the mouth (itis held by the left hand
  22. 22. • The tongue is swept to the left and the tip of the blade is advanced until a fold of skin / cartilage is visualised at twelve o’ clock• This is the epiglottis, and this sits over the glottis (the opening of the larynx) during swallowing
  23. 23. • The tip of the blade is advanced to the base of the epiglottis, known as the vallecula, and the entire laryngoscope is lifted upwards and outwards• This flips the epiglottis upwards and exposes the glottis below• An opening is seen with two white vocal cords forming a triangle on each side
  24. 24. • The tip of the ET tube is advanced through the vocal cords and once the cuff has passed through, one stops advancing The tube is secured at this level and the cuff inflated
  25. 25. ET tube sizes GA Weight ET tubes Size• <28weeks <1Kg 2.5cm• 28-34 1-2Kg 3 cm• 34-38 2-3Kg 3-3.5 cm• >38 >3 Kg 3.5- 4cm
  26. 26. Steps in Resuscitation - ABCDE• Circulation• Assessment of heart rate• Umbilical arteries pulsation• Chest Compressions
  27. 27. Steps in Resuscitation - ABCDEIndication for Chest Compressions1. HR < 60 bpm despite adequate vent with 100% O2 for 30 seconds2. Heart Rate 60 to 80 but not Increasing (±) - controversial
  28. 28. 2 techniques • 2 thumb (preferred) • 2 finger • 3:1 ratio • 1/3 of AP diameter
  29. 29. Chest compression1.Thumb technique: - Place thumbs side by side or one over the other above xyphoid - other fingers provide support for the back - Depress the sternum to a depth of 1/3 of the anterior/posterior diameter of the chest - Your thumbs should remain in contact with the chest at all times - Rate - 3:1
  30. 30. Drugs needed forNewborn Resuscitation
  31. 31. Steps in resuscitation - ABCDEDrugs• Adrenaline• Volume Expanders• Naloxone• Sodium bicarbonate (0.5 mEq/mL)
  32. 32. Drugs1.Adrenaline• HR < 60 /min after 30 seconds of adequate ventilation and chest compressions• Give via ETT, UVC, IV• Repeat dose if no response after 60 seconds• IV or ET dose - 0.1 to 0.3 mL/kg of 1:10,000 (0.01 to 0.03 mg/kg) repeated every 3 to 5 /min• ET: 0.3 to 1.0 mL/kg of 1:10,000• No different dose for premature infants
  33. 33. Steps in resuscitation - ABCDE• Volume expanders• Not given routinely• Useful in hypovolemia – Suspected where there is a pale tachycardic infant• Normal saline - 10mL/kg over 5-10 min• Route - UVC, IV• Blood or packed red cells - If haemorrhagic shock is suspected
  34. 34. Drugs• Naloxone• Inadequate spontaneous respiratory effort• Mothers who received narcotics within 4 hrs of delivery• Dose - 0.1mg/kg of a 0.4 mg/mL solution• Route - ETT, IV, UVC, IM, SC
  35. 35. Steps in resuscitation- ABCDE• Environment – Turn on radiant warmer – Warm blankets/cap/plastic wrap for preterms – Shut doors and windows – Heat Lamps
  36. 36. : Equipments Prepare for birth• Two clean towels for thermal protection• Warm delivery room > 25oC• A radiant heater / warmer• Clean delivery kit for cord care, gloves• an additional set of equipment in reserve for multiple births or in case of failure of the first set
  37. 37. Equipments- Oxygen supply- Bag and mask, face mask, oral airway (Guedel airway)- Intubation – Laryngoscope (0 and 1 sized blades) ET tubes, (2.5-4) Scissors ,gloves Extra bulbs and batteries Stethoscope
  38. 38. Fluids- IV catheters (22 g)- Tape and sterile dressing material- D10W- Isotonic saline solution- T-connectors- Syringes (1-20 mL)
  39. 39. Rapid assessment - 5 characteristics• Full-term gestation?• Amniotic fluid clear of meconium ?• Breathing or crying?• Good muscle tone?• Color pink?
  40. 40. If the answer to any of these assessment is "no"• Initial steps in stabilization ( warmth, position, clear airway, dry, stimulate)• Ventilation• Chest compressions• Administration of epinephrine and/or volume expansion
  41. 41. Resuscitation Priorities- Drying, Warming, Positioning - Suctioning, Stimulation - BVM Vent - Oxygen - Chest Compressions -Intubation -Medications
  42. 42. • BIRTH ↓Clear of meconium?Breathing or crying?Good muscle tone? YES Routine careColour pink? -WarmthTerm gestation? -Clear airway -Dry the baby NO• Provide warmth• Position and clear airway*-suction• Dry, stimulate, reposition• Give oxygen
  43. 43. • Evaluate:- Breathing Supportive care HR>100 pinkApnoea or HR <100Provide positive pressure ventilation* by ambu bag →Breathing HR >100 pink ↓ Ongoing care
  44. 44. IF• HR<60• Provide positive pressure ventilation*• Administer chest compression ↓• HR<60• Administer Epinephrine***ET may be considered at several steps
  45. 45. Discontinuing resuscitation efforts• After 10 minutes of continuous and adequate resuscitative efforts, discontinuation of resuscitation may be justified if there are no signs of life (no heart beat and no respiratory effort)
  46. 46. Thank youDownload more documents and slide shows on The Medical Post [ www.themedicalpost.net ]

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