CH42 Neonatal Care -
Specific Intervention and Resuscitation Steps: Drying and stimulation
After ensuring airway patency, dry and stimulate the newborn. Nasal suctioning stimulates the newborn to breathe. Position on the back or side with the neck in the sniffing position. If airway is not clear, suction with the head turned to the side. - Suction mouth before nose. Flick the soles of the feet and gently rub the back.
Pathophysiology, Assessment, and Management of Specific Conditions: Apnea - Assessment and Management
Assessment includes: - Careful history to find etiologic risk factors Performing a physical exam focusing on: - Neurologic signs - Signs and symptoms of infection Differentiate between: - Primary and - Secondary Apnea Primary apnea - After a relatively short period of hypoxia, may have a period of rapid breathing followed by apnea and bradycardia - Drying and stimulation may cause resumption of breathing and pulse rate improvement. Secondary apnea - If hypoxia continues during primary apnea, the newborn will gasp and go into the secondary phase. - PPV by bag-mask device is then necessary.
Pathophysiology, Assessment, and Management of Common Birth Injuries in the Newborn
A. Birth trauma comes from injuries resulting from mechanical forces during the delivery process. 1. Most are self-limiting with a favorable outcome. a. Birth injuries account for 2% to 3% of all infant deaths. b. Newborn injuries can occur because of: i. Newborn size ii. Position during labor and delivery c. Conditions associated with a difficult birth include: i. Primigravida (first pregnancy) ii. Prolonged labor iii. Cephalopelvic disproportion iv. Rapid labor v. Abnormal presentation vi. Large size vii. Shoulder dystocia viii. Prematurity ix. Low birth weight 2. Birth trauma injuries include: a. Those that can involve instruments used during delivery i. Abrasions ii. Lacerations iii. Bruises iv. Subcutaneous fat necrosis b. Excessive molding of the head and overriding parietal bones c. Caput succedaneum: Swelling of soft tissue of the scalp from pressing against the dilating cervix i. Usually disappears in a day or two after birth d. Cephalhematoma: Area of bleeding between the parietal bone and the covering periosteum i. Often appears several hours after birth as a raised lump on the head ii. May take 2 weeks to 3 months to resolve iii. Do not try to drain because it may worsen or prolong bleeding. e. Linear skull fractures i. Avoid pressure to involved areas. ii. Displaced fractures need neurosurgical evaluation. f. Brachial plexus injuries i. Usually occurring in large newborns ii. Erb palsy (most common)—involvement of C5, C6 iii. Klumpke paralysis (rare)—involvement of C7, C8, T1 (a) Results in intrinsic hand muscle weakness g. Facial nerve palsy i. Findings include asymmetric faces when crying. ii. Full resolution of cranial nerves may take several weeks. h. Diaphragmatic paralysis i. May occur from cervical root injury or a brachial plexus injury ii. Symptoms may include: (a) Respiratory distress with hypoxemia (b) Hypercapnia (c) Acidosis i. Laryngeal nerve injury resulting from intrauterine posture i. Presents with stridor or hoarse cry ii. Paralysis often resolves in 4 to 6 weeks. j. Spinal cord injury resulting from: i. Excessive traction (breech delivery) ii. Rotation and torsion (vertex delivery) 3. Clavicle is most frequently fractured bone in the newborn. a. Most often an unpredictable and unavoidable complication b. Risk factors include: i. Large size ii. Mid-forceps delivery iii. Shoulder dystocia c. May present with pseudoparalysis to minimize pain d. Examination will show: i. Crepitus ii. Palpable bony irregularity iii. Possible lack of arm movement on affected side 4. Long bone fracture may present as loss of spontaneous arm or leg movement. a. Treatment includes splinting. b. Check for signs of radial nerve injury with a humerus fracture. 5. Intra-abdominal injury is uncommon in newborns. a. Possible injuries include: i. Liver contusion or fracture ii. Spleen rupture iii. Adrenal hemorrhage b. Bleeding either catastrophic or insidious c. Consider in every newborn presenting with: i. Shock or unexplained pallor ii. Abdominal distension 6. Hypoxia and shock could be caused by birth trauma.
Pathophysiology, Assessment, and Management of Cardiac Conditions in Newborns
A. Pathophysiology 1. Congenital heart disease (CHD) a. Most common birth defect, occurring in 8 per 1,000 live births i. Approximately 1/3 are critical. ii. Accounts for approximately 40% of deaths caused by congenital anomalies b. Use pulse oximetry to detect oxygenated versus nonoxygenated blood. i. The highest sensitivity and highest specificity in monitoring is with the right hand and one foot. (a) Cutoff values of less than 95% or a greater than 3% difference between the two ii. Department of Health and Human Services and the American Academy of Pediatrics recommend pulse oximetry screening for full-term healthy newborns. c. Pulmonary stenosis: Pulmonic valve near the right ventricle becomes damaged. i. Patient will have a decrease in blood flow to the lungs and will present with: (a) Jugular vein distention (b) Cyanosis (c) Right ventricular hypertrophy ii. Typically associated with CHD d. Septal defects can exist in either the atrias or the ventricles. i. With an atrial septal defect (ASD), deoxygenated blood can shift from the right or left atrium to the other atria and mix with oxygen-rich blood. (a) May occur if the foramen ovale, which allows the fetus to receive oxygen-rich blood from the placenta, does not close after birth. (b) Hemodynamic status is dependent on how much blood flow is shunted. ii. In a ventricular septal defect (VSD), blood flows back into the right ventricle when the left ventricle contracts. (a) Causes an increase in the right ventricle pressure (b) Results in pulmonary hypertension e. Patent ductus arteriosus (PDA): The ductus arteriosus does not close after birth. i. Before birth, an open ductus arteriosus allows blood flow to bypass the right ventricle and lungs. ii. After birth, it should evolve into the ligamentum arteriosum. iii. Congestive heart failure may be the result of an untreated PDA. f. Coarctation of the aorta (CoA): Narrowing of the aorta i. The heart must work harder to keep the blood flowing past the narrowed area. ii. Signs and symptoms include: (a) Shortness of breath (b) Chest pain (c) Hypertension (d) Headaches (e) Muscle weakness iii. Treatment is usually heart surgery. g. Truncus arteriosus: The pulmonary and aorta arteries are combined as one vessel. i. Greatly increases blood flow into the lungs, causing congestive heart failure ii. Patient will have slightly lower oxygen levels early in life, eventually resulting in cyanosis. iii. Will require surgical intervention h. Tricuspid atresia: The tricuspid valve is missing. i. Results in an undersized or absent right ventricle ii. Will have a significantly decreased blood flow into the lungs, leading to severe hypoxemia and death iii. May require a Fontan procedure to redirect the inferior vena cava and hepatic vein into the pulmonary circulation i. Hypoplastic left heart syndrome (HLHS): The left side of the heart is completely underdeveloped. i. Left side of the heart is unable to fulfill circulation needs. ii. Patients present with murmur or cyanosis. iii. Heart transplant is necessary. j. Tetralogy of Fallot (ToF): Combination of four heart defects i. Defects: (a) Ventricular septal defect—Hole in the septum separating the right and left ventricles, allowing blood flow between the two (b) Pulmonary stenosis—Narrowing of the pulmonary valve (c) Right ventricular hypertrophy—Thickening of the right ventricle (d) Overriding aorta—Aorta connected between the left and right ventricles over the VSD ii. Results in poor oxygenation iii. Open heart surgery is required. k. Transposition of the great arteries (TGA): Blood goes to the lungs for oxygenation, then returns to the lungs, while blood from the body to the heart goes back to the body without becoming oxygenated. i. Patients present with: (a) Shortness of breath (b) Finger and toe clubbing (c) Cyanosis ii. May require surgical intervention l. Total anomalous pulmonary venous return (TAPVR): The four pulmonary veins connect to the right atrium instead of the left atrium. i. Results in diminished oxygen and increased load on the right ventricle B. Assessment and management 1. Critical CHD presents in the neonatal period. a. Rapid detection and transport are mandatory. b. Communication with medical control is critical to have adequate services available upon arrival at the emergency facility.
Pathophysiology, Assessment, and Management of Specific Conditions: Bradycardia - Assessment and Management
Heart rate is assessed by auscultation or palpating base of umbilical cord. If heart rate is less than 100 beats/min, provide PPV. Assess airway patency. If less than 60 beats/min in spite of effective bag-mask ventilation: - Begin chest compressions per NRP guidelines. If less than 60 beats/min after 30 seconds of effective ventilation and 30 seconds of chest compression: Administer epinephrine. - Recommended concentration: 1:10,000 - Recommended IV dose: 0.1 to 0.2 mL/kg of 1:10,000, administered rapidly, followed with a normal saline flush - Recommended ET tube dose (if IV line not established): 0.3 to 1 mL/kg of 1:10,000 Repeat dose every 3 to 5 minutes for persistent bradycardia.
Pharmacologic Interventions: Low Blood Volume
If there is significant intravascular volume depletion, fluid resuscitation may be needed. Causes may include: - Placenta abruptio - Twin-to-twin transfusion - Placenta previa - Septic shock Signs of hypovolemia include: - Pallor - Persistently low pulse rate - Weak pulses - No improvement in circulatory status after adequate resuscitation efforts. Place a low umbilical vein line in a newborn. - If more than a few days old, place a peripheral IV or IO line. Fluid bolus in a newborn is 10 mL/kg given IV every 5 to 10 minutes of: - Saline - Lactated Ringer's - O Rh-negative blood Multiple boluses may be given if needed.
General Pathophysiology and Assessment: Neonatal resuscitations - 1) Initial Steps of neonatal resuscitation
Initial steps of neonatal resuscitation include: - Airway (position and clear) - Breathing (stimulate to breathe) - Circulation (assess heart rate and oxygenation)
Pathophysiology, Assessment, and Management of Specific Conditions: Seizures in the newborn - Pathophysiology
Most distinctive sign of neurologic disease in the newborn More common in premature newborns Identified by direct observation in the field - Diagnosis is confirmed by electroencephalogram in the hospital. The following are often mistaken for seizures in the newborn: - Normal movements when a newborn is drowsy or asleep - Jitteriness - Gastroesophageal reflux and choking episodes Seizures are usually related to an underlying abnormality. Seizures may interfere with: - Cardiopulmonary function - Feeding -Metabolic function Prolonged seizures may cause brain injury.
Pathophysiology, Assessment, and Management of Specific Conditions: Bradycardia - Pathophysiology
Most frequently occurs in newborns because of inadequate ventilation Often responds to effective PPV Other causes include: - Hypothyroidism - Acidosis - Congenital atrioventricular block in newborns whose mothers have lupus - Prolonged suctioning or attempts at intubation - Vagal stimulation from an inadequately secured ET tube or orogastric tube Morbidity and mortality are determined by underlying cause and how quickly it is corrected.
Pathophysiology, Assessment, and Management of Specific Conditions: Pneumothorax - Pathophysiology
Pneumothorax evacuation Pneumothorax can occur if: - Infant inhales meconium at birth - Lung is weakened by infection - PPV is needed. Signs of significant pneumothorax: - Severe respiratory distress unresponsive to PPV - Unilateral decreased breath sounds - Shift of heart sounds if pneumothorax on left side
General Pathophysiology and Assessment: The Apgar Score
The Apgar score helps record the newborn's condition in the first few minutes after birth. Helps paramedics determine specific resuscitation measures needed and their effectiveness Each sign is given a value of 0, 1, or 2. Recorded at 1 and 5 minutes after birth. - If the 5-minute score is less than seven, an additional score should be done every 5 minutes until 20 minutes after birth. If resuscitation is necessary, the Apgar score is done by determining the resuscitation results.
Family and Transport Considerations: 1) Transport to the nearest facility
Transport to the nearest facility to provide the next level of care once the newborn is stabilized as much as possible. Contact the facility for advice regarding care and disposition. Provide ongoing communication with the family about the current care. - Do not be specific about survival statistics. - If you cannot answer questions, tell them you will help find those who can. During transport, monitor the newborn and frequently assess for status changes. Vital to check: - Thermoregulation - Respiratory effort - Airway patency - Skin color - Pulse rate
Pathophysiology, Assessment, and Management of Specific Conditions: Hypoglycemia - Pathophysiology
A blood glucose level of less than 45 mg/dL in full-term or preterm newborns An imbalance between glucose supply and utilization, with low glucose levels due to: - Inadequate intake or storage - Increased glucose utilization Most newborns are asymptomatic until glucose level falls below 20 mg/dL. May result in: - Seizures The newborn may be at risk for hypoglycemia due to:... Disorders related to decreased glycogen stores - Small for gestational age - Prematurity - Postmaturity Increased use of glucose - Newborn of a diabetic mother - Large for gestational age - Hypoxia - Hyperthermia - Sepsis
Pathophysiology, Assessment, and Management of Specific Conditions: Diaphragmatic hernia - Assessment and Management
A newborn may demonstrate: - Few or no symptoms - Severe hypoxia and increased work of breathing Resuscitate on 100% oxygen. - Bag-mask ventilation will distend intestines and compromise ventilations further. - If PPV is necessary, place an ET tube, and deliver a peak ventilatory pressure of 25 mm Hg or less. - Place an orogastric tube, and provide intermittent suctioning to minimize distention. Monitor heart rate continuously during transport. Ultimately requires surgical correction, so transport to a facility with a neonatal intensive care and pediatric surgery.
Pathophysiology, Assessment, and Management of Conditions Related to Thermoregulation
A. Thermoregulation is limited in a newborn. 1. Average normal temperature of newborn—37°C (99.5°F) a. Range for neonate—36.6°C to 37.2°C (97.9°F to 99°F) b. The production of heat by metabolism (nonshivering thermogenesis) is the newborn's primary source of heat production. i. Brown fat is unique to newborns. (a) Deposited in fetus after 28 weeks of gestation (b) Stored around the scapula, kidneys, adrenal glands, neck, and axilla 2. Heat loss occurs through: a. Evaporation—water evaporates from the skin and respiratory tract. b. Convection—heat lost to cooler surrounding air c. Conduction—heat lost to cooler solid objects in direct contact to the newborn d. Radiation—heat lost to cooler objects not in direct contact to the newborn
General Pathophysiology and Assessment: Neonatal resuscitations - 3) Additional resuscitation steps
Additional resuscitation steps include: - Providing supplemental oxygen - Assisting in ventilation by providing positive pressure - Intubating - Providing chest compressions - Administering medications Complications during resuscitation must be anticipated and prepared for.
Pathophysiology, Assessment, and Management of Specific Conditions: Diaphragmatic hernia - Pathophysiology
An abnormal opening in the diaphragm Causes the abdominal contents to herniate into the chest cavity Causes the heart and mediastinum to shift to the contralateral side of the hernia Postnatal signs and symptoms: - Respiratory distress - Heart sounds shifted to the right - Decreased breath sounds on the left - Bowel sounds heard in the chest - Scaphoid abdomen Mortality may be as high as 50%.
General Pathophysiology and Assessment: Algorithm for neonatal resuscitation
Approximately 10% of newborns need additional assistance, and 1% need major resuscitation. Interventions, assessment, and determination of need to progress to the next level delineated in 30-second intervals. Following delivery, the initial resuscitation steps should be done for 30 seconds. If no response, further intervention is needed. Asses respiratory rate and effort, pulse rate, and color. - Determine respiratory and pulse rate per minute by counting them for 6 seconds and multiplying by 10. - Determine pulse rate by auscultation or feeling the base of the umbilical cord at the baby's abdomen. Many newborns have blue hands and feet (acrocyanosis) after they turn pink. - If there is a normal breathing pattern and pulse rate greater than 100 beats/min, but central cyanosis of the trunk or mucous membranes, provide supplemental free-flow oxygen. If still apneic or has a pulse rate of less than 100 beats/min after 30 seconds of drying, stimulation, and oxygen: - Begin positive-pressure ventilation (PPV) by a newborn-sized bag-mask device. - Be careful to not squeeze the bag too hard in order to avoid delivering too much volume. - If blended oxygen is not available, start with room air, then switch to 100% oxygen if needed. - If pulse rate is less than 50 beats/min, begin chest compressions in addition to PPV. Fewer than 1% of deliveries result in bradycardia that requires chest compressions. Most common etiology is hypoxia, which is reversed by PPV. A less common etiology is tension pneumothorax, which is treated with needle decompression. If ventilation and chest compression do not improve the bradycardia, administer epinephrine via IV line or ET intubation.
Pathophysiology, Assessment, and Management of Conditions Related to Thermoregulation
B. Fever 1. Fever: Rectal temperature greater than 38°C (100.4°F). a. Oral temperature—0.6°C (1°F) lower than rectal temperature on average b. Axillary temperature—1.1°C (2°F) lower than rectal temperature on average 2. A newborn may not always present with fever in an illness or infection because of the immaturity of its temperature regulation system. a. May become hypothermic or hypoglycemic instead b. No matter the presenting symptoms, it is imperative to identify serious bacterial infection in newborns so they can be treated. i. Of infants younger than age 28 days with a temperature of more than 38°C (100.6°F), approximately 13% will have serious bacterial infection. 3. Fever may be caused by overheating or dehydration. 4. Limited ability to control their temperature a. Do not sweat when they are hot b. Do not shiver to raise temperature c. Core temperature may drop in newborns with serious life-threatening infection, giving them a higher risk of: i. Hypoglycemia ii. Metabolic acidosis 5. Signs and symptoms include: a. Irritability b. Somnolence c. Decreased feeding d. Warm to touch 6. Assessment and management a. Examine for presences of rashes, especially: i. Petechiae ii. Pinpoint pink or red skin lesions b. Obtain a careful history about: i. General activity ii. Feeding iii. Voiding iv. Stooling c. Note increased respiratory rate and work of breathing. d. Obtain vital signs, and ensure adequate oxygenation and ventilation. i. Provide free-flow supplemental oxygen and chest compressions as necessary. e. Antipyretic agents are controversial in the field. i. Do not give ibuprofen. f. To cool: i. Remove additional layers of clothing. ii. Improve ventilation in environment.
Pathophysiology, Assessment, and Management of Conditions Related to Thermoregulation
C. Hypothermia 1. A drop in body temperature to less than 25°C (95°F) a. Linked to impaired growth and infection vulnerability b. Moderate hypothermia linked with increased risk of death in low birth weight newborns c. Newborns have increased surface area-to-volume ratio and are sensitive to environmental conditions, especially when wet after delivery i. Metabolic function increase to overcome heat loss can cause: (a) Hypoglycemia (b) Metabolic acidosis (c) Pulmonary hypertension (d) Hypoxemia d. If a newborn is hypothermic, investigate for infection. 2. Assessment and management a. Hypothermic newborns may be: i. Cool to the touch, initially in the extremities ii. Pale with acrocyanosis b. May present with: i. Decreased respiratory effort ii. Apnea iii. Bradycardia iv. Cyanosis v. Irritability vi. Weak cry vii Sclerema (hardening of the skin associated with reddening and edema) on the back, limbs, or over the entire body. c. Preventive measures include: i. Warming hands before touching the newborn ii. Drying thoroughly after birth and removing wet blankets iii. Placing a cap on the head iv. Placing the newborn "skin-to-skin" with the mother and placing warm blankets over the newborn d. Treatment includes: i. Ensure adequate oxygenation and ventilation, performing chest compressions if needed. ii. If glycemic, administer D10W. iii. Administering warm IV fluids if indicated. iv. Once stabilized, the critically ill newborn should be placed in a prewarmed incubator. v. If not available, place on mother's chest and cover with a blanket. vi. Continue until temperature reaches normal or the feet are not cold.
Pathophysiology, Assessment, and Management of Specific Conditions: Pneumothorax - Pathophysiology
Clean area with alcohol around second intercostals space, midclavicular line Prepare equipment: - 22-g butterfly needle attached to extension tubing - Three-way stopcock - 20-mL syringe Palpate upper edge of second rib, and insert needle above it. - At the same time, a second provider pulls back on the syringe. - Slowly advance the needle until air is recovered. If syringe fills with air: - Turn stopcock off to newborn. - Push air out from the syringe. - Open stopcock to the newborn. - Continue withdrawing air. Remove the needle when there is no more air to be withdrawn. If symptomatic ongoing air leak, insert a 22-g angiocatheter in a similar location. - May further tear the lung and is more likely to kink than the butterfly needle. Tubing may be taped to chest and briefly occluded. - Place tubing in a small bottle of sterile water and release the tubing occlusion. - Relieves pressure buildup until patient can be transported. During transport, monitor for reaccumulation of the pneumothorax.
Pathophysiology, Assessment, and Management of Specific Conditions: Apnea - Pathophysiology
Common in newborns delivered before 32 weeks of gestation Rarely seen in the first 24 hours Defined as respiratory pause of greater than 20 seconds Can lead to hypoxemia and bradycardia Often follows hypoxia or hypothermia Other causes include: - Maternal or infant narcotic exposure - Airway or respiratory muscle weakness - Septicemia - Prolonged or difficult labor and delivery - Gastroesophageal reflux - Central nervous system abnormalities - Metabolic disorders Pathophysiology depends on the underlying etiology. Newborns need respiratory support to minimize hypoxic brain damage and other organ damage.
Pathophysiology, Assessment, and Management of Specific Conditions: Seizures in the newborn - Causes of seizures
Seizure onset up to 3 days after delivery are often caused by: - Hypoxic ischemic encephalopathy - Hypoglycemia - Other metabolic disturbances Seizures that begin 3 days or longer after birth are likely from other causes: - Intracranial infections (meningitis) - Epileptic syndromes - Intracranial hemorrhage - Development defects - Hypocalcemia - Meningitis - Encephalopathy - Drug withdrawal Hypoxic ischemic encephalopathy: Most common cause of seizures in newborns Occur 12 to 24 hours after hypoxic event - Usually more severe over first 2 to 3 days of life. Metabolic abnormalities include disturbances in: Levels of: - Glucose - Calcium - Magnesium - Other electrolytes Amino acids Organic acids Blood ammonia Certain toxins
Pathophysiology, Assessment, and Management of Specific Conditions: Hypoglycemia - Assessment and Management
Symptoms may be nonspecific, including: - Cyanosis - Apnea - Irritability - Poor sucking or feeding - Limpness - Irregular respirations - Eye rolling - Hypothermia Symptoms may be associated with: - Lethargy - Tremors - Twitching or seizures - Coma - Tachycardia - Tachypnea - Vomiting Check blood glucose level in all sick newborns and evaluate vital signs. Manage hypoglycemia after taking care of the ABCs. - If the blood glucose level is less than 45 mg/dL, medical control may order a bolus of 2 mL/kg IV of 10% dextrose solution. Maintain normal body temperature.
Pathophysiology, Assessment, and Management of Specific Conditions: Meconium-stained amniotic fluid - Assessment and Management
Determine if fluid is thin and green-stained or thick with particulates. Assess activity level. If crying and vigorous, use standard interventions. If depressed, do not dry or stimulate.. - Clear meconium from airway - Intubate the trachea. - Attach a meconium aspirator and suction catheter to the end of the ET tube. - Suction the ET tube while withdrawing the tube from the trachea. - Cover the meconium aspirator hole with your finger while suctioning. If intubation is unsuccessful and the newborn is bradycardic, continue standard resuscitation per NRP guidelines. Start with room air. If hypoxia persists, provide blended oxygen or 100% oxygen to reverse hypoxia. - Preductal oxygen saturation takes about 10 minutes after birth to reach 90%. If the newborn remains bradycardic after effective PPV, initiate chest compressions and further interventions. Suspect airway occlusion or pneumothorax if the newborn does not respond well to resuscitation. Take steps to minimize hypothermia. Frequently reassess to ensure the newborn's condition has not changed. When transporting a newborn with these issues, stay in communication with a facility skilled at managing high-risk newborns.
Family and Transport Considerations: 2) New Techniques
Development of new techniques for newborn care has reduced mortality among high-risk newborns. It may be necessary to transfer critically ill newborns to a regional center to get needed treatment. Transport of a high-risk newborn should include the following steps: A physician at the referring hospital initiates a request for transport. - A physician at the region control center decides which intensive care nursery can accommodate the patient. A mode of transportation is chosen depending on distance, availability, and weather conditions. The transport team is mobilized and equipment assembled. Ideal team consists of: - A nurse with special training in neonatal intensive care - A respiratory therapist with similar training - A paramedic with an apprenticeship in neonatal intensive care - A physician (for particularly critical patients) Highly specialized equipment includes: - Appropriately designed ventilation and oxygenation units - An incubator meeting stringent criteria On arrival at the referring hospital, the transport team continues to stabilize the newborn. Conditions that should be treated before leaving the referring hospital: - Hypoxemia - Acidosis - Hypoglycemia - Hypovolemia The team collects information while stabilizing the newborn, including: - A copy of the mother's and infant's charts - Any radiographic studies of the newborn
Specific Intervention and Resuscitation Steps: Circulation - 2) Vascular Access
Emergent access is necessary for: - Fluid administration to support circulation - IV resuscitation medication and therapeutic drugs The umbilical vein can be catheterized with an umbilical vein line. Clean the cord with antiseptic. - Drape area with sterile towels, keeping the stump exposed. - Place a sterile tie firmly around the base of the cord to control bleeding. Attach a 3-mL syringe and stopcock to a sterile 3.5F to 5F umbilical vein line catheter and prefill, turning the stopcock to off toward the patient. Cut the cord with a scalpel between the clamp and the cord tie, keeping about 1 to 2 cm from the skin. Insert a "low-UV line" into the umbilical vein Insert the catheter into this vein for a distance of 2 to 4 cm (less in preterm newborns) until blood can be aspirated. - If advanced into the liver, may cause irreversible damage - If advanced into the heart, may cause dysrhythmias - Flush the catheter with 0.5 mL of normal saline and tape into place. A peripheral IV or IO line can be used, but a smaller needle should be used in newborns.
Pathophysiology, Assessment, and Management of Specific Conditions: Respiratory distress and cyanosis - Assessment and Management
Ensure patent airway. Check that the breathing is adequate. Check to see that pulse is present. Assess respiratory rate, respiratory effort, and breath sounds. Ask parents about increased symptoms with feeding attempt. Treatment includes: - Establishing patent airway - Ensuring adequate oxygen delivery - Establishing effective ventilation - Ensuring adequate circulation If resuscitative efforts do not result in improvement, needle thoracentesis may be a necessary.
Specific Intervention and Resuscitation Steps: Airway Management - 1) Oxygen
Free-flow oxygen If a newborn is cyanotic or pale, provide supplemental oxygen. Clinical cyanosis only becomes apparent when 5 g/dL of hemoglobin is deoxygenated. Provide oxygen to a pale newborn until a pulse oximeter reading can give an accurate reading. If PPV is not indicated, oxygen can initially be delivered through: - Oxygen mask - Oxygen tubing cupped and held close to the newborn's nose and mouth. Oxygen flow rate should be 5 L/min.
General Pathophysiology and Assessment: Transition from fetus to newborn
In utero, the fetus receives oxygen from the placenta. - As the fetus is delivered, fetal transition occurs, enabling the newborn to breath. - First breath triggered by mild hypoxia and hypercapnia from partial occlusion of the umbilical cord during delivery. - Tactile stimulation and cold stress promote early breathing. - Pulmonary vascular resistance drops as the lungs fill with air. - More blood flows to the lungs, picking up oxygen. Delay in pulmonary pressure leads to: - Delayed transition - Hypoxia - Brain injury - Death Gestation times: - Preterm—less than 37 completed weeks - Term—38 to 42 completed weeks - Post-term—more than 42 weeks
Specific Intervention and Resuscitation Steps: Circulation - 1) Chest Compressions
Indicated if pulse rate remains at less than 60 beats/min despite: - Positioning - Clearing airway - Drying and stimulations - 30 seconds of effective PPV Two people are needed for effective chest compressions while ventilating. Two different techniques: Thumb technique - Preferred: Generates superior peak systolic and coronary arterial perfusion pressure while causing less fatigue in the provider Encircle the torso with both hands, with fingers supporting the spine. - Place two thumbs side by side (one over the other in a small preterm baby) over the lower third of the sternum. Once the airway is secure or the newborn is intubated, chest compressions can be delivered from the head of the bed. - Allows easier access to the umbilicus Two-finger technique - Place the tips of index and middle fingers of one hand over the lower third of the sternum. - The second hand supports the spine. The compression depth is one third of the anteroposterior diameter of the chest. - The thumbs or fingers should be in contact with the chest at all times. - Allow the chest to completely recoil after each compression. Chest compressions and artificial ventilation should not be delivered simultaneously. - Coordinate 90 compressions and 30 breaths/min—equaling 120 events per minute (1/2 second each) - The person doing the compressions should count out loud. Pulse rate should not be assessed for at least 45 to 60 seconds after ventilation and chest compressions are established. Interruption of chest compressions to assess the pulse may decrease perfusion of coronary arteries. If pulse rate is above 60 beats/min: - Chest compressions can be stopped. - Effective ventilation should continue at 40 to 60 breaths/min. - Recheck pulse rate after 30 seconds. When the pulse rate goes above 100 beats/min, gradually slow the rate and decrease PPV pressure.
Specific Intervention and Resuscitation Steps: Airway Management - 5) Gastric decompression
Indicated if: - Prolonged bag-mask ventilation (more than 5 to 10 minutes) - Abdominal distention is impeding ventilation. - Diaphragmatic hernia or gastrointestinal congenital anomaly Diaphragmatic hernias are suspected if: - Decreased breath sounds on left side - Scaphoid or concave abdomen - Increased work of breathing To properly insert an orogastric tube in the newborn, refer to Skill Drill 42-2.
Specific Intervention and Resuscitation Steps: Airway Management - 3) Bag-Mask Ventilation
Indicated when a newborn: - Is apneic - Has inadequate respiratory effort - Has a pulse rate of less than 100 beats/min after: Airway is cleared of secretions. Tongue obstruction is relieved. Newborn is dried and stimulated. Signs of respiratory distress suggesting need for bag-mask ventilation include: - Periodic breathing - Intercostal retractions - Nasal flaring - Grunting on expiration Three devices to deliver bag-mask ventilation to newborns: - Self-inflating bag with an oxygen reservoir—most likely to be found in the field - Flow-inflating bag—needs a gas source, more common in surgery - T-piece resuscitator—needs a gas source; usually found in neonatal intensive care units When using the self-inflating bag, always use the infant size (240 mL) when available. - Only one tenth of the bag's volume will be used for each breath. - If a neonatal bag is not available, use a bag designed for adults or larger children provided that: (a) The delivered breath size is appropriately small. (b) Chest rise is monitored for excessive volumes of delivered breaths. When administering bag-mask ventilation with 100% oxygen, the face mask should provide an airtight seal. - Airway should be patent and head should be in the sniffing position. - The first few breaths after birth frequently need higher pressures (possibly 30 mm Hg). - Subsequent breaths should have enough pressure to deliver a visible but not excessive chest rise. The correct ventilation time (40 to 60 breaths/min) is important because a higher rate can cause: - Hypocapnia - Air trapping - Pneumothorax Continue PPV as long as the pulse rate is less than 100 beats/min or the respiratory effort is ineffective. - If more than 1 minute of PPV is needed, hook the system to a pressure manometer. Causes of ineffective bag-mask ventilation: - Inadequate mask seal on the face - Incorrect head position - Copious secretions - Pneumothorax - Equipment malfunction
Specific Intervention and Resuscitation Steps: Airway Management - 4) Intubation
Indicated when: Meconium-stained fluid is present and the newborn is not vigorous (tracheal suctioning is indicated). Congenital diaphragmatic hernia is known and suspected, and respiratory support is necessary. - Abdominal organs herniate through an opening in the diaphragm into the chest cavity. No response to bag-mask ventilation and chest compressions, necessitating ET administration of epinephrine - Prolonged PPV needed - Craniofacial defects impede an adequate airway. The following equipment should be available: - Suction equipment - Laryngoscope - Blades—straight - Shoulder roll - Adhesive tape - ET tube - Stylet (used by some paramedics—must be secured at top of ET tube) To properly intubate a newborn, refer to Skill Drill 42-1. Complications of ET tube placement include: - Oropharyngeal or tracheal perforation - Esophageal intubation with subsequent persistent hypoxia - Right mainstem intubation Risks can be minimized by: - Ensuring optimal placement of laryngoscope blade - Noting how far the ET tube is advanced
General Pathophysiology and Assessment: Neonatal resuscitations - 2) Initial Steps of stabilizing a newborn
Initial steps of stabilizing a newborn include: Warming the newborn to prevent hypothermia - Place on prewarmed towels or blankets and dry. - Replace wet towels with dry, prewarmed ones. - When resuscitation is complete, place the newborn on the mother's chest or abdomen, another heat source, or under a radiant warmer. Positioning the newborn - Position on the back or side with the neck in the sniffing position. - Use a small shoulder roll to keep the head in this position. Clearing the airway if necessary - Use a bulb syringe or suction catheter. - Turn the head to the side. - Suction the mouth before the nose to prevent aspiration. - Suctioning hard or deeply can induce a vagal response and bradycardia. - Return the head to the sniffing position. Drying and stimulating breathing - Dry the head and body with towels to provide stimulation. - Additional tactile stimulation methods include: Slapping/flicking soles of the feet Rubbing gently on the back or trunk - Keep appropriate position of the head throughout stimulation.
Pathophysiology, Assessment, and Management of Specific Conditions:
J. Vomiting 1. Common in newborns a. Ranges from spitting up to severe, bloody, or bilious projectile vomiting i. Bilious and/or bloody emesis needs medical treatment. ii. Persistent vomiting is a warning sign and can cause: (a) Excessive fluid loss (b) Dehydration (c) Electrolyte imbalances b. Persistent vomiting in the first 24 hours may indicate: i. Upper digestive tract obstruction ii. Increased intracranial pressure c. Vomitus with dark blood indicates gut bleeding and may be a sign of life-threatening illness. d. Vomitus aspiration may cause respiratory insufficiency or airway obstruction. 2. Causes of vomiting a. Esophageal atresia: Failure to develop the distal lumen i. Newborns seen with excessive frothing soon after birth ii. Possible choking when trying to feed b. Pathogenic gastroesophageal reflux (GER) i. May vomit either immediately or a few hours after feeding ii. In infants and young children, presents as: (a) Typical or atypical crying and/or irritability (b) Apnea and/or bradycardia (c) Poor appetite (d) Apparent life-threatening event (e) Vomiting (f) Wheezing (g) Stridor (h) Weight loss or poor growth (i) Hoarseness (j) Laryngitis c. Infantile hypertrophic pyloric stenosis (IHPS): Hypertrophy and hyperplasia of the two muscular layers of the pylorus i. Pylorus thickens and obstructs the end of the stomach. ii. Stomach muscles cannot contract to overcome the obstruction. iii. Patients present with: (a) Projectile vomiting (b) Dehydration (c) Malnutrition (d) Electrolyte changes d. Malrotation: Congenital anomaly of midgut rotation i. Predisposes infant to midgut volvulus and secondary obstruction of intestinal blood supply ii. Vomitus is bile stained and possibly feculent if obstruction is distal in intestines. iii. Early mortality rate ranges from 23% to 33%, with most deaths resulting from: (a) Bowel dysfunction (b) Malnutrition e. Congenital conditions where parts of the bowel may not have developed properly (intestinal atresia) or are narrow (intestinal stenosis) i. Conditions affecting the upper bowel may present with bilious vomiting. ii. Lower bowel obstruction may present as feeding intolerance and abdominal distention. f. Meconium plug seen in Hirschsprung disease i. The last colon segment fails to relax, causing mechanical obstruction. ii. Infant usually has history of not passing meconium in the first 24 hours of life. g. Sudden, unexpected, and forceful vomiting may occur in conjunction with: i. Asphyxia ii. Meningitis iii. Hydrocephalus h. Withdrawal symptoms in an addicted newborn can include vomiting. 3. Assessment and management a. Stomach may be distended due to vomiting. b. Suspect infection if newborn has a fever or hypothermia, or has been in contact with ill people. c. May also note: i. Temperature instability ii. Apnea/bradycardia iii. Abdominal tenderness/guarding iv. Minimal or absent bowel sounds d. Start management with ABCs. i. Maintain a patent airway—newborns may aspirate vomitus. ii. Keep face turned to one side to prevent aspiration. iii. Suction or clear vomitus from airway with a suction catheter or suction bulb. iv. Provide either free-flow supplemental oxygen or bag-mask ventilation as necessary. e. Consider a nasogastric or orogastric tube to decompress the stomach. f. Do not administer antiemetics in the field. g. The newborn may need fluid resuscitation of normal saline if signs point to dehydration: i. Dry mucous membranes ii. Tachycardia iii. Sunken fontanelle h. Place newborn on the side when transporting to a facility that can manage a high-risk newborn.
General Pathophysiology and Assessment: Newborn vs neonate
Newborn or neonate care must be adapted to meet the needs of the population. Newborn: An infant within the first few hours after birth Neonate: An infant within the first month after birth If a newborn needs special support and intervention by trained caregivers, parents may feel inadequate. Supporting the needs of both the newborn and caregivers is important. - Allow them to be as physically close as possible. - Explain what is happening. - Provide details for transport plan to the next level of care.
Pathophysiology, Assessment, and Management of Specific Conditions: Meconium-stained amniotic fluid - Pathophysiology
Meconium-stained amniotic fluid Carries a high risk of morbidity More common in: - Postterm newborns - Those small for their gestational age - Newborns stressed before or during delivery If newborns pass stool before birth, they may inhale the meconium-stained amniotic fluid. Airway may become plugged, causing:... Hypoxia, which can lead to: - Atelectasis - Persistent pulmonary hypertension - Hypoxemia - Aspiration pneumonitis Ball-valve effects with an increased risk of pneumothorax May cause a delayed drop in pulmonary vascular resistance, which can cause: - Right-to-left shunting across the foramen ovale or the patent ductus arteriosus (persistent pulmonary hypertension of the newborn) To decrease the risk of persistent pulmonary hypertension: - Ensure a clear airway. - Keep newborn warm. - Minimize stimulation. - Provide supplemental oxygen when necessary. If meconium aspiration occurs, follow closely for signs of deterioration.
Pharmacologic Interventions: Weight Based
Medications are rarely needed in newborn resuscitation because they can usually be resuscitated with ventilator support. Medication dosages are based on weight. A full-term newborn usually weighs 6½ to 9 lb and is 20 inches long. A newborn at 28 weeks of gestation usually weighs 2½ lb and is 14¾ inches long.
Pharmacologic Interventions: Hypoglycemia
Most often seen in newborns: - Who are small for gestational age - Who are large for gestational age - Whose mothers were diabetic during pregnancy Neurologic symptoms include: - Jitteriness - Decreased response to stimuli - Hypotonia - Apnea - Poor feeding - Seizures Obtain baseline vital signs and oxygen saturation readings. Provide as necessary: - Additional oxygen - Assisted ventilation - Blood pressure support - IV access If the blood glucose level is less than 40 mg/dL: - An IV bolus of 10% dextrose solution (2 mL/kg) can be given. - Recheck blood glucose level in about 30 minutes. - Dextrose IV administration may need to be followed by a 10% dextrose infusion at 60 to 100 mL/kg/d.
General Pathophysiology and Assessment: Arrival of the newborn
Obtain a patient history, and prepare the environment and equipment with any available time. Key questions to help determine resuscitation and needed equipment include: - Woman's age - Length of pregnancy - Presence and frequency of contractions - Presence or absence of fetal movement - Any pregnancy complications - If membranes have ruptured (a) Timing (b) Makeup of fluid - Medications being taken 90% of newborns are vigorous and at term, and transition well with basic intervention. - Minimum needs: - Warm, dry blankets - Bulb syringe - Two small clamps or ties - A pair of clean scissors **Complications need prompt management. If delivered in the ambulance: - Cover the foot of the stretcher with clean, warm blankets for the initial stabilization. - After confirming adequate airway, breathing, and pulse rate, place the newborn on the mother's chest. - If more extensive resuscitation is necessary, transition newborn to a second ambulance with a neonatal transport incubator. - Suction the mouth, then the nose with a bulb syringe once the head is delivered. - Keep the newborn at the level of the mother after delivery, with head slightly lower than the body. Clamp the umbilical cord in two places and cut cord between clamps. - If the cord comes out ahead of the newborn, the blood supply to the fetus may be cut off. - Relieve pressure on the cord by gently moving the newborn's body off the cord and pushing the cord back. Do an initial rapid assessment simultaneous with treatment interventions. - Note time of delivery. - Monitor ABCs. - Assess airway patency, respiratory rate and effort, tone, pulse rate, and color. Newborn is at risk for hyperthermia. Ensure thermoregulation by: - Placing the newborn on prewarmed towels or radiant warmer - Drying the head and body thoroughly - Discarding wet towels and covering with a dry towel - Covering the head with a cap Position the newborn to ensure a patent airway, clear secretions, and assess the respiratory effort. All babies are cyanotic right after birth. If the newborn stays vigorous and begins to turn pink in the first 5 minutes: - Maintain ongoing observation. - Continue thermoregulation with direct skin-to-skin contact with mother while en route.
Pharmacologic Interventions: Bradycarda
Often the result of inadequate ventilation and will respond to effective PPV Epinephrine administration is indicated when a newborn still has a pulse rate of less than 60 beats/min after effective ventilation and chest compressions. Recommended concentration: 1:10,000 Recommended dose: 0.1 to 0.3 mL/kg of 1:10,000 epinephrine IV, administered rapidly Followed by 0.5- to 1-mL saline flush The preferred method during resuscitation is through a low umbilical vein catheter. Epinephrine can also be administered via ET tube while IV access is being established. - Recommended dose: 0.5 to 1 mL/kg of 10,000 epinephrine Check pulse rate 1 minute after administering epinephrine (longer if by ET tube). May repeat dose every 3 to 5 minutes for persistent bradycardia, ensuring that: - Ventilation is adequate and effective - ET tube is not dislodged - Chest compressions are given to adequate depth
Pathophysiology, Assessment, and Management of Specific Conditions: Premature and low birth weight infants - Pathophysiology
Premature—newborns delivered before 37 weeks of gestation. Often idiopathic, but maternal conditions associated with preterm labor and delivery include: - Maternal infection (including urinary tract infection) - Chorioamnionitis - Maternal illness leading to dehydration - Placental insufficiency - Polyhydramnios - Preeclampsia/eclampsia - Pregnancy-induced hypertension In addition to increased mortality, a number of morbidities are associated with prematurity: - Respiratory distress syndrome - Respiratory suppression and apnea - Hypothermia - Sepsis - Central nervous system compromise ** Intraventricular hemorrhage ** Periventricular leucomalacia Low birth weight—newborns weighing less than 5½ lb (2,500 g) The most common etiology is prematurity Factors that can predispose a woman to deliver prematurely include: - Genetic factors - Infection - Cervical incompetence - Abruption - Multiple gestations (twins, triplets) - Previous delivery of a premature infant - Drug use - Trauma Other factors contributing to low birth weight include: - Chronic maternal hypertension - Smoking - Placental abnormalities - Chromosomal abnormalities Morbidity and mortality are related to degree of prematurity. - Most delivered after 28 weeks of gestation who receive cardiovascular support survive long term. - Those born at 24 weeks of gestation have high morbidity and mortality.
Pathophysiology, Assessment, and Management of Specific Conditions: Seizures in the newborn - Assessment and Management
Quickly evaluate prenatal and birth history. Perform a careful physical exam. Hypoglycemia must be recognized and treated quickly with: - Blood glucose measurement and dextrose administration Obtain baseline vital signs and oxygen saturation readings. Provide additional oxygen, assisted ventilation, blood pressure evaluation, and IV access as necessary. If blood glucose level is less than 40 mg/dL, give an IV bolus of 10% dextrose solution and recheck in 30 minutes. Before giving an anticonvulsant medication, consult medical control. - May interfere with respiratory and cardiac function Monitor respiratory status and oxygen saturation carefully. Maintain normal body temperature. Keep family informed as you transport the newborn.
Specific Intervention and Resuscitation Steps: Airway Management - 2) Oral Airways
Rarely used on newborns. Conditions that may require oral airways: - Bilateral choanal atresia - Pierre Robin sequence - Macroglossia (large tongue) - Craniofacial defects that affect the airway In all these cases (except bilateral choanal atresia), an ET tube is inserted down a nostril. - Keep the mouth open to provide adequate ventilation. Bilateral choanal atresia: Bony or membranous obstruction of the back of the nose The Pierre Robin sequence: Series of developmental anomalies that include: - Small chin - Posteriorly positioned tongue
Pharmacologic Interventions: Respiratory Depression secondary to narcotics
Respiratory depression secondary to narcotics If the mother is a drug addict, administration of naloxone (Narcan) to the newborn may cause potentially fatal seizures. If a newborn has respiratory suppression from the mother's chronic use of narcotics: - Provide ventilator support. - Transport immediately. If respiratory depression is from the mother being treated acutely with narcotics: - 0.1 mg/kg of naloxone may be administered via IV or intramuscularly
Pathophysiology, Assessment, and Management of Specific Conditions: Respiratory distress and cyanosis - Pathophysiology
Single most common cause in the neonate is prematurity. Respiratory causes include: - Airway obstruction - Aspiration - Pneumonia - Pneumothorax - Tracheoesophageal fistula - Congenital diaphragmatic hernia - Immature lungs Other causes: - Any process resulting in a delay in drop of pulmonary vascular resistance after birth leading to shunting of blood across the patent ductus arteriosus and patent foramen ovale - Central nervous system depression - Septic shock and severe metabolic acidosis - Cardiac anomalies
Pathophysiology, Assessment, and Management of Specific Conditions: Seizures in the newborn - Types of seizures
Subtle seizure—characterized by: - Eye deviation - Blinking - Sucking - Pedaling leg movements - Apnea Tonic seizure—characterized by: - Tonic limb extension - Possible flexion of arms and leg extension Focal clonic seizure—characterized by clonic, localized jerking Myoclonic seizure—characterized by flexion jerks of upper or lower extremities Multifocal seizure: Clonic activity that involves more than one site, is asynchronous, and is usually migratory Generalized seizure: Activity that is bilateral, synchronous, and nonmigratory
Pharmacologic Interventions: Acidosis
Suspected metabolic acidosis if bradycardia persists after: - Adequate ventilation - Chest compressions - Volume expansion A saline bolus of 10-mL/kg normal saline may improve perfusion and clear acid.
Pathophysiology, Assessment, and Management of Specific Conditions: Premature and low birth weight infants - Assessment and Management
To determine prematurity, rely on: Physical features - Maturity of skin - Size of infant - Degree of respiratory distress Information from family about gestational dating - Last menstrual period - Estimated due date - Ultrasound dating Information related to maternal or fetal complications To optimize survival for a newborn delivered prematurely in the field: - Provide cardiorespiratory support. - Provide a thermoneutral environment. - Use only minimum pressure necessary to move chest when providing PPV. - Risk of retinopathy of prematurity, worsened by long-term oxygen exposure Management focuses on: - Clearing airway - Gentle stimulation - Providing supplemental oxygen and PPV if needed - Provide peak inspiratory pressures to maintain physiological chest rise. - Provide chest compressions if effective ventilation does not result in adequate heart rate. - Maintain a warm environment.
