Download - Resuscitation of a Newborn
Resuscitation In Newborns
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Dr. Kalpana MallaMD Pediatrics
Manipal Teaching Hospital
Approximately 10% of newborns require some assistance to begin breathing at birth.
Approximately 1% require extensive resuscitative measures.
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
• Always assume infant has secondary Apnea & commence Resuscitation
Resuscitation Assignments
• Team Leader- Airway
• Second Rescuer- Pulse Check (HR) Chest Compression• Third Rescuer- Medications Equipment
Core Knowledge and Skills
• Airways - Establish Clear Airway• Breathing- Ventilation & Oxygenation• Circulation- Adequate Cardiac Output• Drugs • Environment - Reduce Heat Loss
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
Airway
DO NOT SUCTION IF AIRWAY IS CLEAR– Positioning
• Supine or lateral • Head in neutral or slightly extended
position - Avoid overextension or flexion
CLEARING THE AIRWAY OF MECONIUM
Current recommendations No longer advise routine intrapartum oropharyngeal and
nasopharyngeal suctioning for infants born to mothers with meconium staining of
amniotic fluid
Suction
• Suction - Bulb syringe DeLee mucus trap Suction catheters (6F, 8F, 10F)
Feeding tube with syringe Meconium aspirator
Steps in Resuscitation - ABCDE
• Breathing -Initiate breathing - Tactile stimulation - PPV – bag & mask – bag & ET tube• Assessment of respiratory effort and color
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.
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
Use of oxygen duringneonatal 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
Steps in Resuscitation - ABCDE
Indications for PPV / Bag-Valve-Mask Ventilation
• Apnoeic • Gasping respiration • HR < 100 bpm • Persistent central cyanosis despite 100% O2 • 40-60 breaths/min • No response
Bag-Valve-Mask Ventilation
• Neutral Position of Head• Tight Mask Seal• Avoid Pressure on Trachea•Assisted rate= 40 to 60 bpm
Bag-Valve-Mask Ventilation
• Signs of Adequate Ventilation: - Bilateral Chest Expansion - Bilateral Breath Sounds - Adequate Heart Rate & Color
Bag and mask
Ventilate for 30 seconds:
Rate: 40-60 /minPressure: Visible rise and fall of chest
Continue ventilation Initiate chest compression
Consider intubation
HR > 100 bpm:Check for spontaneous
respirations
HR < 60 HR >100
Bag and mask the most important tool in newborn resuscitation
ENDOTRACHEAL TUBE PLACEMENT
• ET intubation - indicated at several points during neonatal resuscitation:
1. Tracheal suctioning for meconium 2. 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)
Place a pillow under the head and neck but NOT under the shoulders
This allows a straight line of
vision from the mouth to the vocal cords
The laryngoscope is
introduced into the right hand side of the mouth (it is held by the left hand
• 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
• 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
• 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
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
Steps in Resuscitation - ABCDE
• Circulation • Assessment of heart rate• Umbilical arteries pulsation• Chest Compressions
Steps in Resuscitation - ABCDE
Indication for Chest Compressions1. HR < 60 bpm despite adequate vent with 100%
O2 for 30 seconds
2. Heart Rate 60 to 80 but not Increasing (±) - controversial
2 techniques
• 2 thumb (preferred) • 2 finger • 3:1 ratio • 1/3 of AP diameter
Chest compression
1.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
Drugs needed forNewborn Resuscitation
Steps in resuscitation - ABCDE
Drugs • Adrenaline • Volume Expanders • Naloxone ±• Sodium bicarbonate (0.5 mEq/mL)
Drugs
1.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
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
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
Steps in resuscitation- ABCDE
• Environment – Turn on radiant warmer – Warm blankets/cap/plastic wrap for
preterms – Shut doors and windows – Heat Lamps
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
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
Fluids
- IV catheters (22 g)
- Tape and sterile dressing material
- D10W
- Isotonic saline solution
- T-connectors
- Syringes (1-20 mL)
Rapid assessment - 5 characteristics
• Full-term gestation?
• Amniotic fluid clear of meconium ?
• Breathing or crying?
• Good muscle tone?
• Color pink?
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
Resuscitation Priorities
- Drying, Warming, Positioning - Suctioning, Stimulation - BVM Vent - Oxygen - Chest Compressions -Intubation -Medications
• 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
• Evaluate:- Breathing Supportive care HR>100 pink
Apnoea or HR <100Provide positive pressure ventilation* by ambu bag
→Breathing HR >100 pink ↓ Ongoing care
IF• HR<60• Provide positive pressure ventilation*• Administer chest compression ↓• HR<60• Administer Epinephrine***ET may be considered at several steps
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)
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