provincial reciprocity attainment program neonatal assessment
TRANSCRIPT
Provincial Reciprocity Attainment ProgramProvincial Reciprocity Attainment Program
Neonatal Assessment
The Need for Resuscitation
Most term newborns require no resuscitation beyond maintenance of temperature, suctioning of the airway, and mild stimulation Approximately 6% of deliveries require
life support Incidence of complications increases as
birth weight decreases
The Need for Resuscitation
Antepartum (before labor and delivery) and intrapartum (during labor and delivery) risk factors may affect the need for resuscitation When any of these risk factors are present
during delivery or imminent delivery, prepare equipment and drugs that may be required for neonatal resuscitation
Medical direction should also be advised of the situation so that the appropriate destination hospital can be determined.
Antepartum Risk Factors
Multiple gestation Inadequate prenatal care Mother’s age
Less than age 16 or more than 35 History of perinatal morbidity or mortality Post-term gestation Drugs/medications Toxemia, hypertension, diabetes
Intrapartum Risk Factors
Premature labor Meconium-stained amniotic fluid Rupture of membranes greater than 24 hours
before delivery Use of narcotics within 4 hours of delivery Abnormal presentation Prolonged labor or precipitous delivery Prolapsed cord Bleeding
The Premature Infant
Refers to a baby born before 37 weeks gestation The weight of these newborns is often between 0.6 to 2.2
kg [1.5 to 5 pounds]
Premature infants have an increased risk for: Respiratory depression Hypothermia Head and brain injury
Resuscitation should be attempted if the infant has any signs of life
Congenital Anomalies
Choanal atresia A bony or membranous occlusion that
blocks the passageway between the nose and pharynx
Can result in serious ventilation problems in the neonate
Cleft lip One or more fissures that originate in the
embryo A vertical, usually off-center split in the
upper lip that may extend up to the nose
Congenital Anomalies
Cleft palate A fissure in the roof of the mouth that runs
along its midline May extend through both the hard and soft
palates into the nasal cavities
Pierre Robin syndrome A complex of anomalies including:
A small mandible Cleft lip Cleft palate Other craniofacial abnormalities Defects of the eyes and ears
Diaphragmatic Hernia
Protrusion of a part of the stomach through an opening in the diaphragm
Risk factors Bag and mask ventilation can
worsen condition
Pathophysiology Abdominal contents are displaced
into the thorax Heart may be displaced Respiratory compromise
Physiological Adaptations at Birth
At birth, newborns make three major physiological adaptations necessary for survival Emptying fluids from their lungs and
beginning ventilation Changing their circulatory pattern Maintaining body temperature
Transition From Fetal to Neonatal Circulation
Respiratory system must suddenly initiate and maintain oxygenation
Infants are very sensitive to hypoxia Permanent brain damage will occur
with hypoxemia Apnea in newborns
Causes of Hypoxia
Compression of the cord Difficult labor and delivery Maternal hemorrhage Airway obstruction Hypothermia Newborn blood loss Immature lungs in the premature newborn
Hypothermia
Newborns are at great risk for rapidly-developing hypothermia because of: Their larger body surface area Decreased tissue insulation Immature temperature regulatory mechanisms
Newborns attempt to conserve body heat through vasoconstriction and increasing their metabolism, placing them at risk for: Hypoxemia Acidosis Bradycardia Hypoglycemia
Assessment and Management
Initial steps of neonatal resuscitation (except infants born through meconium):
1. Prevent heat loss
2. Clear the airway by positioning and suctioning
3. Provide tactile stimulation and initiate breathing if necessary
4. Further evaluate the infant
Prevention of Heat Loss
Immediately after delivery Dry the infant's head and body Remove any wet coverings from the
infant Cover with dry wrappings Cover the newborn's head
Accounts for 20% of the newborn’s BSA
Opening the Airway
Position Suction
Technique Mouth first, than nares Nasal suctioning is a stimulus to breathe
Equipment Bulb suction Suction catheters
Provision of Tactile Stimulation
If drying and suctioning do not induce respirations, provide additional tactile stimulation Two safe and appropriate methods are:
Slapping or flicking the soles of the feet Rubbing the infant's back
If the infant remains apneic after a brief period (5 to 10 seconds) of stimulation: Immediately initiate positive-pressure ventilation with
a pediatric bag-valve device and supplemental oxygen (40 to 60 ventilations/min)
Evaluation of the Infant
Observe and evaluate the infant's respirations Evaluate the infant's heart rate by stethoscope, or
by palpating the pulse in the umbilical cord or brachial artery HR < 100
Provide ventilation via BVM for 30 seconds and reassess
HR < 60 Provide ventilation via BVM for 30 seconds and
reassess If not resolved begin CPR (a rate of > 100)
Evaluation of the Infant
Evaluate the infant's color If Central cyanosis, bradycardia and other signs of
distress are present in an infant with spontaneous respirations and an adequate heart rate, administer free-flow oxygen at 5 LPM
A maximum oxygen concentration of about 80% can be achieved when the tube is one-half inch from the infant's nose
Peripheral cyanosis is common in newborns and should resolve
Apgar Score
Enables rapid evaluation of a newborn’s condition at specific intervals after birth Routinely assessed at 1 and 5 minutes of age
Sign 0 1 2Appearance (Skin Color)
Central cyanosis, pale Peripheral cyanosis Pink
HR Absent < 100 bpm > 100 bpm
Grimace (Irritability) No response Grimace Cough, sneeze, cry
Muscle tone Limp Some flexion Active motion
Respiratory Effort Absent Slow, irregular Good, crying
Resuscitation of the Distressed Newborn
Risk factors associated with the need for resuscitation include: Premature delivery Maternal health problems Complicated pregnancies Delivery complications
Reevaluating components of the resuscitation process
Neonatal Transport
During transport of the neonate: Maintain body temperature Oxygen administration Ventilatory support
In the prehospital phase of care, transport strategies are usually limited to: Providing a warm ambulance Free-flow oxygen administration Warm blankets
Respiratory Disorders
Respiratory insufficiency in the neonate is generally managed by: Stimulation and positioning of the airway Prevention of heat loss Oxygenation and ventilation Suction Ventilatory support (if needed)
Apnea
Respiratory pauses that exceed 20 seconds Common finding in preterm infants, and if
prolonged, can lead to hypoxemia and bradycardia
Primary apnea self-limited condition (controlled by pCO2 levels) that is
common immediately after birth
Secondary apnea describes respirations that are absent and that do not
begin again spontaneously
Apnea
Risk factors Hypoxia Hypothermia Narcotic or CNS depressants Airway or respiratory muscle weakness Oxyhemoglobin dissociation curve shift Septicemia Metabolic Disorders CNS Disorders
Respiratory Distress and Cyanosis
Prematurity is the single most common factor for respiratory distress and cyanosis in the neonate Occurs most frequently in infants less than 1200
g (2.5 pounds) and 30 weeks gestation Risk factors (see next slide):
Can lead to cardiac arrest Requires immediate intervention to support respirations
Other Risk Factors
Lung or heart disease Primary pulmonary HTN CNS Disorders Mucous obstruction of
nasal passages Spontaneous
pneumothorax Choanal atresia
Meconium aspiration syndrome
Amniotic fluid aspiration Lung immaturity Pneumonia Shock and Sepsis Metabolic acidosis Diaphragmatic hernia
Dyspnea and Cyanosis
S/S may include Tachypnea Tachycardia Paradoxical breathing Intercostal retractions Nasal flaring Expiratory grunting Central cyanosis
Cardiovascular Disorders
All neonates with cardiovascular disorders should be assessed for treatable causes of hypoventilation
Bradycardia A heart rate of less than100 beats/min Causes
Hypoxia (most common) Increased intracranial pressure Hypothyroidism Acidosis
Considered a minimal risk to life in neonates if corrected quickly
Cardiac Arrest
Incidence is rare Risk factors
Intrauterine asphyxia CNS depressants or other drugs taken by Mom Congenital neuromuscular disorder Congenital deformities Intrapartum Hypoxia
Arrest protocols are covered in Pediatrics
Hypovolemia
May result from: Dehydration Hemorrhage Trauma Sepsis
May be associated with myocardial dysfunction
Hypovolemia
Signs and symptoms Mottled or pale skin Cool Tachycardia Diminished peripheral pulses Delayed cap refill Pressure is not a good indicator
Prehospital care Airway Fluid @ 10 ml/kg over 5 - 10 minutes (ALS)
Gastrointestinal Disorders
Occasional vomiting or diarrhea is not unusual in the neonate Vomiting mucus (that may occasionally be
blood streaked) is common in the first few hours of life
5 to 6 stools per day is considered normal, especially if the infant is breast feeding.
Persistent vomiting and/or diarrhea should be considered warning signs of serious illness
Seizures
Are usually fragmented and not sustained Subtle seizures may include
Eye deviation Blinking Sucking Swimming movement of arms and peddling of the legs Apnea
Causes Hypoglycemia Hypoxic ischemia encephalopathy Intracranial hemorrhage Metabolic disturbances Meningitis or encephalopathy Development abnormalities Drug withdrawal
Fever
Rectal temperature > 38ºC Often a response to an acute viral or
bacterial infection May also be result of
Lack of internal temperature control Dehydration
May lead to metabolic acidosis From ↑ O2 demand and ↑ glucose metabolism
Fever
Assessment may include ALOC
Irritable Somnolence
History of decreased intake or not feeding at all
Warm or hot skin Treatments are supportive only
Hypothermia
Body temperature drops below 35 º C BSA and surface to volume ratio makes
them susceptible Infants may die of cold exposure at
temperatures adults find comfortable Increased metabolic demand may cause
metabolic acidosis, pulmonary HTN, and hypoxemia
Hypothermia
Assessment may include Pale skin Cool (especially in the extremities) Respiratory distress Apnea Bradycardia Central cyanosis Irritability progressing to lethargic Absence of shivering
Treatment
Hypoglycemia
A blood glucose screening test less than 4 mmol/L indicates hypoglycemia
Risk factors Asphyxia Toxemia Being smaller twin CNS hemorrhage Sepsis
Hypoglycemia
S/S Twitching or seizure Limpness Lethargy Eye rolling High pitched cry Apnea Irregular respirations Cyanosis possibly
Treatment 1.0 cc/kg D50 IV (D10 or D25 preferred) – Requires ALS
Common Birth Injuries
2 - 7 % out of 1000 births results in an injury Risk factors include uncontrolled explosive
delivery Types of injuries seen:
Cranial injuries Molding of head and overriding of parietal bones Soft tissue from forceps Subconjunctival and retinal hemorrhage Skull fracture
Common Birth Injuries
Intracranial hemorrhage Spine or spinal cord injury Peripheral nerve damage Liver or spleen or kidney Clavicle or extremity fracture Hypoxia ischemia
Prehospital care Support vital functions Rapidly transport to an appropriate medical facility
for definitive care
Psychologicaland Emotional Support
Be aware of the normal feelings and reactions of parents, siblings, other family members, and caregivers while providing emergency care to an ill or injured child These events also are often highly
charged and emotional for the EMS crew
Psychological and Emotional Support
As a rule, emergency responders should: Never discuss the infant’s chances of survival
with a parent or family member Not give “false hope” about the infant’s condition Assure the family that everything that can be
done for the child is being done Assure the family that their baby will receive the
best possible care during transport and while at the emergency department