Newborn resuscitation: Difference between revisions

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==Evaluation==
==Evaluation==
[[File:NRP.png|thumb|NRP Resuscitation Algorithm]]
===Assessment Triad===
===Assessment Triad===
*Term?
*Term?
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====Evaluate for Tone, Term, and Breathing====
====Evaluate for Tone, Term, and Breathing====
*If yes, stay with mother for routine care (clear secretions, dry, warm and maintain temperature)
*If yes, stay with mother for routine care (clear secretions, dry, warm and maintain temperature)
**Delay cord clamping/cutting for 30-60 seconds
**Presence of meconium no longer changes care (i.e. is not an indication for intubation)
*If no:
*If no:
**Respiration: adequacy, difficulty
**Respiration: adequacy, difficulty
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#**Consider slight extension with rolled diaper or small towel under the infant's shoulders to maximize air entry and avoid obstruction. (Do not place under neck; Do not hyperextend which can cause airway obstruction as well!) <ref> Lo M & Mazor, S. (2014) Neonatal Resuscitation Chapter 11 Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Elsevier. </ref>
#**Consider slight extension with rolled diaper or small towel under the infant's shoulders to maximize air entry and avoid obstruction. (Do not place under neck; Do not hyperextend which can cause airway obstruction as well!) <ref> Lo M & Mazor, S. (2014) Neonatal Resuscitation Chapter 11 Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Elsevier. </ref>
#*Suction: oral then nasal
#*Suction: oral then nasal
#**Mouth before nose, M before N in alphabet
#**Mouth before nose (remember: M before N in alphabet)
#**Suctioning in this order avoids aspiration if infant takes breath after suctioning nose <ref> Lo M & Mazor, S. (2014) Neonatal Resuscitation Chapter 11 Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Elsevier. </ref>
#**Suctioning in this order avoids aspiration if infant takes breath after suctioning nose <ref> Lo M & Mazor, S. (2014) Neonatal Resuscitation Chapter 11 Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Elsevier. </ref>
#*Stimulate: along spine or feet
#*Stimulate: along spine or feet
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#***If patient <2.5 kg and glucose <30mg/dL
#***If patient <2.5 kg and glucose <30mg/dL
#Reexamine patient:
#Reexamine patient:
#*Continue to be apneic or gasping? HR below 100 (assess HR by auscultation, 3 lead ECG, or umbilical cord palpation)?
#*''Continue to be apneic or gasping? HR below 100?'' (assess HR by: auscultation, 3 lead ECG, or umbilical cord palpation)
#**PPV/BVM x 30 seconds (40-60 breaths/min @ 20-25 cmH20)
#**PPV/BVM x 30 seconds (40-60 breaths/min @ 20-25 cmH20)
#**SpO2 monitor: Place O2 sat monitor preductal (right hand or wrist)
#**SpO2 monitor: Place O2 sat monitor preductal (right hand or wrist)
#**Initial resuscitation >35 wks 21% FiO2, < 35 wks 21-30% FiO2
#**Initial resuscitation >35 weeks 21% FiO2, < 35 weeks 21-30% FiO2
#**Titrate O2 to target sat (see table; hyperoxia can be harmful)
#**Titrate O2 to target sat (see table; hyperoxia can be harmful)
{| class="wikitable"
{| class="wikitable"
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**Check chest movement and make sure patient is being ventilated appropriately
**Check chest movement and make sure patient is being ventilated appropriately
**Ventilation corrective steps ('''MRSOPA''')
**Ventilation corrective steps ('''MRSOPA''')
**If ventilation not improving, intubate patient and continue resuscitation until HR > 100 BPM  
**If ventilation not improving, [[neonatal intubation|intubate]] patient and continue resuscitation until HR > 100 BPM  
***ET (indications); ETT size = Gest age (wks) / 10^^
***ET (indications); ETT size = Gest age (wks) / 10^^
***Laryngeal mask airway alternative
***[[Laryngeal mask airway]] alternative
*If patient HR < 60 BPM on reassesment
*If patient HR < 60 BPM on reassessment
**Intubate if not already done
**Intubate if not already done
**Chest Compressions
**Chest Compressions
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***Use only 1:10,000 (0.1mg/kg concentration)
***Use only 1:10,000 (0.1mg/kg concentration)


*For prolonged code (HR < 60) consider hypovolemia and pneumothorax
*For prolonged code (HR < 60) consider [[hypovolemia]] and [[pneumothorax]]


====Medications to consider====
====Medications to consider====
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*[[NaHCO3]] - prolonged resuscitation
*[[NaHCO3]] - prolonged resuscitation
**(1-2 meQ/kg)
**(1-2 meQ/kg)
*[[Nalaxone]] (0.1 - 0.4mg/kg)
*Naloxone
**In past, for [[opioid]] use <4hrs
**In past, used for [[opioid]] use <4hrs, however no longer recommended as can precipitate acute withdrawal and seizures if prolonged intrauterine exposure. Overall effect unknown, therefore respiratory support preferred to using naloxone <ref> Lo M & Mazor, S. (2014) Neonatal Resuscitation Chapter 11 Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Elsevier. </ref>.
**No longer recommended
**Assist ventilation as needed instead
**Can precipitate acute withdrawal and seizures if prolonged intrauterine exposure. Overall effect unknown, therefore respiratory support preferred to using naloxone <ref> Lo M & Mazor, S. (2014) Neonatal Resuscitation Chapter 11 Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Elsevier. </ref>


====Newborn Vent Settings====
====Newborn [[ventilation (Settings)|Vent Settings]]====
*Pressure Cycled: RR 30+, PIP 20/2 (Preemie 15/2)
*Pressure Cycled: RR 30+, PIP 20/2 (Preemie 15/2)


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**Position head in sniffing position  
**Position head in sniffing position  
**Suction mouth then nose
**Suction mouth then nose
*Intubate  
*[[neonatal intubation|Intubate]]
**Indicated if patient is poorly responsive or fails BVM  
**Indicated if patient is poorly responsive or fails [[BVM]]
**If have time precut ET tube at 13cm mark  
**If have time precut ET tube at 13cm mark  
**Lip placement = 6 + wt (kg)
**Lip placement = 6 + wt (kg)
**Or, lip placement = measure nasal septum to tragus length (NTL) in cm + 1
**Or, lip placement = measure nasal septum to tragus length (NTL) in cm + 1
**After intubation suction trachea to prevent aspiration (if +meconium)
**After intubation suction trachea to prevent aspiration (if +[[meconium aspiration syndrome|meconium]]; however, meconium is no longer an indication for intubation)


{| class="wikitable"  
{| class="wikitable"  
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====Vascular Access====
====Vascular Access====
*Umbilical vein is site of choice
*[[umbilical vein catheterization|Umbilical vein]] is site of choice
====Volume Expansion====
====Volume Expansion====
*NS 10mL/kg IV or umb vein over 5-10min
*[[NS]] 10mL/kg IV or umb vein over 5-10min
*O Rh-negative blood if abruption/anemic
*O Rh-negative [[pRBCs|blood]] if [[placental abruption|abruption]]/[[anemia|anemic]]


====Medications====
====Medications====
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**Indicated for asystole or HR < 60 despite CPR >30s
**Indicated for asystole or HR < 60 despite CPR >30s
**0.01-0.03mg/kg IVP q3-5min
**0.01-0.03mg/kg IVP q3-5min
*Sodium Bicarbonate
*[[Sodium bicarbonate]]
**Helps to counteract negative inotropy/pulmonary hypertension caused by acidosis
**Helps to counteract negative inotropy/pulmonary hypertension caused by acidosis
**Only give once adequate ventilation is established
**Only give once adequate ventilation is established
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**See [[prostaglandin E1]] for more
**See [[prostaglandin E1]] for more


===Pneumothorax===
===[[Pneumothorax]]===
*Tension [[pneumothorax]] is highly related to subsequent [[ICH]]
*Tension [[pneumothorax]] is highly related to subsequent [[ICH]]
**Place 18-20ga catheter into 4th intracostal space, anterior axillary line
**Place 18-20ga catheter into 4th intracostal space, anterior axillary line
===Hypoglycemia===
 
===[[neonatal hypoglycemia|Hypoglycemia]]===
*<30-35 in preterm newborn
*<30-35 in preterm newborn
*<35-40 in term newborn
*<35-40 in term newborn
*Treatment
*Treatment
**D10W 2mL/kg IV  
**D10W 2mL/kg IV  
===Congenital Diaphragmatic Hernia===
===Congenital Diaphragmatic Hernia===
*Persistent respiratory distress with "seesaw" pattern
*Persistent [[shortness of breath (peds)|respiratory distress]] with "seesaw" pattern
*Treat via immediate intubation, OG tube placement
*Treat via immediate intubation, OG tube placement
**Use lowest peak inspiratory pressure that allows for adequate chest rise
**Use lowest peak inspiratory pressure that allows for adequate chest rise

Revision as of 19:07, 6 October 2019

Use this note for immediate after-delivery resuscitation; see neonatal resuscitation for the non-delivery related resuscitation of the newborn.

Background

Newborn Vital Signs

  • HR RR SBP^
  • >100 40-80 60-70

^<3kg (premature) SBP = 40-60

Differential Diagnosis

Newborn Problems

Evaluation

NRP Resuscitation Algorithm

Assessment Triad

  • Term?
  • Tone?
  • Breathing or crying?
  • If yes, stay with mother for routine care (clear secretions, dry, warm and maintain temperature)
  • If no:
    • Respiration: adequacy, difficulty
    • Circulation: HR >100, palpate at umbilical base or auscultate for HR
    • Color - central cyanosis?

Apgar score

Score of 0 Score of 1 Score of 2
Appearance blue or pale all over
(central cyanosis)
peripheral cyanosis (acrocyanosis)
body pink
no cyanosis
body and extremities pink
Pulse absent <100 beats per minute >100 beats per minute
Grimace no response to stimulation grimace on suction or aggressive stimulation cry on stimulation
Activity none some flexion flexed arms and legs that resist extension
Respiration absent weak, irregular, gasping strong, lusty cry

Score at 1 minute and 5 minutes post delivery.

Management

See newborn critical care quick reference for drug doses and equipment sizes.

Resuscitation Algorithm

Evaluate for Tone, Term, and Breathing

  • If yes, stay with mother for routine care (clear secretions, dry, warm and maintain temperature)
    • Delay cord clamping/cutting for 30-60 seconds
    • Presence of meconium no longer changes care (i.e. is not an indication for intubation)
  • If no:
    • Respiration: adequacy, difficulty
    • Circulation: HR >100, palpate at umbilical base or auscultate for HR
    • Color - central cyanosis?

Patient have poor tone or is apneic?

  1. Dry, warm, position, suction, stimulate
    • Gently dry newborn with warm towel
    • Position: neutral (sniffing position)
      • Consider slight extension with rolled diaper or small towel under the infant's shoulders to maximize air entry and avoid obstruction. (Do not place under neck; Do not hyperextend which can cause airway obstruction as well!) [1]
    • Suction: oral then nasal
      • Mouth before nose (remember: M before N in alphabet)
      • Suctioning in this order avoids aspiration if infant takes breath after suctioning nose [2]
    • Stimulate: along spine or feet
    • Check glucose
      • D10W (2-4 mL/kg = 0.2gm/kg)
        • If patient >2.5 kg and glucose <40mg/dL
        • If patient <2.5 kg and glucose <30mg/dL
  2. Reexamine patient:
    • Continue to be apneic or gasping? HR below 100? (assess HR by: auscultation, 3 lead ECG, or umbilical cord palpation)
      • PPV/BVM x 30 seconds (40-60 breaths/min @ 20-25 cmH20)
      • SpO2 monitor: Place O2 sat monitor preductal (right hand or wrist)
      • Initial resuscitation >35 weeks 21% FiO2, < 35 weeks 21-30% FiO2
      • Titrate O2 to target sat (see table; hyperoxia can be harmful)
Min of life Target sat
1 min 60-65%
2 min 65-70%
3 min 70-75%
4 min 75-80%
5 min 80-85%
10 min 85-95%
  • If patient on reexam just has persistent cyanosis or labored breathing:
    • For improving ineffective ventilation, think MRSOPA
      • Mask is tightly applied to the face
      • Re-position the head into the “sniffing” orientation
      • Suction the nares and the pharynx
      • Open the mouth
      • Pressure of PPV can be increased to a max of 40 cm H2O
      • Alternate airway, i.e. ET, should be considered and planned for

On reassessment after 30 seconds of above intervention

  • If HR continues to be below 100
    • Check chest movement and make sure patient is being ventilated appropriately
    • Ventilation corrective steps (MRSOPA)
    • If ventilation not improving, intubate patient and continue resuscitation until HR > 100 BPM
  • If patient HR < 60 BPM on reassessment
    • Intubate if not already done
    • Chest Compressions
      • Aim for 120 compressions per min (Respirations 3:1), stop when HR > 60
      • For compressions, wrap hands around patient's thorax and use thumbs to compress anterior chest wall
    • Consider Epi (0.01-0.03mg/kg) if:
      • HR<60 despite above intervention
      • Use only 1:10,000 (0.1mg/kg concentration)

Medications to consider

  • D10W (2-4 mL/kg = 0.2gm/kg)
  • NS (10 mL/kg boluses)
  • PRBC 10mL/kg if abruption with anemia
  • Dopamine drip
    • (5-20 mcg/kg/min)
  • NaHCO3 - prolonged resuscitation
    • (1-2 meQ/kg)
  • Naloxone
    • In past, used for opioid use <4hrs, however no longer recommended as can precipitate acute withdrawal and seizures if prolonged intrauterine exposure. Overall effect unknown, therefore respiratory support preferred to using naloxone [3].

Newborn Vent Settings

  • Pressure Cycled: RR 30+, PIP 20/2 (Preemie 15/2)

Airway

  • Optimize
    • Position head in sniffing position
    • Suction mouth then nose
  • Intubate
    • Indicated if patient is poorly responsive or fails BVM
    • If have time precut ET tube at 13cm mark
    • Lip placement = 6 + wt (kg)
    • Or, lip placement = measure nasal septum to tragus length (NTL) in cm + 1
    • After intubation suction trachea to prevent aspiration (if +meconium; however, meconium is no longer an indication for intubation)
Tube Size / age / wt Blade Suction Catheter Insertion Depth (cm)
2.5 / <28 / <1000 Miller 0 5F or 6F 6-7
3.0 / 28-34 / 1000-2000     Miller 0 6F or 8F 7-8
3.5 / 34-38 / 2000-3000 Miller 0 8F 8-9
3.5-4.0 />38 / >3000 Miller 0-1 8F or 10F 9-10

Vascular Access

Volume Expansion

Medications

  • Epinephrine
    • Indicated for asystole or HR < 60 despite CPR >30s
    • 0.01-0.03mg/kg IVP q3-5min
  • Sodium bicarbonate
    • Helps to counteract negative inotropy/pulmonary hypertension caused by acidosis
    • Only give once adequate ventilation is established
    • 1-2 mEq/kg of 4.2% solution (2-4 mL/kg)
  • Naloxone
    • Previously given if persistent respiratory depression AND maternal opioids within 4hr
    • No longer recommended; assist ventilations as needed until opioids wear off
    • 0.1-0.4mg/kg IV
Other
  • Delay cord clamping 30-60 seconds if able
  • Keep infant warm; heat loss leads to apnea, acidosis
    • Consider placing body in plastic bag to prevent heat loss

Disposition

  • Admission

Withholding Resuscitation

  • Consider if:
    • <22wk or <400g
    • No signs of life after 10min of CPR

Special Problems

Cyanosis

  • Must distinguish between central and peripheral
  • Consider Prostaglandin E1 0.05-0.1 mcg/kg/min for cyanotic congenital heart disease and ductus closing
    • Beware of three common side effects that may require further resuscitation[4][5]:
      • Apnea, 12%, which requires respiratory monitoring with ETCO2 capnography, potential mechanical ventilation, and/or ALS/PALS transport if needing transfer to higher level of care
      • Peripheral flushing with or without hypotension, 10%, which requires fluid resuscitation
      • Fever, 14%
    • See prostaglandin E1 for more

Pneumothorax

  • Tension pneumothorax is highly related to subsequent ICH
    • Place 18-20ga catheter into 4th intracostal space, anterior axillary line

Hypoglycemia

  • <30-35 in preterm newborn
  • <35-40 in term newborn
  • Treatment
    • D10W 2mL/kg IV

Congenital Diaphragmatic Hernia

  • Persistent respiratory distress with "seesaw" pattern
  • Treat via immediate intubation, OG tube placement
    • Use lowest peak inspiratory pressure that allows for adequate chest rise
  • Transfer to tertiary center with NICU and pediatric surgeon

See Also

References

  1. Lo M & Mazor, S. (2014) Neonatal Resuscitation Chapter 11 Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Elsevier.
  2. Lo M & Mazor, S. (2014) Neonatal Resuscitation Chapter 11 Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Elsevier.
  3. Lo M & Mazor, S. (2014) Neonatal Resuscitation Chapter 11 Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Elsevier.
  4. Martin RJ et al. Pathophysiologic Mechanisms Underlying Apnea of Prematurity. NeoReviews Vol.3 No.4 April 2002.
  5. Segar JL. Protocol for Use of Prostaglandin E. University of Iowa Stead Family Children's Hospital. Accessed Dec 2016. https://uichildrens.org/health-library/protocol-use-prostaglandin-e?id=234424