Newborn resuscitation: Difference between revisions
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''Use this note for immediate after-delivery resuscitation; see [[neonatal resuscitation]] for the non-delivery related resuscitation of the newborn.'' | ''Use this note for immediate after-delivery resuscitation; see [[neonatal resuscitation]] for the non-delivery related resuscitation of the newborn.'' | ||
==Background== | ==Background== | ||
{{Newborn vital signs}} | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
Line 11: | Line 7: | ||
==Evaluation== | ==Evaluation== | ||
[[File:NRP.png|thumb|NRP Resuscitation Algorithm]] | |||
===Assessment Triad=== | ===Assessment Triad=== | ||
*Term? | *Term? | ||
Line 26: | Line 23: | ||
''See [[3.5kg (newborn)|newborn critical care quick reference]] for drug doses and equipment sizes.'' | ''See [[3.5kg (newborn)|newborn critical care quick reference]] for drug doses and equipment sizes.'' | ||
===Resuscitation Algorithm=== | ===Resuscitation Algorithm=== | ||
Patient have poor tone or is apneic? | ====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?==== | |||
#Dry, warm, position, suction, stimulate | #Dry, warm, position, suction, stimulate | ||
#*Gently dry newborn with warm towel | #*Gently dry newborn with warm towel | ||
#*Position: neutral (sniffing position) | #*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!) <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 | #**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> | |||
#*Stimulate: along spine or feet | #*Stimulate: along spine or feet | ||
#*Check glucose | #*Check glucose | ||
#**[[D10W]] (2-4 mL/kg = 0.2gm/kg) | #**[[D10W]] (2-4 mL/kg = 0.2gm/kg) | ||
#*** If patient >2.5 kg and glucose <40mg/dL | #***If patient >2.5 kg and glucose <40mg/dL | ||
#*** 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 | #**Initial resuscitation >35 weeks 21% FiO2, < 35 weeks 21-30% FiO2 | ||
#**Titrate O2 to target sat | #**Titrate O2 to target sat (see table above; hyperoxia can be harmful) | ||
*If patient on reexam just has persistent cyanosis or labored breathing: | |||
**For improving ineffective ventilation, think '''MRSOPA''' | |||
***'''M'''ask is tightly applied to the face | |||
***'''R'''e-position the head into the “sniffing” orientation | |||
***'''S'''uction the nares and the pharynx | |||
***'''O'''pen the mouth | |||
***'''P'''ressure of PPV can be increased to a max of 40 cm H2O | |||
***'''A'''lternate 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, [[neonatal intubation|intubate]] patient and continue resuscitation until HR > 100 BPM | |||
***ET (indications); ETT size = Gest age (wks) / 10^^ | |||
***[[Laryngeal mask airway]] alternative | |||
*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) | |||
*For prolonged code (HR < 60) consider [[hypovolemia]] and [[pneumothorax]] | |||
====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 <ref> Lo M & Mazor, S. (2014) Neonatal Resuscitation Chapter 11 Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Elsevier. </ref>. | |||
====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) | ||
===Airway=== | ===Airway=== | ||
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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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| '''Insertion Depth (cm)''' | | '''Insertion Depth (cm)''' | ||
|- | |- | ||
| 2.5 / | | 2.5 / <28 / <1000 | ||
| Miller 0 | | Miller 0 | ||
| 5F or 6F | | 5F or 6F | ||
Line 129: | Line 125: | ||
| 8-9 | | 8-9 | ||
|- | |- | ||
| 3.5-4.0 / | | 3.5-4.0 />38 / >3000 | ||
| Miller 0-1 | | Miller 0-1 | ||
| 8F or 10F | | 8F or 10F | ||
| 9-10 | | 9-10 | ||
|} | |} | ||
====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 | *[[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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*Delay cord clamping 30-60 seconds if able | *Delay cord clamping 30-60 seconds if able | ||
*Keep infant warm; heat loss leads to apnea, acidosis | *Keep infant warm; heat loss leads to apnea, acidosis | ||
**Consider placing body in plastic bag to prevent heat loss | |||
==Disposition== | ==Disposition== | ||
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===Cyanosis=== | ===Cyanosis=== | ||
*Must distinguish between central and peripheral | *Must distinguish between central and peripheral | ||
*Consider | *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<ref>Martin RJ et al. Pathophysiologic Mechanisms Underlying Apnea of Prematurity. NeoReviews Vol.3 No.4 April 2002.</ref><ref>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</ref>: | |||
***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=== | ===[[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 | ||
Line 187: | Line 190: | ||
==See Also== | ==See Also== | ||
*[[ | *[[Emergent delivery]] | ||
*[[Umbilical | *[[Umbilical vein catheterization]] | ||
*[[Transient tachypnea of the newborn]] | *[[Transient tachypnea of the newborn]] | ||
*[ | {{Pediatric critical care pages}} | ||
==External Links== | |||
*[https://emergencymedicinecases.com/neonatal-resuscitation/ EM Cases - Neonatal Resuscitation May 2020] | |||
==References== | ==References== | ||
<references/> | |||
[[Category:Pediatrics]] | [[Category:Pediatrics]] | ||
[[Category:Critical Care]] | [[Category:Critical Care]] | ||
[[Category:EMS]] | [[Category:EMS]] |
Latest revision as of 13:55, 12 December 2020
Use this note for immediate after-delivery resuscitation; see neonatal resuscitation for the non-delivery related resuscitation of the newborn.
Background
Newborn Vital Signs[1]
Age | Pulse^ | Respiratory Rate | Systolic BP |
Preterm < 1 kg | 120-160 | 30-60 | 36-58 |
Preterm 1 kg | 120-160 | 30-60 | 42-66 |
Preterm 2 kg | 120-160 | 30-60 | 50-72 |
Newborn | 126-160 | 30-60 | 60-70 |
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% |
^Fever directly causes an increase in heart rate of 10 beats per minute per degree centigrade[2] ^^Hyperoxia can be harmful
Differential Diagnosis
Newborn Problems
- Newborn resuscitation
- Hypoxia
- Primary apnea
- Secondary apnea
- Hypothermia
- Hypoglycemia
- Meconium aspiration syndrome
- Anemia (abruption)
- Infant scalp hematoma
- Transient tachypnea of the newborn
- Respiratory distress syndrome
- Congenital pneumonia
- Congenital heart disease
- Neonatal sepsis
- Pneumothorax
- Pulmonary hypertension
Evaluation
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?
- 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!) [3]
- 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 [4]
- 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
- D10W (2-4 mL/kg = 0.2gm/kg)
- 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 above; hyperoxia can be harmful)
- Continue to be apneic or gasping? HR below 100? (assess HR by: auscultation, 3 lead ECG, or umbilical cord palpation)
- 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
- For improving ineffective ventilation, think MRSOPA
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
- ET (indications); ETT size = Gest age (wks) / 10^^
- Laryngeal mask airway alternative
- 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)
- For prolonged code (HR < 60) consider hypovolemia and pneumothorax
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
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
- Umbilical vein is site of choice
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[6][7]:
- 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
- Beware of three common side effects that may require further resuscitation[6][7]:
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
Pediatric Critical Care
- Critical care quick reference
- Neonatal resuscitation
- Newborn resuscitation
- PALS (Main)
- Intubation (peds)
- Initial mechanical ventilation settings (peds)
- Vital signs (peds)
External Links
References
- ↑ National-Model-EMS-Clinical-Guidelines-23Oct2014
- ↑ Davies P, Maconochie I. The relationship between body temperature, heart rate and respiratory rate in children. Emerg Med J. 2009 Sep;26(9):641-3. doi: 10.1136/emj.2008.061598.
- ↑ Lo M & Mazor, S. (2014) Neonatal Resuscitation Chapter 11 Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Elsevier.
- ↑ Lo M & Mazor, S. (2014) Neonatal Resuscitation Chapter 11 Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Elsevier.
- ↑ Lo M & Mazor, S. (2014) Neonatal Resuscitation Chapter 11 Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Elsevier.
- ↑ Martin RJ et al. Pathophysiologic Mechanisms Underlying Apnea of Prematurity. NeoReviews Vol.3 No.4 April 2002.
- ↑ 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