Newborn resuscitation

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

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!) [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
  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 above; hyperoxia can be harmful)
  • 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 [5].

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[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

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

External Links

References

  1. ↑ National-Model-EMS-Clinical-Guidelines-23Oct2014
  2. ↑ 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.
  3. ↑ Lo M & Mazor, S. (2014) Neonatal Resuscitation Chapter 11 Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Elsevier.
  4. ↑ Lo M & Mazor, S. (2014) Neonatal Resuscitation Chapter 11 Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Elsevier.
  5. ↑ Lo M & Mazor, S. (2014) Neonatal Resuscitation Chapter 11 Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Elsevier.
  6. ↑ Martin RJ et al. Pathophysiologic Mechanisms Underlying Apnea of Prematurity. NeoReviews Vol.3 No.4 April 2002.
  7. ↑ 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
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