Neonatal/Pediatric Cardiopulmonary Care

1. Neonatal/Pediatric Cardiopulmonary Care Resuscitation

2. When To Resuscitate • Need usually related • Combination of • Can occur in

3. Causes of Fetal Asphyxia

4. Apnea

5. Effect of Asphyxia on Lungs • Initial adaption to extra-uterine life requires 2 steps:

6. Effect of Asphyxia on Lungs Asphyxia Blood flow continues through d.a. & f.o. (by-passing lungs) Apneic or ineffective respirations Negative pressure not generated to open Alveo li to push fluid out Pulmonary hypertension Pulmonary vasoconstriction PaO2, PaCO2 ,  pH

7. Effect of Asphyxia on Lungs If asphyxia severe with lactic acidosis  Ventilation alone will not change acid-base imbalance 

8. Effect of Asphyxia on Lungs • In severe cases - might be beneficial to give HCO3- to

9. Effect of Asphyxia on Lungs • NOTE: Adequate ventilation must be maintained when bicarb given!!! Why??

10. Effect of Asphyxia on Lungs

11. Preparation For Resuscitation

12. Basics of Neonatal Resuscitation • A - • B - • C - 3 steps:

13. Resuscitation Cycle Evaluation Decision Action

14. Steps in Resuscitation 1st step =

15. Mechanisms of Heat Loss • Radiation • Loss to • Conduction • Loss to • Evaporation • Loss when • Convection • Loss to

16. Causes of Heat Loss

17. ColdStress

18. Steps in Resuscitation Next Step = Open airway

19. Steps in Resuscitation

20. Evaluate Respiratory Effort Evaluate respirations None or Spontaneous gasping PPV with Evaluate 100% O2 heart rate Below 100 15 - 30 sec.

21. Evaluate Heart Rate Evaluate heartrate Above 100 Evaluate color Blue Pink or peripheral cyanosis Provide oxygen Observe and monitor

22. Indications for PPV

23. Positive Pressure Ventilation • Flow-inflating bag • Self-inflating bag • Pressure gauge • Oxygen flow 5-8 lpm • Pop-off at 30-40 cmH2O

24. PPV Technique • Slightly extend neck • Mask held with thumb & forefinger • Bag squeezed with fingertips • Initial rate - • Done for 15-30 sec., then re-evaluate • May require -

25. Re-evaluate Heart Rate

26. 2 fingers or thumbs Lower 1/3 of sternum Sternum depressed 1/2-3/4 inches 3:1 compression-to-ventilation ratio Continue for 30 sec., stop for 6 sec. to re-evaluate HR DC’d when HR > 80, then re-evaluate RR Chest Compressions

27. Indications for Intubation • Bag/mask ventilation is difficult or ineffective • Prolonged PPV is required • Thick meconium is present in amniotic fluid • Suspicion of diaphragmatic hernia

28. ETT Sizes

29. Laryngoscope Blades • Size 1 for • Size 0 for

30. Intubation Technique • Same as adult • Limit attempts to - • Provide blow-by oxygen at - • ETT tip midway between carina & clavicles • Cut ETT to leave -

31. Medications - Uses

32. Medications - Routes

33. Instillation Into ETT N A V E L O2

34. Medications - Indications • HR < 80 despite PPV and chest compressions for at least 30 sec. • HR is 0

35. Epinephrine • Powerful sympathomimetic • 1st drug given • IV or ETT, delivered rapidly • Repeated q3-5’ until HR -

36. Volume Expanders • Given if hypovolemic •  BP • Pallor with adequate oxygenation • HR > 100 with weak pulses • Failure to respond to resuscitation • Whole blood, 5% albumin, plasma expanders, NS • IV, may be repeated as needed

37. Sodium Bicarbonate • Prolonged arrest & not responding • Alkaline to buffer metabolic acidosis • Only given when ventilation is adequate • IV

38. Narcan (naloxone) • Reversal of narcotic depression • Demerol (meperidine) • Morphine sulfate • Fentanyl (Sublimaze) • IV, IM, sub-q, ETT • Given rapidly

39. Dopamine

40. APGAR Scoring

41. 0 1 2 T o t ally cya n o t ic Pi n k bo d y , bl u e T o t ally pi n k A p p e ara n ce ex t re m i t ies Ab se n t Un d e r 100 O ver 1 0 0 P u lse Un res po n s ive F r o w n o r g ri m ace C ryi ng , s n ee z e o r G ri m ac e c ou g h F lacci d , li mp S om e f lexi on o f A c t ive f lexi on , A c t ivi t y ex t re m i t ies g o od m o t i o n Ab se n t Ir r e g ula r , w e ak, C ryi ng , vi go r o us R es p ir a ti on s g as p in g b rea th in g APGAR Scoring

42. Serum Glucose Sources • Nutritional needs of fetus supplied by Mom & regulated by placenta • Fetus prepares for postnatal life by  energy stores & developing enzyme-dependant processes for usage of stored energy

43. Serum Glucose Energy Storage • Glycogen • Triglycerides (brown fat)

44. Serum Glucose At 2 hours - By 3 days - Post-delivery

45. Serum Glucose Term - Preterm - Hypoglycemia

46. Tremors Irritability orMoro reflex Apnea/tachypnea Cyanosis Seizures Lethargy Hypothermia Weak/high-pitched cry Poor feeding Vomiting CV failure Hypoglycemia - Signs

47. Hypoglycemia

48. Hyperinsulinism Prematurity IUGR Starvation Sepsis Shock Asphyxia Hypothermia Glucogen Storage Disease Galactosemia Adrenal insufficiency Polycythemia Congenital heart defects Iatrogenic causes Hypoglycemia - Causes

49. Hyperinsulinism • Fetus of diabetic Mom • Rh incompatibility • Insulin-producing tumors • Maternal tocolytic therapy (ritodrine, terbutaline)

50. Glucose Measurement • Glucose Test Strip “Dextrostik” • “One Touch” • Lab sample (blood glucose)