Neonatal Emergencies

1. Neonatal Emergencies Put me back!!!

2. OBJECTIVES • Upon completion, the student will be able to: • Define newborn and neonate. • Identify important antepartum factors that can affect childbirth. • Identify important intrapartum factors that can determine high-risk newborn patients. • Identify the factors that lead to premature birth and low-birth weight newborns. • Distinguish between primary and secondary apnea.

3. OBJECTIVES • Discuss pulmonary perfusion and asphyxia. • Identify the primary signs utilized for evaluating a newborn during resuscitation. • Identify the appropriate use of the APGAR scale. • Calculate the APGAR score given various newborn situations. • Formulate an appropriate treatment plan for providing initial care to a newborn.

4. OBJECTIVES • Describe the indications, equipment needed, application, and evaluation of the following management techniques for the newborn in distress: a) Blow-by oxygen b) Ventilatory assistance c) Endotracheal intubation d) Orogastric tube e) Chest compressions f) Vascular access

5. OBJECTIVES • Discuss the routes of medication administration for a newborn. • Discuss the signs of hypovolemia in a newborn. • Discuss the initial steps in resuscitation of a newborn. • Discuss the effects of maternal narcotic usage on the newborn. • Determine the appropriate treatment for the newborn with narcotic depression.

6. OBJECTIVES • Discuss appropriate transport guidelines for a newborn. • Determine appropriate receiving facilities for low- and high-risk newborns. • Describe the epidemiology, including the incidence, morbidity/mortality, risk factors and prevention strategies, pathophysiology, assessment findings, and management for the following neonatal problems: a) Meconium aspiration b) Apnea c) Diaphragmatic hernia

7. OBJECTIVES d) Bradycardia e) Prematurity f) Respiratory distress/cyanosis g) Seizures h) Fever i) Hypothermia j) Hypoglycemia k) Vomiting

8. OBJECTIVES l) Diarrhea m) Common birth injuries n) Cardiac arrest o) Post-arrest management 20. Given severe scenarios involving neonatal emergencies, provide the appropriate procedures for assessment, management, and transport.

9. Chapter 41: Neonatology

10. Terminology • Newborn refers to a recently born infant in the first few hours of life • Neonate refers to infants in the first 28 days of life

11. Risk Factors Associated with 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

12. Risk Factors Associated with 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.

13. 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

14. 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

15. 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

16. 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

17. Chonal Atresia Pic

18. Cleft Lip Pic

19. 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

20. Cleft Palate Pic

21. Pierre-Robin Pic

22. Diaphragmatic Hernia • Protrusion of a part of the stomach through an opening in the diaphragm • In some cases the intestines may herniate into the chest, displacing the heart and resulting in severe respiratory distress • Risk factors • Bag and mask ventilation can worsen condition • Pathophysiology • Abdominal contents are displaced into the thorax • Heart may be displaced

23. 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

24. 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 • Both fetal circulation and transitional circulation will be covered in the OB slides

25. 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

26. 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

27. Assessment and Management • Initial steps of neonatal resuscitation (except infants born through meconium): Figure 41-1

28. 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

29. Opening the Airway • Position • Suction • Technique • Mouth first, then nares • Nasal suctioning is a stimulus to breathe • Equipment • Bulb suction • Suction catheters • Meconium aspirator

30. Meconium Staining • The presence of fetal stool in amniotic fluid (occurring either in utero or intrapartum) • After meconium is observed in the amniotic fluid, intervention is aimed at preventing or minimizing the risk of aspiration by the newborn

31. Meconium-stained birth Figure 41-2

32. 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)

33. 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 base of the umbilical cord • Evaluate the infant's color • If central cyanosis, bradycardia, or other signs of distress are present in an infant with spontaneous respirations and an adequate heart rate, administer 100% oxygen and evaluate the need for additional intervention • Free-flow oxygen can be given through: • A face mask and flow-inflating bag • An oxygen mask • A hand cupped around oxygen tubing

34. Meconium Staining • DO NOT stimulate newborn to breath! • Suction only oropharynx w/ bulb syringe. • Do not cut umbilical cord. • Attach meconium aspirator to appropriate sized ET tube (2.5-3.0). Prepare multiple tubes. • Intubate neonate and suction as you remove tube. • Suction as much meconium as possible.

35. Action-evaluation-decision cycle Figure 41-3

36. Apgar Score • Enables rapid evaluation of a newborn’s condition at specific intervals after birth • Routinely assessed at 1 and 5 minutes of age • Appearance, Pulse, Grimace, Activity, Respiratory

37. APGAR example

38. Resuscitationof 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

39. Inverted Pyramid • Inverted pyramid reflecting approximate relative frequency of neonatal resuscitative efforts Figure 41-4

40. Routes of Drug Administration • Drugs are rarely indicated in the resuscitation of a newborn • Drugs should be administered only if the heart rate remains < 60 bpm despite adequate ventilation with 100% oxygen and chest compressions • The tracheal route is generally the most rapidly accessible route • The umbilical vein is the most rapidly accessible venous route • Peripheral sites (scalp or peripheral vein) may be adequate but more difficult to cannulate • The intraosseous (IO) route is not commonly used in newborns

41. Umbilical Vein Cannulation • Identify umbilical vein after trimming cord • Insert umbilical catheter or angiocath into vein • Secure base of cord to hold catheter in place and stabilize catheter with tape Figure 41-5

42. Drugs Used in Neonatal Resuscitation • Medications most frequently used during neonatal resuscitation • Epinephrine • Volume expanders • Naloxone

43. Important Points to Remember in Neonatal Resuscitation • Prevent heat loss and avoid hypothermia • If a newborn has a heart rate of < 100 bpm and is unresponsive to stimulation, the primary concern is adequate ventilation • When meconium is observed, deliver the head and suction the meconium • Provide chest compressions if the heart rate is absent or remains < 60 bpm despite adequate assisted ventilations with 100% oxygen for 30 seconds • Coordinate chest compressions at a ratio of 3:1 and a rate of 120 events per minute • Administer epinephrine (Adrenalin) when the heart rate remains < 60 bpm despite 30 seconds of effective assisted ventilation and chest compression

44. Postresuscitation Care • The three most common complications of the postresuscitation period are: • Endotracheal tube migration (including dislodgement) • Tube occlusion by mucus or meconium • Pneumothorax

45. Postresuscitation Care • These complications should be suspected in the presence of: • Decreased chest wall movement • Diminished breath sounds • Return of bradycardia • Unilateral decrease in chest expansion • Altered intensity to pitch of breath sounds • Increased resistance to hand ventilation

46. Postresuscitation Care • Corrective management in the field for these postresuscitative complications may include: • Adjustment of the endotracheal tube • Reintubation • Suction • Needle decompression to manage a suspected pneumothorax must be carefully guided by medical direction

47. 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

48. Neonatal Transport Team Figure 41-6

49. Specific Situations

50. Respiratory Disorders • Respiratory insufficiency in the neonate is generally managed by: • Stimulation and positioning of the airway • Prevention of heat loss and hypothermia • Oxygenation and ventilation • Suction • Intubation with ventilatory support (if needed)