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72 Cards in this Set
- Front
- Back
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Why is neonatal resuscitation important?
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Birth asphyxia causes ~1million neonatal deaths each year worldwide
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What percentage of newborns require resuscitation at birth?
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10% need help to start breathing @ birth
1% need extensive resuscitation and NICU care to survive |
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What is definition of asphyxia?
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Significant and progressive hypoxemia, hypercapnia, metabolic acidemia
Can affect fxn of vital organs and lead to permanent brain damage and death |
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What percentage of cardiac output passes thru to fetal lungs in utero?
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~8% of combined ventricular output
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What is main structure responsible for shunting blood away from fetal lungs in circulation?
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Most blood from Right heart flows through Ductus Arteriosis into Aorta
Bypasses lungs |
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What is PaO2 of fetus in utero?
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20-25mmHg
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What allows the fetus to grow and mature in the relatively hypoxic environment?
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Fetal HbO2 binding, fetal O2 extraction, local influences or respiratory acidosis
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Which factors contribute to high pulmonary vascular resistance in utero?
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Small pulmonary arteries are compressed by fluid-filled alveolar space
Low estrogen production and low O2 tension → make vasoconstrictors (ET-1) plus inhibit vasodilators (NO + prostacyclin) |
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What is primary stimuli for increasing pulmonary blood flow after birth?
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Ventilation to the lungs
Increase in oxygen tension |
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What is primary apnea?
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Significant oxygen deprivation in a newborn → cause abnormalities of heart rate and respiratory pattern
Oxygen deprivation → rapid breathing + HR decreases |
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What is primary apnea?
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Significant oxygen deprivation in a newborn → cause abnormalities of heart rate and respiratory pattern
Oxygen deprivation → rapid breathing + HR decreases |
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How to treat primary apnea?
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Stimulate w/ O2 during rapid breathing and low HR → can restore normal respirations and HR
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When does secondary apnea occur?
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If O2 deprivation continues when infant has rapid breathing + low HR
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How to treat secondary apnea?
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Start positive pressure ventilation
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In fetal asphyxia, what happens with:
Lactate Plasma K Free fatty acid Glycerol Catecholamine PCO2 PVR Blood shunting through foramen ovale |
All INCREASE
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In fetal asphyxia, what happens with:
PO2 pH Umbilical blood flow Cardiac output Skin perfusion O2 consumption |
All DECREASE
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In fetal asphyxia, what happens with:
Blood pressure Heart rate |
Transient or modest INCREASE, then decrease with prolonged asphyxia
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In fetal asphyxia, what happens with:
Glucose metabolism |
Shifts from aerobic to anaerobic
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What are four basic steps of adult resuscitation?
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establish an Airway – position and clear AW
establish Breathing – est adequate ventillation (spont or assisted) assist Circulation – assess HR and skin color give Drugs – give meds |
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What are initial steps of NEONATAL resuscitation?
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Prevent heat loss!!!
1) Position head and clear airway as needed 2) Stimulate baby to breath 3) Evaluate respirations, heart rate, skin color; give O2 as needed 4) Provide warmth by drying infant thoroughly and placing under radiant warmer |
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What is poikilothermia?
What does this have to do w/ neonates? |
Body temperature varies w/ environmental temperature
Most extremely low-birth-rate infants are poikilothermic and need to be dried (prevent evaporative heat loss) and warmed as part of resuscitation |
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What is appropriate stimulation in neonatal resuscitation?
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Gently rubbing newborn's back, trunk, or extremities
Slap or flick soles of feet |
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What is potential complication of slapping newborn's back in resuscitation?
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Bruising
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What is potential complication of squeezing newborn's ribcage in resuscitation?
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Fractures, pneumothorax, respiratory distress, death
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What is potential complication of forcing newborn's thighs onto abdomen in resuscitation?
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Spleen/liver rupture
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What is potential complication of dilating newborn's anal sphincter in resuscitation?
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Tearing it
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What is potential complication of using hot/cold compresses or baths in neonatal resuscitation?
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Hyperthermia, hypothermia, or burns
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What is potential complication of shaking newborn in resuscitation?
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Brain damage
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At what heart rate do you start compressions in neonatal resuscitation?
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60bpm
Give with positive pressure ventilation |
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What is ratio of chest compressions to ventilation in newborns?
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3:1 compressions:ventilation
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What HR usually indicates that you can stop resuscitative measures?
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100bpm
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When is Epi used during neonatal resuscitation?
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If HR is below 60bpm after receiving 30s of assisted chest compressions w/ ventilation
If you haven't established adequate ventilation, don't use Epi |
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What is dose of Epi in newborn resuscitation?
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1:10,000 endotracheally
0.1-0.3 mg/kg IV |
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What access is used for volume expansion in newborn resuscitation?
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Umbilical vein or peripheral vein
If can't get either, use intraosseous line |
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If suspect hypovolemia in neonatal resuscitation, which volume expander to use?
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Normal saline
Ringer's lactate O-negative blood |
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Why do we not use albumin during neonatal resuscitation?
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Limited availability
Risk of infection Increased risk or mortality |
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What is Apgar score used for?
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Developed by Virginia Apgar.
Used to quantify newborn's response to extrauterine environment and to resuscitation |
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When are Apgar scores measured?
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At 1 and 5 minutes after birth
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When to take a third Apgar score?
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If 5 minute score is <7
Then, give every 5 minutes up to 20 minutes |
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What gives you scores of 0, 1, 2 for heart rate Apgars?
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0: Absent HR
1: <100bpm HR 2: >100bpm |
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What gives you scores of 0, 1, 2 for respiration Apgars?
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0: Absent respirations
1: Slow, irregular 2: Good, crying |
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What gives you scores of 0, 1, 2 for muscle tone Apgars?
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0: Limp
1: Some flexion 2: Active motion |
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What gives you scores of 0, 1, 2 for reflex irritability Apgars?
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0: No response
1: Grimace 2: Cough, sneeze, cry |
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What gives you scores of 0, 1, 2 for skin color Apgars?
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0: Blue or pale
1: Pink body, blue extremities 2: Completely pink |
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Should we use Apgar to determine whether neonatal resuscitation is needed?
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Nope
Don't delay resuscitation until 1 minute assessment! |
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When to use endotracheal intubation in neonatal resuscitation?
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1) When meconium is present and infant is not vigorous
2) When there is prolonged or ineffective bag and mask ventilation 3) If need chest compression is needed to improve cardiovascular status 4) To administer Epi if required for persistent bradycardia 5) Known history of diaphragmatic hernia (immediately give ET intubation to these kiddos!) |
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When to intubate an infant born w/ meconium in the amniotic fluid?
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If kiddo has poor respiratory effort, decreased muscle tone, &/or HR <100bpm
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How to reduce neonate's risk of developing meconium aspiration syndrome if kiddo is born w/ mec in fluid?
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Do direct tracheal suctioning after delivery
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How is delivery differ if meconium is present?
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Once head is delivered, suction nose & mouth w/ catheter, then deliver infant in usual manner
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How to choose appropriate size ET tube to intubate the neonate?
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Sizes range from 2.0-4.0, describes internal diameter of tube
Estimate size to use by kiddo's wt & gestatonal age ET should pass through the vocal cords into trachea w/o resistance |
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What size ET tube for:
Wt <1000g Gestational age <28wks |
2.5
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What size ET tube for:
Wt 1000-2000g Gestational age 28-34wks |
3.0
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What size ET tube for:
Wt 2000-3500g Gestational age 34-38wks |
3.5
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What size ET tube for:
Wt >3500g Gestational age >38wks |
4.0
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What are the 6 landmarks to ID before placing ET tube in neonate?
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Tongue
Vallecula Epiglottis Glottis Vocal cords Esophagus |
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How to confirm that ET tube is in place in neonate?
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1) Good and equal chest rise w/ each breath
2) Auscultation of equal breath sounds bilaterally 3) Mist in ET tube 4) Good response to intubation (skin color and HR) 5) CO2 monitor indicates presence of exhaled CO2 |
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How to know ET tube is in correct place in neonate's trachea?
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Tip is mid-trachea, 1/2way btw vocal cords and carina
Tip-to-lip length ~infant's birth wt (kg) + 6 |
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Why don't you need cuffed ET tube in neonates?
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Neonates and kids <8y/o have funnel shaped larynx
Diameter of cricoid cartilage is smaller than entrance of vocal cords This helps prevent aspiration |
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What are some risk factors associated w/ need for neonatal resuscitation that occur during pregnancy?
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Maternal DM
HTN of pregnancy Chronic HTN or other chronic maternal illness (CV, TH, Neuro, Pulm, Renal) Anemia or isoimmunization Previous fetal or neonatal death Bleeding in 2nd or 3rd trimester Maternal infection Polyhydramnios Oligohydramnios PROM Postterm gestation Multiple gestation Size-dates discrepancy Drugs: LiCarbonate, Mg, Adrenergic-blockers Maternal substance abuse Fetal malformation Diminished fetal activity No PNC Age <16 or >35 yrs |
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What are some risk factors associated w/ need for neonatal resuscitation that occur during delivery?
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Emergency c-section
Forceps or vacuum delivery Breech or abnormal presentation Premature labor Precipitous labor Chorioamnionitis Prolonged ROM (>18hrs) Prolonged labor (>24hrs) Prolonged 2nd stage of labor (>2hrs) Fetal bradycardia Nonreassuring FHR Use of general anesthesia Uterine tetany Narcotics to mom w/in 4hrs of delivery Meconium stained amniotic fluid Prolapsed cord Abruptio placenta Placenta previa |
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Which factors make preterm infants at high risk for needing resuscitation at birth?
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Surfactant delivery
Heat loss Infection Intraventricular hemorrhage |
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When to give antenatal steroids?
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Recommended for any inevitable preterm delivery 34wks or less
2 doses betamethasone, 12mg IM 24 hrs apart OR 4 doses BMZ 6mg IM q6h |
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Maternal lupus is associated w/ what HR dysrhythmia?
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Congenital heart block
2/2 anti-Ro/SSA & anti-La/SSB antibodies |
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What effect can MgSO4 have on the neonate in the delivery room?
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Ineffective respirations and apnea
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What role can naloxone take in tx of neonate?
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Reverses respiratory depression in newborn whose mom got narcotics w/in 4 hrs of delivery
(Don't give to infant of heroin addict) |
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What effect can tocolytics like terbutaline or ritodrine have on neonate in delivery room?
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Hypoglycemia (b/c they give mom hyperglycemia)
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What is an en caul delivery?
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Delivery w/o rupturing membranes – may prevent bruising
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How long should resuscitation continue w/ no HR (asystole) despite appropriate resuscitative measures?
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No spontaneous circulation for 15 minutes
Resuscitation after 10mins of asystole is unlikely to result in survival, or might cause survival w/ severe disabilities |
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When is it appropriate to d/c or even not start resuscitation?
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Extreme prematurity (<23wks)
Very low birth wt (<400g) Known underlying deficits (e.g., anencephaly, trisomy 13 or 18) |
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Is room air or 100% O2 better for neonatal resuscitation?
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Right now it seems that 100% O2 is better for positive-pressure ventilation
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Infant w/ severe perinatal depression – what can be used?
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Cerebral hypothermia
(Book says it's still being studied – I saw this used in NICU) |
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What is amnioinfusion?
What is it good for? |
Transcervical instillation of warmed fluid into uterus after ROM
Decreases risk of umbilical cord compression May dilute viscous meconium & decrease risk of meconium aspiration May also decrease decels, reduce incidence of c-sections, give lower rate of infection if used for oligohydramnios |
