Pathway 4: Neonatal Emergencies
The team continues the resuscitation along the pathway suggested by the initial clinical impression. Each pathway includes a complete, thorough, and rapid physical examination with additional history taking. The team leader is wary of conditions that may not be apparent. To obtain additional clinical data or to correct a missed or newly developed condition, the team leader repeats the initial survey if the patient is not responding satisfactorily.
Be prepared.
Only about 10% of newborns require life support and resuscitation in the delivery room or nursery.1 However, it is not always possible to predict when an infant will need resuscitation. The probability of the need for resuscitation increases for infants weighing less than 1500 g. At least one person skilled in neonatal resuscitation should be present at every delivery. In many rural EDs, this means that most team members must be skilled to ensure that a qualified individual is always present.
Successful resuscitation depends upon preparation for and anticipation of a high-risk neonate. The American Academy of Pediatrics defines the neonate period as the first 28 days of life. One may need to readjust the neonate period due to gestational age/prematurity.
Factors
for High-Risk Neonates
Antepartum (fetomaternal)
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Intrapartum
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Resuscitation
Equipment in the Delivery Room
A
special work surface must be provided with radiant warmers; all
necessary equipment must be displayed and ready for use. A drug dosage
book is also useful. All delivery rooms should be stocked with the
following equipment, which should be checked and replenished
periodically.
Suction Equipment |
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Airway Equipment |
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Circulation Equipment |
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Miscellaneous |
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Neonatal
Resuscitation Algorithm
| Immediate assessment for all births | Routine initial care of newborns | |
| Clear
of meconium? Crying or breathing? Good muscle tone? Gestational age |
Place
and position under a radiant warmer. Clear airway as needed. Suction with bulb syringe-oral then nasal. If particulate meconium is present and newborn not vigorous, suction the trachea. Dry thoroughly; remove wet linen; assess color |
If no response to treatments, consider airway malformation, lung problems, or congenital heart.
*Place pulse oximeter on right side of body. Maintain SpO2 between 85% and 95%. Use O2 blender if available
Place the newborn infant on a work surface with radiant warming lights. Do not take the time to set up the servomechanism (skin probe), whereby the radiant warmer is turned off automatically when the infant’s temperature rises. This may be done later. Place the infant on the work surface on his or her back with the neck slightly extended to open the airway. Place a folded towel or small blanket (about 1 inch thick) behind the baby’s shoulders, but avoid overextending the neck. If there are copious secretions coming from the mouth, turn the head to the side.
A. Initial Stabilization
Prevent Heat Loss
Critical actions: maintain a warm delivery room, place the infant under a radiant heat source, and quickly dry off the infant. Vigorous towel drying has an added effect of stimulating the infant. Throw the wet linen away after drying.
All newborns face increased metabolic stress in cold environments; this is of particular concern in already compromised asphyxiated neonates. Infants who are cold-stressed have an increased metabolic rate and require more oxygen. Minimize the effects of cold stress by providing all newborns with a suitable warm environment. Avoid hypothermia.
These early actions take only a few seconds and have the added advantage of providing some tactile stimulation, which may help in stimulating respirations. Keep the infant’s head covered as excessive heat loss may occur due to the size of the infant’s head. A heated mattress, commercially made for neonates, may be placed under the infant for added warmth.
Meconium-stained amniotic fluid has the potential to complicate delivery. If the infant is vigorous, endotracheal intubation and suctioning is probably not necessary. These infants display strong respiratory effort, good muscle tone, and HR > 100 bpm. Non-vigorous infants showing signs of distress need suctioning. These infants display poor respiratory effort and poor muscle tone, and HR < 100 bpm. Intrapartum suctioning is no longer routine, especially if shoulder dystocia is anticipated.
If particulate meconium is present at delivery and the infant is non-vigorous, suction the trachea immediately. Suction before the infant is dried, because tactile stimulation may make the infant gasp in more meconium. Adjust the suction bottle on the resuscitation cart to 80 to 100 torr negative pressure. Attach a meconium aspirator to the suction tubing coming from the suction bottle.
Prepare
3 ET tubes (size 3) with obturators and 3 ET tubes (size 2.5) in case
the size 3 tubes are too large. The intubator visualizes the vocal
cords using a laryngoscope with an infant Macintosh or Miller blade and
inserts the first ET tube about 3 cm into the trachea. An assistant
pulls out the obturator and attaches the meconium suction adaptor to
the ET tube. The assistant then removes the ET tube, keeping a finger
over the side hole of the aspirator to apply suction and turns the ET
tube while removing it. One team member provides free-flow oxygen and
checks heart rate throughout endotracheal suctioning. If the infant
becomes bradycardic even after suctioning once, begin PPV and consider
the possibility of meconium aspiration syndrome.
The intubator does not withdraw the laryngoscope and must continue to keep the vocal cords in view. If the heart rate remains stable, the process may be repeated until meconium is removed or infant becomes bradycardic (heart rate decreases from 100 down to 80). It may take 2 or 3 aspirations to remove the meconium. Place suction on the ET tube; withdraw as before. Evaluate the heart rate with each repetition. Following this, insert an 8 French gastric tube through the mouth to prevent aspiration of gastric meconium.
Meconium suctioning is a team effort that must be accomplished quickly. Rehearse this team effort at every opportunity to maintain the team’s skill. (Vol III—NRP3 Meconium Suctioning)
Opening the Airway
Critical actions: Place the infant on his or her back with the neck slightly extended; suction the mouth and nose.
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It is important to prevent overextension or flexion of the neck in order to keep the airway open. Place a blanket or towel (about 1 inch thick) under the infant’s shoulders to maintain proper head position. If the infant has copious secretions coming from the mouth, it is helpful to turn the infant’s head to one side.
As soon as the infant has been properly positioned, suction first the mouth and then the nose. This will prevent the infant from aspirating material that has collected in the posterior pharynx. The person delivering the neonate can suction the mouth and nose of the infant after the head is delivered, but do not delay delivery of the shoulders for suctioning. It is important to remember that the infant’s first respirations will be strong gasps through the mouth before nasal breathing is established. While suctioning, be careful to avoid suctioning deeply within the pharynx, which could stimulate a vagal response and bradycardia; limit suctioning efforts to no longer than 5 seconds at a time.
Tactile Stimulation
Drying and suctioning often provide enough tactile stimulation to induce respirations in most infants. However, if an infant is not breathing immediately, additional stimulation is required. Safe methods of providing tactile stimulation include (1) slapping or flicking the soles of the feet and (2) rubbing the back. Avoid more vigorous methods of stimulation. If the infant does not initiate respirations after 10 to 15 seconds of stimulation, PPV will be required.
Evaluate respiratory effort, heart rate, and color in the next 30 seconds.
Respiratory Effort
Observe the neonate’s ventilatory effort. If the infant is obviously gasping or not breathing, go immediately to PPV using a BVM. As in any resuscitation, adequate ventilation is assessed by chest wall motion and auscultation of breath sounds. The initial lung inflation following delivery may require 30 to 40 cm H2O pressure; subsequent breaths require less pressure (15 to 20 cm H2O). Deliver ventilations at a rate of 40 to 60 breaths per minute. Hypoxia in a newborn produces bradycardia, so use heart rate to help determine the need for continued PPV. A 500 cc BVM is ideal for purposes of neonatal resuscitation.
Heart Rate
Count the heart rate for 6 seconds and multiply by 10. You may evaluate the heart rate by stethoscope or by feeling the pulse by lightly grasping the base of the umbilical cord. If the heart rate is < 60 bpm, begin cardiac compressions while continuing PPV. Two techniques are used for chest compressions in the newborn. In the thumb technique, the thumbs are placed on the sternum just below the nipple line, and the fingers encircle the chest for back support. This is the preferred technique. In the two-finger technique, the chest is compressed with the ring and middle finger, and the other hand is used to support the back. This technique is used when placing an umbilical catheter.
The depth of compression should be 1/3 to 1/2 of the anterior/posterior dimension of the chest.3 The compression depth should be adequate to produce a palpable pulse. Avoid giving compressions and ventilations simultaneously. There should be a 3:1 ratio, with one ventilation imposed after every third compression. There should be a rate of 90 compressions and 30 breaths or approximately 120 “events” per minute.3
Prolonged PPV will result in gastric distension, so insert an orogastric tube. After 2 minutes of assisted ventilations, place an orogastric tube. The diaphragm is the main muscle of respiration in infants and may result in regurgitation of a distended stomach.
Check heart rate every 30 seconds to determine whether to continue CPR. Usually a brief application of chest compressions and BVM ventilation results in improvement in heart rate. Palpate the umbilical cord for the pulse rate, or listen to the heart sounds. Tap the rate on the table so that all team members are aware of it.
If the heart rate is > 60, PPV alone is probably sufficient. Check heart rate every 30 seconds to determine whether PPV should continue.
If the heart rate is > 100 bpm, the infant is stabilized. Continue to observe.
Color
Evaluate color for central cyanosis. Acrocyanosis (cyanosis of the extremities only) is common and does not require oxygen. If the infant is pink or there is cyanosis of the limbs only, there is no cause for concern. Continue to observe.
If the infant’s trunk is cyanotic, apply 80% oxygen. This is done by holding the end of an oxygen tube ½ inch from the infant’s nose and mouth at a flow rate of 5 L/min. Continue this until the baby is all pink, but re-apply the oxygen if cyanosis returns.
Use of Free-Flow Oxygen
If the infant has adequate respirations and a heart rate > 100 but central cyanosis is present, administer free-flow oxygen. A concentration of at least 80% oxygen is initially used. This may be administered through oxygen tubing with a flow rate of 5 L/min and held 1/2 inch from the nose. While the infant becomes pink, the oxygen is gradually withdrawn until the infant remains pink while breathing room air. As you withdraw the tubing further from the nose, the oxygen concentration falls off rapidly. Alternatively, the oxygen tubing can be connected to a face mask held firmly against the infant’s face. Be careful not to direct oxygen to the eyes or apply pressure around the eyes, as bradycardia will result. Neonates are highly responsive to vagal stimulation.
B. Ventilation
The majority of infants who require ventilatory support will be adequately ventilated by a BVM. The indications for PPV include:
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apnea or gasping respirations
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heart rate < 100/min
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persistence of central cyanosis despite 100% oxygen
Perform ventilation of the infant at a rate of 40 to 60 per minute.
As in any resuscitation, adequate ventilation is assessed by increasing heart rate, chest wall motion, and auscultation of breath sounds. The initial lung inflation following delivery may require 30 to 40 cm H2O pressure; subsequent breaths require less pressure (15 to 20 cm H2O).
Prolonged BVM ventilation may produce gastric distention, which can be relieved by insertion of an 8F orogastric tube left open to air and periodically aspirated with a syringe.
Endotracheal intubation is indicated when BVM ventilation is ineffective, when tracheal suctioning is required, and when prolonged PPV is necessary or anticipated (including when a diaphragmatic hernia is suspected). For ET intubation of the neonate, see Vol II—Air Skills 1 Aids to Intubation, Air Skills 3 Orotracheal Intubation.
C. Chest Compressions
Perform chest compressions if the heart rate is < 60/min, despite adequate ventilation with 100% oxygen for approximately 30 seconds.
There are two techniques for performing chest compressions in a neonate: thumb technique and two-finger technique. In both techniques, the sternum is compressed by placing the thumbs or fingers on the sternum just below the nipple line. In the thumb technique, the two thumbs are placed on the sternum, with the fingers encircling the chest and supporting the back. (Note: this technique cannot be used if another procedure [such as umbilical vein cannulation] needs to be performed.) In the two-finger technique, the ring and middle fingers of one hand are placed on the sternum; the other hand is used to support the infant’s back.
The depth of compression of the chest is 1/3 to 1/2 the anterior-posterior dimension of the chest.3 The rate of compressions is 90/minute.
The combined rate of compressions and ventilation can be 120 events/minute with a 3:1 ratio of compressions to ventilation. (This would provide 90 compressions and 30 breaths per minute.)
Continued Bradycardia
If PPV with a BVM and chest compressions do not result in a rise in heart rate within about 30 seconds, begin more aggressive measures. Consider more aggressive measures including endotracheal intubation and the use of medications.
Orotracheal Intubation and Ventilation
ET intubation is necessary when prolonged PPV is required, when BVM is ineffective, and with small, premature infants. Prepare necessary supplies and equipment for ET intubation in advance. The approximate size of the ET tube is determined by the infant’s weight. Depth of insertion is 6+ the neonate’s weight in kilograms. See Vol II—Air Skills 1 Aids to Intubation, Pediatric ET Tube Sizes.
D. Medication and Venous Access
Medications are administered if, despite adequate ventilation and chest compressions, the heart rate remains < 60 bpm. Routes of drug administration include umbilical veins, peripheral veins, and intraosseous. Use endotracheal tube for epinephrine only if needed while obtaining other access.
The umbilical veins are the most accessible vascular route of drug administration immediately after birth. A 3.5 or 5 F umbilical catheter is inserted into the vein of the umbilical stump until the tip of the catheter is just below skin level and a free flow of blood is present. If the catheter is inserted further, there is risk of infusing hypertonic solutions into the liver and causing liver damage. Use twill tape to provide hemostasis before and after the cannula is inserted. (Vol III—NRP4 Umbilical Artery and Vein Cannulation)
1. Epinephrine
Epinephrine increases the strength and rate of cardiac contractions and causes vasoconstriction. Epinephrine is the first medication administered. Give a dose of 0.1 mL/kg to 0.3 mL/kg (equal to 0.01 mg/kg to 0.03 mg/kg) of 1:10 000 solution, rapid IV push. Epinephrine can be injected directly into the ET tube. If the heart rate remains below 60, consider repeating the dose every 3 to 5 minutes as required. Epinephrine may be given down the ET tube only while obtaining other access. The dose for epinephrine ET is higher (up to 0.1 mg/kg or 1 mL/kg) of 1:10 000 solution. Higher doses in newborns may result in brain and heart damage.1
2. Dextrose
Sick and stressed newborns are very susceptible to becoming hypoglycemic. Infants at high risk to develop hypoglycemia include:
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Small for gestational age (SGA) infant
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Large for gestational age (LGA) infant
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Infants of diabetic mothers (IDM)
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Premature infants
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Infants with perinatal stress, sepsis, shock, asphyxia, and hypothermia
If blood sugar below 40 mg/dL, give 2 mL/kg of D10 over several minutes. Re-check blood sugar within 15 to 30 minutes after glucose bolus. Infant may need to be re-bolused and have IV infusion of 10% dextrose started to have blood sugar stabilize over 50 mg/dL. Starting infusion rate is 80 mL/kg/day.
3. Volume expanders
Consider volume expanders for any newborn who fails to respond to initial resuscitation. The infant could be hypovolemic because blood was sequestered in the placenta or because of blood loss from the placenta. Signs of hypovolemia in the newborn include pallor, weak pulse (even with a good rate), and poor response to resuscitative measures.
Three commonly used volume expanders include:
1. Whole blood (O-negative crossmatched with the mother’s
blood or with
cord blood)
2. NS solution
3. Ringer’s lactate solution
The fluid bolus is administered at a volume of 10 mL/kg using a syringe and stopcock over 5 to 10 minutes. This may be repeated if signs of hypovolemia persist.
4. Sodium bicarbonate
Use sodium bicarbonate for prolonged CPR and resuscitation and for documented acidosis. Use sodium bicarbonate only after ventilation is established. The adult solution is 8.4% and contains 1 mEq/mL. Dilute this to 4.2% with NS (0.5 mEq/mL). Alternatively, 10 mL syringes at 4.2% are commercially available. Administer sodium bicarbonate 2 mEq/kg IV (4 cc/kg of the 4.2%) slowly over at least 2 minutes.
5. Naloxone hydrochloride
Naloxone hydrochloride (Narcan) is a narcotic antagonist that may be indicated in neonates for the reversal of respiratory depression caused by maternal narcotic administration within 4 hours of delivery. Always establish and maintain adequate ventilations before administrating naloxone. The duration of narcotic effect may exceed that of naloxone; therefore, continued monitoring of the neonate is necessary. It can also induce narcotic withdrawal if the mother is narcotic dependent. Severe seizure activity may result; therefore, continued respiratory support of the neonate may be preferable to reversing the narcotic. Consult a neonatologist regarding this possibility.
The dose is 0.1 mg/kg (0.25 cc/kg of 0.4 mg/mL dosage) and may be repeated every 2 to 3 minutes as needed. Its duration of action is 1 to 4 hours. It may be given IV or IM; IV is the preferred method.
6. Dopamine
Dopamine infusion is an adrenergic drug with mainly beta effects at low doses. Dopamine can be useful in the management of neonates who remain hypotensive despite the previously named aggressive measures. Consultation with a neonatologist is mandatory at this point. In preparation for transfer, a dopamine drip solution may be prepared for continuous infusion to support the neonate’s BP. The infusion should start at 2 μg/kg/min and may be increased up to 20 μg/kg/min if necessary. (Vol III—NRP2 Drugs in Neonatal Resuscitation)
Other Neonate Medications
Seizure
activity in neonates can be subtle. Rhythmic eye movements; facial,
oral and lingual movements; apnea; and stertorous breathing may all
indicate seizure activity. Treat seizures with rectal diazepam 0.3
mg/kg. If unsuccessful, use phenobarbital 20 mg/kg IV. If still
unsuccessful, administer phenytoin 18 mg/kg over 20 to 30 minutes or
fosphenytoin 18 mg/kg IV over 10 minutes. (Vol
III—NEU4 Phenytoin and Fosphenytoin Loading) Consider as possible causes:
hypoglycemia,
pyridoxine deficiency, low sodium, low calcium, and low magnesium.
Treat hypoglycemia with 10% dextrose 2 to 4 mL/kg.
Treat possible pyridoxine deficiency with pyridoxine 100 mg IV.
Treat hyponatremia with 6 mL/kg of 3% NS solution.
Treat hypocalcemia with 50 to 100 mg/kg of calcium gluconate.
Treat hypomagnesemia with 2 to 4 mL of 2% MgSO4.
Treat seizures with phenobarbital 20 mg/kg slow IV push (1 mg/kg/min);
use caution as it may cause respiratory depression.
Consult a neonatologist about these difficult cases. Toxoplasmosis, cytomegalovirus, herpes simplex, and coxsackievirus infections are other possible causes of seizures in newborns. Congenital causes are hydrocephalus and microcephalus.
Finally, calculate the Apgar Score at 1 minute, 5 minutes, 10 minutes, and 15 minutes, until the resuscitation is over.
Apgar Score
| Sign | Score | ||
| 0 | 1 | 2 | |
| heart rate | absent | < 100 | > 100 |
| respirations | absent | slow, irregular | good, crying |
| muscle tone | limp | some flexion | active motion |
| relfex irritability | none | grimace | cough or sneeze |
| color | blue or pale | pink body, blue extremities |
all pink |
Caveats
Newborn infants tire easily when breathing is impaired. Do not hesitate to aggressively manage the airway.
Do not resort to vasopressors until full advantage is taken of blood volume restoration.
Any birth can result in the need for neonatal resuscitation. Be prepared.
References
- Textbook of Neonatal Resuscitation (5th edition). Kattwinkel J, Short J (editors). American Academy of Pediatrics, 2006.
- 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Part 13: Neonatal Resuscitation Guidelines. Circulation. 2005;112(suppl IV)IV-188—IV-195.
- Textbook of Neonatal Resuscitation. 4th ed. Elk Grove Village, Ill: American Academy of Pediatrics and American Heart Association, 2004.