newborn emergencies

EMSResuscitation of

the Newborn

Jim Morgan, D.O. FAAEMEmergency MedicineEMS Medical Director

Joplin, MO

EpidemiologyEpidemiology

10% of newborns will require “assistance” when they’re born

Incidence of complications increase as Birth weight decreases Prenatal problems increase Prenatal age decreases

Look for antepartum & intrapartum issues

PhysiologyPhysiology

Prior to delivery, newborn lungs filled with fluid

Capillaries & arterioles of lungs are closed

Blood pumped by heart bypasses lungs thru ductus arteriosis

Ductus ArteriosisDuctus Arteriosis

PhysiologyPhysiology

During delivery (or shortly after), the newborn begins using lungs Compression of chest removes fluid Sudden inspiration causes air movement

to displace fluid Resistance thru lungs decreases & blood

flow preferentially bypasses ductus

Ductus closes & becomes ligamentum arteriosum

Initial CareInitial Care

Airway Maintain at level of mother’s vagina Bulb suction Gentle stimulation

Assess initial APGAR score

Prevent heat loss Gently dry Swaddle in warm receiving blanket Avoid air drafts Skin-to-skin with mother

Cutting umbilical cord Do not milk the cord Clamp 30 seconds after delivery Clamp ~ 4 cm from newborn

At BirthAt Birth

Is newborn full-term?

Is newborn breathing &/or crying?

Does newborn have good muscle tone?

At BirthAt Birth

Is meconium present? Thin meconium Thick meconium

Assess O2 saturation 60 – 70% at birth May take 5 – 10 minutes to reach > 95%

Cyanosis common esp. acrocyanosis

HR ~ 150 – 180 slowing to 130 – 140 HR < 100 abnormal – begin resuscitation

The Distressed NewbornThe Distressed Newborn

Inverted Pyramid of Inverted Pyramid of

ResuscitationResuscitation

Basic “Resuscitation”Basic “Resuscitation”

Initial care Drying Warming Positioning Suctioning Tactile stimulation

Assessment Respiratory effort Heart rate Color

AirwayAirway

Ventilation HR < 100 Apnea Poor O2 saturation Persistence of central cyanosis

Use neonatal BVM with pop-off valve with supplemental oxygen

Ventilate @ 40 – 60 bpm Ventilate @ ~ 35 – 45 cm H2O OR adequate chest rise

Supplemental oxygen 100% oxygen in the field

Neonatal Ambu BagNeonatal Ambu Bag

AirwayAirway

Consider intubation Chest compressions Difficult to ventilate Thick meconium Inadequate response

Chest CompressionsChest Compressions

Encircle chest with both hands & use thumbs

Compress lower half of sternum @ 100 per minute

Discontinue if HR increases to > 80

Vascular AccessVascular Access

MOST distressed newborns respond to initial care, ventilation, & chest compressions

If vascular access needed, can use umbilical catheter Umbilical cord with 2 arteries & 1 vein Insert catheter into vein & secure

with umbilical tape

MedicationsMedications

Naloxone Do not use in newborn resuscitation

Glucose No specific glucose level at birth can be agreed

upon Prehospital glucose administration difficult

Epinephrine 0.05 - 0.1 mg/kg

(0.3 to 1 mL/kg of a 1:10,000 solution)

Specific Neonatal Specific Neonatal SituationsSituations

Meconium-stained amniotic fluid Apnea Diaphragmatic hernia Bradycardia Prematurity Respiratory distress/cyanosis Hypovolemia Seizures Fever Hypothermia Hypoglycemia Vomiting Diarrhea Common birth injuries

Congenital heart Congenital heart conditionsconditions

Atrial septal defect (ASD) Ventricular septal defect (VSD)

Tetralogy of Fallot Transposition of the great vessels Coarctation of the aorta Pulmonary stenosis Aortic stenosis

Failure to respondFailure to respond

Mechanical blockage Meconium

Impaired lung function Pneumothorax Diaphragmatic hernia Pulmonary atresia

Central cyanosis Congenital heart disease

Apnea Brain injury Neuromuscular disease

Enroute to the callEnroute to the call

Review how you will handle Normal birth & newborn Newborn in distress

Warm patient compartment

Consider possibility of needing back-up personnel

Remember….Remember….

Most newborns will respond to minimal intervention

If meconium is present AND… Child is vigorous, light suctioning Child is flaccid, may need ETT + suction

If HR > 100, supplemental oxygen Between 60 – 100, positive pressure ventilation < 60, chest compressions

Rarely…..epinephrine thru umbilical vein

Reassess every 30 seconds

Questions?Questions?