5 tips to better Neonatal Care

2016 Eastern Oregon EMS Conference

AKA: “I Hope I don’t F*ck this up…”

Introduction and Disclaimer

• croaker260@gmail.com• • No financial disclaimers

• No Conflict of interest

Just a note

Courses to Take, Repeatedly

“The Golden Minute”

• Most neonatal arrests are asphyxia in nature. • First ventilation (if needed) should be

administered within 60 seconds of initial assessment.

• “Initial Assessment” can be done on Mom– Permitting delayed cord clamping if stable

Initial three questions

• Term gestation?• Good tone? • Breathing or

crying?• If “Yes” to all

three, let infant stay on MOM

Evaluation, Decision, Action Cycle

30 Seconds

What do we assess/evaluate• Appearance– Central cyanosis

• Provide free flow oxygen• When pink, gradually remove oxygen• If no improvement consider PPV with 100% O2

– Acrocyanosis• Observe, monitor

• Pulse• Respiration• SPO2 (?)• Tone (?)

Treatment Basics

• Assessments, decisions and interventions are made on 15-30 second cycles.

• Treatment decisions ARE NOT made on APGAR

APGAR

Meds

Intubation

Chest Compressions

BVM Ventilations

Oxygen

Drying, Warming, Positioning, Suction, Tactile Stimulation

Meds (EPI)FLUIDS

Advanced Airway

Chest Compressions

BVM Ventilations (Room Air)

Blow By Oxygen (optional)

Drying, Warming, Positioning, Suction, Tactile Stimulation

5 H’s

• Heart Rate• Hypoxia• Hypothermia• Hypoglycemia• Hypovolemia

HEART RATETreatment of the Newborn

Heart Rate is one of the best indicators of clinical status

• “Assessment of heart rate remains critical during the first minute of resuscitation”…

• “Use of the ECG does not replace the need for pulse oximetry to evaluate the newborn’s oxygenation”

How do we assess accurately?

• Auscultate– < 25/15 seconds = Bad– < 15/15 seconds = very bad

• EKG

Heart Rate

• Evaluate Heart Rate• Above 100

• Evaluate other signs• Reevaluate after 30 seconds

• Below 100• PPV (Titrated 21% - 100% O2)• Reevaluate after 30 seconds

• Below 60• Continue PPV with 100% Oxygen• Initiate compressions • Reevaluate after 30 seconds

Wait..what?

• Yes, initiate compressions if HR between 60-100 and not increasing or responsive to other interventions…

• 3:1 ratio• Two thumb , not two finger

Bradycardia

• Possible causes– Hypoxia– Increased intracranial pressure– Hypothyroidism– Acidosis

• Minimal risk if corrected quickly• Discontinue chest compressions when HR > 100• Pharmacological– Use as last resort– Epinephrine 0.01 to 0.03 mg per kg (0.1-0.3 ml/kg) 1:10,000

HYPOXIATreatment of the Newborn

Key Points

• It is acceptable to ventilate with Room AirHOWEVER

• Use 100% O2 if doing compressions • If known pre-term, it is acceptable to begin

with low flow O2 and titrate.

SPO2 in the Newly BornTargeted SPO2 after Birth

• 1 minute 60-65%• 2 minutes 65-70%• 3 minutes 70-75%• 4 minutes 75-80%• 5 minutes 80-85%• 10 minutes 85-95%

Measure on the Right Arm

Primary apnea Secondary apnea

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Positive Pressure Ventilation• Positive Inspiratory Pressure (PIP)• Term:

– Initial up to 40 cm H20– Decrease to 20 cm H2O

• Pre-Term:– 20-25 cm H20– Adequate for most– ↑ if no prompt ↑ in HR or chest movement

• Goal- Small rise in chest, and HR improvement (>100/min)• GOAL- 40-60 breaths a minute

Getting a good mask seal can be difficult

• 48% demonstrated significant mask leak– – Majority were corrected with repositioning of

the mask– – Some required changing the way mask was held

• 25% demonstrated significant airway obstruction– – Majority corrected with repositioning the infant

in the open airway position– Schmolzer et al. ADC 2011

Getting Good Ventilations…

A comment about Tidal Volume

• Tidal Volumes are generally less for newborns– Small baby (<1500 grams/3.3 lbs) 4-6 ml/kg– Term Baby: 6-8 ml/kg– Adult (for comparison) 7-8 ml/kg

Pneumothorax is a real possibility

BVMs do not provide BLOW BY O2!!!!

A comment about Meconium

HYPOTHERMIA

Hypothermia

• Infants cannot tolerate temperatures comfortable to adults

• Hypothermia is a predictor of mortality

Key Points

• Temperature of newly born non asphyxiated infants should be maintained between 36.5°C (97.7 ° F) and 37.5°C (99.5 ° F) after birth through admission and stabilization.

Brown Fat????

• Hypothermia -> Sympathetic Response• Sympathetic Response (Nor-Epi) - >

Biochemical response in “Brown Fat”– Located in the Neck and between the scapula

• This produces local heat, which warms blood supply passing through, therefore warming the infant…

• Short term response.

Street Secrets: Newborn Hypothermia clues

• Cold Feet• Red or White Extremities (shunting)• Flaccid, limp, Or weak crying• Low BG (<40 mg/dl heel stick)

Treatment Basics:

• Get rid of wet towels!• Maternal warming in the

stable newborn

Treatment Basics: Hypothermia in the tine-tiny

• Very Low Birth weight (<1500 GM) can become cyanotic simply due to hypothermia– This can occur despite normal warming methods– Use Active Warming- Port-a-warm mattress, heat

lamps, etc.

Hypothermia Treatment

• Control Temperature– All newborns have difficulty with cold– Dry infant– Wrap in warm, dry blanket– Aluminum foil wrap– Well - insulated warm water containers– Do NOT use chemical hot packs• EXCEPTION: Port-A Warm mattress

HYPOGLYCEMIA

“Most babies who are critically ill, are too sick to tolerate oral feedings…”

- S.T.A.B.L.E. text pg. 8

When the cord is cut…

• The baby no longer receives sugar from mom• The baby begins to use brown fat for sugar

and heat production• Ideally, the child should be provided a food

source

What is normal glucose level for a newborn?

• Ideally it is 80% of maternal glucose levels.• < 40 mg/dl within 10 minutes of birth• 50-110 mg/dl on follow up • When to check?– Within 10 minutes of birth– (Q 15-30) minutes until two consecutive readings

above 50 mg/dl– Sudden change

Who is at risk?• Any baby under “stress”

– Pre-birth or post birth– hypoxia

• Hypothermia/shivering• Small for gestational age (SGA) , i.e. twins

– 25% incidence• Exceptionally large infants (>90th percentile)• “Premature” infants (< 37 weeks)• Maternal factors

– Diabetes– Beta Blockers to Tx HTN– TCA’s in 3rd trimester– Beta adrenergics (Terbutaline) to treat pre-term labor

Hypoglycemia

• Assessment– Twitching/Seizures– Limpness– Lethargy– Eye rolling– High pitched or weak cry– Apnea– Irregular respirations

Hypoglycemia

• Management– Assure adequate oxygenation, ventilation– IV/IO TKO• Warm fluids only

– ECG– Dextrose (D10W or D12.5W)– Maintain warmth

Dextrose?

• D10– 10 GM /100 CC buritrol = 1 GM/10 cc– or– 25 GM D50 /250 bag NS

• DOSE 0.2-0.5 GM/KG IV (2-5 ml/kg)– Slow IV push (5 min)– May need repeat boluses.

• Document response to treatment

A comment about Hyperglycemia

• The more premature the infant, the less mature their endocrine system is. Expect fluctuations.

HYPOVOLEMIATreatment of the Newborn

Key points to remember

• Premature and SGA infants may need more fluid requirments because of increased fluid loss through thinner skin.

Tips for IV access

• 24 gauges for most infants• IO’s only work for full term– Consider Umbilical Lines (medic/RN Only)

• Locations– Scalp – Hands– Feet– A/C

• Use own finger as a tourniquet• Remember: Blood return will be slow

Shallow angle of insertion [Photograph found in Royal Children's Hospital Melbourne, Melbourne, Australia]. (n.d.). Retrieved February 22, 2016, from http://www.rch.org.au/clinicalguide/guideline_index/Intravenous_access_Peripheral/

Scott-Warren, V., & Morley, R. (2015). Paediatric vascular access. BJA Education Bja Educ, 15(4), 199-206. Retrieved February 22, 2016, from http://bjaed.oxfordjournals.org/content/early/2015/06/03/bjaceaccp.mku050

Trans-illumination?

Umbilical Lines (UVC)

• May be the best option for an unstable premature infant.

• Size:– Under 1.5 kg: 3.5 French– 1.5 + kg: 5 French

• IV Caths?– 18 Gauge – Do not advance past abd wall

Fluids

• Rarely needed– Refractory bradycardia and arrest– Severe Maternal Blood loss pre-birth

• 10 cc / kg• “Volume expansion should be considered when

blood loss is known or suspected (pale skin, poor perfusion, weak pulse) and the infant’s heart rate has not responded adequately to other resuscitative measures.” (Class IIb, LOE C)

SPECIAL SITUATIONS

Comments about Narcan and the Newly Born

Non Viable?

• Fundus below the umbilicus• Eyes Fused• Maternal Report

Final Thoughts

The 4 “Ts” Recalled“THROMBIN” Check labs if

suspicious.