neonatology nsc

8/2/2019 Neonatology NSC

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Neonatalogy

Temple College

EMS Professions


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Neonatalogy

Newborn

First few hours of life

Neonate

First 28 days of life


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Morbidity/Mortality

Complications increase as birth weightdecreases.

Resuscitation rate of those less than1500 g is 80%


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Risk Factors

Antepartum Multiple gestation

Inadequate prenatal care Mothers age 35

History of perinatal morbidity or mortality

Post-term gestation

Drugs/ medications

Toxemia, hypertension, diabetes


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Risk Factors

Intrapartum factors Premature labor

Meconium-stained amniotic fluid

Rupture of membranes greater than 24 hours priorto delivery

Use of narcotics within four hours of delivery

Abnormal presentation

Prolonged labor or precipitous delivery

Prolapsed cord

Bleeding


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Fetal Circulation


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Respiratory Changes

Fetus

Lungs filled with fluid

Arterioles and capillaries closed Ductus arteriosus

Stimulation of first breath

Mild acidosis

Initiation of stretch reflex in the lung

Hypoxia

Hypothermia


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Ductus arteriosus


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Respiratory Changes

Air displaces fluid

Pulmonary arterioles and capillaries open

Decreases vascular resistance Blood diverted from ductus arteriosus

Ductus arteriosus eventually closes

Persistent fetal circulation


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Cardiovascular Changes

Fetus

Most of blood from placenta bypasses liver

Ductus Venosus Most blood passes from right to left atria

Foramen ovale

Extrauterine Life

Blood diverted from placenta Lungs expand

Changes pressure levels in heart


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Foramen Ovale


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Closure of Foramen Ovale

Low right atrial pressure

High left atrial pressure

Blood flows backwards towards right side

Valve closes


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Closure of the Ductus Venosus

Ductus venosus contracts

Blood forced through liver sinuses


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Congenital Anomalies

Diaphragmatic hernia

Meningomyelocele

Exposed abdominal contents

Choanal atresia

Cleft lip/palate Pierre Robin Syndrome


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Assessment of newborn

Time of delivery

Vital Signs

Respirations 30-60

Heart rate 100-180

Systolic BP 60-90 mmHg

Temp 36.7o - 37.8o C (98o - 100o F)


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Assessment of the newborn

Color

Central vs peripheral cyanosis

Mucosal membranes

End organ perfusion

Central pulses vs peripheral pulses

Capillary refill


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APGAR Scoring


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APGAR

One minute, five minutes

postpartum


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APGAR

7 - 10

Normal Infant

Suction oropharnyx

Keep warm


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APGAR

4 - 6

Moderate asphyxia

Suction oropharnyx

Keep warm

Oxygenate

If 5 minute score < 7, repeat every 5minutes for 20 minutes


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APGAR

0 - 3

Asphyxia neonatorum

Resuscitate aggressively


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APGAR

Scores can be misleading

Do not work well with pre-term infants

Primarily measure brainstem function


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APGAR

Do not wait 1 minute in

obviously distressed infant


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Treatment

Prior to delivery, prepare environmentand equipment

During delivery, suction mouth, thennose as head delivers

Note amniotic fluid color, thickness


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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


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Treatment

Position

On back - slight Trendelenburg

1-inch thick towel under shoulders

Avoid neck under, overextension

If secretions heavy, place on left side


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Treatment

Suction

Bulb syringe

Mouth first, then nose Neonates are obligate nasal breathers

Monitor heart rate for bradycardia

Meconium


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Treatment

Tactile Stimulation (optional)

Flicking soles of feet

Stroking back


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Treatment

Evaluate respirations

Spontaneous

Evaluate heart rate

Absent or gasping

Brief tactile stimulation (optional)

PPV with 100% Oxygen

15 - 30 seconds

Primary Apnea vs. Secondary Apnea


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Treatment

Evaluate Heart Rate

Above 100

Evaluate Color

Below 60

Continue PPV with 100% Oxygen

Initiate compressions

Reevaluate after 30 seconds

Initiate medications if below 80


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Treatment

Evaluate Heart Rate

Between 60 - 100

HR not increasing Continue PPV with 100% Oxygen

Initiate compressions

After 30 seconds reevaluate

Initiate medications if below 80 HR increasing

Continue PPV with 100% Oxygen


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Treatment

Evaluate Color

Central cyanosis

Provide free flow oxygen When pink, gradually remove oxygen

If no improvement consider PPV with 100% O2

Acrocyanosis

Observe, monitor


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Meconium

10 - 15% of deliveries

Risk factors Fetal distress

Post-term infants

Complications Hypoxemia

Aspiration pneumonia

Pneumothorax

Pulmonary hypertension


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Meconium

Management

In depressedinfant

Do not stimulate Tracheal suction under direct visualization

End Points

Airway is clear

Infant breathes on own Bradycardia

Ventilate with 100% Oxygen


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Meconium


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Diaphragmatic Hernia

1 in 2200 live births

Most commonly on left side (90%)

Failure of the pleurperitoneal canal (Foramenof Bochdalek) to close completely

50% survival if mechanical ventilationrequired

Near 100% survival if no respiratory distress


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Assessment

Little to severe distress present from birth

Dyspnea and cyanosis unresponsive toventilation and oxygenation

Scaphoid abdomen

Bowel sounds in thorax Heart sounds displaced to the right


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Management

Elevate head, chest

Intubation PRN Do NOT use BVM

Orogastric tube (low, intermittent suction)

Requires surgical repair


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Bradycardia

Possible causes

Hypoxia

Increased intracranial pressure Hypothyroidism

Acidosis

Minimal risk if corrected quickly


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Bradycardia

Assessment

Upper airway for obstruction

Foreign object Secretions

Tongue/soft tissue

Hypoventilations


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Bradycardia

Management Position

Suction

Heart rate less than 100

BVM with 100% O2 and reassess

Heart rate less than 60 Chest compressions with PPV 100% O2 and reassess

Heart rate 60 - 80 but not improving

Chest compressions with PPV 100% O2 and reassess Maintain Temperature


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Bradycardia

Discontinue chest compressions whenHR > 100

Pharmacological Use as last resort

Epinepherine


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Premature Infants

Born prior to 37 weeks gestation

Weigh less than 2.2 kg (4 lb., 13 oz.)

Healthy infants weighing < 1700 g (3lb., 12 oz.) have good prognosis

Fetal viability considered 23 -24 weeks

gestation


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Premature Infants

Complications from Respiratory suppression

Head/brain injury

Hypothermia

Change in blood pressure

Hypoxemia

Intraventricular hemorrhage Fluctuations in serum osmolarity


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Premature Infants

Assessment

Large trunk

Short extremities Transparent skin

Less wrinkles

Less subcutaneous fat


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Premature Infants

Management

Same as with full term newborn

Transport Appropriate facility


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Respiratory Distress/Cyanosis

Prematurity is most common factor

Most frequently in infants less than

1200 grams (2 lb., 10 0z.) 30 weeks gestation

Multiple gestations

Prenatal maternal complications


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Immature central respiratory control center

Easily affected by environmental or metabolicchanges

Lung or heart disease Aspiration

Shock

Sepsis

Infection Diaphragmatic hernia

CNS disorders

Airway Obstruction


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Assessment findings

Tachypnea

Paradoxical breathing Periodic breathing

Intercostal retractions

Nasal flaring Expiratory grunt


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Management Airway/Breathing

Position Suction

High concentration oxygen

PPV/Intubation PRN

Circulation Compression PRN

Maintain warmth


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Seizures

Rare in newborns

Indicate serious underlying medical

abnormality Prolonged, frequent seizures may result

in metabolic, cardiopulmonary

difficulties


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Seizures

Tonic/clonic seizures typically do not occur infirst month of life

Subtle seizures

Eye deviation, blinking, sucking, swimmingmovements, apnea, changes in color

Tonic seizures

Posturing of extremities, trunk

More common in premature infants

Intraventricular hemorrhage


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Seizures

Focal clonic seizures Rhythmic twitching of muscle group

Can migrate to other areas

Multifocal seizures Multiple muscle groups involved Can migrate to other areas

Myoclonic seizures

Generalized jerks of extremities May occur singly or repetitively


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Seizures

Causes

Hypoglycemia

Sepsis Fever

Infection

Developmental abnormalities Drug withdrawal


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Seizures

Assessment Decreased level of consciousness

Seizure activity

Management ABCs

High concentration Oxygen

Benzodiazepines

Dextrose (D10W or D25W)

Maintain Warmth

Rapid Transport


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Fever

> 100.4o F (average temp 99.5o F)

Life-threatening condition

Limited ability to control temperature Increased use of glucose may lead to

anaerobic metabolism


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Fever

Assessment

Irritability

Somnolence

Decreased intake

Rashes, petechia

Sweat

On brow only of term newborns

Not present on premature newborns


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Fever

Management

Assure adequate oxygenation, ventilation

Avoid rapid cooling Avoid cold packs

Avoid antipyretic agents


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Hypothermia

Infants cannot tolerate

temperatures comfortable toadults


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Hypothermia

Below 35o C (95o F)

Increased surface to volume ratio

Can be an indicator of sepsis

Can lead to:

metabolic acidosis

pulmonary hypertension

hypoxemia


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Hypothermia

Assessment Acrocyanosis

Irritability (early) Lethargy (late)

Pale, cool to touch

Respiratory distress/Apnea

Bradycardia

NEWBORNS DO NOT SHIVER


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Hypothermia

Management

Assure adequate oxygenation and

ventilation Chest compressions if indicated

Warm infant

Ambient temperature

Cover infant

Warm IV Fluids


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Hypoglycemia

Less than 45 mg/dL

Causes

Do not have to have diabetes mellitus

Inadequate glucose stores

Inadequate intake

Increased glucose utilization Stress


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Hypoglycemia

Assessment Twitching/Seizures

Limpness

Lethargy

Eye rolling

High pitched cry

Apnea Irregular respirations


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HypoglycemiaALL SICK INFANTS REQUIRE BLOOD

GLUCOSE ASSESSMENT


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Hypoglycemia

Management

Assure adequate oxygenation, ventilation

IV/IO TKO ECG

Dextrose (D10W or D25W)

Maintain warmth


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Vomiting

Rare during first weeks of life

May be confused with regurgitation

Life threatening if contains blood

Symptom of underlying problem Upper digestive tract obstruction

Increased intracranial hemorrhage

Infection

May lead to dehydration, electrolyteimbalance


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Vomiting

Assessment

Distended stomach

Infection Increased ICP

Drug withdrawal


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Vomiting

Management

Maintain a patent airway

Assure adequate oxygenation Vagal stimulation may cause bradycardia

IV NS TKO (if concerned about

dehydration)


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Diarrhea

5 - 6 stools pre day normal

Can lead to

Dehydration

Electrolyte imbalance


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Diarrhea

Causes

Bacterial or viral infection

Gastroenteritis Phototherapy

Thyrotoxicosis

Cystic fibrosis


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Diarrhea

Assessment

Loose stools

Decreased urinary output Listlessness

Prolonged capillary refill

Number of diapers per day


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Diarrhea

Management

Assure adequate oxygenation

Maintain temperature IV NS TKO (if concerned with dehydration)


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Birth Injuries

Avoidable and unavoidable traumaduring labor and delivery

Occur in 2 to 7 of every 1,000 live births 5 to 8 of every 100,000 die of birth

trauma

25 of every 100,000 die of anoxicinjuries

2 - 3 % of infant deaths


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Birth Injuries

Cranial Injuries

Molding of head, overriding of parietal

bones Skull fracture

Subperiosteal hemorrhage

Subconjunctival and retinal hemorrhage Erythema, abrasions, ecchymosis, and

subcutaneous fat necrosis


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Birth Injuries

Intracranial Hemorrhage

Trauma

Asphyxia Spinal Cord Damage

Traction when spine is hyperextended

Lateral pull


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Birth Injuries

Peripheral nerve injury

Liver or spleen rupture

Fracture Clavicle

Extremities

Hypoxia - ischemia


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Birth Injuries

Assessment

Edema, ecchymosis to soft tissue

Paralysis below level of spinal cord injury Paralysis of upper arm with or without

paralysis of forearm

Hypoxia Shock


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Birth Injuries

Management

Assure adequate oxygenation ventilation

Chest compressions as needed Pharmacology as needed

Maintain warmth


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Cardiac Arrest

Risk factors

Intrauterine asphyxia

Prematurity Drugs administered or taken by mother

Congenital neuromuscular diseases

Congenital malformations Intrapartum hypoxemia


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Cardiac Arrest

Causes

Primary apnea

Secondary apnea Bradycardia

Pulmonary hypertension

Persistent fetal circulation


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Cardiac Arrest

Central cyanosis

Inadequate respiratory effort

Ineffective or absent heart rate


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Meds

Intubation

Chest Compressions

BVM Ventilations

Oxygen

Drying, Warming, Positioning,

Suction, Tactile Stimulation


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Cardiac Arrest

Management

Dry

Warm Position

Suction

Evaluate Respiration Evaluate Heart Rate


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Most depressed infants will

respond to warming, positioning,

suction, stimulation


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Oxygenation

If pale or cyanotic, O2 until

pink


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Oxygenation

Mask tent over head with sheet or holdmask near face; flow at 4 - 5 LPM

Avoid blowing O2 directly onto face; canproduce bradycardia

02 toxicity NOT a concern


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Ventilation

Indications

Apnea

Heart rate < 100 Persistent central cyanosis on 100% 02

Infant BVM

NOT adult equipment


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Ventilation

Judge by chest expansion

Tidal volume is 7cc/kg

Ventilation rate is 40 - 60/minute


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Chest Compressions

If heart rate


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Endotracheal Intubation

If ventilations, chest compressionsineffective

Especially important if < 28 weeksgestation

Place gastric tube if ventilated under

mask for extended time


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Medication

Epinephrine

Fluid

Glucose


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Epinephrine

For asystole, bradycardia (rate


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Volume Expansion

Consider if:

Pallor continues after oxygenation

Pulses weak after oxygenation Response to resuscitation poor

History of hemorrhage from maternal/fetalunit

10cc/kg LR over 5 - 10 minutes


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Hypoglycemia Symptoms

Jitters

Lethargy

Apnea Color changes

Respiratory distress

Seizures


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Hypoglycemia Symptoms

Hypoglycemia may mimic hypoxemia

Some hypoglycemic infants are

asymptomatic Consider blood glucose test 20 - 30

minutes postpartum


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Neonatal Resuscitation

Most respond to simple measures

Stepwise resuscitation, frequent

reassessment Heart rate guides resuscitation


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Neonatal Transport

l


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Neonatal Transport

Best transport device = Moms uterus

Second best = Specialized team

l


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Neonatal Transport

Assessment

Vital signs

Axillary temperature (96.5 - 990

F) Pulse (120 - 160/minute)

Respirations (30 - 60/minute)

APGAR scores

N l T


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Neonatal Transport

Cardiovascular Stabilization

Keep airway clear (obligate nasal

breathers) Maintain body temperature

Humidified oxygen

N l T


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Neonatal Transport

Cardiovascular Stabilization

Assist ventilation if

cyanosis/pallor/respiratory distress present Vascular access D10W 4cc/kg/hr

Nasogastric intubation

N l T


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Neonatal Transport

Documentation

Copies of infants/mothers charts

Names of infant, parents referring

physician, parents telephone number

Any X-rays

Maternal/umbilical cord blood samples

Consent forms

T l i Th


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Tocolytic Therapy

Indications for tocolysis

20 - 36 weeks gestation

Preterm labor Healthy fetus

Dilated 4cm or less/membranes intact

T l i Th


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Tocolytic Therapy

Left side position, supplemental O2, IVfluids (1 liter LR)

Improves uterine oxygenation Inhibits oxytocin release from posterior

pituitary

T l ti Th


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Tocolytic Therapy

2 Adrenergic agents

Cause uterine smooth muscle relation

Ritodrine (Yutopar) Terbutaline

T l ti Th


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Tocolytic Therapy

Magnesium Sulfate

Competes with calcium at cellular level

Blocks actin/myosin interaction/inhibitscontraction

neonatology nsc

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