Provincial Reciprocity Attainment ProgramProvincial Reciprocity Attainment Program

Neonatal Assessment

The Need for Resuscitation

Most term newborns require no resuscitation beyond maintenance of temperature, suctioning of the airway, and mild stimulation Approximately 6% of deliveries require

life support Incidence of complications increases as

birth weight decreases

The Need for Resuscitation

Antepartum (before labor and delivery) and intrapartum (during labor and delivery) risk factors may affect the need for resuscitation When any of these risk factors are present

during delivery or imminent delivery, prepare equipment and drugs that may be required for neonatal resuscitation

Medical direction should also be advised of the situation so that the appropriate destination hospital can be determined.

Antepartum Risk Factors

Multiple gestation Inadequate prenatal care Mother’s age

Less than age 16 or more than 35 History of perinatal morbidity or mortality Post-term gestation Drugs/medications Toxemia, hypertension, diabetes

Intrapartum Risk Factors

Premature labor Meconium-stained amniotic fluid Rupture of membranes greater than 24 hours

before delivery Use of narcotics within 4 hours of delivery Abnormal presentation Prolonged labor or precipitous delivery Prolapsed cord Bleeding

The Premature Infant

Refers to a baby born before 37 weeks gestation The weight of these newborns is often between 0.6 to 2.2

kg [1.5 to 5 pounds]

Premature infants have an increased risk for: Respiratory depression Hypothermia Head and brain injury

Resuscitation should be attempted if the infant has any signs of life

Congenital Anomalies

Choanal atresia A bony or membranous occlusion that

blocks the passageway between the nose and pharynx

Can result in serious ventilation problems in the neonate

Cleft lip One or more fissures that originate in the

embryo A vertical, usually off-center split in the

upper lip that may extend up to the nose

Congenital Anomalies

Cleft palate A fissure in the roof of the mouth that runs

along its midline May extend through both the hard and soft

palates into the nasal cavities

Pierre Robin syndrome A complex of anomalies including:

A small mandible Cleft lip Cleft palate Other craniofacial abnormalities Defects of the eyes and ears

Diaphragmatic Hernia

Protrusion of a part of the stomach through an opening in the diaphragm

Risk factors Bag and mask ventilation can

worsen condition

Pathophysiology Abdominal contents are displaced

into the thorax Heart may be displaced Respiratory compromise

Physiological Adaptations at Birth

At birth, newborns make three major physiological adaptations necessary for survival Emptying fluids from their lungs and

beginning ventilation Changing their circulatory pattern Maintaining body temperature

Transition From Fetal to Neonatal Circulation

Respiratory system must suddenly initiate and maintain oxygenation

Infants are very sensitive to hypoxia Permanent brain damage will occur

with hypoxemia Apnea in newborns

Causes of Hypoxia

Compression of the cord Difficult labor and delivery Maternal hemorrhage Airway obstruction Hypothermia Newborn blood loss Immature lungs in the premature newborn

Hypothermia

Newborns are at great risk for rapidly-developing hypothermia because of: Their larger body surface area Decreased tissue insulation Immature temperature regulatory mechanisms

Newborns attempt to conserve body heat through vasoconstriction and increasing their metabolism, placing them at risk for: Hypoxemia Acidosis Bradycardia Hypoglycemia

Assessment and Management

Initial steps of neonatal resuscitation (except infants born through meconium):

1. Prevent heat loss

2. Clear the airway by positioning and suctioning

3. Provide tactile stimulation and initiate breathing if necessary

4. Further evaluate the infant

Prevention of Heat Loss

Immediately after delivery Dry the infant's head and body Remove any wet coverings from the

infant Cover with dry wrappings Cover the newborn's head

Accounts for 20% of the newborn’s BSA

Opening the Airway

Position Suction

Technique Mouth first, than nares Nasal suctioning is a stimulus to breathe

Equipment Bulb suction Suction catheters

Provision of Tactile Stimulation

If drying and suctioning do not induce respirations, provide additional tactile stimulation Two safe and appropriate methods are:

Slapping or flicking the soles of the feet Rubbing the infant's back

If the infant remains apneic after a brief period (5 to 10 seconds) of stimulation: Immediately initiate positive-pressure ventilation with

a pediatric bag-valve device and supplemental oxygen (40 to 60 ventilations/min)

Evaluation of the Infant

Observe and evaluate the infant's respirations Evaluate the infant's heart rate by stethoscope, or

by palpating the pulse in the umbilical cord or brachial artery HR < 100

Provide ventilation via BVM for 30 seconds and reassess

HR < 60 Provide ventilation via BVM for 30 seconds and

reassess If not resolved begin CPR (a rate of > 100)

Evaluation of the Infant

Evaluate the infant's color If Central cyanosis, bradycardia and other signs of

distress are present in an infant with spontaneous respirations and an adequate heart rate, administer free-flow oxygen at 5 LPM

A maximum oxygen concentration of about 80% can be achieved when the tube is one-half inch from the infant's nose

Peripheral cyanosis is common in newborns and should resolve

Apgar Score

Enables rapid evaluation of a newborn’s condition at specific intervals after birth Routinely assessed at 1 and 5 minutes of age

Sign 0 1 2Appearance (Skin Color)

Central cyanosis, pale Peripheral cyanosis Pink

HR Absent < 100 bpm > 100 bpm

Grimace (Irritability) No response Grimace Cough, sneeze, cry

Muscle tone Limp Some flexion Active motion

Respiratory Effort Absent Slow, irregular Good, crying

Resuscitation of the Distressed Newborn

Risk factors associated with the need for resuscitation include: Premature delivery Maternal health problems Complicated pregnancies Delivery complications

Reevaluating components of the resuscitation process

Resuscitation

Neonatal Transport

During transport of the neonate: Maintain body temperature Oxygen administration Ventilatory support

In the prehospital phase of care, transport strategies are usually limited to: Providing a warm ambulance Free-flow oxygen administration Warm blankets

Specific Situations

Respiratory Disorders

Respiratory insufficiency in the neonate is generally managed by: Stimulation and positioning of the airway Prevention of heat loss Oxygenation and ventilation Suction Ventilatory support (if needed)

Apnea

Respiratory pauses that exceed 20 seconds Common finding in preterm infants, and if

prolonged, can lead to hypoxemia and bradycardia

Primary apnea self-limited condition (controlled by pCO2 levels) that is

common immediately after birth

Secondary apnea describes respirations that are absent and that do not

begin again spontaneously

Apnea

Risk factors Hypoxia Hypothermia Narcotic or CNS depressants Airway or respiratory muscle weakness Oxyhemoglobin dissociation curve shift Septicemia Metabolic Disorders CNS Disorders

Respiratory Distress and Cyanosis

Prematurity is the single most common factor for respiratory distress and cyanosis in the neonate Occurs most frequently in infants less than 1200

g (2.5 pounds) and 30 weeks gestation Risk factors (see next slide):

Can lead to cardiac arrest Requires immediate intervention to support respirations

Other Risk Factors

Lung or heart disease Primary pulmonary HTN CNS Disorders Mucous obstruction of

nasal passages Spontaneous

pneumothorax Choanal atresia

Meconium aspiration syndrome

Amniotic fluid aspiration Lung immaturity Pneumonia Shock and Sepsis Metabolic acidosis Diaphragmatic hernia

Dyspnea and Cyanosis

S/S may include Tachypnea Tachycardia Paradoxical breathing Intercostal retractions Nasal flaring Expiratory grunting Central cyanosis

Cardiovascular Disorders

All neonates with cardiovascular disorders should be assessed for treatable causes of hypoventilation

Bradycardia A heart rate of less than100 beats/min Causes

Hypoxia (most common) Increased intracranial pressure Hypothyroidism Acidosis

Considered a minimal risk to life in neonates if corrected quickly

Cardiac Arrest

Incidence is rare Risk factors

Intrauterine asphyxia CNS depressants or other drugs taken by Mom Congenital neuromuscular disorder Congenital deformities Intrapartum Hypoxia

Arrest protocols are covered in Pediatrics

Hypovolemia

May result from: Dehydration Hemorrhage Trauma Sepsis

May be associated with myocardial dysfunction

Hypovolemia

Signs and symptoms Mottled or pale skin Cool Tachycardia Diminished peripheral pulses Delayed cap refill Pressure is not a good indicator

Prehospital care Airway Fluid @ 10 ml/kg over 5 - 10 minutes (ALS)

Gastrointestinal Disorders

Occasional vomiting or diarrhea is not unusual in the neonate Vomiting mucus (that may occasionally be

blood streaked) is common in the first few hours of life

5 to 6 stools per day is considered normal, especially if the infant is breast feeding.

Persistent vomiting and/or diarrhea should be considered warning signs of serious illness

Seizures

Are usually fragmented and not sustained Subtle seizures may include

Eye deviation Blinking Sucking Swimming movement of arms and peddling of the legs Apnea

Causes Hypoglycemia Hypoxic ischemia encephalopathy Intracranial hemorrhage Metabolic disturbances Meningitis or encephalopathy Development abnormalities Drug withdrawal

Fever

Rectal temperature > 38ºC Often a response to an acute viral or

bacterial infection May also be result of

Lack of internal temperature control Dehydration

May lead to metabolic acidosis From ↑ O2 demand and ↑ glucose metabolism

Fever

Assessment may include ALOC

Irritable Somnolence

History of decreased intake or not feeding at all

Warm or hot skin Treatments are supportive only

Hypothermia

Body temperature drops below 35 º C BSA and surface to volume ratio makes

them susceptible Infants may die of cold exposure at

temperatures adults find comfortable Increased metabolic demand may cause

metabolic acidosis, pulmonary HTN, and hypoxemia

Hypothermia

Assessment may include Pale skin Cool (especially in the extremities) Respiratory distress Apnea Bradycardia Central cyanosis Irritability progressing to lethargic Absence of shivering

Treatment

Hypoglycemia

A blood glucose screening test less than 4 mmol/L indicates hypoglycemia

Risk factors Asphyxia Toxemia Being smaller twin CNS hemorrhage Sepsis

Hypoglycemia

S/S Twitching or seizure Limpness Lethargy Eye rolling High pitched cry Apnea Irregular respirations Cyanosis possibly

Treatment 1.0 cc/kg D50 IV (D10 or D25 preferred) – Requires ALS

Common Birth Injuries

2 - 7 % out of 1000 births results in an injury Risk factors include uncontrolled explosive

delivery Types of injuries seen:

Cranial injuries Molding of head and overriding of parietal bones Soft tissue from forceps Subconjunctival and retinal hemorrhage Skull fracture

Common Birth Injuries

Intracranial hemorrhage Spine or spinal cord injury Peripheral nerve damage Liver or spleen or kidney Clavicle or extremity fracture Hypoxia ischemia

Prehospital care Support vital functions Rapidly transport to an appropriate medical facility

for definitive care

Psychologicaland Emotional Support

Be aware of the normal feelings and reactions of parents, siblings, other family members, and caregivers while providing emergency care to an ill or injured child These events also are often highly

charged and emotional for the EMS crew

Psychological and Emotional Support

As a rule, emergency responders should: Never discuss the infant’s chances of survival

with a parent or family member Not give “false hope” about the infant’s condition Assure the family that everything that can be

done for the child is being done Assure the family that their baby will receive the

best possible care during transport and while at the emergency department