Resuscitation By : dr sanjeev Resuscitation algorithm - Resuscitation chart :. . Initial steps of resuscitation: POSITIONING: Placed on her back or side with the neck slightly extended, prevent hyperextension or under extension. In case of large occiput, edema or prematurity, place a rolled blanket or towel under the shoulder. If copious secretions, keep head turned to the side. Position of Newborn for Resuscitation suctioning. Meconium present : Mouth is suctioned first (to prevent aspiration) than nose Meconium absent cont.. Dry, stimulate and reposition : DRY : To prevent heat loss Remove wet clothes from the baby STIMULATE : Suctioning and drying Tactile stimulation FREE FLOW OF OXYGEN : (5 6 liter per minute) BAG AND MASK VENTILATION: Indication : If the infant is apneic or gasping, Respiration is spontaneous but HR is below 100 beats per minute Contraindication : - Diaphragmatic hernia - Meconium stained liquor (MSL) Cont.. Procedure : Neck should be slightly extended to ensure an open airway. The appropriate facemask should cover mouth and nose but not eyes of the infant. Compress the bag and observe the chest. Ventilate at the rate of 40 60 breaths per minute. After 30 seconds of ventilation with 100 % oxygen, evaluate the heart rate. Cont.. HEART RATE : Above 1oo Between 60 100 Below 60 ACTION : Provide tactile stimulation, monitor heart rate and color Continue ventilation Continue to ventilate. Begin chest compressions. Cont.. Improvement : Increasing heart rate, spontaneous respiration, improving color Fails to improve : Check : position, facemask seal tight or not,oxygen tubing attached or not, chest movement adequate or not. If ventilation continues for more than 2 minutes, an orogastric tube should be inserted and left open to prevent abdominal distention. Bag and mask FIG : Self inflating bag Fig : Masks Positive Pressure Ventilation - Correct Position & Size of Face Mask Cont.. Fitting the face mask Ventilation with bag and mask Resuscitation With Bag & Mask Chest compressions : Consist of rhythmic compressions of the sternum that compress the heart against the spine, increase intrathoracic pressure and circulate blood to the vital organs of the body. Indication : HR below 60 beats per minute even after 30 seconds of positive pressure ventilation with 100 % oxygen. Once the HR is 60 beats per minute or more, chest compression should be discontinued. External Chest Compression Technique of chest compression -Note the position of the thumbs on the midsternum,just below the nipples Cont.. Fig : Chest compression with thumb technique: Cont.. Fig : Chest compression with two finger technique: Rate : In one minute, 90 chest compressions and 30 breaths (3 : 1) Compress the chest 3 times in 1 seconds, second for ventilation. Check the blood circulation (femoral, carotid) Complication : Broken ribs, Laceration of liver and Pneumothorax. Evaluation After 30 seconds check HR: HR below 60 (continue): chest compression with bag and mask ventilation and medication. HR 60 or above (discontinue): Continued until the HR is abive 100 beats per minute and the infant is capable of breathing spontaneously. ENDOTRACHEAL INTUBATION INDICATION : When tracheal suction is required When prolonged PPV is required When bag and mask ventilation is ineffective, and When diaphragmatic hernia is suspected. Correct Positioning of Laryngoscope Medication used in resuscitation: Epinephrine Route : IV or IT Indication : HR below 60/min after 30 seconds of ventilation and chest compression. Effects : - inotropic, chronotropic, peripheral vasoconstriction Dose : - 0.1mL/kg 0.3 mL/kg Cont.. Volume expanders( NS, ringer lactate) Route : - IV Indication : - evidence of acute bleeding with signs of hypovolemia. Effects : - increased intravascular volume, Dose : - 10 mL/kg Cont.. Sodium bicarbonate : Route : - IV Indication : - metabolic acidosis, Apgar score 3 or less at 5 min. Effects : - correction of pH, volume expansion. Dose : - 4mL/kg use only after epinephrine and volume expanders Cont.. Naloxone : Route : - IV, IT or IM Indication : - respiratory depression with H/O narcotic administration 4 hrs before delivery. Effects : - narcotic antagonist Dose : mg/kg. . 1. Cut the umbilical cord about 2 3 cm and tie it with sterile thread or disposable clip 2. Examine the baby completely : - Area Examination Head - Fontanelle, sutures, ears, eyes,face, lip, and palate Arms - Numbers of fingers, palmar creases Chest - Listen to heart and lungs Abdomen - Umbilicus, groins, anus, genitalia Back - Skin, spine Legs - Toes, ankles, hips Management after resuscitation: Cont.. 3. weigh the baby 4. decide whether this is normal, at risk or sick neonate and decide the level of care. 5. make a case record of the baby. 6. if normal : - clothe the baby, transfer to mother. - initiate breastfeeding within half hour. - communicate with mother. - monitor the baby. - provide immunization (BCG, OPV and hepatitis B) - give discharge advice - plan follow up. Cont.. Level of care : Home care : Weight more than 1800g, able to feed on breast, have no danger signs Nursery care : Preterm babies less than 36 weeks LBW infants less than 1800g, Apgar scores less than 7 at 5 minutes Meconium aspiration Sepsis, RD, severe jaundice, seizure etc. Estimation of gestational age : Preterm baby: Deep sole creases absent or limited to the anterior one - third of the sole Genitalia : testes at external ring Scrotum with a few rugosities Labia majora (in female) widely separated exposing labia minora and clitoris Breast nodule :less than 5mm in diameter Ear cartilage :poor elastic recoil Hair : wooly or fuzzy Danger signs : General / CNS : Poor feeding (most important )Convulsion Respiratory : Rapid respiration (more than 40/min),chest retraction, Apnea or grunting Temperature :Cold to touch, fever Change in color : central cyanosis, jaundice extending to palms / soles G.I.T : diarrhea, persistent vomiting, abdominal distension, no passage of meconium within 24 hrs. Others :no passage of urine within 48 hrs, bleeding from any site, poor weight gain.