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1. Neonatal Field Stabilization 2008
Jaime Ruddell, ARNP
Children’s Hospital Regional
3. Objectives Review Near code situations and common reasons for EMS involvement in Neonate.
Review NRP and “code” and “near code” situations in the neonate following 2005 NRP recommendations.
Review case studies.
Review the pitfalls of a neonatal resuscitation.
Outline the need and procedure of vascular access in neonatal code situations. 1. 1.
5. Near Code- Respiratory compromise in babies 2 –30 days -Infection; GBS, Listeria, Staphylococcus, E-coli, Herpes.
Hypoglycemia (<50 mg/dl).
Respiratory Viral Illness; RSV, Influenza, pertusis, bacterial/viral pneumonia.
Cardiac defects- Heart failure related to TOF, large VSD, SVT. Any ductal dependent lesion, ie transposition, pulmonary atresia, etc.
Acidosis. Without intervention, any one of these kids can lead to code situation.Without intervention, any one of these kids can lead to code situation.
6. Code Situations in the Field Most codes in the field in neonates are respiratory related.
Respiratory compromise leading to Bradycardia.
SIDS; never witnessed events.
7. Neonatal Resuscitation Newly initiated 2005; Current guidelines have changed regarding.
Epinephrine dosing and route.
Umbilical venous access.
Initiation of chest compressions.
Use of sodium bicarb.
Use of oxygen (it’s a drug).
8. You’re on a need to know basis and you do need to know ? Collect a detailed history if possible.
What is the babies gestation?
Is the fluid clear?
? It is always helpful to have all your equipment ready prior to delivery if you have the time.
Does all the needed equipment work?
Do you have the right sized equipment?
Do you have extra hands to help stabilize the baby if you have to manage a sick mom?
9. Initial Steps in Resuscitation Provide a warm environment.
Position airway and use bulb syringe in mouth and then nose.
Dry stimulate and reposition as needed.
Evaluate heart rate, color and respiratory effort.
Is the Heart rate > 100?
What is the babies color?
11. The babies HR is > 100bpm If baby is breathing and pinking up quickly, simply offering drying and bulb suction will be enough to facilitate a healthy resuscitation.
If baby is apneic with HR> 100.
Bag and mask x 30 seconds or until baby is responsive, and then reassess.
Progress to intubation if after 1 minute, baby still has no resp. effort and/of if HR has dropped to < 100.
12. The babies HR is <100 Initiate positive pressure ventilation.
Ventilate with PPV x minimum 30 seconds or until respiratory effort or baby responsive. Recheck vital signs after 30 seconds.
Bag and mask ventilation, if able to ventilate, will work very well for early resuscitation. If you are intubated and not sure of placement, extubate and defer to bag and mask.
13. The babies HR is < 60 Bag and mask for 30 seconds, if remains bradycardic;
*Start chest compressions and continue bag and mask ventilation at a rate of 3/1.
Ready your intubation equipment.
Start thinking epinephrine.
Bag and chest compressions for 30 seconds before reassessing.
*If HR remains < 60, intubate and give epi 1ml/kg down the ETT followed by 0.5-1ml NS. Be thinking venous access.
14. NRP Drugs *Epinephrine: 0.1-0.3ml/kg (1:10,000)via UVC and 0.3-1ml/kg down the ETT.
Normal saline bolus of 10-20ml/kg via UVC or PIV.
*Sodium Bicarb is no longer a standard use drug in NRP.
*Oxygen; considered a drug and is limited in the hospital setting, but you’ll never be wrong if you use it in the field.
15. Common pitfalls in the field ABC and Re-ACT.
16. Common pitfalls in the field Normal saline bolus and Dextrose boluses.
Know your equipment. You cannot give BBO2 with a self inflating bag.
Oro/nasal gastric tubes.
17. The Neonatal Code from Bacterial Infection (case 1) A 16 day old AGA term infant with hx of fever, and poor feeding. (fever in a baby < 30 days is never normal and should always be evaluated).
Day1- Parents note baby not feeding well, very irritable, low grade fever of 99F.
Day2- Parents note, poor feeding, lethargy, temp 100.6F, cold extremities.
Day 3- Parents note non-responsive, cyanosis, cold extremities, pale and mottled, fever 103.6F.
Baby may seize, have apnea, or complete circulatory and respiratory failure at any time.
18. The term home delivery (case 2) A term baby who was a midwife delivery and had been having severe fetal decels in labor. He was born with a nuchal cord that was reduced prior to delivery. He is born limp and apneic. You arrive at 5 minutes of life. The midwife has left the cord intact to attempt to get blood to the baby and he is still apneic and has a HR of 30. She has been bagging him, but has not started chest compressions.
19. Resuscitation of the newborn Cut the cord and move the baby to a warm dry environment.
Intubate using a 3.5 or 4.0 ETT and bag at a rate of 40-60bpm.
Start chest compression at a rate of 1 breath per 3 compressions for at least 30 seconds before reassessing (goal is 1 cycle every 2 sec).
Prepare Epi and UVC placement.
20. Premature infant born in the field (case 3) The tiny premature infant born at home into the toilet.
The baby is tiny (very premature) bradycardic, apneic.
Heat the baby up. B&M-intubate/chest compressions.
Umbilical venous catheter.
Give dextrose, NS.
26. Coarctation of the Aorta (case #4) Intrauterine circulation
At birth, hormonal changes, pulmonary perfusion and increased oxygen cause the PDA to begin to constrict. Most PDA’s close within 2-5 days.
Coarct is constriction of the aorta that does not allow blood flow via normal circulation to the body= minimal blood flow to body= severe acidosis, hypoxia and shock.
27. Presents w/ Severe Acidosis Term previously healthy baby, now 4 days old. 911 dispatch of infant difficulty breathing, blue.
Medics arrive to see very cyanotic infant, with tachypnea, but minimal work of breathing.
HR 170’s, sinus tach, cap refill horrible, pulses to lower extremities barely palpable.
Where do I go from here? What do you treat first.
What clues do you see for differential diagnosis?
28. Treatment of the Coarctation PIV, IO, UVC
FLUID, FLUID, FLUID- treat the shock
Respiratory- intubate if resp distress, provide O2
The only actual treatment for Coarct is prostaglandins (PGE) and eventually surgery once stable.
Call ahead, call early
29. GBS Meningitis GBS + mom, normal delivery at home.
2 hours after birth, baby sleepy, difficult to arouse.
4 hours- baby pale, shocky- parents called 911.
Medics arrive, baby dusky, Respiratory distress, shocky, limp
Progressed to full code by arrival to ER.