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EMERGENCY MANAGEMENT OF THE NEONATE. Neonatal Objectives. Upon completion the student will be able to: Describe the routine care of the newborn List four means by which heat loss occurs in neonates Define the parameters of APGAR scoring and the numerical values used

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neonatal objectives
NeonatalObjectives

Upon completion the student will be able to:

  • Describe the routine care of the newborn
  • List four means by which heat loss occurs in neonates
  • Define the parameters of APGAR scoring and the numerical values used
  • Identify special considerations in the care of the premature neonate
  • Explain the significance of meconium staining
  • Describe the inverted pyramid approach to neonatal resuscitation
neonatal objectives3
NeonatalObjectives
  • Describe two methods of stimulating a distressed neonate
  • Describe the appropriate administration o oxygen to neonate
  • Describe the indications for endotracheal intubation of a distressed neonate
  • Describe methods and problems in ventilating the distressed infant
  • Describe the technique and rates used in chest compressions in the neonate
introduction
Introduction
  • Neonate: defined as an infant less than one month of age.
anatomic and physiologic changes at birth
Anatomic and Physiologic Changes at Birth
  • Lungs must be opened
  • Capillaries and arterioles of the lungs will now become filled with blood
  • First few breaths are the strongest ever taken. Responsible for opening the lungs and causing normal blood circulation through the lungs to occur.
anatomic and physiologic changes at birth6
Anatomic and Physiologic Changes at Birth
  • Factors that stimulate respirations include:

1. Mild acidosis

2. Initiation of the stretch reflexes in the lung

3. Hypoxia

4. Hypothermia

routine care of the neonate
Routine Care of the Neonate
  • Follows same priorities as all patients
  • 80% do not require resuscitation
  • You must be prepared to resuscitate at all times
airway
Airway
  • Suctioning of the mouth then the nose as soon as the head is delivered.
prevent heat loss
Prevent Heat Loss
  • Heat loss occurs through:

1. Evaporation

2. Convection

3. Conduction

4. Radiation

  • Most heat loss in the neonate is through evaporation
prevention of heat loss
Prevention of Heat Loss
  • Heat loss can also occur through convection depending on the temperature of the room and the movement of the air
  • Conduction occurs through the surfaces in contact with the neonate
  • Also, heat loss can occur through radiation to colder objects nearby
prevention of heat loss12
Prevention of Heat Loss
  • Dry the neonate to prevent evaporative cooling.
  • Place in a warm towel or blanket to minimize other means of heat loss and maintain a warm body temperature
umbilical cord
Umbilical Cord
  • After airway and heat, clamp and cut the cord
  • Do not “milk” the umbilical cord: causes increased blood viscosity (polycythemia)
  • 1st clamp is 7 inches away from the infant, 2nd clamp is 3 inches above. Cut in the middle with sterile device
assessment of the neonate
Assessment of the Neonate
  • One rescuer attends to the infant, or if second unit on scene they become responsible for the infant.
  • Obtain vitals:

1. Respiratory Rate: 40-60

2. Heart Rate: 150-180 at birth, slowing to 130-140

  • Heart less than 100 is a need for concern
apgar score
APGAR Score
  • Should be done at 1 and 5 minutes after birth.
  • Is not a tool to make resuscitative decisions
  • Parameters include:

A appearance

P pulse

G grimace

A activity

R respiratory effort

apgar score16
APGAR Score
  • Scoring of 0, 1, 2 for each parameter
  • Lowest score 0; highest score 10
  • 4-6 moderately depressed neonate
  • 7-10 indicates active and vigorous neonate
  • < 4 requires immediate resuscitation
premature neonate
Premature Neonate
  • Defined: weighs less than 5.5 pounds (2500 grams), born before the 38th week of gestation.
  • At risk for: hypothermia, hypoglycemia, volume depletion, respiratory problems, and possible cardiovascular problems
heat loss
Heat Loss
  • Premature neonates are more susceptible:

1. Relatively large body surface area and comparatively small weight

2. Thermoregulatory mechanisms are immature

3. Smaller subcutaneous stores of insulating fat

4. Cannot shiver

distressed neonate
Distressed Neonate
  • Presence of meconium; particulate meconium vs staining of meconium
  • Aspiration can result in severe lung inflammation and pneumonia
  • If present DO NOT induce respiratory effort until meconium removed from trachea by suctioning with laryngoscope and ET
airway and ventilation
Airway and Ventilation
  • Most common problems are airway and ventilation
  • Other means of resuscitation are usually not needed
  • Single most important indicator of neonatal distress if fetal heart rate
  • Pulse rate of less than 60 is an absolute indicator for CPR
  • 60-80, not improving with O2 is another indicator for CPR
inverted pyramid
Inverted Pyramid
  • Illustrates the various steps involved neonatal resuscitation
drying warming positioning suction and tactile stimulation
Drying, Warming, Positioning, Suction, and Tactile Stimulation
  • Assessment includes:

1. Respiratory Effort

2. Heart Rate

3. Color: central cyanosis vs. peripheral cyanosis

supplemental oxygen
Supplemental Oxygen
  • Central cyanosis present: use blow by.
  • Make sure the oxygen is warm
  • Continue until color improves
  • NEVER DEPRIVE A NEONATE OF OXYGEN IN THE PREHOSPITAL SETTING FOR FEAR OF TOXICITY
ventilation
Ventilation
  • Positive-pressure if any of the following exist:

1. Heart rate less than 100 beats per minute

2. Apnea

3. Persistence of central cyanosis after administration of oxygen

ventilation35
Ventilation
  • Pressures required to ventilate may be as high as 60 cm/H2O.
  • If BVM has a pop-off valve, you may have to depress it to ensure adequate ventilation is present
ventilation36
Ventilation
  • Endotracheal intubation may be require in the following situations:

1. BVM unit does not work

2. Tracheal suctioning is required

3. Prolonged ventilation will be required

  • Tubes should be uncuffed
chest compressions
Chest Compressions
  • Initiate when:

1. Heart rate is less than 60 beats per minute

2. Heart rate is between 60-80, but does not increase even with 30 seconds of positive-pressure ventilation and supplemental oxygenation

  • When heart rate exceeds 80 discontinue compressions
medications and fluids
Medications and Fluids
  • If ventilation and oxygenation fail we must look to other means for resuscitation which includes fluid and medications
  • Vein of choice is the umbilical vein
  • Located between the two arteries
  • Trim umbilical about 1 inch above the abdomen
medications and fluid
Medications and Fluid
  • Use a 5 french umbilical catheter and attach to a three-way stopcock
  • Insert until the tip is just below the skin and note free flow of blood
  • To not insert to far because it will wedge against the liver and not function
  • Fluid therapy consists of 10 ml/kg over a 5-10 minute period