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Neonatal Emergencies. Put me back!!!. OBJECTIVES. Upon completion, the student will be able to: Define newborn and neonate. Identify important antepartum factors that can affect childbirth. Identify important intrapartum factors that can determine high-risk newborn patients.

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neonatal emergencies
Neonatal Emergencies

Put me back!!!

  • Upon completion, the student will be able to:
  • Define newborn and neonate.
  • Identify important antepartum factors that can affect childbirth.
  • Identify important intrapartum factors that can determine high-risk newborn patients.
  • Identify the factors that lead to premature birth and low-birth weight newborns.
  • Distinguish between primary and secondary apnea.
  • Discuss pulmonary perfusion and asphyxia.
  • Identify the primary signs utilized for evaluating a newborn during resuscitation.
  • Identify the appropriate use of the APGAR scale.
  • Calculate the APGAR score given various newborn situations.
  • Formulate an appropriate treatment plan for providing initial care to a newborn.
  • Describe the indications, equipment needed, application, and evaluation of the following management techniques for the newborn in distress:

a) Blow-by oxygen

b) Ventilatory assistance

c) Endotracheal intubation

d) Orogastric tube

e) Chest compressions

f) Vascular access

  • Discuss the routes of medication administration for a newborn.
  • Discuss the signs of hypovolemia in a newborn.
  • Discuss the initial steps in resuscitation of a newborn.
  • Discuss the effects of maternal narcotic usage on the newborn.
  • Determine the appropriate treatment for the newborn with narcotic depression.
  • Discuss appropriate transport guidelines for a newborn.
  • Determine appropriate receiving facilities for low- and high-risk newborns.
  • Describe the epidemiology, including the incidence, morbidity/mortality, risk factors and prevention strategies, pathophysiology, assessment findings, and management for the following neonatal problems:

a) Meconium aspiration

b) Apnea

c) Diaphragmatic hernia


d) Bradycardia

e) Prematurity

f) Respiratory distress/cyanosis

g) Seizures

h) Fever

i) Hypothermia

j) Hypoglycemia

k) Vomiting


l) Diarrhea

m) Common birth injuries

n) Cardiac arrest

o) Post-arrest management

20. Given severe scenarios involving neonatal emergencies, provide the appropriate procedures for assessment, management, and transport.

  • Newborn refers to a recently born infant in the first few hours of life
  • Neonate refers to infants in the first 28 days of life
risk factors associated with the need for resuscitation
Risk Factors Associated with 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
risk factors associated with the need for resuscitation12
Risk Factors Associated with 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
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
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
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
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 anomalies19
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
Diaphragmatic Hernia
  • Protrusion of a part of the stomach through an opening in the diaphragm
    • In some cases the intestines may herniate into the chest, displacing the heart and resulting in severe respiratory distress
  • Risk factors
    • Bag and mask ventilation can worsen condition
  • Pathophysiology
    • Abdominal contents are displaced into the thorax
    • Heart may be displaced
physiological adaptations at birth
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
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
  • Both fetal circulation and transitional circulation will be covered in the OB slides
causes of hypoxia
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
  • 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
Assessment and Management
  • Initial steps of neonatal resuscitation (except infants born through meconium):

Figure 41-1

prevention of heat loss
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
Opening the Airway
  • Position
  • Suction
    • Technique
      • Mouth first, then nares
      • Nasal suctioning is a stimulus to breathe
    • Equipment
      • Bulb suction
      • Suction catheters
      • Meconium aspirator
meconium staining
Meconium Staining
  • The presence of fetal stool in amniotic fluid (occurring either in utero or intrapartum)
    • After meconium is observed in the amniotic fluid, intervention is aimed at preventing or minimizing the risk of aspiration by the newborn
provision of tactile stimulation
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
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 base of the umbilical cord
  • Evaluate the infant's color
    • If central cyanosis, bradycardia, or other signs of distress are present in an infant with spontaneous respirations and an adequate heart rate, administer 100% oxygen and evaluate the need for additional intervention
    • Free-flow oxygen can be given through:
      • A face mask and flow-inflating bag
      • An oxygen mask
      • A hand cupped around oxygen tubing
meconium staining34
Meconium Staining
  • DO NOT stimulate newborn to breath!
    • Suction only oropharynx w/ bulb syringe.
    • Do not cut umbilical cord.
    • Attach meconium aspirator to appropriate sized ET tube (2.5-3.0). Prepare multiple tubes.
    • Intubate neonate and suction as you remove tube.
    • Suction as much meconium as possible.
apgar score
Apgar Score
  • Enables rapid evaluation of a newborn’s condition at specific intervals after birth
    • Routinely assessed at 1 and 5 minutes of age
  • Appearance, Pulse, Grimace, Activity, Respiratory
resuscitation of the distressed newborn
Resuscitationof 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
inverted pyramid
Inverted Pyramid
  • Inverted pyramid reflecting approximate relative frequency of neonatal resuscitative efforts

Figure 41-4

routes of drug administration
Routes of Drug Administration
  • Drugs are rarely indicated in the resuscitation of a newborn
  • Drugs should be administered only if the heart rate remains < 60 bpm despite adequate ventilation with 100% oxygen and chest compressions
  • The tracheal route is generally the most rapidly accessible route
  • The umbilical vein is the most rapidly accessible venous route
  • Peripheral sites (scalp or peripheral vein) may be adequate but more difficult to cannulate
  • The intraosseous (IO) route is not commonly used in newborns
umbilical vein cannulation
Umbilical Vein Cannulation
  • Identify umbilical vein after trimming cord
  • Insert umbilical catheter or angiocath into vein
  • Secure base of cord to hold catheter in place and stabilize catheter with tape

Figure 41-5

drugs used in neonatal resuscitation
Drugs Used in Neonatal Resuscitation
  • Medications most frequently used during neonatal resuscitation
    • Epinephrine
    • Volume expanders
    • Naloxone
important points to remember in neonatal resuscitation
Important Points to Remember in Neonatal Resuscitation
  • Prevent heat loss and avoid hypothermia
  • If a newborn has a heart rate of < 100 bpm and is unresponsive to stimulation, the primary concern is adequate ventilation
  • When meconium is observed, deliver the head and suction the meconium
  • Provide chest compressions if the heart rate is absent or remains < 60 bpm despite adequate assisted ventilations with 100% oxygen for 30 seconds
  • Coordinate chest compressions at a ratio of 3:1 and a rate of 120 events per minute
  • Administer epinephrine (Adrenalin) when the heart rate remains < 60 bpm despite 30 seconds of effective assisted ventilation and chest compression
postresuscitation care
Postresuscitation Care
  • The three most common complications of the postresuscitation period are:
    • Endotracheal tube migration (including dislodgement)
    • Tube occlusion by mucus or meconium
    • Pneumothorax
postresuscitation care45
Postresuscitation Care
  • These complications should be suspected in the presence of:
    • Decreased chest wall movement
    • Diminished breath sounds
    • Return of bradycardia
    • Unilateral decrease in chest expansion
    • Altered intensity to pitch of breath sounds
    • Increased resistance to hand ventilation
postresuscitation care46
Postresuscitation Care
  • Corrective management in the field for these postresuscitative complications may include:
    • Adjustment of the endotracheal tube
    • Reintubation
    • Suction
  • Needle decompression to manage a suspected pneumothorax must be carefully guided by medical direction
neonatal transport
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
respiratory disorders
Respiratory Disorders
  • Respiratory insufficiency in the neonate is generally managed by:
    • Stimulation and positioning of the airway
    • Prevention of heat loss and hypothermia
    • Oxygenation and ventilation
    • Suction
    • Intubation with ventilatory support (if needed)
respiratory disorders51
Respiratory Disorders
  • Pharmacological therapy
    • Sodium Bicarbonate for prolonged resuscitation that is unresponsive to other therapies.
    • Dextrose (D10) if patient is hypoglycemic.
    • Nalaxone for reversal of respiratory depression in a newborn whose mother received narcotics within 4 hours of delivery.
  • Apnea (respiratory pauses that exceed 20 seconds) is a common finding in preterm infants, and if prolonged, can lead to hypoxemia and bradycardia
  • Primary apnea
    • A self-limited condition (controlled by PCO2 levels)
    • Common immediately after birth
  • Secondary apnea
    • Respirations absent and do not begin again spontaneously
  • Risk factors:
    • Narcotics or CNS depressants
    • Airway & resp. muscle weakness
    • Oxyhemoglobin dissociation curve shift
    • Septicemia
    • Metabolic Disorders
    • CNS disorders
  • Pre-hospital management will include positive pressure ventilation, as necessary.
respiratory distress and cyanosis
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
    • Other risk factors for respiratory distress and cyanosis include:
      • Can lead to cardiac arrest
      • Requires immediate intervention to support respirations
respiratory distress and cyanosis56
Respiratory Distress and Cyanosis
  • Assessment findings: tachypnea, paradoxical breathing, intercostal retractions, nasal flaring, expiratory grunting, and central cyanosis.
  • Provide patient with proper oxygenation and medication to ensure adequate ventilation.
cardiovascular disorders
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
Cardiac Arrest
  • Incidence: Uncommon
  • Morbidity/mortality:
    • Less than 10% of all children in cardiac arrest are resuscitated successfully
  • Risk factors
    • Intrauterine asphyxia
    • Drugs administered to or taken by mother
    • Congential diseases
    • Intrapartum hypoxemia
cardiac arrest59
Cardiac Arrest
  • Pathophysiology
    • Most likely caused by hypoxemia
  • Assessment findings
    • Slow, or absent pulse
    • Apnea
  • Emergency care
    • Follow 2005 PALS guidelines
  • May result from:
    • Dehydration
    • Hemorrhage
    • Trauma
    • Sepsis
  • May be associated with myocardial dysfunction
  • Signs and symptoms
    • Mottled or pale skin
    • Cool skin
    • Tachycardia
    • Slow capillary refill
  • Prehospital care
    • 10 ml/kg fluid bolus, reassess
    • If pt. is still hypovolemic, repeat bolus.
gastrointestinal disorders
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
  • Incidence
    • Occasional vomiting is not unusual
    • Persistent vomiting is a warning sign
  • Pathophysiology
    • Persistent vomiting in the 1st 24 hours of lif suggests Upper GI obstruction or increased ICP.
    • Non-bile stained vomitus suggests either duodenal obstruction, or GERD.
    • Bile stained vomitus suggests bile duct obstruction.
  • Assessment findings
    • Distended stomach
    • Signs of infection
    • Dehydration
    • Increased ICP (fontanells bulging)
  • Prehospital care
    • Maintain airway, adequate oxygenation
    • IV therapy, as directed
  • Incidence
    • As with vomiting, occasional diarrhea is not unusual.
    • Persistent diarrhea can lead to serious dehydration and electrolyte imbalance in the neonate.
  • Pathophysiology
    • Often associated with a bacterial or viral infection
    • Other causes include: Gastroenteritis, Rotavirus, Lactose intolerance
  • Assessment findings
    • Decreased urinary output
    • Signs of dehydration
  • Treatment
    • Support vital functions
    • IV therapy
    • Rapid transport
  • Incidence
    • Very small percentage of newborns have seizures and, when present, usually are a sign of an underlying abnormality.
  • Causes
    • Hypoxia
    • Congenital diseases
    • Metabolic imbalance
    • Intracranial bleeding (more common in premature infants)
  • Emergency care
    • Managing airway
    • Providing ventilatory and circulatory support
    • Maintaining infant’s body temperature
    • Dextrose for hypoglycemia
    • Benzodiazepines
  • Fever in neonates = rectal temp. >100.4 F
  • Is often a response to an acute viral or bacterial infection.
  • Pathophysiology
    • Rise in core temperature is associated with increase oxygen demand and glucose metabolism, which may lead to metabolic acidosis.
  • Assessment findings
    • Altered LOC
    • Decreased I’s and O’s
    • Warm or hot skin
  • Prehospital care
    • Supportive
    • Do not cool (spray bottles, etc) unless directed by medical control
  • Incidence
    • Body temperature drops below 35 º C
  • Morbidity/mortality
    • Infants may die of cold exposure at temperatures adults find comfortable
  • Risk factors
    • Due to large surface-to-volume ratio, neonates are particularly susceptible to cold
  • Pathophysiology
    • Increase in metabolic demand to maintain body temperature can cause metabolic acidosis, pulmonary hypertension, and hypoxemia
  • Assessment findings
    • Pale, cool skin
    • Respiratory distress
    • Bradycardia
    • Apnea
  • Prehospital care
    • BLS and ALS care as necessary
    • Rapid transport
    • Keep child dry and warm
    • Keep back of ambulance warm (76-80 deg F)
  • A blood glucose screening test less than 40 mg/dL indicates hypoglycemia
  • Assessment findings
    • Seizures
    • Limpness
    • Lethargy
    • Eye rolling
    • High-pitched crying
    • Apnea
    • Irregular respirations
  • Prehospital care
    • Support ABC’s
    • Maintain body temperature
    • Rapid transport
    • Dextrose 10%
common birth injuries
Common Birth Injuries
  • Incidence
    • About 2-7% of every 1,000 live births result in avoidable and unavoidable mechanical and anoxic trauma.
  • Morbidity/mortality
    • Of every 100,000 infants, 5-8 die of birth trauma; 25 out of every 100,000 die of anoxic injuries.
  • Risk factors
    • Uncontrolled, explosive delivery is the greatest risk factor for birth injuries.
common birth injuries77
Common Birth Injuries
  • Assessment findings
    • May range from minor soft tissue trauma to paralysis to life-threatening cardio-respiratory compromise and shock
  • Prehospital care
    • Support vital functions
    • Rapidly transport to an appropriate medical facility for definitive care
psychological and emotional support
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 support79
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
  • In general, most neonates will not experience any serious emergencies
  • Rapid assessment and treatment is key for any emergency that may arise
  • Keep’em warm, listen to mom, and when in doubt: BURN LOTSA DIESEL!!!!