Neonatalogy :Neonatalogy Temple College EMS Professions


Neonatalogy :Neonatalogy Newborn First few hours of life Neonate First 28 days of life


Morbidity/Mortality :Morbidity/Mortality Complications increase as birth weight decreases. Resuscitation rate of those less than 1500 g is 80%


Risk Factors :Risk Factors Antepartum Multiple gestation Inadequate prenatal care Mother’s age 35 History of perinatal morbidity or mortality Post-term gestation Drugs/ medications Toxemia, hypertension, diabetes


Risk Factors :Risk Factors Intrapartum factors Premature labor Meconium-stained amniotic fluid Rupture of membranes greater than 24 hours prior to delivery Use of narcotics within four hours of delivery Abnormal presentation Prolonged labor or precipitous delivery Prolapsed cord Bleeding


Fetal Circulation :Fetal Circulation


Respiratory Changes :Respiratory Changes Fetus Lungs filled with fluid Arterioles and capillaries closed Ductus arteriosus Stimulation of first breath Mild acidosis Initiation of stretch reflex in the lung Hypoxia Hypothermia


Ductus arteriosus :Ductus arteriosus


Respiratory Changes :Respiratory Changes Air displaces fluid Pulmonary arterioles and capillaries open Decreases vascular resistance Blood diverted from ductus arteriosus Ductus arteriosus eventually closes Persistent fetal circulation


Cardiovascular Changes :Cardiovascular Changes Fetus Most of blood from placenta bypasses liver Ductus Venosus Most blood passes from right to left atria Foramen ovale Extrauterine Life Blood diverted from placenta Lungs expand Changes pressure levels in heart


Foramen Ovale :Foramen Ovale


Cardiovascular Changes :Cardiovascular Changes Closure of Foramen Ovale Low right atrial pressure High left atrial pressure Blood flows backwards towards right side Valve closes


Cardiovascular Changes :Cardiovascular Changes Closure of the Ductus Venosus Ductus venosus contracts Blood forced through liver sinuses


Congenital Anomalies :Congenital Anomalies Diaphragmatic hernia Meningomyelocele Exposed abdominal contents Choanal atresia Cleft lip/palate Pierre Robin Syndrome


Assessment of newborn :Assessment of newborn Time of delivery Vital Signs Respirations 30-60 Heart rate 100-180 Systolic BP 60-90 mmHg Temp 36.7o - 37.8o C (98o - 100o F)


Assessment of the newborn :Assessment of the newborn Color Central vs peripheral cyanosis Mucosal membranes End organ perfusion Central pulses vs peripheral pulses Capillary refill


APGAR Scoring :APGAR Scoring


APGAR :APGAR One minute, five minutes postpartum


APGAR :APGAR 7 - 10 Normal Infant Suction oropharnyx Keep warm


APGAR :APGAR 4 - 6 Moderate asphyxia Suction oropharnyx Keep warm Oxygenate If 5 minute score < 7, repeat every 5 minutes for 20 minutes


APGAR :APGAR 0 - 3 Asphyxia neonatorum Resuscitate aggressively


APGAR :APGAR Scores can be misleading Do not work well with pre-term infants Primarily measure brainstem function


APGAR :APGAR Do not wait 1 minute in obviously distressed infant


Treatment :Treatment Prior to delivery, prepare environment and equipment During delivery, suction mouth, then nose as head delivers Note amniotic fluid color, thickness


Treatment :Treatment Control Temperature All newborns have difficulty with cold Dry infant Wrap in warm, dry blanket Aluminum foil wrap Well - insulated warm water containers Do NOT use chemical hot packs


Treatment :Treatment Position On back - slight Trendelenburg 1-inch thick towel under shoulders Avoid neck under, overextension If secretions heavy, place on left side


Treatment :Treatment Suction Bulb syringe Mouth first, then nose Neonates are obligate nasal breathers Monitor heart rate for bradycardia Meconium


Treatment :Treatment Tactile Stimulation (optional) Flicking soles of feet Stroking back


Treatment :Treatment Evaluate respirations Spontaneous Evaluate heart rate Absent or gasping Brief tactile stimulation (optional) PPV with 100% Oxygen 15 - 30 seconds Primary Apnea vs. Secondary Apnea


Treatment :Treatment Evaluate Heart Rate Above 100 Evaluate Color Below 60 Continue PPV with 100% Oxygen Initiate compressions Reevaluate after 30 seconds Initiate medications if below 80


Treatment :Treatment Evaluate Heart Rate Between 60 - 100 HR not increasing Continue PPV with 100% Oxygen Initiate compressions After 30 seconds reevaluate Initiate medications if below 80 HR increasing Continue PPV with 100% Oxygen


Treatment :Treatment Evaluate Color Central cyanosis Provide free flow oxygen When pink, gradually remove oxygen If no improvement consider PPV with 100% O2 Acrocyanosis Observe, monitor


Meconium :Meconium 10 - 15% of deliveries Risk factors Fetal distress Post-term infants Complications Hypoxemia Aspiration pneumonia Pneumothorax Pulmonary hypertension


Meconium :Meconium Management In depressed infant Do not stimulate Tracheal suction under direct visualization End Points Airway is clear Infant breathes on own Bradycardia Ventilate with 100% Oxygen


Meconium :Meconium


Diaphragmatic Hernia :Diaphragmatic Hernia 1 in 2200 live births Most commonly on left side (90%) Failure of the pleurperitoneal canal (Foramen of Bochdalek) to close completely 50% survival if mechanical ventilation required Near 100% survival if no respiratory distress


Diaphragmatic Hernia :Diaphragmatic Hernia Assessment Little to severe distress present from birth Dyspnea and cyanosis unresponsive to ventilation and oxygenation Scaphoid abdomen Bowel sounds in thorax Heart sounds displaced to the right


Diaphragmatic Hernia :Diaphragmatic Hernia Management Elevate head, chest Intubation PRN Do NOT use BVM Orogastric tube (low, intermittent suction) Requires surgical repair


Bradycardia :Bradycardia Possible causes Hypoxia Increased intracranial pressure Hypothyroidism Acidosis Minimal risk if corrected quickly


Bradycardia :Bradycardia Assessment Upper airway for obstruction Foreign object Secretions Tongue/soft tissue Hypoventilations


Bradycardia :Bradycardia Management Position Suction Heart rate less than 100 BVM with 100% O2 and reassess Heart rate less than 60 Chest compressions with PPV 100% O2 and reassess Heart rate 60 - 80 but not improving Chest compressions with PPV 100% O2 and reassess Maintain Temperature


Bradycardia :Bradycardia Discontinue chest compressions when HR > 100 Pharmacological Use as last resort Epinepherine


Premature Infants :Premature Infants Born prior to 37 weeks gestation Weigh less than 2.2 kg (4 lb., 13 oz.) Healthy infants weighing < 1700 g (3 lb., 12 oz.) have good prognosis Fetal viability considered 23 -24 weeks gestation


Premature Infants :Premature Infants Complications from Respiratory suppression Head/brain injury Hypothermia Change in blood pressure Hypoxemia Intraventricular hemorrhage Fluctuations in serum osmolarity


Premature Infants :Premature Infants Assessment Large trunk Short extremities Transparent skin Less wrinkles Less subcutaneous fat


Premature Infants :Premature Infants Management Same as with full term newborn Transport Appropriate facility


Respiratory Distress/Cyanosis :Respiratory Distress/Cyanosis Prematurity is most common factor Most frequently in infants less than 1200 grams (2 lb., 10 0z.) 30 weeks gestation Multiple gestations Prenatal maternal complications


Respiratory Distress/Cyanosis :Respiratory Distress/Cyanosis Immature central respiratory control center Easily affected by environmental or metabolic changes Lung or heart disease Aspiration Shock Sepsis Infection Diaphragmatic hernia CNS disorders Airway Obstruction


Respiratory Distress/Cyanosis :Respiratory Distress/Cyanosis Assessment findings Tachypnea Paradoxical breathing Periodic breathing Intercostal retractions Nasal flaring Expiratory grunt


Respiratory Distress/Cyanosis :Respiratory Distress/Cyanosis Management Airway/Breathing Position Suction High concentration oxygen PPV/Intubation PRN Circulation Compression PRN Maintain warmth


Seizures :Seizures Rare in newborns Indicate serious underlying medical abnormality Prolonged, frequent seizures may result in metabolic, cardiopulmonary difficulties


Seizures :Seizures Tonic/clonic seizures typically do not occur in first month of life Subtle seizures Eye deviation, blinking, sucking, swimming movements, apnea, changes in color Tonic seizures Posturing of extremities, trunk More common in premature infants Intraventricular hemorrhage


Seizures :Seizures Focal clonic seizures Rhythmic twitching of muscle group Can migrate to other areas Multifocal seizures Multiple muscle groups involved Can migrate to other areas Myoclonic seizures Generalized jerks of extremities May occur singly or repetitively


Seizures :Seizures Causes Hypoglycemia Sepsis Fever Infection Developmental abnormalities Drug withdrawal


Seizures :Seizures Assessment Decreased level of consciousness Seizure activity Management ABC’s High concentration Oxygen Benzodiazepines Dextrose (D10W or D25W) Maintain Warmth Rapid Transport


Fever :Fever > 100.4o F (average temp 99.5o F) Life-threatening condition Limited ability to control temperature Increased use of glucose may lead to anaerobic metabolism


Fever :Fever Assessment Irritability Somnolence Decreased intake Rashes, petechia Sweat On brow only of term newborns Not present on premature newborns


Fever :Fever Management Assure adequate oxygenation, ventilation Avoid rapid cooling Avoid cold packs Avoid antipyretic agents


Hypothermia :Hypothermia Infants cannot tolerate temperatures comfortable to adults


Hypothermia :Hypothermia Below 35o C (95o F) Increased surface to volume ratio Can be an indicator of sepsis Can lead to: metabolic acidosis pulmonary hypertension hypoxemia


Hypothermia :Hypothermia Assessment Acrocyanosis Irritability (early) Lethargy (late) Pale, cool to touch Respiratory distress/Apnea Bradycardia NEWBORNS DO NOT SHIVER


Hypothermia :Hypothermia Management Assure adequate oxygenation and ventilation Chest compressions if indicated Warm infant Ambient temperature Cover infant Warm IV Fluids


Hypoglycemia :Hypoglycemia Less than 45 mg/dL Causes Do not have to have diabetes mellitus Inadequate glucose stores Inadequate intake Increased glucose utilization Stress


Hypoglycemia :Hypoglycemia Assessment Twitching/Seizures Limpness Lethargy Eye rolling High pitched cry Apnea Irregular respirations


Hypoglycemia :Hypoglycemia ALL SICK INFANTS REQUIRE BLOOD GLUCOSE ASSESSMENT


Hypoglycemia :Hypoglycemia Management Assure adequate oxygenation, ventilation IV/IO TKO ECG Dextrose (D10W or D25W) Maintain warmth


Vomiting :Vomiting Rare during first weeks of life May be confused with regurgitation Life threatening if contains blood Symptom of underlying problem Upper digestive tract obstruction Increased intracranial hemorrhage Infection May lead to dehydration, electrolyte imbalance


Vomiting :Vomiting Assessment Distended stomach Infection Increased ICP Drug withdrawal


Vomiting :Vomiting Management Maintain a patent airway Assure adequate oxygenation Vagal stimulation may cause bradycardia IV NS TKO (if concerned about dehydration)


Diarrhea :Diarrhea 5 - 6 stools pre day normal Can lead to Dehydration Electrolyte imbalance


Diarrhea :Diarrhea Causes Bacterial or viral infection Gastroenteritis Phototherapy Thyrotoxicosis Cystic fibrosis


Diarrhea :Diarrhea Assessment Loose stools Decreased urinary output Listlessness Prolonged capillary refill Number of diapers per day


Diarrhea :Diarrhea Management Assure adequate oxygenation Maintain temperature IV NS TKO (if concerned with dehydration)


Birth Injuries :Birth Injuries Avoidable and unavoidable trauma during labor and delivery Occur in 2 to 7 of every 1,000 live births 5 to 8 of every 100,000 die of birth trauma 25 of every 100,000 die of anoxic injuries 2 - 3 % of infant deaths


Birth Injuries :Birth Injuries Cranial Injuries Molding of head, overriding of parietal bones Skull fracture Subperiosteal hemorrhage Subconjunctival and retinal hemorrhage Erythema, abrasions, ecchymosis, and subcutaneous fat necrosis


Birth Injuries :Birth Injuries Intracranial Hemorrhage Trauma Asphyxia Spinal Cord Damage Traction when spine is hyperextended Lateral pull


Birth Injuries :Birth Injuries Peripheral nerve injury Liver or spleen rupture Fracture Clavicle Extremities Hypoxia - ischemia


Birth Injuries :Birth Injuries Assessment Edema, ecchymosis to soft tissue Paralysis below level of spinal cord injury Paralysis of upper arm with or without paralysis of forearm Hypoxia Shock


Birth Injuries :Birth Injuries Management Assure adequate oxygenation ventilation Chest compressions as needed Pharmacology as needed Maintain warmth


Cardiac Arrest :Cardiac Arrest Primarily related to hypoxia Outcome is poor if interventions not initiated quickly


Cardiac Arrest :Cardiac Arrest Risk factors Intrauterine asphyxia Prematurity Drugs administered or taken by mother Congenital neuromuscular diseases Congenital malformations Intrapartum hypoxemia


Cardiac Arrest :Cardiac Arrest Causes Primary apnea Secondary apnea Bradycardia Pulmonary hypertension Persistent fetal circulation


Cardiac Arrest :Cardiac Arrest Central cyanosis Inadequate respiratory effort Ineffective or absent heart rate


Slide 84:Meds Intubation Chest Compressions BVM Ventilations Oxygen Drying, Warming, Positioning, Suction, Tactile Stimulation


Cardiac Arrest :Cardiac Arrest Management Dry Warm Position Suction Evaluate Respiration Evaluate Heart Rate


Most depressed infants will respond to warming, positioning, suction, stimulation :Most depressed infants will respond to warming, positioning, suction, stimulation


Oxygenation :Oxygenation If pale or cyanotic, O2 until pink


Oxygenation :Oxygenation Mask tent over head with sheet or hold mask near face; flow at 4 - 5 LPM Avoid blowing O2 directly onto face; can produce bradycardia 02 toxicity NOT a concern


Ventilation :Ventilation Indications Apnea Heart rate < 100 Persistent central cyanosis on 100% 02 Infant BVM NOT adult equipment


Ventilation :Ventilation Judge by chest expansion Tidal volume is 7cc/kg Ventilation rate is 40 - 60/minute


Chest Compressions :Chest Compressions If heart rate <60 1/2 to 1 inch at 120/minute 3:1 ratio


Endotracheal Intubation :Endotracheal Intubation If ventilations, chest compressions ineffective Especially important if < 28 weeks gestation Place gastric tube if ventilated under mask for extended time


Medication :Medication Epinephrine Fluid Glucose


Epinephrine :Epinephrine For asystole, bradycardia (rate <60) 0.01 mg/kg every 5 minutes May be given down ET tube 0.03mg/kg


Volume Expansion :Volume Expansion Consider if: Pallor continues after oxygenation Pulses weak after oxygenation Response to resuscitation poor History of hemorrhage from maternal/fetal unit 10cc/kg LR over 5 - 10 minutes


Hypoglycemia Symptoms :Hypoglycemia Symptoms Jitters Lethargy Apnea Color changes Respiratory distress Seizures


Hypoglycemia Symptoms :Hypoglycemia Symptoms Hypoglycemia may mimic hypoxemia Some hypoglycemic infants are asymptomatic Consider blood glucose test 20 - 30 minutes postpartum


Hypoglycemia Management :Hypoglycemia Management Blood glucose < 40 mg% 4 cc/kg D10W Do not use D50W


Neonatal Resuscitation :Neonatal Resuscitation Most respond to simple measures Stepwise resuscitation, frequent reassessment Heart rate guides resuscitation


Neonatal Transport :Neonatal Transport


Neonatal Transport :Neonatal Transport Best transport device = Mom’s uterus Second best = Specialized team


Neonatal Transport :Neonatal Transport Assessment Vital signs Axillary temperature (96.5 - 990F) Pulse (120 - 160/minute) Respirations (30 - 60/minute) APGAR scores


Neonatal Transport :Neonatal Transport Cardiovascular Stabilization Keep airway clear (obligate nasal breathers) Maintain body temperature Humidified oxygen


Neonatal Transport :Neonatal Transport Cardiovascular Stabilization Assist ventilation if cyanosis/pallor/respiratory distress present Vascular access D10W 4cc/kg/hr Nasogastric intubation


Neonatal Transport :Neonatal Transport Documentation Copies of infant’s/mother’s charts Names of infant, parent’s referring physician, parent’s telephone number Any X-rays Maternal/umbilical cord blood samples Consent forms


Tocolytic Therapy :Tocolytic Therapy Indications for tocolysis 20 - 36 weeks gestation Preterm labor Healthy fetus Dilated 4cm or less/membranes intact


Tocolytic Therapy :Tocolytic Therapy Left side position, supplemental O2, IV fluids (1 liter LR) Improves uterine oxygenation Inhibits oxytocin release from posterior pituitary


Tocolytic Therapy :Tocolytic Therapy 2 Adrenergic agents Cause uterine smooth muscle relation Ritodrine (Yutopar) Terbutaline


Tocolytic Therapy :Tocolytic Therapy Magnesium Sulfate Competes with calcium at cellular level Blocks actin/myosin interaction/inhibits contraction