Chapter 41:

Neonatology

SHG EMERGENCY MEDICAL

TECHNICIAN
- Paramedic
 Terminology
• Newborn refers to an 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
• Most full term newborns require no
resuscitation beyond keeping warm,
suctioning of the airway, and mild
stimulation (rubbing the chest or back,
tapping the feet)
– Approximately 6% of deliveries require life
support
– Incidence of complications increases as birth
weight decreases
 Risk Factors Before Birth
• Multiple gestation (twins, triplets…)
• Inadequate prenatal care
• Mother’s age
– Less than age 16 or more than 35
• History of perinatal morbidity or mortality
• Post-term gestation (over 42 weeks)
• Drugs/medications
• Toxemia, hypertension, diabetes
 Risk Factors during Labor
• Premature labor (before 37 weeks)
• Meconium-stained amniotic fluid
• Rupture of membranes greater than 24 hours
before delivery
• Use of narcotics within 4 hours of delivery
• Abnormal presentation (breech, leg…)
• Prolonged labor or too fast delivery
• Prolapsed cord
• Heavy bleeding
 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
• Choanal atresia
– A bony or membranous blockage of 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 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
• Part of the stomach slides 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 (PPV) can worsen condition
• Pathophysiology
– Abdominal contents are displaced into the thorax
– Heart may be displaced
• Assessment findings
– Heart sounds displaced; decreased breath sounds; respiratory distress
• Management considerations:
– Transport quickly; PPV only if necessary; decompress stomach if
possible
 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
• Respiratory system must suddenly start to
maintain oxygenation
• Infants are very sensitive to hypoxia
• Permanent brain damage will occur with
hypoxemia within minutes
• Apnea in newborns is common when under
stress
 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
 Hypothermia
• Newborns are at great risk for rapidly-developing
hypothermia because of:
– Their larger body surface area
– Decreased insulation; wet skin at birth
– Immature temperature regulatory mechanisms
• Newborns attempt to conserve body heat through
vasoconstriction and increasing their metabolism,
placing them at risk for:
– Hypoxemia
– Bradycardia
– Acidosis
– Hypoglycemia
 Assessment and Management
• Initial steps of neonatal resuscitation (except
infants born through meconium):
 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 (body
surface area)
 Opening the Airway
• Position:
– Head slightly tilted back on flat surface
• Suction
• Mouth first, than nares (nose)
• Nasal suctioning is a stimulus to breathe
– Equipment
• Bulb suction
• Suction catheters
 Meconium Staining
• The presence of fetal stool (meconium) in
amniotic fluid
– After meconium is observed in the amniotic fluid, You
need to prevent or minimize the risk of aspiration by
the newborn
• Emergency care
– Suction mouth, nares with bulb
– Suction lungs, mouth and stomach with catheter if
respiratory compromise present
– Laryngoscopy to see if meconium is at vocal cords
 Stimulation to Breath
• If drying and suctioning do not improve
respirations, provide additional stimulation
– 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
• Observe and evaluate the infant's respirations
• Evaluate the infant's heart rate by stethoscope, or
by palpating the pulse in the umbilical cord stump
• Evaluate the infant's color
– If cyanosis, bradycardia, or other signs of distress are present in an
infant with spontaneous respirations, administer 100% oxygen and
evaluate the need for additional intervention
– If infant improves, observe and continue oxygen
– If infant does not improve, or worsens, start resuscitation with
PPV. If bradycardia worsens or stays less than 60 bpm, consider
cardiac resuscitation
Action-evaluation-decision cycle
 Apgar Score
• For rapid evaluation of a newborn’s
condition after birth
– Assessed at 1 and 5 minutes of age
 Resuscitation of Newborns
• Approximate frequency of neonatal
resuscitative efforts needed
 Routes of Drug Administration
• Drugs are rarely needed 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 (IT) is usually 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 get an IV into
• The intraosseous (IO) route is not commonly used in newborns,
but can be if unable to get other routes
 Umbilical Vein Cannulation
• Identify umbilical vein
after cutting the cord
• Insert umbilical catheter or
IV into vein
• Secure base of cord to hold
catheter in place and
stabilize catheter with tape
 Drugs Used in Neonatal Resuscitation

• Medications most frequently used during

neonatal resuscitation
– Epinephrine
• 0.01-0.03 mg/kg IV or IT every 3-5 minutes
– Volume expanders (fluids)
– Naloxone
• 0.1 mg/kg IV or IT, only if respiratory depression has
been reversed with PPV, and mother received narcotic
in past 4 hours
• 0.01 mg/kg if needed, if mother is on narcotics
chronically (higher dose in infant may cause seizures)
 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 before delivering the rest of the body
– 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
 Post Resuscitation Care
• The three most common complications of
the post resuscitation period are:
– Endotracheal tube migration (including coming
out of the trachea)
– Tube occlusion by mucus or meconium
– Pneumothorax (commonly from overly
aggressive PPV)
 Post Resuscitation 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
 Post Resuscitation Care
• Corrective management in the field for
these 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
• During transport of the neonate:
– Maintain body temperature
– Oxygen administration
– Ventilatory support
 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)
• Pharmacological therapy
 Apnea
• Apnea (respiratory pauses that exceed 20
seconds) is a common finding in preterm
infants, and if prolonged, can lead to
hypoxemia and bradycardia
 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 gm.
and 30 weeks gestation
– Other risk factors for respiratory distress and cyanosis
include:
• Congenital malformations
• Fevers or meconium present during birth
 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
 Hypovolemia
• May result from:
– Dehydration
– Hemorrhage
– Trauma
– Sepsis
• May be associated with myocardial dysfunction
• Signs and symptoms:
– lethargy, hypoventilation, poor circulation and color
• Prehospital care: pace IV, fluids, oxygen, warm
 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
 Hypothermia
• Incidence
– Body temperature drops below 35 º C
• Morbidity/mortality
– Infants may die of cold exposure
• Risk factors: wet, premature, ill
• Pathophysiology: unable to increase
metabolism to compensate
• Assessment findings: poor circulation,
irritable or lethargic, poor circulation
 Hypoglycemia
• A blood glucose screening test less than 40
mg/dL indicates hypoglycemia
• Common causes
– Premature, small size, delaying of feeding,
hyperinsulinemia (diabetic mother)
• Assessment findings: tachycardia, cyanosis,
seizures, apnea, lethargy
• Prehospital care
– IV 4-8 mg/kg/min glucose (D10 at 2.5-5 cc/kg/h)
 Common Birth Injuries
• Shoulder or clavicle injury, brachial plexus
injury, brain injury, hypoxic injury
• Risk factors:
– Large babies, prematurity, no prenatal care
• Prehospital care
– Support vital functions
– Rapidly transport to an appropriate medical
facility for definitive care
 Psychological
and Emotional Support
• Be aware of the normal feelings of parents,
other family members while providing
emergency care to an ill or injured child
• EMT 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