Neonatalogy

Temple College EMS Professions

Neonatalogy

Newborn
First few hours of life

Neonate
First 28 days of life

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

Risk Factors

Antepartum
Multiple gestation Inadequate prenatal care Mothers age <16 or >35 History of perinatal morbidity or mortality Post-term gestation Drugs/ medications Toxemia, hypertension, diabetes

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

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

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

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

Cardiovascular Changes

Closure of Foramen Ovale

Low right atrial pressure High left atrial pressure Blood flows backwards towards right side Valve closes

Cardiovascular Changes

Closure of the Ductus Venosus

Ductus venosus contracts Blood forced through liver sinuses

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

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

Color
Central vs peripheral cyanosis Mucosal membranes

End organ perfusion

Central pulses vs peripheral pulses Capillary refill

APGAR Scoring

APGAR
One minute, five minutes postpartum

APGAR

7 - 10
Normal Infant Suction oropharnyx Keep warm

APGAR

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

APGAR

0-3
Asphyxia neonatorum Resuscitate aggressively

APGAR

Scores can be misleading

Do not work well with pre-term infants Primarily measure brainstem function

APGAR
Do not wait 1 minute in obviously distressed infant

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

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

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

Treatment

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

Meconium

Treatment

Tactile Stimulation (optional)

Flicking soles of feet Stroking back

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

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

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

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

10 - 15% of deliveries Risk factors

Fetal distress Post-term infants

Complications
Hypoxemia Aspiration pneumonia Pneumothorax Pulmonary hypertension

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

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

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

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

Bradycardia

Possible causes
Hypoxia Increased intracranial pressure Hypothyroidism Acidosis

Minimal risk if corrected quickly

Bradycardia

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

Hypoventilations

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
Discontinue chest compressions when HR > 100 Pharmacological

Use as last resort Epinepherine

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

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

Premature Infants

Assessment
Large trunk Short extremities Transparent skin Less wrinkles Less subcutaneous fat

Premature Infants

Management
Same as with full term newborn

Transport
Appropriate facility

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

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

Assessment findings
Tachypnea Paradoxical breathing Periodic breathing Intercostal retractions Nasal flaring Expiratory grunt

Respiratory Distress/Cyanosis

Management
Airway/Breathing
Position Suction High concentration oxygen PPV/Intubation PRN

Circulation
Compression PRN

Maintain warmth

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

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

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

Causes
Hypoglycemia Sepsis Fever Infection Developmental abnormalities Drug withdrawal

Seizures

Assessment
Decreased level of consciousness Seizure activity

Management
ABCs High concentration Oxygen Benzodiazepines Dextrose (D10W or D25W) Maintain Warmth Rapid Transport

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

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

Fever

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

Hypothermia
Infants

cannot tolerate temperatures comfortable to adults

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

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

Hypothermia

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

Hypoglycemia
Less than 45 mg/dL Causes

Do not have to have diabetes mellitus Inadequate glucose stores Inadequate intake Increased glucose utilization Stress

Hypoglycemia

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

Hypoglycemia
ALL SICK INFANTS REQUIRE BLOOD GLUCOSE ASSESSMENT

Hypoglycemia

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

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

Assessment
Distended stomach Infection Increased ICP Drug withdrawal

Vomiting

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

Diarrhea
5 - 6 stools pre day normal Can lead to

Dehydration Electrolyte imbalance

Diarrhea

Causes
Bacterial or viral infection Gastroenteritis Phototherapy Thyrotoxicosis Cystic fibrosis

Diarrhea

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

Diarrhea

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

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

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

Intracranial Hemorrhage
Trauma Asphyxia

Spinal Cord Damage

Traction when spine is hyperextended Lateral pull

Birth Injuries
Peripheral nerve injury Liver or spleen rupture Fracture

Clavicle Extremities

Hypoxia - ischemia

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

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

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

Cardiac Arrest

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

Cardiac Arrest

Causes
Primary apnea Secondary apnea Bradycardia Pulmonary hypertension Persistent fetal circulation

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

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

Cardiac Arrest

Management
Dry Warm Position Suction Evaluate Respiration Evaluate Heart Rate

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

Oxygenation
If pale or cyanotic, O2 until pink

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

Indications
Apnea Heart rate < 100 Persistent central cyanosis on 100% 02

Infant BVM NOT adult equipment

Ventilation

Judge by chest expansion

Tidal volume is 7cc/kg Ventilation rate is 40 - 60/minute

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

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

Medication
Epinephrine Fluid Glucose

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

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
Jitters Lethargy Apnea Color changes Respiratory distress Seizures

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

Hypoglycemia Management

Blood glucose < 40 mg%

4 cc/kg D10W Do not use D50W

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

Neonatal Transport

Neonatal Transport
Best transport device = Moms uterus Second best = Specialized team

Neonatal Transport

Assessment
Vital signs
Axillary temperature (96.5 - 990F) Pulse (120 - 160/minute) Respirations (30 - 60/minute)

APGAR scores

Neonatal Transport

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

Neonatal Transport

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

Neonatal Transport

Documentation
Copies of infants/mothers charts Names of infant, parents referring physician, parents telephone number Any X-rays Maternal/umbilical cord blood samples Consent forms

Tocolytic Therapy

Indications for tocolysis

20 - 36 weeks gestation Preterm labor Healthy fetus Dilated 4cm or less/membranes intact

Tocolytic Therapy

Left side position, supplemental O2, IV fluids (1 liter LR)

Improves uterine oxygenation Inhibits oxytocin release from posterior pituitary

Tocolytic Therapy
2 Adrenergic

agents

Cause uterine smooth muscle relation Ritodrine (Yutopar) Terbutaline

Tocolytic Therapy

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