ASPHYXIA – THE BASIC 1. Primary Apnea: When asphyxiated, the infant responds with a increased RR. If the episode continues, the infant becomes apnic, followed by a drop in HR and a slight increase in BP.The infant will respond to stimulation and therapy with spontaneous respirations.
2. Secondary apnea: after primary apnea, the infant responds with a period a gasping respirations, falling HR, and falling BP.The infant takes a last breath and then enters the secondary apnea period.The infant will not respond to stimulation and death will occur unless resuscitation begins immediately. * Because after delivery of an infant it is impossible to differentiate between primary apnea and secondary apnea, assume the infant is in secondary apnea and begin resuscitation immediately.
Antepartum FactorsIntrapartum Factors Age > 35 years Maternal diabetes Pregnancy-induced hypertension Chronic hypertension Other maternal illness (e.g. CVS, thyroid, neuro) Previous Rh sensitization Drug therapy (e.g. magnesium, lithium adrenergic-blockers) Abnormal presentation Operative delivery Premature labour Premature rupture of membranes Precipitous labour Prolonged labour Indices of fetal distress (FHR abnormalities, biophysical profile) Anticipation and Recognition of the Neonate in Distress 1. Antepartum and intrapartum history
Antepartum FactorsIntrapartum Factors Maternal substance abuse No prenatal care Previous stillbirth Bleeding - 2nd/3rd trimester Hydramnios Oligohydramnios Multiple gestation Post-term gestation Small-for-dates fetus Fetal malformations Maternal narcotics (within 4 hrs of delivery) General anaesthesia Meconium-stained fluid Prolapsed cord Placental abruption Placenta previa Uterine tetany 1. Antepartum and intrapartum history CONT.
Equipment Equipment and medications should be checked as a daily routine and then prior to anticipated need. Used items should be replenished as soon as possible after a resuscitation. The delivery room should be kept relatively warm and the radiant heater should be preheated when possible. Prewarming of towels and blankets can also be helpful in preventing excessive heat loss from the neonate.
Equipment SUCTION EQUIPMENT BULB SYRINGE SUCTION CATH NO 5 6 8 10 Fr 8 Fr FEEDING TUBE 20 ml SYRINGE MECONIUM ASPIRATOR BAG-MASK EQUIPMENT FACE MASK ORAL AIRWAY OXYGEN
Equipment CONT. INTUBATION EQUIPMENT LARYNGOSCOPY-BLADE NO 0-1 BATTERY FOR LARYNGOSCOPE ETT NO 2.5 3.0 3.5 4.0 mm STYLET SCISSOR GLOVE MISCELLANEOUS RADIANT WARMER-STETHOSCOPE-TAPE- SYRINGE-NEEDLE-ALCOHOL-UMBILICAL CATH
Initial Steps for Neonatal Resuscitation in Delivery Room ANTICIPATION ASSESSMENT OF ACTION 1.PREVENT HEAT LOSS Place the infant under an overhead radiant heater to minimize radiant and convective heat loss. Dry the body and head to remove amniotic fluid and prevent evaporative heat loss. This will also provide gentle stimulation to initiate or help maintain breathing.
Initial Steps for Neonatal Resuscitation in Delivery Room CONT. 2.ABCDE STEP A-AIRWAY POSITION CLEAR AIRWAY-SUCTION MOUTH THEN NOSE
Initial Steps for Neonatal Resuscitation in Delivery Room CONT. B-BREATHING ADEQUACY 1.TACTILE STIMULATION slapping or flicking the soles of the feet rubbing the back gently Do not waste time continuing tactile stimulation if there is no response after 10 - 15 seconds. 2.FREE FLOW OXYGEN 3.PPV
Initial Steps for Neonatal Resuscitation in Delivery Room CONT. C-CARDIOVASCULAR RESUSCITATION D-DRUG -DIAGNOSIS E-ENVIRONMENT -EXTENDED CARE
Resuscitation in the delivery room
PPV 1.INDICATION FOR PPV APNEA OR GASPING HR < 100 bpm CENTRAL CYANOSIS 2.BAG- Self inflating vs. flow dependent bag 3. Rate 40-60 bpm 4. Pressure used = a. Initial breath after delivery = 30-40 cm H2O b. Normal delivery = 15-20 cm H2O c. Diseased Lungs =20-40 cm H2O
PPV CONT. 5. Technique/Trouble shooting problems of Bag mask ventilation a. Check for a good seal b. Check for a patent airway c. Are you using enough pressure ? 6.Checking for chest movement check mask position head position-hyperflexion or hyperextention secretion obstruction slighly open infant mount checking for pressure
Chest compression 1. Indications: If after 15-30 seconds of positive pressure ventilation with 100% FIO2 the heart rate is a. below 60 bpm b.between 60-80 bpm and not increasing 2. Technique: a. 1 fingers breadth below nipple line, using 2 fingers b. 1/2 to 3/4 compression depth c. accompanied by ventilations, ratio is 3:1
ENDOTRACHEAL TUBE INTUBATION 1.Indications for intubation: a. Prolonged bag and mask ventilation b. Bag and mask is ineffective c. Tracheal suctioning 2.Tube size Tube size Weight Gestational Age (ID mm) (gm) (weeks) 2.5<1000<28 3.01000-2000 28-34 3.5 2000-3000 34-38 3.5-4.0>3000 >38
MEDITATION 1.Indication HR < 80 bpm despite 100% O2 and chest compression 30 sec No heart rate
Drug -adrenaline -volume expander -NaHCO3 -Dopamine -Naloxone hydrochloride
Drug dosage DrugPreparationDosageRate/Precautions Epinephrine 1:10,000 1 ml0.01-0.03 mg/kg 0.1-0.3 ml/kg Give rapidly IV or ET Repeat q 3-5 min (ET: dilute to 1-2 ml with NS) Volume Expanders -NS or RL -5% Albumin -O-neg Blood 40 ml10 ml/kgGive IV over 5-10 min Naloxone 0.4 mg/ml 1.0 mg/ml 1 ml 0.1mg/kg 0.25ml/kg 0.1 ml/kg Give rapidly IV or ET preferred
Drug dosage cont. Reserved for prolonged resuscitations only Sodium Bicarbonate (0.5 mEq/ml = 4.2% soln) 20 ml 10 mlx2 2 mEq/kg (4ml/kg) Give slowly, over at least 2 min, IV ONLY, Infant must be ventilated Dopamine (6 x weight in kg = mg of dopamine diluted to 100 ml) 100 mlContinuous infusion by pump