4ASPHYXIA – THE BASIC1.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.
52. 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.
8Anticipation and Recognition of the Neonate in Distress 1 Anticipation and Recognition of the Neonate in Distress 1.Antepartum and intrapartum historyAntepartum FactorsIntrapartum FactorsAge > 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)
91.Antepartum and intrapartum history CONT. Antepartum FactorsIntrapartum FactorsMaternal substance abuse No prenatal care Previous stillbirth Bleeding - 2nd/3rd trimester Hydramnios Oligohydramnios Multiple gestation Post-term gestation Small-for-dates fetus Fetal malformationsMaternal narcotics (within 4 hrs of delivery) General anaesthesia Meconium-stained fluid Prolapsed cord Placental abruption Placenta previa Uterine tetany
10EquipmentEquipment 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.
12Equipment CONT. INTUBATION EQUIPMENT LARYNGOSCOPY-BLADE NO 0-1 BATTERY FOR LARYNGOSCOPEETT NO mmSTYLET SCISSOR GLOVEMISCELLANEOUSRADIANT WARMER-STETHOSCOPE-TAPE-SYRINGE-NEEDLE-ALCOHOL-UMBILICAL CATH
13Initial Steps for Neonatal Resuscitation in Delivery Room ANTICIPATIONASSESSMENT OF ACTION1.PREVENT HEAT LOSSPlace 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.
14Initial Steps for Neonatal Resuscitation in Delivery Room CONT. 2.ABCDE STEPA-AIRWAYPOSITIONCLEAR AIRWAY-SUCTION MOUTH THEN NOSE
15Initial Steps for Neonatal Resuscitation in Delivery Room CONT. B-BREATHING ADEQUACY1.TACTILE STIMULATIONslapping or flicking the soles of the feetrubbing the back gentlyDo not waste time continuing tactile stimulation if there is no response after seconds.2.FREE FLOW OXYGEN 3.PPV
16Initial Steps for Neonatal Resuscitation in Delivery Room CONT. C-CARDIOVASCULAR RESUSCITATIOND-DRUG-DIAGNOSISE-ENVIRONMENT-EXTENDED CARE
18PPV 1.INDICATION FOR PPV 2.BAG-Self inflating vs. flow dependent bag APNEA OR GASPINGHR < 100 bpmCENTRAL CYANOSIS2.BAG-Self inflating vs. flow dependent bag3. Rate bpm4. Pressure used =a. Initial breath after delivery = cm H2O b. Normal delivery = cm H2O c. Diseased Lungs =20-40 cm H2O
19PPV CONT.5. Technique/Trouble shooting problems of Bag mask ventilationa. Check for a good seal b. Check for a patent airway c. Are you using enough pressure ?6.Checking for chest movementcheck mask positionhead position-hyperflexion or hyperextentionsecretion obstructionslighly open infant mountchecking for pressure
20Chest compression 1. Indications: If after seconds of positive pressure ventilation with 100% FIO2 the heart rate isa. below 60 bpm b.between bpm and not increasing2. 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
22ENDOTRACHEAL TUBE INTUBATION 1.Indications for intubation:a. Prolonged bag and mask ventilation b. Bag and mask is ineffective c. Tracheal suctioning2.Tube sizeTube size Weight Gestational Age (ID mm) (gm) (weeks)2.5 <1000 <28> >38
26Drug dosage Drug Preparation Dosage Rate/Precautions Epinephrine 1:10,0001 mlmg/kg ml/kgGive 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 Blood40 ml10 ml/kgGive IV over 5-10 minNaloxone0.4 mg/ml1.0 mg/ml0.1mg/kg0.25ml/kg0.1 ml/kgGive rapidly IV or ET preferred
27Drug dosage cont. Reserved for prolonged resuscitations only Sodium Bicarbonate (0.5 mEq/ml = 4.2% soln)20 ml10 mlx22 mEq/kg (4ml/kg)Give slowly, over at least 2 min, IV ONLY, Infant must be ventilatedDopamine (6 x weight in kg = mg of dopamine diluted to 100 ml)100 mlContinuous infusion by pump