1. Neonatal emergencies
dr. Miada Mahmoud Rady

2. Definitions Newborn: within the first few hours after birth.
Neonate: within the first month after birth.

3. General Pathophysiology and Assessment of newborn and neonates
Neonatal resuscitation steps :
The same basic steps of adult resuscitation :
Airway
Breathing
Circulation
Newborn stabilization procedures :
Warming
Positioning
Clearing the airway
Drying and breathing stimualtion

4. General Pathophysiology and Assessment
Additional resuscitation steps that may be required in certain situations :
Supplemental oxygen
Positive pressure ventilatory assistance
Intubation
Chest compressions
Medications

5. Transition from Fetus to Newborn
First breath is triggered by mild hypoxia and hypercapnia.
Pulmonary vascular resistance drops as the lungs fill with air.
More blood flows to the lungs.

6. Transition from Fetus to Newborn
Delay in pulmonary pressure drop leads to:
Delayed transition
Hypoxia
Brain injury
Death

8. Arrival of the Newborn Obtain patient history and prepare environment.
Minimum needs:
Warm, dry blankets
Bulb syringe
Two small clamps or ties
A pair of clean scissors

9. Arrival of the Newborn If delivery in ambulance: Use blankets.
Confirm ABCs.
Place on mother’s chest.
Suction mouth, then nose.
Keep newborn at level of mother.

11. Arrival of the Newborn Clamp and cut the umbilical cord.
Do an initial rapid assessment.
Newborn is at risk for hyperthermia so Ensure thermoregulation.
Position the newborn, clear secretions, and assess the respiratory effort.

12. Arrival of the Newborn
If the newborn begins to turn pink in the first 5 minutes:
Maintain ongoing observation.
Continue thermoregulation with direct skin-to-skin contact with mother.

13. Apgar score

15. APGAR test Definition :
A quick test performed on a baby at 1 and 5 minutes after birth.
The 1-minute score determines how well the baby tolerated the birthing process.
The 5-minute score determines how well the baby is doing outside the mother's womb.

16. How the test is done?
The health care provider will examine the baby's:
Breathing effort
Heart rate
Muscle tone
Reflexes
Skin color
Each category is scored with 0, 1, or 2, depending on the observed condition

17. This test is done to determine whether a newborn needs help breathing or is having heart trouble.
Normal Results
The APGAR rating is based on a total score of 1 to 10.
 The higher the score, the better the baby is doing after birth.
A score of 7, 8, or 9 is normal and is a sign that the newborn is in good health.

18. APGAR score

19. A for appearance Appearance (Skin color):
If the skin color is pale blue, the infant scores 0 for color.
If the body is pink and the extremities are blue, the infant scores 1 for color.
If the entire body is pink, the infant scores 2 for color

20. P for pulse Pulse (Heart rate) :
is evaluated by stethoscope ,this is the most important assessment:
If there is no heartbeat, the infant scores 0 for heart rate.
If heart rate is less than 100 beats per minute, the infant scores 1 for heart rate.
If heart rate is greater than 100 beats per minute, the infant scores 2 for heart rate.

21. G for grimace Grimace response ( reflex irritability ):
It is a term describing response to stimulation such as a mild pinch :
If there is no reaction, the infant scores 0 for reflex irritability.
If there is grimacing, the infant scores 1 for reflex irritability.
If there is grimacing and a cough, sneeze, or vigorous cry, the infant scores 2 for reflex irritability.

22. A for activity Activity ( Muscle tone):
If muscles are loose and floppy, the infant scores 0 for muscle tone.
If there is some muscle tone, the infant scores 1.
If there is active motion, the infant scores 2 for muscle tone.

23. R for respiration Respiration ( Breathing )effort:
If the infant is not breathing, the respiratory score is 0.
If the respirations are slow or irregular, the infant scores 1 for respiratory effort.
If the infant cries well, the respiratory score is 2.

27. Drying and Stimulation
Nasal suctioning stimulates breathing:
Position on the back or side in sniffing position.
If airway is not clear, suction with the head turned to the side.
Flick the soles of the feet and rub the back.

29. Airway Management Free-flow oxygen given :
If newborn cyanotic or pale, provide oxygen.
If Positive Pressure Ventilation is not indicated, oxygen can be given via Oxygen mask and Oxygen tubing

30. Oral airways
Rarely used on newborns , Conditions that may require oral airways:
Bilateral choanal atresia
Pierre Robin sequence
Macroglossia (large tongue)
Craniofacial defects that affect the airway
In all these cases (except bilateral choanal atresia), an ET tube is inserted down a nostril.

31. Pierre Robin syndrome
Pierre Robin syndrome (or sequence) is a condition present at birth, in which the infant has a smaller-than-normal lower jaw, a tongue that falls back in the throat, and difficulty breathing.

32. Bag-mask ventilation Indicated if newborn: Is apneic
Has inadequate respiratory effort
Has a pulse rate of less than 100 beats/min after stimulation efforts

33. Self-inflating bag with an oxygen reservoir.
Three devices are used to deliver bag-mask ventilation:
Self-inflating bag with an oxygen reservoir.
Flow-inflating bag that needs a gas source
T-piece resuscitator that needs a gas source.

35. Correct ventilation time: 40 to 60 breaths/min
Causes of ineffective bag-mask ventilation:
Inadequate mask seal on the face and Equipment malfunction
Incorrect head position
Copious secretions
Pneumothorax

36. D. Intubation Indications:
Meconium-stained fluid and non vigorous newborn
Congenital diaphragmatic hernia
ET administration of epinephrine is needed
Prolonged PPV needed
Craniofacial defects impeding airway

37. Equipment needed:
Suction equipment
Laryngoscope
Blades
Shoulder roll and adhesive tape
ET tube and stylet

38. stylets

39. Gastric decompression
Indications:
Prolonged bag-mask ventilation
Abdominal distention impeding ventilation
Diaphragmatic hernia or gastrointestinal congenital anomaly

40. Circulation Chest compressions
Indicated if pulse rate remains at less than 60 beats/min after resuscitation efforts
Two people needed
Depth: one third of the anteroposterior diameter
Do not deliver simultaneously with artificial ventilation.
Coordinate 90 compressions and 30 breaths/min

41. Circulation Chest compressions Two techniques:
Thumb technique (preferred).
Two-finger technique.

42. Circulation If pulse rate is above 60 beats/min:
Chest compressions can be stopped.
Continue ventilation at 40 to 60 breaths/min.
Recheck pulse rate after 30 seconds.
If rate goes above 100 beats/min, gradually slow the rate and decrease PPV pressure.

43. Circulation
Vascular access : Umbilical vein can be catheterized.

44. Pharmacologic Interventions
Rarely needed in newborn resuscitation
Medication dosages based on weight

45. Bradycardia Mainly caused by hypoxia Often will respond to PPV
Epinephrine administration is indicated for pulse rate of less than 60 beats/min with the following precautions :
Check pulse rate 1 minute after administration.
May repeat dose every 3 to 5 minutes

46. Bradycardia Assessment and management
Heart rate less than 100 beats/min  provide PPV.
If still less than 60 beats/min  Begin chest compressions.
If still less than 60 beats/min  Administer epinephrine and Repeat every 3 to 5 minutes for persistent bradycardia.

47. Fluid resuscitation may be needed.
Low Blood Volume
Fluid resuscitation may be needed.
Signs of hypovolemia include:
Pallor
Persistently low pulse rate
Weak pulses
No improvement in circulatory status after resuscitation efforts

48. Low Blood Volume
Fluid bolus in a newborn is 10 mL/kg given IV every 5 to 10 minutes of:
Saline
Lactated Ringer’s
O Rh-negative blood

49. Acidosis Suspect acidosis if bradycardia persists after:
Adequate ventilations
Chest compressions
Volume expansion

50. Respiratory Depression from Narcotics
Management of respiratory suppression from use of narcotics:
Provide ventilator support.
Transport immediately.
Respiratory depression from acute treatment with narcotics:
Administer 0.1 mg/kg of naloxone.

51. Hypoglycemia Neurologic symptoms of hypoglycemia :
Decreased stimuli response
Hypotonia
Apnea
Poor feeding
seizures

52. Management of hypoglycemia
Obtain baseline vital signs and oxygen saturation readings.
If blood glucose level is less than 40 mg/dL:
Give IV bolus of 10% dextrose solution.
Recheck level in about 30 minutes.
May need to follow with a 10% dextrose infusion

53. Family and Transport Considerations
Transport to nearest facility once newborn is stabilized as much as possible.
Provide ongoing communication with the family.
During transport, monitor the newborn.