Newborn Resuscitation
Answer D
This term infant was born precipitously to a multigravida mother. As much information as feasible should be gathered quickly from the mother or collateral sources, especially if there are special circumstances such multiple gestations.
During any delivery, three key questions should be asked: Is this a term gestation? Is the baby breathing or crying? Does he have good tone?
If yes to all, give routine care of providing warmth, drying, and nasal bulb suctioning if needed. This will be the case in 90% of deliveries. Note: even a child with meconium staining who is vigorous and crying needs only routine care.
Approximately 10% of newborns require some intervention and only 1% will need intensive resuscitative measures. If the child has poor tone or is not breathing and the amniotic fluid is clear, the initial steps of drying, warming, and gentle stimulation are in order (A). If the child responds with crying, good tone, and a heart rate above 100 beats per minute (bpm) within 30 seconds of the initial steps and has no labored breathing or cyanosis, routine care can be resumed.
If the non-vigorous or apneic infant is stained in meconium, the child should not be stimulated. Immediate endotracheal intubation is required with suctioning via a meconium aspirator. This process may need to be repeated, until the secretions are clear of meconium. Again, if the child begins crying, has normal tone, and a heart rate above 100 bpm, routine care is then indicated.
If after the initial steps are taken and the child is gasping/apneic or has a heart rate below 100 bpm, provide positive pressure ventilation for 30 seconds. If the heart rate remains below 100 bpm, verify adequate chest rise and re-assess breathing and adequacy of ventilations and technique (i.e. repositioning) and heart rate. If the baby corrects to a heart rate above 100 bpm and is breathing adequately, provide post-resuscitative care.
If the infant’s heart rate falls below 60 bpm after taking ventilator corrective steps, begin CPR with two thumbs-encircling hands technique at a rate of 3 compressions to 1 ventilation (90 compressions to 30 breaths per minute = 120 ‘events’ per minute). Intubate the child and ventilate. Reassess for recovery (spontaneous breathing and heart rate above 100); if the heart rate improves above 60 bpm but remains below 100 bpm, continue ventilation and optimizing oxygenation and reassess.
If the heart rate remains below 60 bpm despite oxygenation/ventilation and initiation of CPR, administer epinephrine ideally through parenteral access such as an IV or umbilical vein catheter, if established. Initially medications may be given via endotracheal tube (ETT): epinephrine via ETT is ten times the IV dosage, or 0.1 mg/kg. The 1:10,000 solution should be used for any route. Consider hypovolemia, pneumothorax, congenital heart disease, sepsis, opioid toxicity, hypoglycemia.
Based on the above, starting positive pressure ventilation on a non-vigorous meconium-stained child would likely promote meconium aspiration syndrome (B). Clear the airway first via ETT and meconium aspirator. An intraosseous (IO) line may be used if IV or UVC lines are not quickly established. However, the child’s airway and breathing must be established before moving to epinephrine administration (C).
Reference
Kattwinkel, J et al. Part 15: neonatal resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 2010. 122(18 Suppl 3): p. S909-19.
This term infant was born precipitously to a multigravida mother. As much information as feasible should be gathered quickly from the mother or collateral sources, especially if there are special circumstances such multiple gestations.
During any delivery, three key questions should be asked: Is this a term gestation? Is the baby breathing or crying? Does he have good tone?
If yes to all, give routine care of providing warmth, drying, and nasal bulb suctioning if needed. This will be the case in 90% of deliveries. Note: even a child with meconium staining who is vigorous and crying needs only routine care.
Approximately 10% of newborns require some intervention and only 1% will need intensive resuscitative measures. If the child has poor tone or is not breathing and the amniotic fluid is clear, the initial steps of drying, warming, and gentle stimulation are in order (A). If the child responds with crying, good tone, and a heart rate above 100 beats per minute (bpm) within 30 seconds of the initial steps and has no labored breathing or cyanosis, routine care can be resumed.
If the non-vigorous or apneic infant is stained in meconium, the child should not be stimulated. Immediate endotracheal intubation is required with suctioning via a meconium aspirator. This process may need to be repeated, until the secretions are clear of meconium. Again, if the child begins crying, has normal tone, and a heart rate above 100 bpm, routine care is then indicated.
If after the initial steps are taken and the child is gasping/apneic or has a heart rate below 100 bpm, provide positive pressure ventilation for 30 seconds. If the heart rate remains below 100 bpm, verify adequate chest rise and re-assess breathing and adequacy of ventilations and technique (i.e. repositioning) and heart rate. If the baby corrects to a heart rate above 100 bpm and is breathing adequately, provide post-resuscitative care.
If the infant’s heart rate falls below 60 bpm after taking ventilator corrective steps, begin CPR with two thumbs-encircling hands technique at a rate of 3 compressions to 1 ventilation (90 compressions to 30 breaths per minute = 120 ‘events’ per minute). Intubate the child and ventilate. Reassess for recovery (spontaneous breathing and heart rate above 100); if the heart rate improves above 60 bpm but remains below 100 bpm, continue ventilation and optimizing oxygenation and reassess.
If the heart rate remains below 60 bpm despite oxygenation/ventilation and initiation of CPR, administer epinephrine ideally through parenteral access such as an IV or umbilical vein catheter, if established. Initially medications may be given via endotracheal tube (ETT): epinephrine via ETT is ten times the IV dosage, or 0.1 mg/kg. The 1:10,000 solution should be used for any route. Consider hypovolemia, pneumothorax, congenital heart disease, sepsis, opioid toxicity, hypoglycemia.
Based on the above, starting positive pressure ventilation on a non-vigorous meconium-stained child would likely promote meconium aspiration syndrome (B). Clear the airway first via ETT and meconium aspirator. An intraosseous (IO) line may be used if IV or UVC lines are not quickly established. However, the child’s airway and breathing must be established before moving to epinephrine administration (C).
Reference
Kattwinkel, J et al. Part 15: neonatal resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 2010. 122(18 Suppl 3): p. S909-19.