Rosen & Barkin's 5-Minute Emergency Medicine Consult (613 page)

• Newborn’s transition from dependence on the placenta to dependence on the lungs for oxygen.
  
• Hypoxia initially causes tachypnea followed by primary apnea.
  
• Stimulation may cause resumption of breathing during primary apnea.
  
• Continued hypoxia leads to secondary apnea.
  
• Secondary apnea requires assisted ventilation.
  
• Antepartum risk factors associated with need for resuscitation include:
  
  • Maternal diabetes
    
  • Pregnancy-induced hypertension
    
  • Chronic hypertension
    
  • Anemia
    
  • Previous fetal or neonatal death
    
  • Bleeding in 2nd or 3rd trimester
    
  • Maternal infection
    
  • Maternal cardiac, renal pulmonary, thyroid or neurologic disease
    
  • Polyhydramnios
    
  • Oligohydramnios
    
  • Premature rupture of membranes
    
  • Post-term gestation
    
  • Multiple gestation
    
  • Size–dates discrepancy
    
  • Drug therapy
    
  • Maternal substance abuse
    
  • Fetal malformation
    
  • Diminished fetal activity
    
  • No prenatal care
    
  • Maternal age <16 yr or >35 yr
    
• Intrapartum risk factors associated with need for resuscitation include:
  
  • Emergency C-section
    
  • Forceps or vacuum assist
    
  • Breech or other abnormal presentation
    
  • Premature labor
    
  • Precipitous labor
    
  • Chorioamnionitis
    
  • Prolonged rupture of membranes
    
  • Prolonged 2nd stage of labor
    
  • Fetal bradycardia
    
  • Nonreassuring fetal heart tracing
    
  • General anesthesia
    
  • Uterine tetany
    
• Narcotics administered to mother within 4 hr:
  
  • Meconium-stained amniotic fluid
    
  • Prolapsed cord
    
  • Abruptio placenta
    
  • Placenta previa
    

DIAGNOSIS

Compromised infants requiring resuscitation may exhibit 1 or more of:

• Decreased muscle tone
  
• Depressed respiratory drive
  
• Bradycardia
  
• Hypotension
  
• Tachypnea
  
• Cyanosis
  

Risk factors as above predict the need for resuscitation

• Respirations—rate and effectiveness
  
• HR—by auscultation or palpation of umbilical cord
  
• Color
  

ABCs:

• Airway
  
• Breathing
  
• Circulation
  
• Drying and warming child
  

• Bedside blood glucose measurement
  
• Blood gas
  

Chest radiograph

• Endotracheal intubation:
  
  • Straight blades Miller 1 for full term, Miller 0 for preterm
    
  • Endotracheal tubes (ETTs):
    
    • 2.5 for <1,000 g or <28 wk
      
    • 3 for 1,000–2,000 g or 28–34 wk
      
    • 3.5 for 2,000–3,000 g or 34–38 wk
      
    • 4 for >3,000 g or >38 wk
      
  • Have stylet, end-tidal CO
    ₂
    detector, suction, tape, meconium aspirator available.
    
• Umbilical vein catheterization:
  
  • Tie umbilical tape around base of cord.
    
  • Prefill syringe attached to umbilical catheter (3.5 or 5F).
    
  • Cut cord on clean edge below clamp.
    
  • Identify umbilical vein (large, thin walled, and single).
    
  • Insert catheter into umbilical vein directed cephalad.
    
  • Advance 2–4 cm until blood flows freely into syringe.
    
  • Check position with plain film.
    
  • Inject drugs/fluids as appropriate.
    

TREATMENT

• Resuscitation should be started by pre-hospital personnel.
  
• Neonatal resuscitation equipment should be available. Anticipation and preparation required.
  
• Pay particular attention to heat retention and warming.
  

• ABCs
  
• Provide warmth, clear airway, stimulate
  
• If meconium, poor respiratory effort, poor muscle tone, cyanosis, or prematurity are present, proceed with resuscitation.
  
• Initial steps include:
  
  • Warm the baby.
    
  • Position (neck slightly extended, sniffing position) and clear the airway (meconium may necessitate intubation—see below).
    
  • Dry thoroughly; stimulate (flick feet, rub trunk or extremities).
    
  • Provide oxygen:
    
    • In term infant, room air resuscitation may be advantageous to avoid hyperoxia.
      
    • In premature infants, blended oxygen with close monitoring of oximetry is appropriate.
      
• Meconium:
  
  • Meconium present and baby is NOT vigorous:
    
    • Insert ETT.
      
    • Suction with ETT meconium aspiration device.
      
    • Slowly withdraw tube.
      
    • Repeat as necessary until little meconium is recovered or HR is maintained.
      
  • Meconium present and baby is vigorous:
    
    • Suction mouth then nose with bulb or suction catheter.
      
• If re-evaluation within 30 sec reveals apnea or HR <100 bpm, proceed with:
  
  • Positive-pressure ventilation with 100% oxygen
    
  • Self-inflating or flow-inflating (anesthesia type) bag
    
  • Proper-fitting mask
    
  • 1st breath may require high pressure, necessitating occlusion of “pop-off” valve.
    
  • Rate of 40–60 breaths/min
    
  • Pressure of 30–40 cm H
    ₂
    O
    
  • If prolonged, place nasogastric (NG) tube.
    
• If re-evaluation after 30 sec of positive-pressure ventilation with 100% oxygen reveals HR <60 bpm, proceed with:
  
  • Continued positive-pressure ventilation and chest compressions
    
  • 2-thumb technique: Hands encircle torso
    
  • 2-finger technique:
    
    • Compress ∼1/3 of the anterior–posterior diameter of chest and release.
      
• 3 compressions followed by 1 ventilation
  
• 120 events/min (90 compressions and 30 breaths)
  
• If after 30 sec HR is >60 bpm, stop compressions.
  
• If after 30 sec HR is >100 bpm, stop positive-pressure ventilator.
  
• If after 30 sec HR still <60 bpm, administer epinephrine (IV or via ET tube).
  

• If evidence of blood loss or poor response to resuscitation, administer volume expander.
  
• NS, lactated Ringer, O-negative blood (cross-matched if time permitting)
  
• If severe metabolic acidosis is suspected or proven:
  
  • Ensure adequate ventilation.
    
  • Administer sodium bicarbonate.
    
• If hypoglycemia is proven or suspected, treat with IV dextrose.
  
• If HR and color improve but respiratory effort and tone are poor and mother received narcotics within 4 hr, treat with naloxone hydrochloride:
  
  • Contraindicated in mothers addicted to narcotics or receiving methadone: Can precipitate seizures.
    
• Persistent distress may indicate pneumothorax.
  
• Known or suspected diaphragmatic hernias should be treated with immediate endotracheal intubation and placement of NG tube.
  
• Consider discontinuation of resuscitation if 10 min of asystole.
  

• Dextrose: 2–4 mL/kg of D
  ₁₀
  W given IV (umbilical vein)
  
• Epinephrine: 0.1–0.3 mL/kg of 1:10,000 solution, may be given IV or via ETT (0.3–1 mL/kg if giving via ETT)
  
• Naloxone hydrochloride: 0.1 mg/kg. Administer IV or via ETT; can administer IM or SC, but onset of action is delayed.
  
• Sodium bicarbonate: 2 mEq/kg (4 mL/kg of 4.2% solution) (0.5 mEq/mL). Administer slowly via IV route (umbilical vein).
  
• Volume expanders: NS, lactated Ringer, blood. Initial dose 10 mL/kg, may be repeated, all given IV (umbilical vein).
  
• Other agents as specifically indicated by newborn’s underlying condition
  

FOLLOW-UP

• All newborns require admission.
  
• If significant resuscitation is necessary, admit to NCIU.
  

• Resuscitation and care of low-birth-weight infants may lead to the following complications:
  
  • Difficulty with thermoregulation
    
  • Intraventricular hemorrhage
    
  • Chronic lung disease
    
  • Retinopathy of prematurity
    
• Oxygen and the very low-birth-weight (VLBW) infant:
  
  • VLBW infant defined as birth weight <1,500 g
    
  • VLBW infants are at increased risk of oxidative stress and damage including retinopathy of prematurity.
    
  • Some studies suggest resuscitating with <100% oxygen in this group, possibly even 21% (room air), to avoid oxidative stress and damage.
    

• Fowlie PW, McGuire W. Immediate care of the preterm infant.
  BMJ.
  2004;329(7470):845–848.
  
• Kattwinkel J, ed.
  Textbook of neonatal resuscitation.
  5th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2006.
  
• Kattwinkel J, Perlman JM, Aziz K, et al. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
  Circulation
  . 2010;122:S909–S919.
  
• Kubicka ZJ, Limauro J, Darnall, RA. Heated, humidified high-flow nasal cannula therapy: Yet another way to deliver continuous positive airway pressure?
  Pediatrics
  . 2008;121:82–88.
  
• Vaucher YE, Peralta-Carcelen M, Finer NN, et al. Neurodevelopmental outcome in the early CPAP and pulse oximetry trial.
  N Engl J Med
  . 2012;36:2495–2504.