Neonatal Assessment

Provincial Reciprocity Attainment Program

The Need for Resuscitation

 Most term newborns require no resuscitation beyond maintenance of temperature, suctioning of the airway, and mild stimulation  Approximately 6% of deliveries require life support  Incidence of complications increases as birth weight decreases

The Need for Resuscitation

 Antepartum (before labor and delivery) and intrapartum (during labor and delivery) risk factors may affect the need for resuscitation  When any of these risk factors are present during delivery or imminent delivery, prepare equipment and drugs that may be required for neonatal resuscitation  Medical direction should also be advised of the situation so that the appropriate destination hospital can be determined.

Antepartum Risk Factors

   Multiple gestation Inadequate prenatal care Mother’s age  Less than age 16 or more than 35     History of perinatal morbidity or mortality Post-term gestation Drugs/medications Toxemia, hypertension, diabetes

Intrapartum Risk Factors

        Premature labor Meconium-stained amniotic fluid Rupture of membranes greater than 24 hours before delivery Use of narcotics within 4 hours of delivery Abnormal presentation Prolonged labor or precipitous delivery Prolapsed cord Bleeding

The Premature Infant

   Refers to a baby born before 37 weeks gestation  The weight of these newborns is often between 0.6 to 2.2 kg [1.5 to 5 pounds] Premature infants have an increased risk for:    Respiratory depression Hypothermia Head and brain injury

Resuscitation should be attempted if the infant has any signs of life

Congenital Anomalies

  Choanal atresia  A bony or membranous occlusion that blocks the passageway between the nose and pharynx  Can result in serious ventilation problems in the neonate Cleft lip  One or more fissures that originate in the embryo  A vertical, usually off-center split in the upper lip that may extend up to the nose

Congenital Anomalies

  Cleft palate  A fissure in the roof of the mouth that runs along its midline  May extend through both the hard and soft palates into the nasal cavities Pierre Robin syndrome  A complex of anomalies including:      A small mandible Cleft lip Cleft palate Other craniofacial abnormalities Defects of the eyes and ears

Diaphragmatic Hernia

   Protrusion of a part of the stomach through an opening in the diaphragm Risk factors  Bag and mask ventilation can worsen condition Pathophysiology  Abdominal contents are displaced into the thorax   Heart may be displaced Respiratory compromise

Physiological Adaptations at Birth

 At birth, newborns make three major physiological adaptations necessary for survival  Emptying fluids from their lungs and beginning ventilation  Changing their circulatory pattern  Maintaining body temperature

Transition From Fetal to Neonatal Circulation

 Respiratory system must suddenly initiate and maintain oxygenation   Infants are very sensitive to hypoxia Permanent brain damage will occur with hypoxemia  Apnea in newborns

Causes of Hypoxia

     Compression of the cord Difficult labor and delivery Maternal hemorrhage Airway obstruction Hypothermia   Newborn blood loss Immature lungs in the premature newborn

Hypothermia

  Newborns are at great risk for rapidly-developing hypothermia because of:   Their larger body surface area Decreased tissue insulation  Immature temperature regulatory mechanisms Newborns attempt to conserve body heat through vasoconstriction and increasing their metabolism, placing them at risk for:   Hypoxemia Acidosis   Bradycardia Hypoglycemia

Assessment and Management

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Initial steps of neonatal resuscitation (except infants born through meconium): Prevent heat loss Clear the airway by positioning and suctioning Provide tactile stimulation and initiate breathing if necessary Further evaluate the infant

Prevention of Heat Loss

 Immediately after delivery  Dry the infant's head and body  Remove any wet coverings from the infant   Cover with dry wrappings Cover the newborn's head  Accounts for 20% of the newborn’s BSA

Opening the Airway

  Position Suction  Technique   Mouth first, than nares Nasal suctioning is a stimulus to breathe  Equipment   Bulb suction Suction catheters

Provision of Tactile Stimulation

 If drying and suctioning do not induce respirations, provide additional tactile stimulation  Two safe and appropriate methods are:   Slapping or flicking the soles of the feet Rubbing the infant's back  If the infant remains apneic after a brief period (5 to 10 seconds) of stimulation:  Immediately initiate positive-pressure ventilation with a pediatric bag-valve device and supplemental oxygen (40 to 60 ventilations/min)

Evaluation of the Infant

  Observe and evaluate the infant's respirations Evaluate the infant's heart rate by stethoscope, or by palpating the pulse in the umbilical cord or brachial artery  HR < 100  Provide ventilation via BVM for 30 seconds and reassess  HR < 60   Provide ventilation via BVM for 30 seconds and reassess If not resolved begin CPR (a rate of > 100)

Evaluation of the Infant

 Evaluate the infant's color  If Central cyanosis, bradycardia and other signs of distress are present in an infant with spontaneous respirations and an adequate heart rate, administer free-flow oxygen at 5 LPM  A maximum oxygen concentration of about 80% can be achieved when the tube is one-half inch from the infant's nose  Peripheral cyanosis is common in newborns and should resolve

Apgar Score

 Enables rapid evaluation of a newborn’s condition at specific intervals after birth  Routinely assessed at 1 and 5 minutes of age Sign Appearance (Skin Color) HR Absent 0 Central cyanosis, pale < 100 bpm 1 Peripheral cyanosis Pink > 100 bpm 2 Grimace (Irritability) Muscle tone Respiratory Effort No response Limp Absent Grimace Some flexion Slow, irregular Cough, sneeze, cry Active motion Good, crying

Resuscitation of the Distressed Newborn

 Risk factors associated with the need for resuscitation include:  Premature delivery  Maternal health problems  Complicated pregnancies  Delivery complications  Reevaluating components of the resuscitation process

Resuscitation

Neonatal Transport

  During transport of the neonate:    Maintain body temperature Oxygen administration Ventilatory support In the prehospital phase of care, transport strategies are usually limited to:    Providing a warm ambulance Free-flow oxygen administration Warm blankets

Specific Situations

Respiratory Disorders

 Respiratory insufficiency in the neonate is generally managed by:  Stimulation and positioning of the airway  Prevention of heat loss  Oxygenation and ventilation  Suction  Ventilatory support (if needed)

Apnea

 Respiratory pauses that exceed 20 seconds  Common finding in preterm infants, and if prolonged, can lead to hypoxemia and bradycardia  Primary apnea  self-limited condition (controlled by pCO 2 common immediately after birth levels) that is  Secondary apnea  describes respirations that are absent and that do not begin again spontaneously

Apnea

 Risk factors  Hypoxia  Hypothermia  Narcotic or CNS depressants  Airway or respiratory muscle weakness  Oxyhemoglobin dissociation curve shift  Septicemia  Metabolic Disorders  CNS Disorders

Respiratory Distress and Cyanosis

 Prematurity is the single most common factor for respiratory distress and cyanosis in the neonate  Occurs most frequently in infants less than 1200 g (2.5 pounds) and 30 weeks gestation  Risk factors (see next slide):  Can lead to cardiac arrest  Requires immediate intervention to support respirations

Other Risk Factors

    Lung or heart disease Primary pulmonary HTN CNS Disorders Mucous obstruction of nasal passages  Spontaneous pneumothorax  Choanal atresia        Meconium aspiration syndrome Amniotic fluid aspiration Lung immaturity Pneumonia Shock and Sepsis Metabolic acidosis Diaphragmatic hernia

Dyspnea and Cyanosis

 S/S may include  Tachypnea  Tachycardia  Paradoxical breathing  Intercostal retractions  Nasal flaring  Expiratory grunting  Central cyanosis

Cardiovascular Disorders

  All neonates with cardiovascular disorders should be assessed for treatable causes of hypoventilation Bradycardia   A heart rate of less than100 beats/min Causes     Hypoxia (most common) Increased intracranial pressure Hypothyroidism Acidosis  Considered a minimal risk to life in neonates if corrected quickly

Cardiac Arrest

 Incidence is rare  Risk factors  Intrauterine asphyxia  CNS depressants or other drugs taken by Mom  Congenital neuromuscular disorder  Congenital deformities  Intrapartum Hypoxia  Arrest protocols are covered in Pediatrics

Hypovolemia

 May result from:  Dehydration  Hemorrhage  Trauma  Sepsis  May be associated with myocardial dysfunction

Hypovolemia

 Signs and symptoms  Mottled or pale skin  Cool  Tachycardia  Diminished peripheral pulses  Delayed cap refill  Pressure is not a good indicator  Prehospital care  Airway  Fluid @ 10 ml/kg over 5 - 10 minutes (ALS)

Gastrointestinal Disorders

 Occasional vomiting or diarrhea is not unusual in the neonate  Vomiting mucus (that may occasionally be blood streaked) is common in the first few hours of life  5 to 6 stools per day is considered normal, especially if the infant is breast feeding.  Persistent vomiting and/or diarrhea should be considered warning signs of serious illness

Seizures

   Are usually fragmented and not sustained Subtle seizures may include  Eye deviation     Blinking Sucking Swimming movement of arms and peddling of the legs Apnea Causes  Hypoglycemia       Hypoxic ischemia encephalopathy Intracranial hemorrhage Metabolic disturbances Meningitis or encephalopathy Development abnormalities Drug withdrawal

Fever

 Rectal temperature > 38 ºC  Often a response to an acute viral or bacterial infection  May also be result of  Lack of internal temperature control  Dehydration  May lead to metabolic acidosis  From ↑ O 2 demand and ↑ glucose metabolism

Fever

 Assessment may include  ALOC  Irritable  Somnolence  History of decreased intake or not feeding at all  Warm or hot skin  Treatments are supportive only

Hypothermia

 Body temperature drops below 35 º C  BSA and surface to volume ratio makes them susceptible  Infants may die of cold exposure at temperatures adults find comfortable  Increased metabolic demand may cause metabolic acidosis, pulmonary HTN, and hypoxemia

Hypothermia

 Assessment may include  Pale skin  Cool (especially in the extremities)  Respiratory distress  Apnea  Bradycardia  Central cyanosis  Irritability progressing to lethargic  Absence of shivering  Treatment

Hypoglycemia

 A blood glucose screening test less than 4 mmol/L indicates hypoglycemia  Risk factors  Asphyxia  Toxemia  Being smaller twin  CNS hemorrhage  Sepsis

Hypoglycemia

 S/S  Twitching or seizure   Limpness Lethargy  Eye rolling   High pitched cry Apnea   Irregular respirations Cyanosis possibly  Treatment  1.0 cc/kg D 50 IV (D 10 or D 25 preferred) – Requires ALS

Common Birth Injuries

 2 - 7 % out of 1000 births results in an injury  Risk factors include uncontrolled explosive delivery  Types of injuries seen:  Cranial injuries  Molding of head and overriding of parietal bones  Soft tissue from forceps  Subconjunctival and retinal hemorrhage  Skull fracture

Common Birth Injuries

 Intracranial hemorrhage  Spine or spinal cord injury  Peripheral nerve damage  Liver or spleen or kidney  Clavicle or extremity fracture  Hypoxia ischemia  Prehospital care  Support vital functions  Rapidly transport to an appropriate medical facility for definitive care

Psychological and Emotional Support

 Be aware of the normal feelings and reactions of parents, siblings, other family members, and caregivers while providing emergency care to an ill or injured child  These events also are often highly charged and emotional for the EMS crew

Psychological and Emotional Support

 As a rule, emergency responders should:  Never discuss the infant’s chances of survival with a parent or family member  Not give “false hope” about the infant’s condition  Assure the family that everything that can be done for the child is being done  Assure the family that their baby will receive the best possible care during transport and while at the emergency department