Newborn resuscitation

Use this note for immediate after-delivery resuscitation; see neonatal resuscitation for the non-delivery related resuscitation of the newborn.

Background

Newborn Vital Signs

• HR RR SBP^
• >100 40-80 60-70

^<3kg (premature) SBP = 40-60

Differential Diagnosis

Newborn Problems

• Newborn resuscitation
• Hypoxia
  • Primary apnea
  • Secondary apnea
• Hypothermia
• Hypoglycemia
• Meconium aspiration syndrome
• Anemia (abruption)
• Infant scalp hematoma
• Transient tachypnea of the newborn
• Respiratory distress syndrome
• Congenital pneumonia
• Congenital heart disease
• Neonatal sepsis
• Pneumothorax
• Pulmonary hypertension

Diagnosis

Assessment Triad

• Term?
• Tone?
• Breathing or crying?
• If yes, stay with mother for routine care
• If no:
  • Respiration: adequacy, difficulty
  • Circulation: HR >100, palpate at umbilical base
  • Color - central cyanosis?

Apgar score

	Score of 0	Score of 1	Score of 2
Appearance	blue or pale all over (central cyanosis)	peripheral cyanosis (acrocyanosis) body pink	no cyanosis body and extremities pink
Pulse	absent	<100 beats per minute	≥100 beats per minute
Grimace	no response to stimulation	grimace on suction or aggressive stimulation	cry on stimulation
Activity	none	some flexion	flexed arms and legs that resist extension
Respiration	absent	weak, irregular, gasping	strong, lusty cry

Score at 1 minute and 5 minutes post delivery.

Management

See newborn critical care quick reference for drug doses and equipment sizes.

Resucitation Inverse Pyramid

1. Dry, warm, position, suction, stimulate
   • Gently dry newborn with warm towel
   • position: neutral (sniffing position)
   • suction: oral then nasal
   • stimulate: along spine or feet
   • check glucose^
2. Oxygen (use liberally)
3. Ventilate (40-60 breaths/min @ 20-25 cmH20)
   • BVM (indications)
     • Apnea/gasping
     • HR <100/min
     • Persistent cyanosis
   • ET (indications); ETT size = Gest age (wks) / 10
     • BVM ineffect after 30s
     • Suction meconium^^
4. Chest compressions (indications)
   • HR <60 after above x 30 sec
     • 120/min (resp 3:1)
     • Stop when HR > 60
5. Medications^^^^
   • Epi (0.01-0.03 mg/kg)
   • D10W (4 mL/kg = 0.2gm/kg)
   • Nalaxone (0.4 mg/kg)
     • For opioid use <4hrs
   • NS (10 mL/kg boluses)
   • Dopamine drip
     • (5-20 mcg/kg/min)
   • NaHCO3 - prolonged resus
     • (1-2 meQ/kg)

Key
^Hypoglycemia (give D10W)

• >2.5 kg = <40 mg/dL
• <2.5 kg = <30 mg/dL

^^Meconium Suctioning Indications (2 passes w/ ET + suction)

• Meconium + -->
  • absent/depressed resp
  • poor muscle tone
  • HR <100
• Suctioning not indicated in stable, crying newborn

^^^Newborn Vent Settings

• Pressure Cycled: RR 30+, PIP 20/2 (Preemie 15/2)

^^^^Umbilical vein catheterization

Airway

• Optimize
  • Position head in sniffing position
  • Suction nose and mouth
• Intubate
  • Indicated if patient is poorly responsive or fails BVM
  • If have time precut ET tube at 13cm mark
  • Lip placement = 6 + wt (kg)
  • After intubation suction trachea to prevent aspiration (if +meconium)

Tube Size / age / wt	Blade	Suction Catheter	Insertion Depth (cm)
2.5 / <28 / <1000	Miller 0	5F or 6F	6-7
3.0 / 28-34 / 1000-2000	Miller 0	6F or 8F	7-8
3.5 / 34-38 / 2000-3000	Miller 0	8F	8-9
3.5-4.0 />38 / >3000	Miller 0-1	8F or 10F	9-10

Breathing

• Apneic and/or bradycardic (<100 bpm)
  • Attempt tactile stimulation first
  • If unsuccessful perform BMV at 40-60 breaths/min
  • After intubation use:
    • Inflation pressure ~ 20

Circulation

• CPR
  • Begin if despite assisted ventilation x30s HR still <60
  • 3 compressions:1 breath (total 90 compresions:30 breaths per min)

Vascular Access

• Umbilical vein is site of choice

Volume Expansion

• NS 10-20mL/kg IV over 5-10min
• O Rh-negative blood

Medications

• Epinephrine
  • Indicated for aystole or HR < 60 despite CPR >30s
  • 0.01-0.03mg/kg IVP q3-5min
• Sodium Bicarbonate
  • Helps to counteract negative inotropy/pulm HTN caused by acidosis
  • Only give once adequate ventilation is established
  • 1-2 mEq/kg of 4.2% solution (2-4 mL/kg)
• Naloxone
  • Give if persistent resp depression AND maternal narcotics w/in 4hr
  • 0.1mg/kg IV

Disposition

• Admission

Withholding Resuscitation

• Consider if:
  • <22wk or <400g
  • No signs of life after 10min of CPR

Special Problems

Cyanosis

• Must distinguish between central and peripheral
• Consider prostaglandin E1 0.05-0.1 mcg/kg/min for cyanotic heart dz

Pneumothorax

• Tension PTX is highly related to subsequent ICH
  • Place 18-20ga catheter into 4th IC in ant axillarly line

Hypoglycemia

• <30-35 in preterm newborn
• <35-40 in term newborn
• Treatment
  • D10W 2mL/kg IV

Congenital Diaphragmatic Hernia

• Persistent respiratory distress w/ "seesaw" pattern
• Treat via immediate intubation, OG tube placement
  • Use lowest peak insp presure that allows for adequate chest rise

See Also

• Neonatal Resuscitation
• Umbilical Vein Catheterization
• Transient tachypnea of the newborn
• Emergent delivery
• Pediatric Advanced Life Support (PALS)