Jenny Brewster NEWBORN RESUSCITATION. University of West London.

Jenny Brewster

NEWBORN RESUSCITATION

University of West London


What is the main cause of collapse in adults

……and what is itin children?


Adults havecardiac arrests

Children haverespiratory arrests


Birth Asphyxia - Causes

• Drugs given to Mother• Obstruction of airway• Antepartum haemorrhage• Stressful delivery (shoulder dystocia,

malpresentation)• Pre-term• Severe infection• Non-patent airway• Cardiovascular or central nervous system

abnormalities• Intracranial haemorrhage


Physiology

• AEROBIC METABOLISM:– Carbohydrate is

converted to glucose– Stored in muscles as

glycogen– Broken down to pyruvic

acid– In presence of oxygen,

pyruvic acid is converted into CO2, H2O and energy.

• ANAEROBIC METABOLISM– If no O2, pyruvic acid is

converted into lactic acid– Lactic acid builds up in

tissues to create a metabolic acidosis

– pH>7.25 = normal– pH 7.2-7.25 = mild

acidosis– pH <7.20 = severe

acidosis


Physiology

• PRIMARY APNOEA– Brief period rapid ‘breathing’

– Stops breathing– HR unchanged, then

decreases to about half normal rate

– Anaerobic metabolism – less fuel-efficient

– Circulation to non-vital organs reduced

– Lactic acid build up

• SECONDARY APNOEA– Deep, shuddering

gasps initiated by primitive spinal centres

– Stops breathing– Lactic acid build up

effects cardiac function– Heart failure


Anticipated Outcomes

• A baby in primary apnoea will generally respond well to stimulation and supplementary oxygen

• A baby in secondary apnoea will need assisted ventilation


Newborn Life Support

• It’s as easy as A,B,C–Airway–Breathing–Circulation


Anticipate• Call for paediatrician and resuscitaire?• Towels• Warmth – close windows/doors• Bag and Mask• Stethoscope• Resuscitaire:

– Pre-heat– Clock– Tom thumb/neopuff – Check Oxygen– Suction


More Physiology!

•What happens as the baby takes it’s first breath?

•Fluid is pushed form the alveoli to establish the resting lung volume


CCD


Airway &

BreathingAB

CD

cover

Dry &

RC (UK)


Initial Actions

Start the clock Dry the baby Assess

Do you need help ?

RC (UK)


Initial assessment

Colour

Tone

Breathing

Heart rate

RC (UK)


Blue PinkGood toneBreathing regularlyFast heart rate

RC (UK)


Dry and coverGive to Mum


When should the cord be cut?

• If baby is in good condition, it can be left for at least a minute before clamping and cutting (resus council 2010)

• If baby Is in need of resuscitation, then this should be a priority, and the cord clamped and cut so that baby can be moved to an appropriate surface.


What if baby isn’t breathing?

Place the head in the neutral position


Always think……………

•DO I NEED HELP and call for the appropriate help

•In hospital?

•At home?


If this doesn’t work………….•Consider inflation breaths

•What is an inflation breath?

•Using bag and mask, or ‘T’ piece ventilation, give breaths lasting 2-3 seconds at 30cms water pressure. For premature babies, this should be reduced to 20-25cms water pressure


Reassess……….•What?

•Colour•Tone•Breathing•Heart Rate


What are you looking for?

•If the heart rate was slow and has increased, you have successfully inflated the lungs

•If the heart rate remains slow, either you have not inflated the lungs, or the heart needs help to respond. How will you know if the lungs have been inflated?

•Look for chest movement.


If the chest is not moving?

•Then the airway is not open.

•Reposition using a single handed jaw thrust if alone………..


ORA two handed jaw thrust if you have help


Mask inflation isnearly always effective

Only about 1 in 500appear to need intubation


When you have chest inflation….•If the heart rate is still slow, consider chest compressions.

•Why is it not beneficial to do chest compressions until the lungs have been inflated?

•There will not be any oxygen available in the lungs for the blood to ‘pick up’ and take back to the heart.


Chest compressions

You want to move oxygenated bloodfrom the lungs to the coronary arteries

Its not that far and won’t take long

RC (UK)


Chest Compressions• Do not start until you are sure the lungs

have been aerated• Place 2 thumbs on lower third of sternum,

just below an imaginary line joining the nipples

• Compress chest quickly (about 100/min) and firmly, reducing the anterio-posterior diameter by about a third

• Ratio of compressions to breaths in newborn resus is 3:1.

• Re-assess every 30 seconds – check position and keep looking for chest movement when breath given

• Stop and continue maintenance breaths once HR>60

University of West LondonCopyright ©1999 BMJ Publishing Group Ltd.

Hamilton, P. BMJ 1999;318:1403-1406

Two Methods of External Chest Compression


Airway

In the unconscious baby airway obstruction is usually due to

loss of pharyngeal tonenot

foreign material in the airway

i.e. Position not suction

RC (UK)


Meconium

Stress leads to passage in

utero

Triggered more easily near

term

Aspiration requires gasping


Meconium

Screaming babies have an open airway: leave them alone

Floppy babies :- HAVE A LOOK


Thick meconium

• CALL FOR HELP• Suck out any visible thick

meconium • No need to clear thin meconium• Proceed to face mask ventilation• If heart rate not improving and

chest not moving, have another look and consider suction between the cords


You will need help

• When to ask?• How to ask?• Who to ask?• What to ask for?• How long will help take to arrive?


A Reminder of the Mechanisms of Heat Loss

Conduction: heat passed to what is in contact with the patient

Convection: air currents over the body

Radiation: heat passed from the body to the environment

Evaporation: evaporative heat loss from exposed viscera or wet surfaces


What happens to a Hypothermic Infant?

Oxygen consumption:– 36% in premature & 23% full-term neonates

Cardiac function

Lactate production and metabolic acidosis

Peripheral vasoconstriction

Shift of O2-hemoglobin dissociation curve to the left

Glomerular filtration rate


What can you do to Reduce heat loss

Conduction Warm surface – TURN ON resuscitaire

(Thermal mattress)

Convection Close doors/windows?Turn off air-conditioning

Radiation Warm room

Evaporation Dry and wrapHat(Plastic wrap)


Ambient TemperatureAt birth

– A naked baby exposed to an ambient temperature of 23 oC at birth suffers the same heat loss as a naked adult at 0 oC WHO 1997

– Infant temperature can drop by 0.1oC /minute

– Mean rectal admission temperature decreases 0.21°C with each 100-g decrease in birth weight Vohra 2004


How warm?Recommended delivery room

temperature 25-28 oC WHO 1999

An adult should not determine the delivery room temperature according to their own comfort WHO 1997


Skin to Skin warming

Very effective if done correctlyFor well term infants

– Warm room– Dry infant– Naked between breasts – Nappy and hat– Cover parent and infant with blanket– Regular checks to ensure improvement


Summary of thermal care

Newborns don’t like being coldKeep the room warmTurn on resuscitaire heaterDry and wrapBag and hat (and thermal mattress)

for premature infantsRegular/continuous

monitoring

Jenny Brewster NEWBORN RESUSCITATION. University of West London.

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Transcript of Jenny Brewster NEWBORN RESUSCITATION. University of West London.