OVERVIEW AND PRINCIPLES OF RESUSCITATION

Collected byDr.AbdulRahman Alnemri, MD

Senior consultant Neonatologist

OVERVIEW AND PRINCIPLES OF RESUSCITATION

Collected byDr.AbdulRahman Alnemri, MD

Senior consultant Neonatologist

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Overview and Principles of ResuscitationLesson content:• Physiologic changes at birth• Resuscitation flow diagram• Resuscitation risk factors• Equipment and personnel needed

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Which Babies Require Resuscitation?• Most newly born babies are vigorous• Only about 10% of newborns require some

assistance• Only 1% need major resuscitative measures

(intubation, chest compressions, and/or medications) to survive

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Fetal Physiology

In the fetus• Alveoli filled with lung fluid• In utero, fetus dependent on placenta for

gas exchange

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Fetal Physiology

In the fetus• Pulmonary arterioles

constricted• Pulmonary blood flow

diminished• Blood flow diverted

across ductus arteriosus Click on the image to play video

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Lungs and CirculationAfter Delivery• Lungs expand

with air• Fetal lung fluid

leaves alveoli

Click on the image to play video

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Lungs and Circulation

• Pulmonary arterioles dilate

• Pulmonary blood flow increases

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Lungs and Circulation

• Blood oxygen levels rise

• Ductus arteriosus constricts

• Blood flows through lungs to pick up oxygen

Click on the image to play video

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Normal Transition

• Fluid in alveoli absorbed• Umbilical arteries and vein constrict thus

increasing blood pressure• Blood vessels in lung relax

The following major changes take place within seconds after birth:

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What Can Go Wrong During Transition• Lack of ventilation of the newborn’s lungs

results in sustained constriction of the pulmonary arterioles, preventing systemic arterial blood from being oxygenated

• Prolonged lack of adequate perfusion and oxygenation to the baby’s organs can lead to brain damage, damage to other organs, or death

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Signs of a Compromised Newborn• Poor muscle tone• Depressed

respiratory drive• Bradycardia• Low blood pressure• Tachypnea• Cyanosis

Good tone with cyanosis

Bad tone with cyanosis

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In Utero or Perinatal CompromisePrimary Apnea• When a fetus/newborn first becomes deprived

of oxygen, an initial period of attempted rapid breathing is followed by primary apnea and dropping heart rate that will improve with tactile stimulation

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Secondary Apnea

• If oxygen deprivation continues, secondary apnea ensues, accompanied by a continued fall in heart rate and blood pressure

• Secondary apnea cannot be reversed with stimulation; assisted ventilation must be provided

QuickTime™ and aSorenson Video 3 decompressorare needed to see this picture.

Click on the image to play video

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Resuscitation of a Baby in Secondary Apnea

• Rapid improvement in heart rate

Initiation of effective positive-pressure ventilation during secondary apnea usually results in

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Preparation for Resuscitation: Risk Factors• The majority, but not all, of neonatal

resuscitations can be anticipated by identifying the presence of antepartum and intrapartum risk factors associated with the need for neonatal resuscitation

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Preparation for Resuscitation:Personnel and Equipment• Every delivery should be attended by at least 1 person

whose only responsibility is the baby and who is capable of initiating resuscitation. Either that person or someone else who is immediately available should have the skills required to perform a complete resuscitation

• When resuscitation is anticipated, additional personnel should be present in the delivery room before the delivery occurs

• Prepare necessary equipment– Turn on radiant warmer – Check resuscitation equipment

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Provider Response

All newborns require initial assessment to determine whether resuscitation is required

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Central Cyanosis and Acrocyanosis

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Free-flow Oxygen

• Free-flow oxygen is indicated for central cyanosis

• Free-flow oxygen cannot be given reliably by a mask attached to a self-inflating bag

• Flow-inflating bag and mask

• Oxygen tubing• Oxygen mask

Free-Flow Oxygen Given Via Flow-Inflating Bag and Mask

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Free-Flow Oxygen Given Via Oxygen Tubing

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Important Points in the Neonatal Resuscitation Flow Diagram• The most important and effective action in

neonatal resuscitation is to ventilate the baby’s lungs

• Effective positive-pressure ventilation in secondary apnea usually results in rapid improvement of heart rate

• If heart rate does not increase, ventilation may be inadequate and/or chest compressions and epinephrine may be necessary

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Causes and Solutions for Inadequate Chest Expansion

Condition Actions

Inadequate seal Reapply mask to face and lift jaw forward

Blocked airway Reposition the headCheck for secretions; suction if present

Ventilate with the newborn’s mouth slightly open

Not enough pressure Increase pressure until there is a perceptible chest movement

Consider endotracheal intubation

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Chest Compressions: Indications

Heart rate remains less than 60 beats per minute (bpm) despite 30 seconds of effective positive-pressure ventilation

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Chest Compressions:

• Compress the heart against the spine

• Increase intrathoracic pressure

• Circulate blood to vital organs, including the brain

• Must be accompanied by ventilation

• Should use 100% oxygen Click on the image to play video

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Chest Compressions: Stopping CompressionsAfter 30 seconds of compressions and ventilation, stop and check heart rate

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Chest Compressions: Heart Rate Remains Less than 60 bpm• Check adequacy of ventilation• Consider intubation if not already done• Insert an umbilical catheter to give

epinephrine

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Endotracheal Intubation: Anatomic Landmarks

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Endotracheal Intubation: Always Hold the Laryngoscope in the Left Hand

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Endotracheal Intubation: Step 5: Inserting Tube • Insert the tube into the

right side of the mouth with the curve of the tube lying in the horizontal plane

• If the cords are closed, wait for them to open

• Insert the tip of the endotracheal tube until the vocal cord guide is at the level of the cords

• Limit attempts to 20 seconds

Click on the image to play video

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Endotracheal Intubation:Radiographic Confirmation

Correct Incorrect

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Chest Compressions: Complications• Laceration of liver

• Broken ribs

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Epinephrine Indications

• 30 seconds of assisted ventilation followed by• 30 seconds of coordinated compressions and

ventilation_____________

Total = 60 seconds

Epinephrine, a cardiac stimulant, is indicated when the heart rate remains below 60 beats per minute despite

Note: Epinephrine is not indicated before adequate ventilation is established.

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Epinephrine Administration

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Epinephrine: Poor Response (Heart Rate < 60 bpm)

Recheck effectiveness of• Ventilation• Chest compressions• Endotracheal intubation• Epinephrine delivery

Consider possibility of• Hypovolemia

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Blood Volume Expansion

Recommended:• Normal saline

Acceptable:• Ringer’s lactate• O Rh-negative blood

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Medication Given: No Improvement

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Positive-Pressure Ventilation Fails to Produce Adequate VentilationImpaired function• Pneumothorax• Congenital pleural effusion• Congenital diaphragmatic hernia• Pulmonary hypoplasia• Extreme prematurity• Congenital pneumonia

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Baby Remains Cyanotic or Bradycardic

• Ensure chest is moving with ventilation• Listen for equal bilateral breath sounds• Confirm 100% oxygen is being given• Consider congenital heart block or cyanotic heart

disease (rare)

Persistent cyanosis and bradycardia are rarelycaused by congenital heart disease. More commonly, the persistent cyanosis and bradycardia are caused by inadequate ventilation

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Narcotic Antagonist: Naloxone Hydrochloride

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Management of Meconium

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Meconium Present and Newborn Not VigorousTracheal Suction• Administer oxygen, monitor heart rate• Insert laryngoscope, use 12F or 14F suction

catheter to clear mouth• Insert endotracheal tube into trachea• Attach endotracheal tube to suction source• Apply suction as tube is withdrawn• Repeat as necessary

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Suctioning Meconium

Click on the image to play video

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Post-resuscitation Problems

• Pulmonary hypertension

• Pneumonia and lung complications

• Metabolic acidosis

• Hypotension

• Fluid management

• Seizures or apnea

• Hypoglycemia• Feeding problems• Temperature

management

A baby who has required resuscitation must have close monitoring and management of

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Resuscitation Outside Hospital or Beyond Newborn Period

Physiologic Principles• Warm, position, clear airway• Stimulate to breathe, O2 as necessary

• Establish effective ventilation• Perform chest compressions• Administer medications

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Keeping Premature Babies Warm• Increase delivery

room temperature• Preheat radiant

warmer• Use warming pad• Consider

polyethylene bag for babies <28 weeks’ gestation

Click on the image to play video

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Oxygen Administration

• Hyperoxic/reperfusion injury may be more significant in preterm babies

• Oxygen blender, air source, and pulse oximeter recommended for babies born at <32 weeks’ gestation.

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Assisting Ventilation in Premature Newborns• Follow same criteria for initiating positive-

pressure ventilation with term babies• Consider using CPAP if the baby is breathing

spontaneously and has a heart rate above 100 bpm, but is having difficulty such as labored respirations, persistent cyanosis, or low oxygen saturation

• Use the lowest inflation pressure to achieve an adequate response

• Consider giving prophylactic surfactant

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Ethics and Care at the End of LifeLesson content:• Ethics of starting and stopping resuscitation• Communication with parents• Withholding resuscitation• Uncertain prognosis• Criteria for stopping resuscitation• What to do when a baby dies• Grieving (parents and staff)

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Prenatal Counseling Before High-Risk Birth• Establish relationship with parents• Consistent information, coordinated care• Issues

– Survival/disability chances– “Comfort care only”– Preventing pain and suffering

• Documentation

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Care of Family After Baby’s Death• Consistent, sensitive, and compassionate

care• Advance preparation, coordination,

training, practice• Skillful communication• Follow-up visits, support groups

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