neonatal resuscitation, dr. wylie 7/17/14
DESCRIPTION
Neonatal resuscitation powerpoint presentationTRANSCRIPT
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Neonatal Resuscitation
Todd Wylie, M.D.
Department of Emergency Medicine
University of Florida College of Medicine
Jacksonville
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Physiology
• Fetal Circulation– Placenta
• Low vascular resistance
– Fetal lungs• High vascular
resistance
2011 UpToDate, Inc.
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Physiology
• Fetal Circulation– Right-to-left
shunts• Foramen ovale• Ductus
arteriosus
2011 UpToDate, Inc.
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Physiology
• Fetal Circulation– From the
placenta…• Oxygenated
blood…• Ductus
venosus into IVC…
• Right atrium…• Shunted thru
foramen ovale…
• Into left atrium
2011 UpToDate, Inc.
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Physiology
• Fetal Circulation– From the SVC
and IVC…• Minimal mixing
with oxygenated blood…
• Right atrium to right ventricle…
• Shunted through ductus arteriosus…
• Into distal aorta
2011 UpToDate, Inc.
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Physiology
• Fetal Oxygenation– Adequate tissue
oxygenation secondary to:
• Fetal hemoglobin• Decreased fetal
oxygen consumption
• Differential blood flow
2011 UpToDate, Inc.
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Physiology
• Changes at Delivery
– Alveolar fluid clearance
– Lung expansion
– Circulatory changes
2011 UpToDate, Inc.
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Physiology
• Difficulties Transitioning– Risk factors
• Maternal conditions (advanced age, diabetes, hypertension, substance abuse)
• Fetal conditions (prematurity, postmaturity, multiple gestation, anomalies)
• Antepartum problems (oligohydramnios, polyhydramnios, placental anomalies)
• Delivery (breech, transverse, meconium, maternal narcotics, difficult delivery)
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Physiology
• Difficulties Transitioning– Lack of respiratory effort– Blockage of the airways– Impaired lung function– Persistent pulmonary hypertension– Cardiac anomalies
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Neonatal Resuscitation
Introduction – Multiparous female to ED with severe contractions; is preterm (28 weeks); precipitous delivery of pre-term neonate as put into resuscitation bay.
PMH for mother –G6P6, Normal prenatal visits, estimate gestational age 28 weeks currently, no other issues.
Exam for mother – Awake, alert, stable, can provide appropriate history as needed
CASE 1
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Neonatal Resuscitation
Initial Description of Neonate – Placed in warmer; is not breathing or crying; poor muscle tone; cyanotic; note clear amniotic fluid.
Exam – Cyanotic neonate, unresponsive, floppyNo respiratory effort/apneicHeart rate 50’sAPGAR = 1
CASE 1
Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
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Neonatal Resuscitation
• APGAR Score– Performed at 1 and 5 minutes– Evaluate condition after delivery and need for intervention
Component 0 1 2Appearance Whole body
cyanoticCyanotic extremities
Good color
Pulse No heart rate < 100 BPM > 100 BPM
Grimace No response to stimulation
Grimace Grimace, vigorous cry
Activity Limp, no movement
Some muscle tone
Active motion
Respiration Not breathing Slow, irregular Cries well
Quick Tangential Point
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Neonatal Resuscitation
APGAR Score
“These scores should not be used to dictate appropriate resuscitative actions, nor should interventions for
depressed newborns be delayed until the 1-minute assessment.”
Textbook of Neonatal Resuscitation, 6th Edition; Page 35.
Quick Tangential Point
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Neonatal Resuscitation
Initial Description of Neonate – Placed in warmer; is not breathing or crying; poor muscle tone; cyanotic; note clear amniotic fluid.
Exam – Cyanotic neonate, unresponsive, floppyNo respiratory effort/apneicHeart rate 50’s APGAR = 1
CASE 1
Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
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Neonatal Resuscitation
• What is the next step?– “ABCDs”
• Initial steps – provide warmth, suction Airway as necessary, dry, stimulate
• Reassess• Positive pressure ventilation (Breathing)• Reassess• Ventilation corrective steps (Breathing)• Reassess• Chest compressions• Reassess• Give Drugs
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Neonatal Resuscitation
• Initial steps– Provide warmth
• Warm towels• Radiant warmer
– Clear airway as necessary
– Dry and stimulate
– Reassess
Term Gestation?Breathing or crying?
Good tone?Routine
Care
WarmClear airway if needed
DryStimulate
HR less than 100?Gasping or
Apnea?
No
Yes
30 sec
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Neonatal Resuscitation
Reassessment
Patient remains: CyanoticApneicPulse is in the 50s
CASE 1
Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
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Neonatal Resuscitation
• Subsequent steps– Positive-pressure
ventilation (PPV)• Self-inflating bag• Position neck in
neutral position• Suction mouth and
nose• Ventilate at 40-60
bpm
– SpO2 monitoring• Right hand or wrist
– Reassess
HR less than 100?Gasping or
Apnea?
LaboredBreathingCyanosis
Positive-PressureVentilation
SpO2 monitoring
HR below 100?
Yes
5-10 breaths
No
Clear airwaySpO2 monitor
CPAP?
Yes
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Neonatal Resuscitation
Reassessment
Somewhat improved heart rate and color
Heart rate increases to 90’s with continued PPV
Oxygen saturation in the 80’s
CASE 1
Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
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Neonatal Resuscitation
• Pulse oximetry– Attached to preductal location on right upper extremity– Saturation may normally remain low for several minutes after
deliveryTargeted preductal SpO2 after
delivery
1 min 60-65 percent
2 min 65-70 percent
3 min 70-75 percent
4 min 75-80 percent
5 min 80-85 percent
10 min 85-95 percent
Quick Tangential Point
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Neonatal Resuscitation
Reassessment
Somewhat improved heart rate and color
Heart rate increases to 90’s with continued PPV
Oxygen saturation in the 80’s
CASE 1
Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
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Neonatal Resuscitation
• Subsequent steps– Heart rate less
than100 BPM• Ventilation
corrective steps• Continue BMV
ventilation
HR below 100? Postresus.care
Ventilation correctivesteps
Yes
No
HR < 60?
No
Continueventilation
YesHR < 100 but > 60?
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Neonatal Resuscitation
• Ventilation Corrective Steps – 3 possible reasons for ineffective ventilation– Inadequate mask seal– Airway is blocked– Not enough pressure used
Measures to improve positive-pressure ventilation
M Mask adjustment
R Reposition airway
S Suction mouth and nose
O Open mouth
P Pressure increase
A Airway alternative
Quick Tangential Point
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Neonatal Resuscitation
Reassessment
Heart rate increases to > 100 with continued PPV
Attempts to provide supplemental oxygen result in decreasing oxygen saturation and decreasing heart rate
Obvious inadequate respiratory effort
CASE 1
Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
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Neonatal Resuscitation
Your kind of stuck here aren’t you…
HR below 100? Postresus.care
Ventilation correctivesteps
Yes
No
HR < 60?
No
Continueventilation
YesHR < 100 but > 60?
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Neonatal Resuscitation
• Consider placing an orogastric tube to…– Suction gastric contents– Serve as vent for air in
stomach
• Consider endotracheal intubation for…– PPV beyond a few minutes– Meconium and floppy– Chest compressions– PPV with inadequate
improvement– Special circumstances
What to do if positive-pressure ventilation is to be continued…
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Neonatal Resuscitation
Reassessment
Heart rate with PPV remains above 100
Color improved
Continue to provide respiratory support (oxygen saturation in low 90’s)
NICU team present with warmer
CASE 1
Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
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Neonatal Resuscitation
Introduction – Multiparous female to ED in labor; precipitous delivery as put into resuscitation bay of term neonate. Meconium stained amniotic fluid.
PMH for mother –G6P6, Normal prenatal visits, due date 2 days from now, no other issues.
Exam for mother – Awake, alert, stable, can provide appropriate history as needed
CASE 2
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Neonatal Resuscitation
Initial Description of Neonate – Placed in warmer; is not breathing or crying; poor muscle tone; cyanotic; meconium stained.
Exam – Cyanotic neonate, unresponsive, floppyNo respiratory effort/apneicHeart rate 50’s (< 60)APGAR = 1
CASE 2
Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
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Neonatal Resuscitation
• Initial steps– Provide warmth
• Warm towels• Radiant warmer
– Clear airway as necessary
– Dry and stimulate
– Reassess
Term Gestation?Breathing or crying?
Good tone?Routine
Care
WarmClear airway if needed
DryStimulate
HR less than 100?Gasping or
Apnea?
No
Yes
30 sec
Hold On!!!
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Neonatal Resuscitation
• Meconium is present and baby is NOT vigorous– Provide warmth
• Warm towels• Radiant warmer
– Before drying (!!!)• Oropharynx and
hypopharynx suctioned • Trachea suctioned under
direct visualization
– Dry and stimulate
– Reassess
Term Gestation?Breathing or crying?
Good tone?Routine
Care
WarmDirect suctioning of trachea
DryStimulate
HR less than 100?Gasping or
Apnea?
No
Yes
30 sec
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Neonatal Resuscitation
• To suction the trachea– Insert a laryngoscope– Suction mouth and
posterior pharynx– Insert endotracheal
tube– Attach to meconium
aspirator– Suction
Quick Tangential Point
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Neonatal ResuscitationQuick Tangential Point
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Neonatal Resuscitation
Reassessment
No improvement in respirations (apneic), heart rate (50’s), or color (cyanotic)
CASE 2
Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
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Neonatal Resuscitation
• Subsequent steps– Positive-pressure
ventilation (PPV)• Self-inflating bag• Position neck in
neutral position• Suction mouth and
nose• Ventilate at 40-60
bpm
– Reassess
HR less than 100?Gasping or
Apnea?
LaboredBreathingCyanosis
Positive-PressureVentilation
SpO2 monitoring
HR below 100?
Yes
5-10 breaths
No
Clear airwaySpO2 monitor
CPAP?
Yes
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Neonatal Resuscitation
Reassessment
Neonate with no improvement (apneic, heart rate in 50’s, poor color and tone)
CASE 2
Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
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Neonatal Resuscitation
• Subsequent steps– Heart rate less
than100 BPM• Ventilation
corrective steps• Continue BMV
ventilation
HR below 100? Postresus.care
Ventilation correctivesteps
Yes
No
HR < 60?
No
Continueventilation
YesHR < 100 but > 60?
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Neonatal Resuscitation
Reassessment
Neonate with no improvement (apneic, heart rate in 50’s, poor color and tone)
CASE 2
Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
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Neonatal Resuscitation
• Subsequent steps– Heart rate < 60
BPM• Chest
compressions (90/min)
• Continue ventilation at 30 BPM
– Reassess
Ventilation correctivesteps
Chest compressionsConsider intubation
Coordinate with PPV
Yes
HR < 60?
No
Continueventilation
Yes
HR < 60?
HR < 100 but > 60?
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Neonatal Resuscitation
• Indications for endotracheal intubation– PPV beyond a few minutes– Meconium and floppy– Chest compressions– PPV with inadequate
improvement– Special circumstances
Quick Tangential Point
Sondeintubation new.jpg; Author – bigomar2
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Neonatal Resuscitation
How do you select the endotracheal tube size?
Weight (grams) Gestational age (wks) Tube size (mm)
< 1,000 < 28 2.5
1,000 – 2,000 28 – 34 3.0
2,000 – 3,000 34 – 38 3.5
> 3,000 > 38 3.5 – 4.0
Quick Tangential Point
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Neonatal Resuscitation
Reassessment
Neonate with improved heart rate (is now up to 80’s)
Need to continue PPV
CASE 2
Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
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Neonatal Resuscitation
• Subsequent steps– Heart rate less
than100 BPM• Continue positive
pressure ventilation
HR below 100? Postresus.care
Ventilation correctivesteps
Yes
No
HR < 60?
No
Continueventilation
YesHR < 100 but > 60?
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Neonatal Resuscitation
Reassessment
Heart rate improves with PPV to 100’s
NICU team present with warmer
CASE 2
Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
![Page 47: Neonatal Resuscitation, Dr. Wylie 7/17/14](https://reader035.vdocuments.mx/reader035/viewer/2022062705/556c922dd8b42a7a738b4e81/html5/thumbnails/47.jpg)
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Neonatal Resuscitation
Introduction – Young female with history of drug abuse (prescription pain medications) to ED in labor; precipitous delivery as put into resuscitation bay of near-term neonate.
PMH for mother – G2P1, drug abuse (prescription pain medications – is currently abusing), 1 prenatal visit, thinks due date is “a couple weeks from now.”
Exam for mother – post-partum, speech somewhat slurred
CASE 3
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Neonatal Resuscitation
Initial Description of Neonate – Placed in warmer; is not breathing or crying; poor muscle tone; cyanotic; note clear amniotic fluid.
Exam – Cyanotic neonate, unresponsive, floppyNo respiratory effort/apneicHeart rate 50’sAPGAR = 1
CASE 3
Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
![Page 50: Neonatal Resuscitation, Dr. Wylie 7/17/14](https://reader035.vdocuments.mx/reader035/viewer/2022062705/556c922dd8b42a7a738b4e81/html5/thumbnails/50.jpg)
Neonatal Resuscitation
• Initial steps– Provide warmth
• Warm towels• Radiant warmer
– Clear airway as necessary
– Dry and stimulate
– Reassess
Term Gestation?Breathing or crying?
Good tone?Routine
Care
WarmClear airway if needed
DryStimulate
HR less than 100?Gasping or
Apnea?
No
Yes
30 sec
![Page 51: Neonatal Resuscitation, Dr. Wylie 7/17/14](https://reader035.vdocuments.mx/reader035/viewer/2022062705/556c922dd8b42a7a738b4e81/html5/thumbnails/51.jpg)
Neonatal Resuscitation
Reassessment
Remains cyanoticApneic Pulse is 50 BPM
CASE 3
Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
![Page 52: Neonatal Resuscitation, Dr. Wylie 7/17/14](https://reader035.vdocuments.mx/reader035/viewer/2022062705/556c922dd8b42a7a738b4e81/html5/thumbnails/52.jpg)
Neonatal Resuscitation
• Subsequent steps– Positive-pressure
ventilation (PPV)• Self-inflating bag• Position neck in
neutral position• Suction nose and
mouth• Ventilate at 40-60
bpm
– Reassess
HR less than 100?Gasping or
Apnea?
LaboredBreathingCyanosis
Positive-PressureVentilation
SpO2 monitoring
HR below 100?
Yes
5-10 breaths
No
Clear airwaySpO2 monitor
CPAP?
Yes
![Page 53: Neonatal Resuscitation, Dr. Wylie 7/17/14](https://reader035.vdocuments.mx/reader035/viewer/2022062705/556c922dd8b42a7a738b4e81/html5/thumbnails/53.jpg)
Neonatal Resuscitation
Reassessment
Patient remains cyanoticApneicPulse is < 60 BPM
CASE 3
Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
![Page 54: Neonatal Resuscitation, Dr. Wylie 7/17/14](https://reader035.vdocuments.mx/reader035/viewer/2022062705/556c922dd8b42a7a738b4e81/html5/thumbnails/54.jpg)
Neonatal Resuscitation
• Subsequent steps– Heart rate less
than100 BPM• Ventilation
corrective steps• Continue BMV
ventilation
HR below 100? Postresus.care
Ventilation correctivesteps
Yes
No
HR < 60?
No
Continueventilation
YesHR < 100 but > 60?
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Neonatal Resuscitation
Reassessment
Patient remains cyanoticApneicPulse is < 60 BPM
CASE 3
Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
![Page 56: Neonatal Resuscitation, Dr. Wylie 7/17/14](https://reader035.vdocuments.mx/reader035/viewer/2022062705/556c922dd8b42a7a738b4e81/html5/thumbnails/56.jpg)
Neonatal Resuscitation
• Subsequent steps– Heart rate < 60
BPM• Chest
compressions (90/min)
• Continue ventilation at 30 BPM
– Reassess
Ventilation correctivesteps
Chest compressionsConsider intubation
Coordinate with PPV
Yes
HR < 60?
No
Continueventilation
Yes
HR < 60?
HR < 100 but > 60?
![Page 57: Neonatal Resuscitation, Dr. Wylie 7/17/14](https://reader035.vdocuments.mx/reader035/viewer/2022062705/556c922dd8b42a7a738b4e81/html5/thumbnails/57.jpg)
Neonatal Resuscitation
Reassessment
Patient remains cyanoticApneicPulse is < 60 BPM
CASE 3
Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
![Page 58: Neonatal Resuscitation, Dr. Wylie 7/17/14](https://reader035.vdocuments.mx/reader035/viewer/2022062705/556c922dd8b42a7a738b4e81/html5/thumbnails/58.jpg)
Neonatal Resuscitation
• Subsequent steps– Vascular access– Drugs
• Epinephrine • Volume expansion
– Reassess
HR < 60?According to
condition
Vascular accessIV Epinephrine
(0.01 mg/kg of 1:10,000)
HR < 60
Continue PPV and Chest compressions
Yes
Every 3-5 min
No
Yes
![Page 59: Neonatal Resuscitation, Dr. Wylie 7/17/14](https://reader035.vdocuments.mx/reader035/viewer/2022062705/556c922dd8b42a7a738b4e81/html5/thumbnails/59.jpg)
Neonatal Resuscitation
• Vascular access– Umbilical vein catheter
• Aseptic technique• Depth of 2-4 cm
Quick Tangential Point
![Page 60: Neonatal Resuscitation, Dr. Wylie 7/17/14](https://reader035.vdocuments.mx/reader035/viewer/2022062705/556c922dd8b42a7a738b4e81/html5/thumbnails/60.jpg)
Neonatal Resuscitation
• Epinephrine– Action – increases heart
rate and myocardial contractility, causes peripheral vasoconstriction
– Indication – heart rate < 60 despite adequate ventilation and chest compressions
– Dose – 0.01 mg/kg of 1:10,000 solution IV
• Isotonic saline– Action – increases
intravascular volume– Indication – hypovolemia– Dose – 10 ml/kg of 0.9 NS
over 5-10 minutes
Quick Tangential Point
Drugs
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Neonatal Resuscitation
Reassessment
Heart rate now > 100
Cyanosis resolving
NICU team present
CASE 3
Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
![Page 62: Neonatal Resuscitation, Dr. Wylie 7/17/14](https://reader035.vdocuments.mx/reader035/viewer/2022062705/556c922dd8b42a7a738b4e81/html5/thumbnails/62.jpg)
Neonatal Resuscitation
• Summary of resuscitation steps– Initially provide warmth, clear airway, dry and stimulate infant– If meconium staining and non-vigorous infant, suction before
stimulation– If infant continues with poor respiratory effort or HR < 100, start
PPV with BMV, initiate pulse oximetry– If not improving take ventilation corrective steps– Intubate if BMV is ineffective or prolonged, or chest
compressions are being performed– If HR < 60 despite adequate ventilation, start chest
compressions at 90 per minute– If HR rate < 60 despite adequate ventilation and chest
compressions, administer IV epinephrine
![Page 63: Neonatal Resuscitation, Dr. Wylie 7/17/14](https://reader035.vdocuments.mx/reader035/viewer/2022062705/556c922dd8b42a7a738b4e81/html5/thumbnails/63.jpg)
![Page 64: Neonatal Resuscitation, Dr. Wylie 7/17/14](https://reader035.vdocuments.mx/reader035/viewer/2022062705/556c922dd8b42a7a738b4e81/html5/thumbnails/64.jpg)
Neonatal Resuscitation
• Suction equipment – Bulb syringe – Mechanical suction– Meconium aspirator – 8F feeding tube
• Vascular access– Umbilical vessel
catheterizations supplies
• Intubation equipment – Laryngoscope with straight
blades– Face masks (preterm and
term infant sizes) – Oxygen source
• Medications – D10 solution – Epinephrine– Isotonic solution (0.9 NS) – Naloxone
• Miscellaneous – Radiant warmer – Warm towels – Cardiac monitor – Pulse oximeter – Oropharyngeal airways
Equipment
![Page 65: Neonatal Resuscitation, Dr. Wylie 7/17/14](https://reader035.vdocuments.mx/reader035/viewer/2022062705/556c922dd8b42a7a738b4e81/html5/thumbnails/65.jpg)
Neonatal Resuscitation
• Subsequent steps– Vascular access– Drugs
• Epinephrine • Volume expansion• Sodium
bicarbonate
– Reassess
HR < 60?According to
condition
Vascular accessIV Epinephrine
(0.01 mg/kg of 1:10,000)
HR < 60
Continue PPV and Chest compressions
Yes
Every 3-5 min
No
Yes
![Page 66: Neonatal Resuscitation, Dr. Wylie 7/17/14](https://reader035.vdocuments.mx/reader035/viewer/2022062705/556c922dd8b42a7a738b4e81/html5/thumbnails/66.jpg)
Neonatal Resuscitation
• Subsequent steps– Vascular access– Drugs
• Epinephrine • Volume expansion• Sodium
bicarbonate
– Reassess
HR < 60?According to
condition
Vascular accessIV Epinephrine
(0.01 mg/kg of 1:10,000)
HR < 60
Continue PPV and Chest compressions
Yes
Every 3-5 min
No
Yes