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EMERGENCY MANAGEMENT OF THE NEONATE

EMERGENCY MANAGEMENT OF THE NEONATE. Neonatal Objectives. Upon completion the student will be able to: Describe the routine care of the newborn List four means by which heat loss occurs in neonates Define the parameters of APGAR scoring and the numerical values used

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EMERGENCY MANAGEMENT OF THE NEONATE

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  1. EMERGENCY MANAGEMENT OF THE NEONATE

  2. NeonatalObjectives Upon completion the student will be able to: • Describe the routine care of the newborn • List four means by which heat loss occurs in neonates • Define the parameters of APGAR scoring and the numerical values used • Identify special considerations in the care of the premature neonate • Explain the significance of meconium staining • Describe the inverted pyramid approach to neonatal resuscitation

  3. NeonatalObjectives • Describe two methods of stimulating a distressed neonate • Describe the appropriate administration o oxygen to neonate • Describe the indications for endotracheal intubation of a distressed neonate • Describe methods and problems in ventilating the distressed infant • Describe the technique and rates used in chest compressions in the neonate

  4. Introduction • Neonate: defined as an infant less than one month of age.

  5. Anatomic and Physiologic Changes at Birth • Lungs must be opened • Capillaries and arterioles of the lungs will now become filled with blood • First few breaths are the strongest ever taken. Responsible for opening the lungs and causing normal blood circulation through the lungs to occur.

  6. Anatomic and Physiologic Changes at Birth • Factors that stimulate respirations include: 1. Mild acidosis 2. Initiation of the stretch reflexes in the lung 3. Hypoxia 4. Hypothermia

  7. Routine Care of the Neonate • Follows same priorities as all patients • 80% do not require resuscitation • You must be prepared to resuscitate at all times

  8. Airway • Suctioning of the mouth then the nose as soon as the head is delivered.

  9. Prevent Heat Loss • Heat loss occurs through: 1. Evaporation 2. Convection 3. Conduction 4. Radiation • Most heat loss in the neonate is through evaporation

  10. Prevention of Heat Loss • Heat loss can also occur through convection depending on the temperature of the room and the movement of the air • Conduction occurs through the surfaces in contact with the neonate • Also, heat loss can occur through radiation to colder objects nearby

  11. Prevention of Heat Loss • Dry the neonate to prevent evaporative cooling. • Place in a warm towel or blanket to minimize other means of heat loss and maintain a warm body temperature

  12. Umbilical Cord • After airway and heat, clamp and cut the cord • Do not “milk” the umbilical cord: causes increased blood viscosity (polycythemia) • 1st clamp is 7 inches away from the infant, 2nd clamp is 3 inches above. Cut in the middle with sterile device

  13. Assessment of the Neonate • One rescuer attends to the infant, or if second unit on scene they become responsible for the infant. • Obtain vitals: 1. Respiratory Rate: 40-60 2. Heart Rate: 150-180 at birth, slowing to 130-140 • Heart less than 100 is a need for concern

  14. APGAR Score • Should be done at 1 and 5 minutes after birth. • Is not a tool to make resuscitative decisions • Parameters include: A appearance P pulse G grimace A activity R respiratory effort

  15. APGAR Score • Scoring of 0, 1, 2 for each parameter • Lowest score 0; highest score 10 • 4-6 moderately depressed neonate • 7-10 indicates active and vigorous neonate • < 4 requires immediate resuscitation

  16. Premature Neonate • Defined: weighs less than 5.5 pounds (2500 grams), born before the 38th week of gestation. • At risk for: hypothermia, hypoglycemia, volume depletion, respiratory problems, and possible cardiovascular problems

  17. Heat Loss • Premature neonates are more susceptible: 1. Relatively large body surface area and comparatively small weight 2. Thermoregulatory mechanisms are immature 3. Smaller subcutaneous stores of insulating fat 4. Cannot shiver

  18. Distressed Neonate • Presence of meconium; particulate meconium vs staining of meconium • Aspiration can result in severe lung inflammation and pneumonia • If present DO NOT induce respiratory effort until meconium removed from trachea by suctioning with laryngoscope and ET

  19. Airway and Ventilation • Most common problems are airway and ventilation • Other means of resuscitation are usually not needed • Single most important indicator of neonatal distress if fetal heart rate • Pulse rate of less than 60 is an absolute indicator for CPR • 60-80, not improving with O2 is another indicator for CPR

  20. Inverted Pyramid • Illustrates the various steps involved neonatal resuscitation

  21. Drying, Warming, Positioning, Suction, and Tactile Stimulation • Assessment includes: 1. Respiratory Effort 2. Heart Rate 3. Color: central cyanosis vs. peripheral cyanosis

  22. Supplemental Oxygen • Central cyanosis present: use blow by. • Make sure the oxygen is warm • Continue until color improves • NEVER DEPRIVE A NEONATE OF OXYGEN IN THE PREHOSPITAL SETTING FOR FEAR OF TOXICITY

  23. Ventilation • Positive-pressure if any of the following exist: 1. Heart rate less than 100 beats per minute 2. Apnea 3. Persistence of central cyanosis after administration of oxygen

  24. Ventilation • Pressures required to ventilate may be as high as 60 cm/H2O. • If BVM has a pop-off valve, you may have to depress it to ensure adequate ventilation is present

  25. Ventilation • Endotracheal intubation may be require in the following situations: 1. BVM unit does not work 2. Tracheal suctioning is required 3. Prolonged ventilation will be required • Tubes should be uncuffed

  26. Chest Compressions • Initiate when: 1. Heart rate is less than 60 beats per minute 2. Heart rate is between 60-80, but does not increase even with 30 seconds of positive-pressure ventilation and supplemental oxygenation • When heart rate exceeds 80 discontinue compressions

  27. Medications and Fluids • If ventilation and oxygenation fail we must look to other means for resuscitation which includes fluid and medications • Vein of choice is the umbilical vein • Located between the two arteries • Trim umbilical about 1 inch above the abdomen

  28. Medications and Fluid • Use a 5 french umbilical catheter and attach to a three-way stopcock • Insert until the tip is just below the skin and note free flow of blood • To not insert to far because it will wedge against the liver and not function • Fluid therapy consists of 10 ml/kg over a 5-10 minute period

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