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Jenny Brewster
NEWBORN RESUSCITATION
University of West London
University of West London
What is the main cause of collapse in adults
……and what is itin children?
University of West London
Adults havecardiac arrests
Children haverespiratory arrests
University of West London
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
University of West London
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
University of West London
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
University of West London
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
University of West London
Newborn Life Support
• It’s as easy as A,B,C–Airway–Breathing–Circulation
University of West London
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
University of West London
More Physiology!
•What happens as the baby takes it’s first breath?
•Fluid is pushed form the alveoli to establish the resting lung volume
University of West London
Newborn Life Support
University of West London
CCD
Newborn Life Support
Airway &
BreathingAB
CD
cover
Dry &
RC (UK)
University of West London
Initial Actions
Start the clock Dry the baby Assess
Do you need help ?
RC (UK)
University of West London
Initial assessment
Colour
Tone
Breathing
Heart rate
RC (UK)
University of West London
Blue PinkGood toneBreathing regularlyFast heart rate
RC (UK)
University of West London
Dry and coverGive to Mum
University of West London
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.
University of West London
What if baby isn’t breathing?
Place the head in the neutral position
University of West London
Always think……………
•DO I NEED HELP and call for the appropriate help
•In hospital?
•At home?
University of West London
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
University of West London
Reassess……….•What?
•Colour•Tone•Breathing•Heart Rate
University of West London
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.
University of West London
If the chest is not moving?
•Then the airway is not open.
•Reposition using a single handed jaw thrust if alone………..
University of West London
ORA two handed jaw thrust if you have help
University of West London
Mask inflation isnearly always effective
Only about 1 in 500appear to need intubation
University of West London
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.
University of West London
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)
University of West London
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
University of West London
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)
University of West London
Meconium
Stress leads to passage in
utero
Triggered more easily near
term
Aspiration requires gasping
University of West London
Meconium
Screaming babies have an open airway: leave them alone
Floppy babies :- HAVE A LOOK
University of West London
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
University of West London
You will need help
• When to ask?• How to ask?• Who to ask?• What to ask for?• How long will help take to arrive?
University of West London
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
University of West London
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
University of West London
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)
University of West London
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
University of West London
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
University of West London
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
University of West London
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