Critical Decisions in Emergency Medicine

Neonatal Resuscitation Lesson 1

Mary Colleen Bhalla, MD, FACEP, and Asif Rahman, MD

■ Objectives On completion of this lesson, you should be able to: 1. Describe the unique pathophysiology of neonates. 2. List indications for resuscitation of a neonate. 3. Explain the indications for chest compressions in a neonate. 4. Describe the treatment of infants born with meconium-stained amniotic fluid. 5. Discuss medications recommended for use during neonatal resuscitation. 6. Discuss postresuscitation management, including hypothermia protocols. 7. Describe indications for withholding or withdrawing resuscitation efforts.

■ From the EM Model 19.0 Procedures and Skills Integral to the Practice of Emergency Medicine 19.2 Resuscitation

In order to successfully resuscitate neonates, physicians must understand the physiology, anatomy, and responses to stress that are unique to these patients. Nearly 10% of all neonates require some form of resuscitation, and nearly 1% require extensive or advanced resuscitation.1 The overwhelming majority of these resuscitations are required because of ventilatory compromise; thus, the initial steps in neonatal resuscitation focus on improving ventilation. This article reviews the updated guidelines and recommendations from the American Heart Association’s (AHA’s) 2010 update and focuses on the newly born child immediately post delivery and during the initial stay in the hospital, as well as within the first few months of life.2 For simplicity, the terms neonate and newborn will be used interchangeably in this article.

Case Presentations ■ Case One A 25-year-old woman, gravida 3, para 2, who is 38 weeks pregnant, based on first-trimester ultrasound, presents with abdominal cramping that she says feels like contractions. The onset was approximately 2 hours ago, and the cramping has become increasingly frequent within the past hour when the patient thinks her “water broke.” The fluid color was reportedly clear. The patient says the cramps are in the midline of her lower abdomen and they are occurring approximately every 2 minutes. She

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states that she delayed coming to the hospital earlier because she “did not want to wait around in the hospital until delivery.” Her gestational history is uncomplicated, and she has had regular obstetrical check-ups. She states that she is group beta-hemolytic streptococcus negative. She has had no complications with her other pregnancies or children, who were vaginally delivered. She has no other medical history and denies the use of drugs and alcohol. Vital signs are blood pressure 137/84, heart rate 89, respiratory rate 22, temperature 99°F (37.2°C), and pulse oximetry 99% on room air. The physical examination shows a pregnant woman in distress because of pain. The abdominal examination shows a gravid abdomen actively contracting on palpation. The examination of her perineum shows labor in its final stages, and the infant is crowning. The patient is immediately moved to the resuscitation room, and preparations are made for emergent delivery. Delivery is uncomplicated; the mother remains stable and alert the entire time. On initial evaluation, the newborn shows no cry immediately post delivery and has poor tone. ■ Case Two A 30-year-old woman, gravida 2, para 1, presents in active labor via ambulance. The paramedics say that, just as they pulled in, the patient stated that she was feeling like the baby was coming and had a desire to push. Because they think delivery

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Critical Decisions • What are the initial steps in the evaluation of a neonate? • What is the appropriate management for a newborn with meconium-stained amniotic fluid? • When is positive-pressure ventilation indicated for a neonate? • What are the indications for intubation of a neonate?

• Which medications are recommended for use during neonatal resuscitation? • What are the recommendations for neonatal postresuscitative care? • When should resuscitation of a newborn be withheld or withdrawn?

• When should chest compressions be initiated in a neonate? is imminent, they bring her to the emergency department rather than sending her to labor and delivery. Initial evaluation in the resuscitation bay reveals a gravid female in obvious distress. She thinks her water broke approximately 3 hours ago. She reports an uncomplicated gestational history; her previous pregnancy was uncomplicated, and the child was born via vaginal delivery. No further medical or surgical history is provided. Vital signs are within normal limits for this patient. She appears in acute distress. The abdomen is gravid with active contractions. The physician prepares for delivery but notices meconium-stained fluid on the perineal examination. The physician successfully delivers the head of the neonate, and large amounts of meconium are noted on the infant’s head and face. ■ Case Three The triage nurse at a free-standing emergency department informs the physician of an 18-year-old woman who presents with a chief complaint of abdominal pain and vaginal discharge that started nearly 10 hours ago. The nurse is concerned that the patient may be in active labor. The patient herself denies any known history of pregnancy but is sexually active. She reports lower abdominal crampy pain occurring intermittently but becoming more frequent; the pain is now occurring every minute. Discharge was noted around the

time of onset of symptoms and was described as watery and clear. The patient denies any obstetrical history or evaluation by a physician. She states that her last menstrual period was approximately 6 months ago. She has no medical or surgical history, no known drug allergies, and smokes nearly a pack of cigarettes a day but denies alcohol or drug use. The physical examination shows a hemodynamically stable patient who is afebrile and in active labor. The perineal examination reveals that the infant is crowning. After successful delivery, the newborn is minimally reactive and apneic. After attempting to stimulate the infant with drying, the physician obtains a heart rate of 70 beats per minute (bpm).

Fetal and Neonatal Physiology Unlike in adult physiology, gas exchange in the fetus occurs at the placenta and not the lungs. During gestation, approximately 60% of right ventricular output bypasses the pulmonary system because of increased pulmonary vascular resistance as well as because of significant shunting systems native to fetal anatomy such as a ductus arteriosus, foramen ovale, and septal openings in the septum between both the atria and ventricles.1 Along with these shunting tracts, the pulmonary airspaces, in particular the alveoli, are filled with amniotic fluid, leading to compression of these alveoli with no significant diffusion of gases into the

fetal circulation via the lungs.1 At birth, two major physiologic changes occur. First, ventilation to previously fluid-filled alveoli takes place; this facilitates the cascade of events that eventually leads to decreases in pulmonary vascular resistance, allowing pulmonary perfusion.1 It is this initial step of ventilation that allows for adequate perfusion. If these changes do not occur, reversion to fetal circulation occurs post partum. Adequate ventilation typically occurs without intervention or assistance and is driven by the newborns themselves, with some assistance from the mother during delivery. Uterine contractions and passage through the birth canal increase intrathoracic pressures aiding in the movement of fluid from the alveoli to the larger branches of the pulmonary tree. After this occurs, the first few breaths the newborn takes further create negative intrathoracic pressures, allowing for pulmonary and alveolar expansion, as long as surfactant is adequately produced. It is these initial ventilatory measures that promote the cascade of further events that leads to the eventual perfusion of the lungs, via decreases in pulmonary vascular resistance, increases in systemic vascular resistance, and closure of the ductus arteriosus and, eventually, the foramen ovale.1 The end result is a loss of the right-to-left shunt found in fetal physiology and the development of normal physiologic gas exchange at 3

Critical Decisions in Emergency Medicine

the level of the alveoli.1 Thus, the driving force in the rapid stabilization and improvement of the distressed neonate is ventilation rather than circulation and perfusion more typical in the adult model.

Neonatal Resuscitation Neonatal resuscitation can broadly be broken into four steps, as follows: initial evaluation, initial resuscitation, advanced resuscitation, and postresuscitative care. CRITICAL DECISION What are the initial steps in the resuscitation of the neonate?

The initiation of neonatal resuscitation starts with identification of the need for resuscitation. Three basic questions must be addressed: 1. Is this a term gestation? 2. Is the newborn crying or breathing? 3. Is there good muscle tone? If the answer to any of the above is no, then the initial steps of resuscitation must take place. These steps can be easily divided into the following: • Temperature control (via drying and warming) • Clearing the airway • Stimulating • Assessing for further intervention Warming and drying the neonate are crucial. Newborns are unable to generate heat by shivering or via the metabolism of fat, and they are prone to heat loss because of their large surface-to-body ratio as well as their increased metabolic demands. Hypothermia leads to metabolic acidosis, increased oxygen demand in the setting of poor oxygen reserve, and hypoglycemia and apnea, which only worsen the cycle of distress. Some of the described techniques for warming are drying the newborn, removing any wet delivery blankets or towels from the neonate’s body, using warmed blankets or specific warming plastic wrappings, and placing the neonate in an ambient warmer.2 If a warmer is not readily available, the emergency physician should increase 4

the ambient temperature within the resuscitation bay or room. It is imperative that the physician monitor the temperature of the neonate closely, however, because combined warming techniques could cause hyperthermia.3 Another critical step in the initial resuscitation is to clear the airway or facilitate the neonate’s ventilatory ability. Place the newborn in the sniffing position, which places the head in slight extension, by placing a diaper or rolled towel under the neonate’s shoulders. Suction the nares and mouth as needed if the newborn has an obvious obstruction within the airway due to secretions. Suctioning intrapartum after delivery of the head and routine suctioning of infants without obvious airway obstruction are no longer recommended.2 If suctioning is required, it should be done first in the mouth and then the nares as this has been shown to decrease aspiration of oral contents.2 Use a light touch; vigorous suctioning can precipitate bradycardia in newborns.2 The third component to the initial resuscitation is stimulation. If warming and clearing the airway fail to improve the neonate’s overall status, then stimulate the neonate by flicking the soles of the neonate’s feet with a finger or by rubbing the newborn’s back. Be cautious of overly vigorous stimulation, however, as this will not aid in the resuscitative efforts and can, in fact, increase the newborn’s overall stress level, further worsening the situation.2 The final step in initial resuscitation is reassessment. Although reassessment is ongoing, it is important to recognize the reassessment process. Once the neonate has been warmed, the airway has been cleared, and stimulation has been attempted, assess the neonate’s response with these three questions (with special attention to the last question): 1. Is the newborn crying and breathing adequately? 2. Is there now good muscle tone

and activity? 3. What is the newborn’s heart rate? Heart rate in the neonatal period is assessed via cardiac auscultation over the precordium or by palpation of the umbilical artery. Palpation of pulses in other areas is inadequate at this stage of development. If the answer is yes to the first two questions, and the heart rate is above 100 bpm, then further resuscitation is not needed. If no resuscitation is required, the neonate’s cord should remain unclamped for at least 1 minute.4 If the answer to either question is no, or if the heart rate is less than 100 bpm, then advanced resuscitative measures must take place. Evidence is insufficient to recommend timing of cord clamping for those infants who require resuscitation.4 CRITICAL DECISIONS What is the appropriate management for a newborn with meconium-stained amniotic fluid?

Meconium aspiration syndrome is a severe disease that can affect newborns who have meconium present at birth. In the past, many interventions were recommended during and immediately after delivery based on the characteristics of the meconium (ie, thin or thick). However, current recommendations are that interventions be based on the infant’s condition. For a vigorous newborn with meconium staining, no resuscitative steps are needed unless indicated based on the normal primary evaluation. Endotracheal intubation with suctioning post delivery if meconium is present is no longer recommended. The practice of bulb suctioning the neonate’s oropharynx before delivering the shoulders has been shown to be of no value in this setting5 and is no longer recommended.2 For the non-vigorous newborn with meconium-stained amniotic fluid who is limp and apneic, endotracheal intubation with tracheal

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suctioning should be performed rather than attempting to stimulate. There is insufficient evidence to suggest noninvasive ventilator measures in this setting; however, if intubation is prolonged and difficult, noninvasive

means of assisted ventilation are recommended, especially if bradycardia is present.2Although the recommendation for tracheal suctioning remains in the 2010 AHA guidelines, tracheal suctioning has

not been found to be associated with a reduction of meconium aspiration syndrome or mortality in depressed infants.2

Figure 1. Newborn resuscitation algorithm. From: Kattwinkel, J, Perlman JM, Aziz K, et al. Part 15: neonatal resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(18 Suppl 3):S909-S919. Copyright 2010. Used with permission.

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Critical Decisions in Emergency Medicine

CRITICAL DECISION When is positive-pressure ventilation indicated for a neonate?

After the initial resuscitative steps of temperature control, clearing the airway, and stimulation, if the neonate’s presentation is not adequately improved or the heart rate is below 100 bpm, more advanced resuscitative efforts should begin. The first of these measures is positivepressure ventilation, initially via noninvasive means. Pulse oximetry monitoring should also begin at this point, if it was not initiated earlier.6 The pulse oximeter should be placed within 1 to 2 minutes post partum; the probe should be placed in a preductal location such as the right wrist.7 As long as there is adequate cardiac output, monitoring of oxygenation status is appropriate via this method. A common pitfall when attempting to resuscitate a neonate is unreasonable pulse oximetry goals. Preductal oxygen levels at 1 minute after birth should be 60% to 65%, by 5 minutes after birth they should be at 80% to 85%, and after 10 minutes they should be at 85% to 95% (Figure 1).2 The initial modality for ventilation should be via a bag-valve mask using a pediatric- or infant-sized bag. Further possible modalities include a flow-inflating or self-inflating bag, a T-piece mechanical device, or continuous positive airway pressure (CPAP).8-11 A T-piece resuscitation device is a piece of tubing with restrictions that attach to an air flow source and can be used to provide CPAP or positive end-expiratory pressure (PEEP) but the upper limits of the pressure are controlled if the flow remains constant.2 Supplemental oxygen percentages in this setting should initially be started at room air levels. Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation initiated with room air to resuscitation using 100% oxygen showed increased survival when resuscitation was initiated with air.12,13 Hyperoxygenation 6

has been shown to increase free radical formation, leading to cellular compromise. However, oxygen percentages may be titrated while providing ventilation to the expected oxygen saturations of the neonate based on time post delivery. If the initial 60 to 90 seconds of ventilation do not result in these expected levels, oxygen concentrations should be titrated up to reach expected levels. The current recommendation for the rate of assisted ventilation is 40 to 60 breaths per minute.2 The ideal tidal volume has not been established, but higher volumes have been shown to increase lung parenchymal injury in preterm animal models and, as such, have not been adopted for use in human neonates.14 Studies in manikins suggest that providers cannot maintain constant pressure or assess delivered volume, but there is insufficient evidence to recommend the use of any tidal volume monitoring device.2 The focus should be on chest rise and ventilations that improve heart rate.2 The primary measure of the adequacy of assisted ventilation is improvement in the heart rate.15 The heart rate should be checked after 30 to 60 seconds of assisted ventilation via cardiac auscultation or umbilical artery palpation. If the heart rate improves to above 100 bpm, postresuscitative care should begin. If the heart rate remains below 100, the physician should reassess the airway, and advanced ventilatory steps should be taken, if needed. The initial steps of reassessment are repositioning, suctioning, and increasing oxygen concentration if appropriate oxygen

saturations are not being met. If these measures do not yield an increase in the heart rate, then the physician may escalate ventilatory efforts via different modalities of noninvasive ventilation such as nasal prongs,4 CPAP, or laryngeal mask airway (LMA). The LMA has been shown to be an effective means of ventilation in newborns who weigh more than 2,000 grams or who are delivered at, or beyond, 34 weeks’ gestation.2 Assisted ventilation should be given as long as the heart rate remains below 100. Assessing ventilatory status in neonates using end-tidal carbon dioxide capnography is a developing modality but currently there is insufficient evidence to recommend its wide-spread use during neonatal resuscitation2 (this differs from treatment guidelines for adults).16 However, practitioners familiar with its assessment may use it to help in clinical decision making.4 CRITICAL DECISION What are the indications for intubation?

While this is still a decision requiring clinical judgment, there are specific indications for intubation of the newborn who requires resuscitation (Table 1). One can broadly categorize these indications as those occurring prior to advanced resuscitation and those occurring during advanced resuscitation. Prior to the resuscitation process, there are three general situations calling for intubation: 1. A meconium-stained, nonvigorous infant; 2. An infant with congenital

Table 1. Indications for intubation Immediate Meconium-stained newborn with decreased tone Congenital anomalies that would affect ventilation (eg, diaphragmatic hernia) Extremely low birth weights (400 to 2,000 grams in the correct setting) During Resuscitation No clinical improvement with noninvasive positive-pressure ventilation Initiation of chest compressions

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anomalies that would hinder adequate ventilation (ie, diaphragmatic hernia); 3. An extremely low-birth-weight infant, typically between 400 and 2,000 grams. Meconium-stained infants who are not vigorous should be intubated for endotracheal suctioning as described previously. Congenital anomalies such as diaphragmatic hernias that indicate the need for a definitive airway are also indications for intubation. Because emergency physicians are typically only involved in unplanned deliveries, it is unlikely that they would know of a preexisting postpartum intubation plan. Finally, extremely low birth weight is another indication for intubation. Although there is no definitive weight limit given in the current guidelines, infants weighing less than 400 grams are typically deemed nonviable, and those weighing more than 2,000 grams are not considered to be of low birth weight, so this range may serve as a guide for possible intubation. Even though these general ranges exist, clinical correlation is necessary when considering intubation in the low-birth-weight population.2 During the resuscitative process, there are multiple indications for intubation, again depending on the overall clinical picture. There are also specific situations in which intubation is definitely indicated, as follows: 1. If noninvasive positivepressure ventilation is deemed ineffective; 2. If noninvasive positive-pressure ventilation is prolonged; 3. If chest compressions are initiated. If noninvasive means of positivepressure ventilation are ineffective, either based on pulse oximetry, chest rise, or the lack of improvement in the neonate’s heart rate to above 100 bpm, then endotracheal intubation may be indicated. Prior to this, the experienced practitioner may attempt other modalities of ventilatory support such as an LMA, in the appropriate population, and other

nondefinitive measures as well. The LMA is currently recommended for use in newborns who weigh more than 2,000 grams or who are at 34 weeks’ or older gestational age.2 The data, however, are limited on use of LMA in neonates below this weight and age; use is not contraindicated, but risks and benefits must be weighed in relation to the clinical presentation. The last definite indication for intubation is when chest compressions are indicated. CRITICAL DECISION When should chest compressions be initiated in a neonate?

After a 30-second trial of assisted ventilation confirmed by chest rise, if the heart rate is below 60 bpm, chest compressions are indicated. It is important to discuss the optimal techniques and the optimal ratio of compressions to ventilation in this age group. There are two general techniques for chest compressions in neonates. One is the thumb and encircling method and the second is the twofinger method. The thumb and encircling method has been shown to result in improved coronary perfusion and increased peak systolic pressures and is the method of choice; however, the two-finger method may be used if access to the umbilical artery for central line placement is required.17 Because poor ventilation and profound hypoxemia are the primary etiologies of neonatal distress, the recommended ratio of compressions to ventilation reflects this and is set at 3:1.2 It is important to remember that compression and ventilations should be coordinated in this setting; before a definitive airway (endotracheal tube within the glottis opening) is established, chest compressions will interfere with adequate ventilation if they are not coordinated. The current recommendation is to complete 90 compressions and 30 ventilations in a 60-second interval, being sure to allow for full re-expansion of the chest wall before the next ventilation. Because this is primarily a ventilatory

and hypoxic issue, endotracheal intubation along with 100% oxygen are indicated in this setting, as opposed to room air during the initial resuscitative phases. Two animal model studies showed more negative biochemical changes in the brains of those who were given 21% oxygen than in those on 100% oxygen.4 Higher ratios of compressions, such as 15:2 or 30:2 may be used in this setting if the physician thinks that the primary source of instability is cardiac.2 Respirations, heart rate, and oxygenation should be reassessed periodically. If the heart rate remains below 60 bpm, compressions should continue with adjunctive medications. If, however, the heart rate increases to above 60 but is still less than 100, chest compressions should cease and resuscitation should continue with mechanical ventilation. If the heart rate exceeds 100, postresuscitative care should begin. CRITICAL DECISION Which medications are recommended for use during neonatal resuscitation?

If during chest compressions there is no improvement in the neonate’s heart rate above 60 bpm, there are two adjunctive measures one may use—epinephrine and volume expanders. Previous approaches to neonatal resuscitation allowed for vasopressors and glucose in the resuscitative phases; however, these are no longer recommended during resuscitation but are adjuncts that can be useful in the postresuscitative phase. This change reflects the likely causes for a neonate’s condition, that is, poor ventilation and oxygenation, rather than hypoglycemia, cardiogenic failure, or opiate toxicity.2 Epinephrine should be given intravenously or intraosseously at a dose of 0.01 to 0.03 mg/kg per dose (0.1-0.3 mL/kg/dose of 1:10,000 dilution).2 Previous recommendations stated endotracheal epinephrine was appropriate, but these studies were based on animal models

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Critical Decisions in Emergency Medicine

that used much higher doses of epinephrine than are currently recommended.18 Higher doses of epinephrine have been shown to exaggerate hypertension, decrease myocardial function, and worsen neurologic functioning.19 Intravenous epinephrine is the delivery route of choice once access is attained. Because of anatomy and medication characteristics, central access is required if intravenous medications are needed. Although common modes of central venous access are acceptable in the neonate, the preferred route during the first or second week of life is venous umbilical cannulation. In

preterm infants, a 3F to 3.5F cannula is preferred, and a 5F cannula is preferred in term neonates.20 Endotracheal epinephrine may still be given at a dose of 0.1 mg/kg (1 mL/kg of 1:10,000 dilution) while intravenous access is being attained; however, this route and dose have not been adequately studied.2 Volume expansion is the other adjunctive measure that may be used in the resuscitative phase. Typically, volume expanders are given in the context of hypovolemia or significant blood loss such as occurs if an infant is delivered prior to arrival and cord clamping was

Pearls • Assisted ventilation is the most critical action in the resuscitative process for neonates in distress. • Infants with meconium-stained amniotic fluid do not require intrapartum bulb suctioning, nor do they necessarily require intubation; intubation is indicated if the infant is not vigorous. • Start resuscitation in term infants using 21% oxygen and titrate to achieve the recommended target oxygen saturation based on the neonate’s age in minutes after delivery. • If the heart rate is less than 60, start compressions with a 3:1 ratio with invasive positive-pressure ventilation. If a cardiac etiology is suspected, this ratio should be increased to 30:2 or 15:2. • Consider withholding or withdrawing resuscitation in neonates born at less than 23 weeks’ gestation, those weighing less than 400 g, and those with no heart rate after 10 minutes of resuscitation efforts.

Pitfalls • Giving naloxone to an infant with respiratory depression during neonatal resuscitation; this is no longer indicated. • Checking for the heart rate via the brachial pulse; cardiac auscultation or umbilical artery palpation is more accurate. • Attempting to increase the neonate’s oxygen saturation quickly to an unreasonable target given the patient’s postpartum age in minutes. Oxygen saturation does not reach 90% until about 10 minutes after birth. Hyperoxia has been shown to increase free radical formation and worsen overall resuscitative efforts and long-term functionality. • Beginning chest compressions in a neonate with a heart rate below 60 without a trial of assisted ventilation. • Performing chest compressions not coordinated with ventilations before a definitive airway is placed. Ventilation is the single most important aspect of the resuscitative process in the neonate.

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delayed after cord cutting. Isotonic saline or blood products should be given. The dosing for both is 10 mL/ kg over 5 to 10 minutes, which may be redosed during the resuscitation. The physician should be cautious of rapid infusion of volume expanders given the known association of intraventricular hemorrhage, particularly in the preterm population.2 The preferred route for fluid delivery is intravenous. The intraosseous route may be used either after unsuccessful attempts at establishing intravenous access or when the person attempting access is more skilled at establishing an intraosseous line.21 Although there are many locations for intraosseous access, the ideal location in the neonate is typically the proximal medial tibia or the distal anterior femur. Sites and locations are based on ease of landmark palpation, underlying risk of potential side effects, and cancellous versus cortical bone ratio. The efficacy of intraosseous versus intravenous delivery is well known and studied, and all medications used during the neonatal resuscitation will successfully enter the neonatal circulation via the intraosseous route. Contraindications for intraosseous insertion include overlying cellulitis, underlying proximal fracture which is open or closed, and underlying bone disease such as osteogenesis imperfecta.20 CRITICAL DECISION What are the recommendations for neonatal postresuscitative care?

Newborns who require resuscitation are at increased risk of decompensation post resuscitation and should be placed in an environment that allows for continuous monitoring and close observation. Although glucose is no longer recommended in the resuscitative phase, it should be given as soon as possible after resuscitation.2 Empiric glucose administration prevents

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Table 2. Neonatal resuscitation summary

Initial assessment Is this a term delivery? Is the newborn crying or breathing? Is there good muscle tone? Initial resuscitation (start if answer to any of the initial assessment questions is no) Temperature control Drying Wrapping in warm blankets Placing under warming light Clearing the airway Suctioning occurs post partum Oropharyngeal suctioning prior to nasal, via bulb suction Sniffing position Stimulating the infant Gentle rubbing of back Heel flicking Assessment for further intervention Is the newborn crying and breathing adequately? Is there now good muscle tone and activity? Is the neonate’s heart rate below 100? Advanced Resuscitation (start if heart rate is below 100 bpm or tone or breathing is inadequate) Positive-pressure ventilation Noninvasive measures Bag-valve mask Flow-inflating, self-inflating devices; T-piece device Nasal prongs CPAP Respiratory rate of 40-60/min, with low tidal volumes Pulse oximetry placement Preductal placement (right upper extremity preferred) Review time-specific oxygen saturation ranges (Figure 1) Supplemental oxygen Start at room air (21%) initially Titrate to 100% if the following occur: Intubation Chest compressions Persistently low pulse oximetry levels Chest compressions Begin only if initial cycle (30 seconds) of positive-pressure ventilation is unsuccessful Start if heart rate is below 60 3:1 compression-to-ventilation ratio Intubation is indicated Begin 100% oxygen if not already initiated Supplemental medications Epinephrine 0.01-0.03 mg/kg if cycle of chest compressions is not corrective Volume expanders, 10 mg/kg bolus Normal saline Blood products Use intravenous or intraosseous route

hypoglycemia, and the correction of hypoglycemia may be protective to the newborn.22 No specific target glucose has yet been identified, but increased glucose levels after hypoxia or ischemia were not associated with adverse effects.2 Naloxone is no longer recommended for routine administration to infants with respiratory depression.2 The focus on these infants should be ventilator support. Naloxone given to infants born to mothers with opiate addiction has been associated with seizures.21 Newer modalities to decrease morbidity and mortality from encephalopathic hypoxic events are becoming more prevalent in neonatal postresuscitative care. Several randomized, multicenter, controlled trials on neonates delivered at or after 36 weeks’ gestation have shown a reduction in mortality and morbidity at followup when induced hypothermia was involved in their care.23-25 Cooling methods vary, but standard treatment protocols suggest reaching a goal temperature of 92.3°F (33.5°C) to 94.1°F (34.5°C) within 6 hours of birth, maintaining this temperature for 72 hours and slowly rewarming over a 4-hour period.2 Hypothermic measures should be managed in conjunction with the accepting neonatologist and in settings that are appropriately equipped. Although a clear benefit to induced therapeutic hypothermia has been shown, adverse events such as thrombocytopenia and inotropic cardiac depression can occur while the patient is still in the emergency department.2 CRITICAL DECISION When should resuscitation of a newborn be withheld or withdrawn?

The decision to withdraw or withhold neonatal resuscitation can be especially difficult. Studies have shown that parents desire a larger role in decisions to initiate and continue resuscitation and life support of severely compromised newborns.2 9

Critical Decisions in Emergency Medicine

Practices vary among physicians and are sometimes dependent on the clinical setting. However, there are clinical guidelines one may use when considering withdrawal or withholding of care. The current recommendation for discontinuation of resuscitative efforts in the newborn with no detectable heart rate at birth is after 10 minutes of resuscitation efforts with no cardiac activity.2,21 This is a general guideline and efforts may be continued based on underlying likely pathology, gestational age, weight, and the parents’ feelings about terminating resuscitative efforts. Withholding care must also be considered prior to initiating resuscitation. Ethically there is no difference between withholding resuscitation, in cases where mortality or severe morbidity is likely, and withdrawing resuscitative efforts when survival is highly unlikely.26 The guidelines below are suggestions that must be interpreted according to current regional outcomes and potential updates in care. In general, withholding of care is appropriate when mortality is almost certain post resuscitation or, in the case of rare survivors, when there are unacceptably high morbidity rates.

Examples of this are: • Gestational age less than 23 weeks; • Birth weight less than 400 grams; • Congenital anomalies associated with high mortality rates such as anencephaly or major chromosomal abnormalities like trisomy 13.2 Neonates born after 25 weeks’ gestation and those with most congenital anomalies have lower rates of mortality and acceptable morbidity. In these cases, resuscitative efforts should take place. If the prognosis is uncertain but survival is perceived to be borderline with likely high morbidity, then parental desires should be supported.2

Case Resolutions ■ Case One Because the infant born at 38 weeks’ gestation had poor tone and did not cry, resuscitation was initiated. The newborn was dried, wrapped in a warm blanket, and placed under ambient heat. Orotracheal suctioning was performed, followed by nasal suctioning, and a small rolled towel was placed under the neonate’s shoulders. A pulse oximeter

was placed on the right wrist for monitoring. There was still insufficient activity of the newborn. The physician then rubbed the infant’s back and flicked his heels. The child began to actively cry and move all extremities vigorously. On reassessment, the child’s status was within normal limits, and no resuscitation was required. ■ Case Two In the case of the delivery complicated by meconium-stained amniotic fluid, based on the updated management guidelines, delivery was not delayed for suctioning. After delivery, the infant was active and breathing without difficulty. The infant was dried, wrapped in a warm blanket, and placed on the mother’s chest. The infant was observed and continued to be active, so no invasive interventions were required. ■ Case Three In the case of the apneic infant with a heart rate of 70, positivepressure ventilation was started via bag-valve mask with an oxygen concentration of 21%. During this time, a pulse oximeter was placed on the infant’s right wrist and continued ventilations were given at a rate of 40 breaths per minute,

Table 3. Changes to AHA 2010 recommendations from previous recommendations Topic Following the initial evaluation Meconium staining Umbilical cord clamping Peripartum suctioning Supplemental oxygen Chest compressions Supplemental medications

Therapeutic hypothermia Discontinuation of resuscitation

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Recommendation Two vital signs—heart rate and respiratory status—are the markers that determine the need for further resuscitation. Endotracheal suctioning is predicated on the neonate’s activity level. Only the nonvigorous infant should be intubated in this setting. Should be delayed at least 1 minute in the newborn who does not require resuscitation Is no longer recommended in any setting If initiated, should begin with 21% oxygen (room air) and may include higher concentrations up to 100% as dictated by the clinical setting Remain at a ratio of 3:1, but if a cardiac etiology is likely, then a higher ratio, such as 15:2, should be initiated. The only medications to be given during the resuscitative process are epinephrine and volume expanders such as blood or isotonic fluid. Adjunctive therapies such as glucose should not be given during the resuscitation, but may be given post resuscitation. Should be initiated post resuscitation in term or near-term neonates who are now showing signs of anoxic brain injury. This should be coordinated with neonatal center. Should be considered if there has been no detectable heart rate for 10 minutes.

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with close attention to volume control. Confirmation of adequate ventilation was noted with equal chest rise. Auscultation of cardiac tones revealed a heart rate of 80 bpm. The mouth was suctioned and the head repositioned. The heart rate fell below 60 bpm on reassessment. Chest compressions were started using the thumb encircling method, and an interosseous line was placed. The newborn was intubated and given 100% oxygen. A coordinated chest compression-to-ventilation ratio of 3:1 was given, allowing for full chest recoil, at a rate of 90 compressions and 30 ventilations per minute. Repeat cardiac auscultation still showed a heart rate below 60, so epinephrine was given at a dose of 0.03 mg/kg. Repeat auscultation after another minute showed that the newborn had a heart rate of 120 beats per minute. Chest compressions were stopped. Blood glucose levels were monitored as well as oxygenation, temperature, and heart rate, while the neonate was being prepared for transport to a local neonatal ICU. The emergency physician discussed therapeutic hypothermia with the neonatologist but agreed that it was not indicated in this preterm infant.

Summary Recent updates to neonatal resuscitation have pointed to a continued focus on ventilation during the resuscitative phases as this is the primary cause of most neonatal distress. See Figure 1 and Table 2 for an outline of treatment recommendations. Table 3 reviews important changes from previous treatment guidelines.

References 1. Mazor SS, Klein EJ. Neonatal resuscitation. In: Rosen’s Emergency Medicine Concepts and Clinical Practice. Philadelphia, PA: Mosby, 2010. 2. Kattwinkel, J, Perlman JM, Aziz K, et al. Part 15: neonatal resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(18 Suppl 3):S909-S919. 3. Singh A, Duckett J, Newton T, Watkinson M. Improving neonatal unit admission temperatures in preterm babies: exothermic mattresses, polythene bags or a traditional approach? J Perinatol. 2010;30(1):45-49.

4. Wyllie J, Perlman JM, Kattwinkel J, et al. Part 11: Neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation. 2010;18 Suppl 1:e260-e287. 5. Vain NE, Szyld EG, Prudent LM, et al. Oropharyngeal and nasopharyngeal suctioning of meconiumstained neonates before delivery of their shoulders: multicentre, randomised controlled trial. Lancet. 2004;364(9434):597-602.

25. Azzopardi DV, Strohm B, Edwards AD, et al. Moderate hypothermia to treat perinatal asphyxial encephalopathy. N Engl J Med. 2009;361(14):13491358. 26. Paris JJ. What standards apply to resuscitation at the borderline of gestational age? J Perinatol. 2005;25(11):683-684.

6. Perlman JM, Risser R. Cardiopulmonary resuscitation in the delivery room. Associated clinical events. Arch Pediatr Adolesc Med. 1995;149(1):20-25. 7. Dawson JA, Kamlin CO, Wong C, et al. Oxygen saturation and heart rate during delivery room resuscitation of infants