Newborn Emergencies

Michael Lohmeier, MD

November 21, 2013

Newborn Emergencies

Outline
Newborns and Neonates
High-Risk Newborn Patients
APGAR Scoring
Newborn Resuscitation
Special Situations
The Newly Born Patient
The Newly Born Patient

Definitions
Neonate
An infant from birth to one month of age

Newborn
A baby in the first few hours of life
Also referred to as newly born
The Newly Born Patient

Epidemiology
Approximately 6% of field deliveries will require life support
The incidence of complications increases as birth weight
decreases
Approximately 80% of newborns weighing less than 1500g
(3lbs 5oz) at birth will require resuscitation
The Newly Born Patient

Antepartum and Intrapartum

Determine at-risk newborns by considering antepartum and
intrapartum factors that may cause delivery complications
Antepartum before the onset of labor
Intrapartum occuring during childbirth
The Newly Born Patient
Antepartum Risk Intrapartum Risk
Factors Factors
Multiple gestation Premature Labor
Meconium stained amniotic
Inadequate prenatal fluid
care Rupture of membranes more
Mothers age than 24 hours before delivery
Narcotic use within 4 hours of
History of prenatal delivery
morbidity or mortality Abnormal presentation
Pre-term gestation Prolonged labor or
percipitous delivery
Drugs/medications
Prolapsed cord or bleeding
Toxemia, HTN, DM
The Newly Born Patient

Pathophysiology
Changes occur in the newborn to prepare it for life outside of
the uterus
Fluid in the lungs squeezed out during delivery
Changes in cardiac circulation
As previously covered

First breaths triggered by

Mild acidosis
Initiation of stretch reflexes in the lungs
Hypoxia
Hypthermia
The Newly Born Patient

Hemodynamic changes at birth (review)

The Newly Born Patient

Congenital Anomalies
Diaphragmatic Hernia
Meningomyelocele
Omphalocele
Choanal Atresia
Cleft Palate
Cleft Lip
Pierre Robin Syndrome
Chain of developmental malformations
Cleft palate, micrognathia, glossoptosis
Newborn Assessment
Newborn Assessment

Assessment
Assess the newborn immediately after birth
Ideally, one paramedic attends the Mother while the
second attends the child
Remember newborns are slippery and require TWO
HANDS!!
Normal heart rate at birth 150-180 bpm
Slows to 130-140 bpm shortly after
Normal respiratory rate is 40-60 bpm
Evaluate skin color
Use the APGAR Score
Newborn Assessment
APGAR Score
Appearance, Pulse, Grimmace, Activity, Respiratory Effort
Newborn Assessment

Airway Management
The most important step in caring for a newborn
Suction the babys mouth first, then the nose
Newborns are obligate nose breathers
Suctioning the nose first could cause aspiration
As soon as the head is delivered and prior to the shoulders,
the mouth, oropharynx and nasopharynx should be
thoroughly suctioned
Any catheter should be no less than 10Fr
Newborn Assessment

Meconium Stained Fluid

After delivery of the infant,
the trachea should be
directly visualized and
meconium suctioned
Do not suction for >10
seconds
If there is a lot of meconium,
an ETT should be placed and
deep suction directly
through the tube
Newborn Assessment

Stimulate the Newborn by

flicking its feet or rubbing its
back
Do NOT spank or vigorously
rub its back!
Newborn Assessment

Prevention of Heat Loss

Can be life threatening to the newborn
Newborns are (obviously) very wet
Most heat loss comes from evaporation
Core temperature can quickly drop

Treatment
Dry the newborn immediately
Maintain room temperature at 74-76oF
Close windows and doors
Swaddle the infant in a warm, dry receiving blanket
Newborn Assessment

Dry the Infant to prevent heat loss

Newborn Assessment

Cutting the umbilical cord

After you have stabilized the airway and minimized heat loss,
clamp and cut the umbilical cord
Keep the infant at the level of the pelvis or lower
Gravity is working against the newborn and its blood
volume!
Do not milk or strip the cord
Apply the clamps within 30-45 seconds after birth
Newborn Assessment

The Distressed Newborn

Can be full term or premature
Most common problems in the first few minutes of life involve
the airway
Aspiration of meconium can cause severe respiratory
complications
Heart Rate is the most important VS indicator of newborn
distress
Heart rate <60 MUST be treated with immediate chest
compressions
Your success of resuscitation is directly related to training,
practice and proper equipment
Newborn Assessment

Inverted Pyramid
for Neonatal
Resuscitation
Resuscitation of the Distressed
Newborn
Resuscitation of the Distressed
Newborn

Positioning the Airway

If cyanotic or pale
Provide
supplemental O2
Warm and humidify
the O2
Flow rate should be
set at 5L/minute
Resuscitation of the Distressed
Newborn

Oral Airways
Rarely used for neonates
Bilateral choanal atresia
Bony or membranous obstruction to the back of the
nose preventing airflow
Can be rapidly fatal
Usually responds to placement of an oral airway
Pierre Robin Syndrome
Series of developmental anomalies
Small chin, posteriorly positioned tongue
Frequently leads to airway obstruction
Resuscitation of the Distressed
Newborn

Bag-Valve Mask
Ventilation
Apnea
Inadequate
respiratory effort
Pulse rate <100 bpm

Ventilate with 100% for

15-30 seconds
Resuscitation of the Distressed
Newborn

Bag-Valve Mask Ventilation

Three devices
Self-inflating bag with an O2 reservoir
Flow-inflating bag
T-piece resuscitator
Self-inflating bag
Most likely to be used in the field
Only 1/10th of the bags volume will be used for each
breath
Easy to cause barotrauma on their tiny little lungs
Resuscitation of the Distressed
Newborn

Bag-Valve Mask Ventilation

When administering
Airtight seal
Patent airway
First few breaths after birth will
frequently require higher
pressures
Visible but no excessive chest
rise
Timing for Ventilation
40-60 breaths per minute
Resuscitation of the Distressed
Newborn

Evaluate the Heart Rate

Initiate chest compressions if HR is <60, or 60-80 and not
increasing

Reassess HR
Continues <80, continue chest compression
>80, discontinue compressions
Resuscitation of the Distressed
Newborn

Intubation
Indicated for the following
Meconium-stained fluid present and the infant is not vigorous
Congenital diaphragmatic hernia
Does not respond to BVM and chest compressions
Prolonged PPV is needed
Equipment
Suction
Laryngoscope
Blades (0 and 1)
Shoulder roll
Adhesive tape
Endotracheal tube
Resuscitation of the Distressed
Newborn

Gastric Decompression
Indicated
Prolonged BVM ventilation
Abdominal distention impeding ventilation
Presence of diaphragmatic hernia
 Resuscitation of the Distressed
Newborn
Venous access
Necessary for
Fluid administration to support circulation
IV resuscitation medications
Therapeutic IV meds
Umbilical Vein Access
Can be catheterized
Clean the cord with alcohol or betadine
Place a sterile tie firmly around the base of
the cord
Prefill a sterile 3.5F to 5F umbilical vein line
catheter with NS
Cut the cord with a scalpel
Insert the catheter into the vein for a
distance of 2-4cm
Flush the catheter with NS and tape in
place
Resuscitation of the Distressed
Newborn

Pharmacology Interventions
Rarely needed
Most infants can be resuscitated with ventilatory support
Medications are based on weight
Epi
Indicated when pulse <60bpm after 30 seconds of effective
ventilation and chest compressions
Recommended 1:10,000
IV or ET tube
Volume replacement
Intravascular depletion 2/2 placental abruption, septic shock, etc.
Low umbilical vein line or peripheral IV or IO line
Fluid bolus of 10mL/kg NS IV over 5-10 minutes
Rapid fluids can cause IVH and death
Resuscitation of the Distressed
Newborn

Respiratory Suppression
Drugs suspected in Mother
Narcan
Reverses narcotic effect
May precipitate seizures
NRP is shying away from Narcan use
Pneumothorax
Severe respiratory distress
Unresponsive to PPV
Unilateral decreased breath sounds
Shift of heart sounds
Resuscitation of the Distressed
Newborn

Pneumothorax Evacuation
Needle decompression
Clean the area around the second intercostal space with
alcohol
Prepare the equipment
22 gauge butterfly needle attached to extension tubing
Three-way stopcock
20mL syringe
Insert the needle above the 2nd rib and pull back on syringe
Advance the needle until the air is recovered
Resuscitation of the Distressed
Newborn

Meconium Stained Amniotic Fluid

High risk of mobridity
Present in 10-15% of deliveries
Either before or during delivery
More common in post-term infants and small for
gestational age
Airway becomes obstructed and hypoxia may result
Develop a chemical pneumonitis, pneumonia, etc.
Newborn Emergencies

Meconium Stained Amniotic Fluid

Delivery with meconium
Determine if the fluid is thin and green stained vs. thick and
particulate
If the baby is crying and vigorous, treat as previously
discussed
If depressed, not vigorous do not dry and stimulate
Intubate the trachea
Insert a suction catheter into the ETT
Suction while withdrawing the tube from the trachea
Then dry and stimulate
O2 and PPV may be necessary
Resuscitation of the Distressed
Newborn

Diaphragmatic Hernia
Abnormal opening in the diaphragm
Most common on the left side
1 in 2,200 births
Diagnosis often made on prenatal US
Mortality may be as high as 50%
Management
BVM introduces air that distends the intestines
If PPV is necessary, place an ETT
Place an OG and intermittently suction to decompress
the stomach
Ultimately will require operative repair
Resuscitation of the Distressed
Newborn

Apnea
Common in infants delivered before 32 weeks gestation
Rarely seen in the first 24 hours after delivery
If prolonged, can lead to hypoxia and bradycardia
Pathophysiology
Depends on the underlying etiology
Apnea of prematurity
GERD
Drug/Medication induced
Respiratory support to minimize hypoxic brain damage
Resuscitation of the Distressed
Newborn

Additional Conditions
Choanal atresia
Place an oral airway
Pierre Robin syndrome
Position the patient prone to maintain the airway
Use and OPA if needed
Cleft Lip and/or Palate
Airway resuscitation usually not an issue
Cricoid pressure if intubation is necessary
PPV via BVM
Risk of aspiration and regurgitation
Resuscitation of the Distressed
Newborn

Additional Conditions
Exposed Abdominal Contents
Developmental defect
Place the newborn from the waist down into a sterile,
clear plastic bag
Keep the bowel clean
Minimize heat and fluid loss
Monitor the color and appearance of the intestines
Prematurity and Low Birth Weight
Prematurity and Low Birth Weight

Premature and Low Birth Weight

Premature
Delivered before 37 weeks completed gestation
Low Birth Weight
Less than 5.5 pounds
Most common cause is premature birth
Prematurity and Low Birth Weight

Premature and Low Birth Weight

Factors for Premature Birth
Genetic
Infection
Cervical incompetence
Abruption
Multiple gestation
Trauma
Drug Use
Previous preterm delivery
Prematurity and Low Birth Weight

Premature and Low Birth Weight

Factors for Premature Birth
Chronic maternal hypertension
Smoking
Placental abnormalities
Chromosomal abnormalities
Approximately 12% of births in the US are preterm
Morbidity and mortality are related to the degree of
prematurity
24 week gestations have very high M&M
Prematurity and Low Birth Weight

Premature and Low Birth Weight

Field deliveries
Cardiorespiratory support and warm environment to
support body temperature
High risk for respiratory distress
Weak lungs
Lack of surfactant
Retinopathy of prematurity
Neonatal Seizures
Neonatal Seizures

Neonatal Seizures
Most distinct sign of neurologic disease
Paroxysmal alteraltion in neuro function
More common in premature infants
Identified by direct observation
Need in-hospital EEG
May have normal motor activity
Shaking sometimes mistaken for seizures
Myoclonic, disconjugate eye movements, incoordinated
sucking movements
Can be easily confused for seizures
Neonatal Seizures

Neonatal Seizures
Four major types
Subtle seizures
Tonic seizure
Focal clonic seizure
Myoclonic seizure
Describing the seizure
Focal
Multifocal
Generalized
Neonatal Seizures

Neonatal Seizures
Causes
Hypoxic ischemic encephalopathy
Usually secondary to perinatal asphyxia
Single most common cause of seizures
Characteristically occur in the first 24 horus
Associated with metabolic abnormalities
Hypoglycemia
Most commonly seen in infants who are:
Small for gestational age
Large for gestational age
Mothers with DM or gestational DM
Neonatal Seizures

Neonatal Seizures
Causes
Hypocalcemia
Two major peaks of incidence
2-3 days after delivery
Late onset
Rare in the US
Neonatal Seizures

Neonatal Seizures
Evaluation
Quick evaluation of prenatal and birth history
Did Mom have prenatal care? Any history of infection
during pregnancy? Febrile during delivery?
Infant typically quiet, may be hypotonic
Lethargy and/or apnea common
CHECK A BLOOD SUGAR!
Hypoglycemia MUST be recognized quickly and
treated promptly
D-E-B!!!
Neonatal Seizures

Neonatal Seizures
Evaluation
Obtain baseline vital signs and O2 saturation readings
Treatment
Antiepileptics
Consult with Medical Control
Lorazepam used for first line control
May need Phenobarb or Phenytoin
Thermoregulatory Problems
Thermoregulatory Problems

Thermoregulation
Balance heat production and heat loss
Maintain normal body temperature
Limited ability in the newborn
Average normal temperature is 37.5oC
Nonshivering thermogenesis
Production of heat by metabolism
Primary source of heat production in the neonate
Brown fat is a thermogenic tissue that is unique to the
newborn
Thermoregulatory Problems

Thermoregulation
Heat Loss
Loss to the environment through one of four mechanisms
Evaporation
Convection
Conduction
Radiation
Thermoregulatory Problems

Fever in the Newborn

Definition
Rectal temperature greater than 38oC (100.4oF)
Why do we care so much?
Temperature regulation in the newborn is
Relatively immature
Can be indicative of a serious bacterial or viral
infection
Not always present, however
Thermoregulatory Problems

Fever in the Newborn

Overheating
Can easily become too warm
Become dehydrated with temperature elevation
Limited ability to control their own temperature
Do not sweat to allow cooling
Do not shiver to raise temperature
Cannot move from uncomfortable environment
appropriately
Thermoregulatory Problems

Fever in the Newborn

Treatment
Believe the parent!!
Studies have proven Moms reporting as good as a
thermometer
Observe the newborn for any rashes
Obtain a careful history
Obtain a full set of vital signs
Can remove additional layers of clothing and improve
environmental ventilation
Thermoregulatory Problems

Hypothermia
Drop in body temperature
Occurs in all climates
Associated with increased risk of death in low birth weight
infants
Risk factors for hypothermia
All neonates in the first 8-12 hours after birth
Home delivery
Prolonged resuscitation
Small for gestational age
CNS problems
Prematurity
Sepsis
Inadequate measures to keep the child warm
Thermoregulatory Problems

Hypothermia
Increased surface area-to-volume ratio
More sensitive to environmental conditions
Have to increase metabolic function to overcome heat
loss
Presentation
Cool to the touch
May be pale, have acrocyanosis
May become lethargic and obtunded
Thermoregulatory Problems

Hypothermia
Prevention
Warm your hands before touching the baby
Dry the newborn thoroughly after birth and remove wet
blankets
Place a cap on the newborns head
Place the infant skin-to-skin with the Mother
Deliver to a prewarmed incubator
Hypoglycemia in the Newborn
Hypoglycemia in the Newborn

Hypoglycemia
In full-term or preterm infants
Blood sugar <40mg/dL
Imbalance between glucose supply and demand
May result in seizures, permanent brain damage
Risk factors
Disorders of fetal growth and maturity
Prematurity
Disorders of maternal glucose regulation
Neonatal conditions with disturbance in metabolism
Severe anemia
Congenital and genetic disorders
Hypoglycemia in the Newborn

Hypoglycemia
Glycogen stores
Glucose comes from the Mother in utero
Uses glycogen stores after birth
Most stores last 8-12 hours
Metabolic adaptations are regulated by hormones
Symptoms
Cyanosis, apnea, irritability, poor sucking or feeding,
hypothermia
Lethargy, tremors, twitching, seizures, coma
Tachycardia, tachypnea, vomiting
Hypoglycemia in the Newborn

Hypoglycemia
Management
Check their blood sugar!
Easy to miss, especially if the child looks sick
D10 is the solution of choice for neonatal hypoglycemia
Maintain the childs normal body temperature
Gastrointestinal Emergencies
Gastrointestinal Emergencies

Vomiting
Common in newborns
85% vomit in the first week of life
spitting up to projectile vomiting
Most episodes are benign
Persistent vomiting is a warning sign
Vomit containing dark blood is often a sign of life-
threatening illness
Gastrointestinal Emergencies

Vomiting
Presentation
May give a clue as to the site of the obstruction or other
problems
Esophageal atresia
The esophagus ends in a blind pouch
May or may not have a tracheoesophageal fistula
Excessive frothing after birth
Can lead to gastric perforation
Gastrointestinal Emergencies

Vomiting
Pathogenic gastroesophageal reflux
Reported prevalence of 2-10%
Vomiting occurs immediately or a few hours after feeding
Uncomplicated GER
Hypertrophic pyloric stenosis
Hypertrophy and hyperplasia of the pylorus
2-4 cases per 1,000 live births
Male:female ratio of 4:1
30% are first-born males
Stomach muscles contract forcibly
May palpate an olive pit in the epigastrium
Gastrointestinal Emergencies

Vomiting
Malrotation
Congenital abnormality of the midgut
Intestines rotate the opposite way when returning to the
abdominal cavity
Small bowel is found on the right side of the abdomen
1 in 500 live births
Correctable by surgery
Meconium plug
Hirshprung disease
Last segment of the colon fails to relax
Usually a history of not passing meconium in the first 24 hours
of life
Gastrointestinal Emergencies

Vomiting
Asphyxia, meningitis, hydrocephalus
Sudden, unexpected and forceful vomiting
May be accompanied by persistent irritability
Management
Start with the ABCs
Suction or clear the vomit as needed
Antiemetics for neonates generally should not be
administered in the field
Transport the newborn on their side to help keep the
airway clear
IVF for volume resuscitation as needed
Gastrointestinal Emergencies

Diarrhea
Normal number of stools per day for an infant is 5-6
Can lose excessive amounts of electrolytes and fluids in stool
Prevalence is higher in infants attending daycare
Causes
Viral infection is the most common cause
Gastroenteritis
Lactose intolerance
Neonatal abstinence syndrome
Thyrotoxicosis
Cystic fibrosis
Gastrointestinal Emergencies

Diarrhea
Severe cases
Generally ill-appearing
Poor vital signs, cap refill >2 seconds
Dry mucous membranes, no tears, low urine output
Weight loss
Assessment
Estimate number and volume of loose stools
Degree of dehydration
Management
ABCs
IVF may be necessary
Birth Trauma
Birth Trauma

Birth Trauma
Avoidable and unavoidable injuries during the delivery
process
2-7 of every 1,000 live births
Most are self-limiting and have a favorable outcome
Account for 2-3% of all infant deaths
Birth Trauma

Birth Trauma
Causes
Infants size or position
Primigravida, prolonged labor
First baby
Cephalopelvic disproportion
Babys head is too large for Mothers pelvis
Rapid labor
Abnormal presentation
Prematurity
Low birth weight
Birth Trauma

Birth Trauma
Injuries
Caput succedaneum
Caused by pressure of the presenting part against the cervix
Cephalhematoma
Blood between the skull and the periosteum
Linear fractures
Brachial plexus injuries
Branches of the facial nerve
Diaphragmatic paralysis
Laryngeal nerve injury
Spinal cord injury
Clavicle fracture
Long bone fractures
Intra-abdominal injuries
Transport Considerations
Transport Considerations

Family and Transport Consideration

Transport to the nearest facility
Once the infant is stabilized as much as possible
Ongoing communication with the family
Do not be specific about survival statistics
New and sophisticated care techniques
Expert personnel, especially for premature infants
Reduced mortality among high-risk newborns
Requires transport to a regional center
Average hospital cant provide this care
Transport Considerations

Family and Transport Considerations

Regional referral system
Physician initiated request for trasnport
Typically has a specialized transport team to stabilize the
infant before transport
Team collects the information and materials
Wrap Up
Newborn Emergencies

Summary
Newborns and Neonates
High-Risk Newborn Patients
APGAR Scoring
Newborn Resuscitation
Special Situations
Newborn Emergencies

Questions?