CASE:

AirCare 1 is dispatched to a scene accident for a 26 year old female 37 week G1P0 who was the restrained passenger in a multi vehicle collision. She was found to be hypotensive and complaining of abdominal pain. Upon arrival, EMS has initiated IV fluids and the patient is now normotensive. Pelvic exam shows that the patient is dilated 5 cm and crowning, with contractions every 3 minutes.

AirCare 2 is placed on standby, as you anticipate another patient, while you set up for vaginal delivery. Upon successful vaginal delivery, the infant is found to be blue and not making any sounds at all, one minute APGAR is 4 (A-0, P-1, G-1, A-1, R-1). With mother stable, you quickly turn your attention to the neonate.

The APGAR scoring system was initially developed in 1952 to quantify the effects of anesthesia on babies. It is used frequently in delivery rooms but in the prehospital setting trying to calculate the score can slow down the medical provider, which leads us to the NALS tripartite assessment which will be discussed further below.

PREPARATION

As with every patient in the critical care transport environment, what you do in preparation is important to your success. On arrival the scene will always be a dynamic situation. When faced with a pregnant patient, be ready for a second, tinier patient. Knowledge of your resources is crucial: the Pedi Bag has all the essential equipment needed to provide life support to a newborn, both premature and term infants (with the exception of your airway equipment found in the black bag).

Fortunately, the majority of infant deliveries are not life threatening. About 10% of newborns at birth will need interventions to assist them in taking their initial breath, with less than 1% of newborns requiring interventions such as compressions or medications.

Table 2: Frequency of interventions performed of neonates based off population data

So what’s in your PediBag?

Compartment 1: BVM Pediatric / 250ml D10 Dextrose / Warming Mattress

Compartment 2: Umbilical line kit / Dual Lumen Suction catheter (10F, 12F, 14F) aka Salem Sump / Sfuction catheter (6F, 8F, 10F) / Hat / Socks / Umbilical cord clamp x2 / Nasal bulb syringe / Pair of scissors / Meconium aspirator

Compartment 3: Limb leads / IO needles (15mm, 25mm both 15 gauge) / BD Vacutainer (Push button blood collection set) / BP cuffs from all different sizes

Compartment 4: PVC Nasopharyngeal airway 12F-20F / Infant & Pediatric Nasal cannula (x2) / Infant & Pediatric NRB (x2) / Infant/Neonatal CO2 Sampling line and Airway adapter for Humid Environments / Neonatal/Adult Pulse Oximeter Adhesive Sensor

The resuscitative hysterotomy kit has recently been relocated into the Pedi Bag. Knowing in which compartment your devices are located increases your efficiency, which is critical in these situations.

Pediatric Pack: Compartments 1-4 above, start from THE front of the pack and go the the back.

ASSESSMENT

There are a number of scoring systems for newborns--the NALS algorithm simplifies the scoring system in the prehospital setting with the 3 key features of assessing every newborn or neonate:

Term gestation? (>37wks)
Breathing or crying?
Do they have good tone?

If the answer is yes to all three, then routine care should be established, and baby should stay with mother. Postnatal assessment has to be done on all neonates. Keep the baby warm and dry. Suctioning healthy neonates with a bulb syringe after delivery has been found not to be beneficial. This vagal stimulation can actually cause bradycardia and apnea. Wiping the mouth and nose has been shown to be equally as effective, with fewer complications.

The majority of your physical exam will be observational. The key vital sign will be your heart rate. In neonates you want to see this above 100 and your pulse oximeter sensor should be able to get you this reading. If the pulse ox does not give you this reliably and immediately, check for a brachial or femoral pulse. Frequently checking a central pulse, as in any resuscitation, is key. Depending on how much of a mess you have around you and on your gloves, a Broselow tape would be better than using your phone. This will always have your VS range as well as your common medications.

INTERVENTIONS REQUIRED IN NEONATAL RESUSCITATIONS

As stated above, most of your patients will require minimal intervention and most of those will be respiratory support. Regardless of acuity, you will want to conduct the first two steps before transporting.

Step 1

Cord Clamping. One of the earliest steps in postnatal care is cord clamping. For term and preterm infants who are vigorous, cord clamping can be delayed 30-60 seconds after delivery.

Provide warmth. Use any blankets or sheets around until the warming mattress is taken out of its box.

Provide tactile stimulation. This can range from rubbing or flicking the soles of the feet, rubbing the back, or a combination thereof.

Position. Neonates have a large head and will naturally flex their neck when supine--rolling some towels from the shoulders down to the buttocks will allow the head to be in neutral position.

All these steps are to be done in less than a minute.

STEP 2

Provide oxygen. It is normal for an infant to have low oxygen saturation readings within the first 10 minutes of life as their physiology adapts to extrauterine life. Do not be alarmed if they cannot maintain levels above 85%. If the neonate continues to be hypoxic on room air, free flow O2 may begin at 30% and this can be provided with a self-inflating bag. Suctioning the hypoxic neonate can help improve their oxygenation status but beware the significant risk of bradycardia.

Positive pressure ventilation. If the patient is bradycardic (<100), gasping, or having apnea you will start PPV.

Correct mask placement should rest on the chin and cover the mouth and nose.
PPV (PIP 20-25 / PEEP 5, RR 40-60).
Caution with over inflating stomach: it can cause “tension tummy,” leading to decreased venous return.

Table 3: Expected oxygenation saturation in newborns

As positive ventilation is started, the neonate should be put on a cardiac monitor. Increasing HR will be an indicator of adequate ventilation. Three lead monitoring is adequate.

Evaluate the neonate for better color, increasing heart rate, better SpO2 readings. If the mask is not adequate and the patient isn’t improving, try using your airway adjuncts such as the NPA or OPA. If this is still inadequate, an advanced airway needs to be placed.

STEP 3

Place an advanced airway. Consider a supraglottic device or endotracheal intubation. This will be found in the black bag. Your pediatric app of choice or Broselow tape should give you the ideal size to use.

3.5 - 4 ETT for most full term neonates.

For induction and paralytics, vascular access in neonates can be achieved via the IO and the targets of choice in neonates are:

Proximal flat broad tibial plateau 1-2 cm below the tibial tubercle on anteromedial surface. Care should be taken as infiltration is often unnoticed putting patient at risk for compartment syndrome.
Distal femur, midline about 2-3 cm above external condyles
IO’s do frequently fail in neonates due to infiltration and thus umbilical vein catheterization is the preferred method of access.

If difficult to obtain IO in the newborn the umbilical vein will be the vessel of choice.

Figure 1: Cross-sectional representation of the umbilical cord in the context of umbilical vein catheter insertion

Use adequate cleaning before cannulation of the vein (similar to central line), use the umbilical line kit found in the Pedi Bag. We carry two sizes of umbilical vein catheters.
3.5 French catheter for < 1 kg.
5.0 French catheter for > 1 kg.
The vein will be the unpaired vessel at the umbilical stump and will be largest
Use a umbilical tie to achieve hemostasis and cut above that (~2-3cm from abdominal wall). Avoid clamping the cord as this can crush and denude the blood vessels.
Attach a 3-way stop cock to the tube and prime the tubing with saline, insert 5cm (full term), 3cm (preemie). Prime the stop cock as well prior to insertion to avoid an air embolus.
Secure with tape bridge (or twill tape) to avoid weight of stopcock and tubing dislodging catheter

Most neonates respond adequately to proper ventilation and airway management. If the neonate continues to decompensate and their HR becomes 60 bpm or less, start compressions.

STEP 4

Perform compressions. Increasing HR is the most sensitive indicator of successful interventions as you do any intervention during resuscitation. ECG lead placement has been shown to be more accurate than pulse oximetry in evaluating HR.

Initiate if HR is 60 bpm or less
3:1 compression-to-ventilation ratio as gas exchange likely to be cause of arrest. If concern for cardiac origin then 15:2 ratio can be used.
Reassess HR as you continue your interventions

STEP 5

Give medications. Consider this if neonate is bradycardic despite:

Adequate ventilation with 100% O2 via ETT
Adequate chest compressions

Epinephrine is the only medication currently recommended for use during neonatal resuscitation.

Current guidelines based on adults and animal studies
Dose is 0.01 - 0.03 mg/kg of 1:10,000 epinephrine

Provide IV fluids. Consider this in neonates in whom you have suspected or known blood loss (i.e., placental rupture). This is rarely given due to risk of adverse effects.

Initial bolus is 10 ml/kg

Post-Resuscitation

Once the patient is stabilized after your successful interventions, transport to a facility with the abilities to provide continued care to the neonate, such as a pediatric hospital.

Discontinuing Resuscitation

According to the AAP, an Apgar score of 0 at 10 minutes is a strong predictor of mortality and morbidity in late preterm and term infants. Positive pressure ventilation should be terminated if there was an undetectable heart rate at that point in time. Resuscitative efforts may continue for numerous reasons and thus the decision to terminate the resuscitation should be done on a case-by-case basis.

Summary

The majority of neonates will have an unremarkable transition from utero into the world. Over 90% of children who do not respond to primary postnatal interventions such as stimulation, warming and suctioning if needed will deteriorate secondary to some component of respiratory distress. The most critical intervention for these neonates will be adequate ventilation.

If the infant continues with respiratory distress or HR < 100, start PPV with BMV, place pulse oximeter. Consider maneuvers to improve ventilation if HR doesn’t improve but is still greater than 60.
Intubate if BMV is ineffective or prolonged. Consider your advanced airway especially if chest compressions are being performed. Use ECG for HR monitoring, not umbilical stump or auscultation.
If HR < 60 despite adequate ventilation, start chest compressions.
If HR rate < 60 despite adequate ventilation and chest compressions, administer IV epinephrine and consider IVF/blood if concern for hemorrhage.
Stabilize patient and transfer to nearby hospital with NICU capabilities.

AUTHORED BY edmond irankunda, MD

POSTED BY ADAM GOTTULA, MD

FACULTY EDITORS whitney bryant, MD

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