Hi, everyone. Welcome back. In today’s video, we’re going to review the 2015 updated treatment algorithm for neonatal resuscitation, having babies.
If you’re in the field and you get called for someone having a baby, right away you’re thinking this: “I don’t know nothin’ about birthin’ babies.” Then you look at your partner, and you see him doing this: “Game over, man. Game over.” Relax. Take a deep breath. Statistically, 90% of all childbirths don’t require any resuscitation. They’re fine. All we basically have to do is not drop them. 10% will require some stimulation to breathe or require some oxygen—the minimum, just oxygen. Only 1% of all deliveries require aggressive resuscitation. So, 90% of your births—no big deal. This is a happy occasion. This is an occasion for joy. You’re helping to bring a new life into the world. Enjoy it. Have fun. Know that 90% of the time, you’re going to be just fine.
Before we dive into the algorithm, let’s take a look at the inverted pyramid because there are some things that we’re always going to do. Starting at the top of the pyramid, we see we have drying, suctioning, stimulating the child to breathe. These are all normal things that we all know about, that we’re going to do right after we deliver a child. This accounts for most of the care that we’re going to be providing. That’s 90% of what we’re going to be doing. As you go down the pyramid, you see we get into oxygenation, then maybe intubation, then maybe chest compressions, and lastly, drugs. These are very rarely needed. This only accounts for 1%. Looking at the top of the algorithm, things we’re always going to do in this pyramid. Moving down, things we’re less likely to need to have to do for this infant.
Let’s take a peek at this algorithm. Starting from the very top, first we see antenatal care—were they doing their prenatal care? Second, team briefing. Get the team together and talk about who’s going to be doing what when we deliver this baby. Third, make sure all your gear is prepared. Make sure you have everything prepared, knowing that 90% of the time you’re not going to have to do much. In EMS and in the hospital, we prepare for things to go south so make sure all your equipment is ready. Next, the birth. We’re having the baby.
Right after that, we’re going to ask three questions:
- Is this a term gestation? Is the baby done cooking?
- Is the baby crying? Are they moving air?
- Do they have good tone? That means the baby’s active. He’s fighting you. He should be fighting you.
If the answer is yes to all those three questions—term gestation, breathing, good tone—we’re golden. That infant can actually stay with Mom while we’re doing the rest of our stuff. We don’t have to pull that kid away. He doesn’t require any resuscitation. If yes to those three questions, baby’s going to stay with Mom. While baby’s staying with Mom, there are still a few things we need to be doing. We need to dry this baby off. Remember thermal regulation. We do not want this newborn getting cold. I did an experiment the other day on myself. I sacrificed myself for science. I woke up, put my robe on, and went outside. Then I took my robe off. I live in the Midwest. It was about 40 degrees. It was really cold outside, so I was cold. I put my robe back on, covered myself back up. I was still cold. I needed to provide myself with some warmth, so I walked back inside. That was the first part of the experiment. For the second part, I took a shower, got out of the shower, dried myself off, put my robe back on, and went outside again. I was really cold. I was freezing. Why? Because even after I dried myself off, I was still wet.
Through evaporation and convection, I was freezing out there. I was losing body heat, just like that baby. Even after you dry the baby off, they’re still wet. They’re still cold. It’s going to require a couple of times of drying this kid off, and you must provide warmth. It’s not enough just to dry the baby off. You have to provide them with warmth. In this scenario, we had yes to our first three questions, so the baby can stay with Mom. What’s the best way to provide warmth in the back of the ambulance to this newborn? What’s the warmest thing in the back of the ambulance? Chances are, it’s Mom. She’s been working for a while trying to deliver this kid. Take the infant, dry them off, put them skin-to-skin with Mom and then cover all that up. That will help keep the infant warm. That’s the best way, really, to apply warmth to this newborn in the back of an ambulance. Give him to Mom. The baby’s now with Mom, all covered up. Continue reassessment. You’ll suction out secretions if you need to. If you do, start with the mouth first, then the nose, and continually reassess this child.
If an answer is no, you’re going to continue to provide warmth. If you’re in the back of the ambulance, make sure that heat is cranked up before you ever get there. Clear out the secretions using a bulb syringe, starting with the mouth first, then the nose. Position the airway. Make sure this child is able to breathe. Provide additional warmth and stimulation of this child. Keep them warm while you’re stimulating them. The best way to stimulate them to breathe is flicking the soles of the feet. That’s annoying to a newborn, so flick the soles of their feet and get this kid to cry and open up those lungs. Next is to assess this child’s breathing and pulse. If the child only has gasping respirations or is apneic, quickly assess the pulse. You can do that by palpating the umbilical cord. Another way to assess heart rate is listening to heart tones. Remember, what makes sound is valves opening and closing in that brand-new heart. You can palpate the umbilical cord to check a pulse or you can listen. Listen to the kid’s chest and count out that heart rate. We need a heart rate over 100. That’s it. There are two magic numbers when it comes to neonatal: over 100 and over 60. In this case, we’re looking to make sure that pulse is over 100. If at any time the pulse is less than 100, we’re providing oxygen or bagging that child, depending on their ventilation status. If this child has gasping respirations, is apneic, or has a pulse less than 100, we immediately begin bagging this child. We’re going to bag with room air to start, room air. Attach the Ambu bag. Begin bagging at a rate of 40 breaths per minute. Then we need to attach an SPO2 monitor. We’re going to get a pulse ox. We’re going to put it on the child’s right hand. We need to start monitoring their pulse oximetry. Additionally, a new recommendation is we can go ahead and throw a 3-lead on this kid because that will detect the pulse. If we felt a pulse, we can match that off our 3-lead EKG now and watch this kid’s heart rate. That’s huge. We want to have one eye on this infant’s heart rate the whole time.
Do we have labored breathing and persistent cyanosis? Remember, cyanosis is that bluish tint throughout the body. It is not uncommon to have acrocyanosis, which means the child may be pink in the core but a little cyanotic out in the periphery. That’s normal. We’ll see that in a lot of births, but we’re looking for persistent cyanosis all over the body, a bluish tint all over coupled with respiratory distress. If you have that, you’re immediately going to provide ventilation to this child at a rate of about 40 per minute using an Ambu bag. Make sure the child is properly positioned when you’re applying these positive pressure ventilations. We’re going to monitor their heart rate. We’re going to attach an SPO2 monitor, a pulse oximeter, to their right hand and begin assessing their pulse oximetry. Looking at our timeframe, from the time the infant is born through our initial assessment—our initial steps of drying, stimulating, and assessing the respirations and pulse on this patient—it should take about 1 minute. That’s our golden minute. In that golden minute, we should assess the infant, provide the stuff we always provide (which is warming, suctioning if needed, drying, stimulating), then evaluate their respirations and their tone. Remember those three questions in the beginning. We want to get all of that done within the first minute after birth. That’s is the golden minute.
We’re providing ventilations for this child. We’re going to reevaluate the heart rate. Is the heart rate above or below 100? If it’s below 100, we’re going to continue our ventilations. Should the heart rate drop below 60, we’re going to begin chest compressions. Those are really our two magic numbers. We always want a heart rate above 100 in a newborn. Any time the heart rate hits 60 or below, we’re starting chest compressions. When you see that on a test, if the heart rate drops below 100, we’re bagging him, we’re providing oxygen. We’re oxygenating this kid to get that heart rate over 100. If it falls below 60, we’re starting chest compressions immediately. Now we’re bagging this child and we’re providing chest compressions. We’re watching that heart rate. We want to see that heart rate come up. If it doesn’t come up, think about an advanced airway, either tubing this child or an LMA for this child to get a better airway, so we can get better oxygenation into this infant. Remember, when we first started bagging this infant, we were doing it with room air. Once we’re starting chest compressions, we’re going to increase that FiO2 straight to 100%. We’ll talk about how to measure pulse oximetry here in a moment, but if we’re resuscitating this child, that’s done with 100% FiO2. Initially, just providing oxygen or bagging, start with room air. If we’re doing chest compressions, we’re going to bump it right up to 100% FiO2.
If despite ventilation, advanced airway, and chest compressions, we still can’t get this kid’s heart rate over 60, that’s when we have to go to medications. We’re going to have to gain vascular access. If you’re in the hospital, you’re probably going to use an umbilical catheter. If you have to gain vascular access, we can use the umbilical cord. That’s a great place. You cut the cord, and when you look at the umbilical cord dissected, you’re going to see two arteries and one vein. The vein is bigger than the arteries, so where are you putting that catheter? Into the one big vessel you see in the cord. Two small arteries, one big vein—that’s where the umbilical line goes. We’re going to insert that catheter just into the body. Measure up to where the umbilical cord meets the body. We’re going to go just past that. We’ve already flushed our catheter with saline. What we’re going to do is we’re going to try to draw back and as soon as we get blood back, we’re golden. That’s where we want to be. Really, we’re going to insert just into the body or until we can get a nice blood return back through a flushed umbilical catheter. That’s how far we’re going to go in. If you’re in the field, you’re probably not going to use an umbilical catheter. You’re probably going to go intraosseous, which is fine, that’s perfect. In fact, here’s an x-ray of the first IO I ever did. This was on a 1-month infant. If you take a look, the IO needle I put into the bone was longer than the bone I put it into. Now we have specific IOs and guns that are designed for little bitty babies, regular-size people, and big old enormous-size people. IO infusion technology has gotten better. It’s use and people’s proficiency and their comfort level with IO infusion has gotten much better over the last decade. So, go head and start. We’re going to have to gain vascular access. Start that IO. First drug up? Epinephrine 1:10,000. Our dose is 0.01 mg/kg or 0.1 mL/kg. Let’s say we have a 4 kg kid, alright? That means I have to draw up 0.4 mL of epinephrine and administer that to this infant, which is very hard to do through a regular syringe of 1:10,000 because it’s measured in 1 mL increments. It’s going to be hard to do. I can take a 1 cc syringe, put a needle on that, and draw the epinephrine right out of that vial of 1:10,000, hook that up to my tubing, and administer the proper dose that way. This way I’m not trying to guess or over-administer the epinephrine when I’m using that big 10 cc syringe/vial of epinephrine.
Measuring this infant using our Broselow tape, we’ve determined he falls into the 3 to 5 kg range. Our first dose of epinephrine is 0.01 mg/kg, which would be 0.04 mg/kg, which is the same as 0.1 mL/kg. In this case, it’s 0.4 mL. That’s what we need to draw up. It’s hard using a 1:10,000 10 cc vial of epinephrine to administer 0.4 mL. If you notice, there’s a needle in here. When we connect this, that needle’s going to puncture into the vial so we can administer our medication, but these are all in 1 mL markings. It’s going to be very difficult to administer 0.4 mL just using this. What we’re going to do is we’re going to attach a syringe, a 1 cc syringe, with the needle and draw it up into a 1 cc syringe. I’ve added food coloring to this vial of epinephrine so we can see when I draw it up. I’m going to take the needle, go right into the epinephrine, and I’m going to draw up my 0.4 mL. I’m going to leave my syringe attached, come over to my port, attach it, clamp off here, and administer my medication. We can see that I’ve administered it from the syringe into the tubing, but I need to get it from the tubing to the heart. I can use the same syringe. I’m going to clamp the tubing distal on the patient’s side and then draw up, using the same syringe, fluid from the IV bag. Then I pinch the tubing on the bag side. I can push that flush in and push that medication into the patient using the same syringe, and then repeat as necessary. This way I can use the same syringe I administered the medication with to provide my post-medication fluid bolus to push that drug to the heart.
The use of pulse oximetry, we use this all the time in adults. We can also use it in the newborn to see is this infant really moving from fetal to adult circulation. Take your pulse oximeter, and place it on the newborn’s right hand. We’re going to use this gauge to see is the newborn’s oxygen saturation improving over time. The way I remember it is I start at minute 1 at 60% and it should go up 5% every minute. SPO2 at 1 minute is 60%, next minute 65%, then 70%, 75%, 80%. At 5 minutes, this newborn’s saturation should be between 80% and 85%. Over the course of the next 5 minutes, we’d like to see their saturations go from 85% to 95%. Again, use pulse oximetry. This should measure how well the oxygen saturation in this newborn is improving over time. Start at 1 minute. Check the first 5 minutes. It should go from 60% to at least 85% over the first 5 minutes and then from 85% to 95% over the next 5 minutes.
Does anybody notice what’s missing in this algorithm? Something important that might pop up that just doesn’t appear, like, when to cut the umbilical cord? Yeah, it’s not in the algorithm, so let’s talk about that. One of the new 2015 recommendations is called delayed cord clamping. What that means is in a normal delivery where we don’t require resuscitation, we can wait. We can take our time. We can give it 30 seconds to 1 minute before we clamp that cord. I was flying with a NICU nurse over the weekend, and we were talking about this delayed cord clamping. She actually called one of her neonatal cardiologist friends and asked him about this. What he said makes sense. Right after this child is born, they’re not breathing yet. They have to start breathing, open up the lungs, get that pulmonary vascular system filled up, and start moving oxygen throughout their body. But before that, they’re still attached to the umbilical to Mom. Mom almost becomes kind of like ECMO for the first few moments of life. The baby is still receiving oxygen and nutrients through that umbilical cord, which is attached to Mom. We want to keep that going. We found that early cord clamping isn’t all that great for the kid. We want to make sure they get all the blood volume and stay oxygenated until the baby has started crying and has opened up those lungs. Now the infant is oxygenating himself, and we can go ahead and cut that umbilical cord. When would we want to clamp and cut the cord right away? Let’s say we deliver this newborn, there’s no activity, they’re not breathing, and we need to begin resuscitation quickly. That’s when we’ll go ahead and clamp and cut the cord because we need to start working that infant. If we don’t clamp the cord right away, it could delay our ability to begin positive pressure ventilations.