159. Neonatal Resus

Question 1

What are 3 main ways that neonatal resus differs from ped/adult?

Answer 1

1. newborns hav rapidly changing dynamic Cardiopulm physiology<br></br>2. almost entirely resp focused<br></br>3. RQ sepcial and dedicated equi

Question 2

What 3 major cardioresp changes must occur when kiddos are born?

Answer 2

1. remove fluid from unexpanded alveoli to allow ventil<br></br>2. lung exapnsion and establishment of FRC<br></br>3. redistribution of cardiac output to provide lung perfusion

Question 3

Reversal of what two shunts is required for extrauterine life?

Answer 3

1. R to L shunt via foramen ovale (R to L atrium)<br></br>2. most RV output shunted from pulmonary artery through ducutus arteriosus to desc aorta (need change in PVR/SVR)

Question 4

What is the first step in shunt reversal at birth?

Answer 4

alveolar fluid clearance by vag delivery, first fewbreaths to have PVR decrease

Question 5

Why clamp the umbilical cord helps with lungs?

Answer 5

increases SVR while first few breaths alllow pulmonary vascular R decrease due to alveolar exposure

Question 6

By _ HOURS of age, shunting through DA reverses as SVR increases

Answer 6

15

Question 7

<div>
<div>
<div>
<div>
<div>Even in the uncompromised newborn, it can take _ minutes for
blood oxygen saturation to reach normal extrauterine levels&nbsp;</div>
</div>
</div>
</div></div>

Answer 7

10

Question 8

Bradycardia in a newborn (<100 bpm) is almost always reflective of …

Answer 8

inadequate ventil and oxygenation 

Question 9

What is required at the onset of primary apnea to stim ventilation and reverse bradycardia?

Answer 9

simple stim 

Question 10

Secondary apnea in a newborn - what is this 

Answer 10

<div>
<div>
<div>
<div>
<div>f asphyxia
persists, the newborn takes several final deep, gasping breaths, fol-
lowed by cessation of respirations (secondary apnea); this is accompa-
nied by worsening bradycardia, refractory to simple stimulation, and
eventually hypotension.&nbsp;&nbsp;</div>
</div>
</div>
</div></div>

Question 11

What is extremely important to do when a newborn is born?

Answer 11

dry and warm!!

Question 12

What newborns might be at high risk for hypoglycemia when born?

Answer 12

premie<br></br>SGA<br></br>diabetic mum<br></br>hypothermia<br></br>polycythemia<br></br>asphyxia<br></br>sepsis

Question 13

Signs of hypoglycemia in a newborn 

Answer 13

<div>
<div>
<div>
<div>
<div>asymptomatic or may cause an array of symptoms, including apnea,
color changes, respiratory distress, lethargy, jitteriness, seizures, acido-
sis, and poor myocardial contractility.&nbsp;</div>
</div>
</div>
</div></div>

Question 14

What is considered premature?

Answer 14

<38 weeks

Question 15

Premature infants requiring cpr are at risk of what complications?

Answer 15

mortality<br></br>IVH<br></br>Periventricular leukomalacia<br></br>early sepsis<br></br>retinopathy of prematurity

Question 16

How to prevent meconium aspiration?

Answer 16

warm, dry, initial ppv<br></br><br></br>then try: <br></br><br></br>tracheal suction for all nonvigorous newborns with meconium stained amniotic fluid via wall suction <100mmhg

Question 17

What maternal factors can increase risk premature delivery?

Answer 17

chorio<br></br>meds - opioids resp depression

Question 18

<div>
<div>
<div>
<div>
<div>ost neonatologists
consider a gestational age more than \_\_ weeks of gestation as the cutoff
for obligatory resuscitation, even with parental refusal&nbsp;</div>
</div>
</div>
</div></div>

Answer 18

25

Question 19

When to terminate resuscitation in a neonate?

Answer 19

<div>
<div>
<div>
<div>
<div>Neonates with no signs
of life (asystole, apnea) after 10 minutes of resuscitation have high mor-
tality or severe lifelong developmental delay, and resuscitation can be
terminated&nbsp;</div><div>++ parental involvement</div>
</div>
</div>
</div></div>

Question 20

Examination findings concerning for congenital diaphragmatic hernia:

Answer 20

<div>
<div>
<div>
<div>
<div>barrel chest, ipsilateral absence
of breath sounds, tracheal or point of maximum cardiac impulse dis-
placement, and scaphoid abdomen.&nbsp;</div>
</div>
</div>
</div></div>

Question 21

BMV makes congenital diaphragmatic hernia __

Answer 21

worse

Question 22

<div>
<div>
<div>
<div>
<div>The neonate should be immediately intubated if a prenatal diagnosis
of diaphragmatic hernia is known or if a diaphragmatic hernia is diag-
nosed on the chest radiograph**&nbsp;</div>
</div>
</div>
</div></div>

Question 23

Myelomeningicocele: never place kiddos __

Answer 23

supine/on side to avoidd pressure on defect

Question 24

<img></img>

Answer 24

RS congenital diaphr hernia

Question 25

Myelomeningocele: resuscitate from where?

Answer 25

prone to avoid pressure on back 

Question 26

Myelomeningocele: how to manage when first born?

Answer 26

sterile gauze pads in warm sterile saline, enclosed in plastic wrap
(same gastroschisis or omphalocele)
IV infusion, NG, IV abx

Question 27

Choanal atresia: what is this?

Answer 27

bilat = upper airway obstruction and resp distress
dx by cannot pass cath in either nares

Question 28

Pierre Robin Sequence - hallmark abnormality?

Answer 28

profound micrognathia - glossoptosis - retraction or downward displ of tongue and cleft palate

Question 29

Pierre Robin Sequence - how to ETT?

Answer 29

fiberoptic
prone/LMA/SGA in meantime 

Question 30

CHD: what med to use on ductal dependent lesions?

Answer 30

PGE1

Question 31

Newborn resus initial prep:

Answer 31

PPE
prep machines : warmer
timing device
blankets
plastic wrap for certain defects
bulb syringe
suction
masks for infant
laryngoscope 00, 0 and 1
ett 2.5, 3, 3.5 4 uncuffed
scissors and tape
co2 detector
mec aspirator
hemostat/sterile drapes/povidone solution, scalpel umbilical tape and suture, 3 way stop cock for catheter umbilicus 

Question 32

Question 33

Question 34

___ is an independent RF for neonatal mortality world wide

Answer 34

hypothermia

Question 35

__thermia is a risk factor for neonatal encephalopathy and correlates with respiratory depression, cerebral palsy, and mortality. 

Answer 35

hyper

Question 36

Question 37

Question 38

Only if meconium is present and the newborn has poor tone, poor respiratory effort, or bradycardia (HR < 100 beats/min) after 1 minute of appropriate PPV should the trachea be suctioned with an ETT and meconium aspirator attachment.** 

Question 39

Time is an important component of NRP guidelines. Within the first 60 seconds of life, the newborn should be:  

Answer 39

ssessed with simultane- ous warming, drying, and stimulation; if necessary, upper airway clear- ance should be performed (see Fig. 159.5). If the HR is less than 100 beats/min or if the newborn has primary apnea or respiratory distress, PPV and pulse oximetry should be initiated within the first minute of life. If bradycardia worsens (HR < 60 beats/min), despite adequate ven- tilation, chest compressions should be initiated. HR calculation can be manual—by palpation of the pulse at the base of the umbilicus or aus- cultation of cardiac sounds—with pulse oximetry, or most accurately with a standard electrocardiography (ECG) lead 

Question 40

Question 41

Pulse oximeter should be placed on the baby’s R/L? wrist or hand to measure preductal saturations after birth 

Answer 41

R

Question 42

Any neonate with persistent cyanosis or signs of respiratory distress (e.g., grunting, nasal flaring, tachypnea) should be assisted by ?  

Answer 42

cpap or ppv

Question 43

For apnea, severe respiratory distress, or HR less than 100 beats/min, ??(with a manometer, if available) should be initiated. 

Answer 43

bmv

Question 44

How to give breaths in a neonate - first born, resuscitation:

Answer 44

The first breaths often require higher pressures (30 to 40 mm Hg) to remove lung fluid, with the adequacy of ventilation assessed by chest rise. 

An initial sustained breath of 2 to 5 seconds may further increase FRC and promote clearance of lung fluid, but several clinical trials and meta-analyses have yet to prove the efficacy and safety of this tech- nique. 

Subsequent breaths generally require 20 mm Hg of peak inspiratory pressure.1,2 To minimize barotrauma and the incidence of pneumothorax, excessive pressures (defined as more than needed to achieve adequate chest rise) should be avoided. 

Question 45

rate of ventilation for neonate resus? aim for ...

Answer 45

ventilation rates are 40 to 60 breaths/min, aimed at achieving a HR greater than 100 beat/min 

Question 46

When BMV is required for more than _ minutes, an orogastric tube should be placed to prevent respiratory compromise from gastric distention 

Answer 46

2

Question 47

Question 48

Endotracheal intubation is indicated at several points during neo- natal resuscitation—what are some situations? 

Answer 48

tracheal suctioning for meconium in infants with failure to improve, despite effective PPV; 

if BMV is ineffective or pro- longed; when chest compressions are performed; and 

for extremely low birth weight infants or infants with anatomic anomalies (e.g., dia- phragmatic hernia) 

Question 49

Bradycardia (HR < 100 beats/min) is a reliable indicator of clinically significant __ 

Answer 49

hypoxia

Question 50

If a neonate has an HR less than 60 beats/min, despite oxygen and adequate ventilation (good air movement and chest rise) for at least 30 seconds, ??should be started 

Answer 50

chest compression 

Question 51

Neonatal compression rate

Answer 51

90/min
coord with 30 breaths for a total of 120 events therefore compression: ventilation rate of 3:1

Question 52

If neonatal certainty cardiac arrest then can consider doing ? ratio compression: vent

Answer 52

0.6263888888888889

Question 53

How to perform chest compressions on a neonate?

Answer 53

preferred method for performing chest compressions, the two thumb-encircling hands technique, is as follows: the fingers of both hands encircle the chest and support the back, with the thumbs of both hands placed side by side or one over the other on the sternum, just below the nipple lin 

Question 54

Technique of cpr for neonates 

Answer 54

The preferred method for performing chest compressions, the two thumb-encircling hands technique, is as follows: the fingers of both hands encircle the chest and support the back, with the thumbs of both hands placed side by side or one over the other on the sternum, just below the nipple line (Fig. 159.6).71,72

The depth of compression is one-third the anteroposterior diame- ter of the chest.2 Spontaneous respirations and HR should be assessed every 30 seconds, attempting to minimize interruptions, when possi- ble, with coordinated chest compressions and ventilation continuing until the HR is at least 60 beats/min. 

Question 55

Umbilical vein access complications (2ex) 

Answer 55

infection 
portal vein thrombosis

Question 56

Preferred IO site newborn 

Answer 56

distal femur (midline; ≈1 cm above the superior border of the patella, with the leg in extension) and the proximal tibia (≈2 cm below the tuberosity and 1 cm medially on the tibial plateau 

Question 57

Question 58

When is epi indicated in a newborn arrest?

Answer 58

asystole
persistent bradycardai <60bpm

Question 59

IV bolus dose for neonate?

Answer 59

10mg/kg over 5-10 mins though then also says full term ?20?

Question 60

MC early onset neonatal sepsis bugs?

Answer 60

GBS
ecoli
klebseilla
enterobacter
Listeria

Question 61

How to tx a newborn with abx for early onset sepsis?

Answer 61

amp 10mmg/kg IV + gent 4mg/kg +/- cefotaxime 50mg/kg

Question 62

How to treat neonate for hypoglycemia?

Answer 62

2 to 4 mL/kg of 10% dextrose in water (D10W)/kg as well as starting a continuous infusion of D10W at 80 to 100 mL/kg/ day. 

Question 63

when to repeat a glucose measurement in hypoglcyemia for neonate?

Answer 63

epeat glucose measurement should be obtained 10 to 20 minutes after glucose administration 

Question 64

what vasopressor to use in neonates with signs of shock despite adequate fluid?

Answer 64

dopamine five micrograms per kg 

Question 65

Current NRP guidelines recommend therapeutic hypo- thermia for patients with suspected early neonatal ___

Answer 65

asphyxia

Question 66

1. With most neonatal deliveries, which resuscitative measures are usually sufficient?
a. Administerfluids.
b. Bag-mask ventilation.

c. Intubate.
d. Warm, dry, stimulate, and position.

Answer 66

d

Question 67

4. A nonvigorous and crying newborn is delivered with copious meco-

nium-stained fluid. What is the correct recommended resuscitative measure?
a. Bag-maskventilate.
b. Intubate.

c. Suction at maternal perineum before cutting umbilical cord.
d. Gentle mouth suctioning if needed, followed by warming, dry- ing, and stimulation.

Answer 67

d

Question 68

2. For a term newborn with cyanosis, respiratory distress, and a heart rate more than 100 beats/min, which of the following is not initially

indicated?
a. Apply 100% oxygen.
b. Position airway.
c. Suction.
d. Warm, dry, and stimulate.

Answer 68

a

Question 69

3. In a typical neonatal resuscitation, what is the preferred compres- sion-to-ventilation ratio?
a. 3:1
b. 5:1

c. 10:2
d. 15:2
e. 30:2

Answer 69

a

Question 70

After drying, stimulating, and bag-mask ventilation, what is the next step in resuscitation of a newborn that appears floppy and apneic and with a heart rate of 50 beats/min?

a. Give a normal saline bolus of 20 mL/kg.

b. Give epinephrine (0.1 mg/mL) intravenous (IV) at a dose of 0.1 mg/kg.

c. Intubate.
d. Start with a chest compression-to-ventilation ratio of 3:1.