Division 5 Special Considerations Operations 152022 Bledsoe et

Chapter 41 Neonatology Bledsoe et al. , Essentials of Paramedic Care: Division V ©

Topics Newborns and Neonates High-Risk Newborn Patients APGAR Scoring Newborn Resuscitation Special Situations Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Introduction Neonate – An infant from the time of birth to one month of age Newborn – A baby in the first few hours of its life, also known as newly born infant Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Term newborn Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006

Epidemiology Approximately 6% of field deliveries require life support. The incidence of complications increases as the birth weight decreases. Approximately 80% of newborns weighing 1500 g (3 pounds, 5 ounces) at birth require resuscitation. Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Antepartum and Intrapartum Determine at-risk newborns by considering antepartum and intrapartum factors that may indicate delivery complications. – Antepartum—before the onset of labor – Intrapartum—occurring during childbirth Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Risk Factors Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006

Pathophysiology Dramatic changes occur within the newborn to prepare it for extrauterine life. Fluid in the fetal lungs will be forced out of the lungs during delivery by compression of the chest and by entry of air into the lungs. Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Factors That Stimulate the Baby’s First Breath Mild acidosis Initiation of stretch reflexes in the lungs Hypoxia Hypothermia Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Hemodynamic changes in the newborn at birth Bledsoe et al. , Essentials of Paramedic

Congenital Anomalies Diaphragmatic hernia Meningomyelocele Omphalocele Choanal atresia Cleft palate Cleft lip Pierre Robin syndrome Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Assessment (1 of 2) Assess the newborn immediately after birth. Ideally, one paramedic attends the mother while the other attends the newborn. Remember—newborns are slippery and require both hands. Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Assessment (2 of 2) Normal heart rate 150– 180 at birth. – Slowing to 130– 140 thereafter. – A pulse less than 100 indicates distress. Normal respiratory rate 40– 60 per minute. Evaluate skin color as well. Use the APGAR score. Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

APGAR Scale Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006

Treatment Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by

Establishing an Airway management is one of the most critical steps in caring for the newborn. Suction the baby’s mouth first, then the nose, to avoid risk of aspiration. Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Position of newborn when first suctioning upon delivery Bledsoe et al. , Essentials of

Suctioning of the mouth using flexible suction catheter Bledsoe et al. , Essentials of

Intubation for removal of residual meconium Bledsoe et al. , Essentials of Paramedic Care:

Stimulate the newborn as required by flicking its feet or rubbing its back— DO NOT spank or vigorously rub a newborn baby! Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Prevention of Heat Loss Heat loss can be life threatening to newborns. Most heat loss results from evaporation. Core temperature can quickly drop 1° Celsius from its original temp. Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

To prevent heat loss… Dry the newborn immediately. Maintain room temperature at 74– 76 degrees. Close all windows and doors. Swaddle the infant in a warm, dry receiving blanket or other suitable material. In colder areas, use water bottles or rubber gloves filled with warm water. Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Dry the infant to prevent loss of evaporative heat. Bledsoe et al. , Essentials

Cutting the Umbilical Cord AFTER you have stabilized the patient’s airway and minimized heat loss, clamp and cut the umbilical cord. Do not “milk” or strip the cord. Apply the clamps within 30– 45 seconds after birth. Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Positioning of the infant before clamping the cord Bledsoe et al. , Essentials of

Clamping and cutting the cord Bledsoe et al. , Essentials of Paramedic Care: Division

The Distressed Newborn The distressed newborn can either be full term or premature. Aspiration of meconium can cause significant problems and should be prevented. The most common problems experienced by newborns during the first minutes of life involve the airway. Of the vital signs, heart rate is the most important indicator of neonatal distress. – A heart rate <60 should be treated with chest compressions. Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Your success in treating at-risk newborns increases with training, ongoing practice, and proper stocking of equipment on board your unit. Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Inverted Pyramid for Resuscitation Bledsoe et al. , Essentials of Paramedic Care: Division V

Resuscitation of the Distressed Newborn Bledsoe et al. , Essentials of Paramedic Care: Division

Positioning the newborn to open the airway Bledsoe et al. , Essentials of Paramedic

Ventilate with 100% oxygen for 15– 30 seconds. Bledsoe et al. , Essentials of

Evaluate heart rate. Bledsoe et al. , Essentials of Paramedic Care: Division V ©

Initiate chest compressions if HR is less than 60 or is between 60 and 80 and is NOT increasing. Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Evaluate heart rate: Below 80—continue chest compressions. 80 or above—discontinue compressions. Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

More Thoughts on the Inverted Pyramid Bledsoe et al. , Essentials of Paramedic Care:

Drying, Warming, Positioning, Suctioning, and Stimulating • Never suction for more than 10 seconds. • Suction first with bulb syringe and use a De. Lee suction trap if meconium is present. • If there is a great deal of meconium, place an appropriately sized ET tube and suction directly from the tube. Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Tracheal Tubes Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006

Endotracheal Intubation and Tracheal Suctioning in the Newborn Bledsoe et al. , Essentials of

Position the infant. Bledsoe et al. , Essentials of Paramedic Care: Division V ©

Insert the laryngoscope. Bledsoe et al. , Essentials of Paramedic Care: Division V ©

Elevate the epiglottis by lifting. Bledsoe et al. , Essentials of Paramedic Care: Division

Visualize the cords. Bledsoe et al. , Essentials of Paramedic Care: Division V ©

Suction any meconium present. Bledsoe et al. , Essentials of Paramedic Care: Division V

Insert a fresh tube for ventilation. Bledsoe et al. , Essentials of Paramedic Care:

Remove the laryngoscope. Bledsoe et al. , Essentials of Paramedic Care: Division V ©

Check proper tube placement. Bledsoe et al. , Essentials of Paramedic Care: Division V

Oxygen If central cyanosis is present, administer supplemental oxygen. If possible, oxygen should be warmed and humidified. Never deprive a newborn of oxygen in the prehospital setting for fear of toxicity. Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Estimating oxygen concentration Bledsoe et al. , Essentials of Paramedic Care: Division V ©

Ventilation Begin positive-pressure ventilation if any of the following is present: – Heart rate less than 100 beats per minute – Apnea – Persistent central cyanosis Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Endotracheal Intubation Endotracheal intubation of a newborn should be carried out in the following situations: – – The BVM does not work. Tracheal suctioning is required. Prolonged ventilation will be required. A diaphragmatic hernia is suspected. Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Use of a bag-valve mask Bledsoe et al. , Essentials of Paramedic Care: Division

Chest Compressions Initiate chest compressions if either of the following conditions exists: – The heart rate is less than 60 beats per minute. – The heart rate is between 60 and 80, but does not increase with 30 seconds of positive-pressure ventilation and oxygenation. Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Finger positions for infant sizes Bledsoe et al. , Essentials of Paramedic Care: Division

Medications and Fluids Most cardiopulmonary arrests in newborns result from hypoxia, so initial therapy consists of oxygen and ventilation. When oxygen and ventilation fail, fluids and medications should be administered. Vascular access can be managed by using the umbilical vein. Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

The umbilical cord Bledsoe et al. , Essentials of Paramedic Care: Division V ©

Neonatal Resuscitation Drugs Bledsoe et al. , Essentials of Paramedic Care: Division V ©

Maternal Narcotic Use May complicate delivery. Shown to produce low birth weight infants. Such infants may demonstrate withdrawal symptoms, such as tremors, startles, decreased alertness, and respiratory distress. Naloxone is the drug of choice for respiratory depression secondary to maternal narcotic use. Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Healthy newborns should be allowed to begin the bonding process with the mother as soon as possible. Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Neonatal Transport Paramedics are called upon to transport a high-risk newborn from one facility to a neonatal intensive care unit (NICU). During transport, help to maintain body temperature, control oxygen, and maintain ventilatory support. Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Neonatal transport isolette Bledsoe et al. , Essentials of Paramedic Care: Division V ©

Specific Neonatal Situations Bledsoe et al. , Essentials of Paramedic Care: Division V ©

Meconium-Stained Amniotic Fluid Occurs in approximately 10– 15% of deliveries. An infant born in the presence of thin meconium may not require treatment, but those born through thick meconium should be intubated immediately. Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Intubating the infant Bledsoe et al. , Essentials of Paramedic Care: Division V ©

Apnea Usually due to hypoxia or hypothermia; other causes include: – – – Narcotics or CNS depressants Weakness of respiratory muscles Septicemia Metabolic disorders CNS disorders Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Diaphragmatic Hernia Most common posterolaterally. A rare condition (1 in every 2200 births). Survival rate is 50%. Do not use BVM; if necessary, provide positive-pressure ventilation via ET tube. Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Head and thorax elevated Bledsoe et al. , Essentials of Paramedic Care: Division V

Congenital Heart Defects – Etiology Environmental factors – Maternal alcoholism – Maternal age >40 years – Maternal insulin dependent diabetes Genetic factors – Chromosomal – Trisomy 21, 18 – Rh incompatibility Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Congenital Heart Defects – Incidence 8 of every 1000 infants born in the U. S. 40, 000 defects per year in the U. S. Ventricular Septal Defect (VSD) 25% Coarctation of the Aorta (COA) 12% Pulmonary Stenosis (PS) 6 -9% Atrial Septal Defect (ASD) 12% Tetralogy of Fallot (TOF) 9% Aortic Stenosis (AS) 8% Patent Ductus Arteriosus (PDA) 12% Transposition of the Great Arteries (TGA) 9% Others 4 -7% Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Acyanotic Heart Disease Left to Right shunts – Oxygenated blood remains in the left heart related to high left heart pressure – Decreased O 2 delivery – Pulmonary edema – Results in ventricular hypertrophy and eventually cardiogenic shock Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Cyanotic Heart Disease Right to Left shunts – Mixing of right and left heart blood Intracardiac (ASD, VSD) Extracardiac (PDA) A greater pressure gradient on the right side of the heart causing a shunt to the left side – Low O 2 saturations (75– 85%) Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Acyanotic CHD Overview Patent ductus arteriosus Atrial septal defect Ventricular septal defect Coarctation of the aorta Aortic stenosis Pulmonary stenosis Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Patent Ductus Arteriosus (1 of 2) Etiology – Congenital rubella syndrome is seen in 60– 70% of PDAs. – Up to 60% of the cases are in pre-term infants if less than 1500 grams. Incidence – ~12% of all CHD More common in females Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Patent Ductus Arteriosus (2 of 2) Bledsoe et al. , Essentials of Paramedic Care:

Atrial Septal Defect (1 of 2) Incidence – Approximately 12% of all CHD – More common in females Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Atrial Septal Defect (2 of 2) Bledsoe et al. , Essentials of Paramedic Care:

Ventricular Septal Defect (1 of 2) Incidence – Approximately 25% of all CHD Most common of all CHD – Often associated with other defects – More frequent in males Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Ventricular Septal Defect (2 of 2) Bledsoe et al. , Essentials of Paramedic Care:

Coarctation of the Aorta (1 of 2) Incidence – Approximately 12% of all CHD Many will have VSD More common in males Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Coarctation of the Aorta (2 of 2) Bledsoe et al. , Essentials of Paramedic

Aortic and Pulmonary Stenosis (1 of 2) Incidence – Aortic stenosis approximately 8% of all CHD – Pulmonary stenosis approximately 6– 9% of all CHD – More common in males Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Aortic and Pulmonary Stenosis (2 of 2) Bledsoe et al. , Essentials of Paramedic

Cyanotic CHD Overview Tetralogy of Fallot Transposition of the great arteries Bledsoe et al.

Tetralogy of Fallot (1 of 2) Incidence – ~9% of all CHD 4 Anomalies – – Ventricular septal defect Pulmonary stenosis Overriding aorta RVH Shunt – Right to Left – Left to Right Assessment – Cyanosis after several months – “TET” spells Sudden increase in cyanosis Irritability Tachypnea – Hypercyanotic spells – CHF and low CO – Arrhythmias Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Tetralogy of Fallot (2 of 2) Bledsoe et al. , Essentials of Paramedic Care:

Transposition of the Great Arteries (1 of 2) Incidence – ~9% of all CHD – More common in males Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Transposition of the Great Arteries (2 of 2) Bledsoe et al. , Essentials of

Management of Congenital Heart Defects Acyanotic defects – Oxygenate. – Provide judicious fluid administration. – Consult medical direction early and as needed. Cyanotic defects – Oxygenate to a target pulse oximeter reading. – Provide judicious fluid administration. – Consult medical direction early and as needed. Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Bradycardia Most commonly caused by hypoxia. Resist the temptation to treat bradycardia in a newborn with pharmacological measures alone. Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Premature Infants …are at a greater risk of respiratory depression, head injury, changes in blood pressure, intraventricular hemorrhage, and fluctuations in fluid osmolarity. Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Other Problems Seizures – May indicate serious illness Fever – Uncommon and may also indicate serious underlying illness Hypothermia – May indicate sepsis Vomiting/diarrhea – May cause dehydration and electrolyte imbalance Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Hypoglycemia Check blood glucose levels (BGL) on all sick infants. – Normal BGL could be as low as 40. Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Cardiac Resuscitation, Post Resuscitation, and Stabilization The incidence of neonatal cardiac arrest is related primarily to hypoxia. Risk factors include: – – – Bradycardia Intrauterine asphyxia Prematurity Maternal drug use Congenital diseases Intrapartum hypoxemia Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Summary Newborns and Neonates High-Risk Newborn Patients APGAR Scoring Newborn Resuscitation Special Situations Bledsoe et al. , Essentials of Paramedic Care: Division V © 2006 by Pearson Education, Inc. Upper Saddle River, NJ