RESUSCITATION

OF A
NEWBORN INFANT
CHILD

DRUGS USED ON
RESUSCITATION
PROCEDURES
RESUSCITATION OF A
NEWBORN INFANT
NEWBORN AIRWAY (position and clear)
BREATHING (stimulate to breathe)
RESUSCITATION CIRCULATION (assess HR and oxygenation)

The sequence of
resuscitation in
newborns is A-B-C as the
etiology of neonatal
compromise is nearly
always a breathing
difficulty.
 NEONATAL RESUSCITATION

• Series of actions, used to assist newborn babies who have difficulty

with making the physiological ‘transition’ from the intrauterine to
extrauterine life.

• Most newborns are vigorous at birth.

• Approximately 10% will require some assistance at birth to begin

breathing.

• Less than 1% will require extensive resuscitation.

 ASSESSMENT OF NEWBORN AT BIRTH

Cord clamping

• In the compromised newborn, the optimal timing of cord clamping

remains unknown

• The more severely compromised the newborn the more likely it is

that resuscitation measures need to take priority over delayed cord
clamping
 INITIAL ASSESSMENT: APGAR SCORE

• Assesses neonatal well-being & resuscitation.

1-min score  Acidosis and Survival
5-minute score  Neurologic outcome.

• Each variable must be evaluated at 1 and 5 minutes.

INITIAL ASSESSMENT: APGAR SCORE

Virginia Apgar
APGAR SCORE

SIGN 0 1 2

Color Blue Body pink,

Completely pink
(Appearance) Pale extremities blue
Heart Rate
Absent < 100/min > 100/min
(Pulse)
Reflex Irritability
Absent Grimace Cough, sneeze
(Grimace)
Some flexion of Active
Muscle Tone None
extremities movement
(Respiratory
Absent Slow Good crying
Effort)
 INITIAL ASSESSMENT: APGAR SCORE

APGAR Score 8-10

• Achieved by 90% of neonates

• Nothing is required, except

- nasal and oral suctioning
- drying of the skin
- maintenance of normal body
temperature.
 INITIAL ASSESSMENT: APGAR SCORE

APGAR Score 5-7

• Suffered mild asphyxia just before

birth.
- Respond to vigorous stimulation
- Oxygen blown over the face.
 INITIAL ASSESSMENT: APGAR SCORE

APGAR Score 3-4

• These Neonates are moderately depressed at birth.

• They are usually cyanotic and have poor respiratory efforts.

• But they usually respond to BMV, breath, and become pink.

 INITIAL ASSESSMENT: APGAR SCORE

APGAR Score 0-2

• These neonates Severely

asphyxiated and require
immediate resuscitation.
WHICH BABIES NEED RESUSCITATION?
 WHICH BABIES NEED RESUSCITATION?

• If “no,” for any of the assessment questions

• Infant should receive one or more of the following action in

sequence:
1. Initial steps in stabilization
2. Ventilation
3. Chest compressions
4. Administration of epinephrine and/or volume expansion
 WHICH BABIES NEED RESUSCITATION?

(“the Golden Minute”)

• ≈60 sec for initial steps, reevaluating, and beginning ventilation if
required.

• The decision to progress beyond initial steps is determined by

simultaneous assessment of:
▫ Respirations (apnea, gasping, or labored or unlabored
breathing)
▫ HR (whether < 100/min or > 100/min)
 WHICH BABIES NEED RESUSCITATION?

(“the Golden Minute”) cont..

• HR is assessed by intermittently auscultating the precordial pulse.

• When pulse detectable, umbilical pulse palpation provide rapid

estimate and is more accurate than other sites.

• Pulse oximeter takes 1-2 min to apply,

 WHICH BABIES NEED RESUSCITATION?

(“the Golden Minute”) cont..

•May not function during states of very poor CO or perfusion

• Provide continuous assessment without interruption of other

resuscitation measures.
 WHICH BABIES NEED RESUSCITATION?

(“the Golden Minute”) cont..

• Once PPV or supplementary O2 administration begun, assessment

consist of simultaneous evaluation of:
▫ HR, Respirations, and State of oxygenation.

• The most sensitive indicator of a successful response to each step

 ↑ in HR.
 PROBLEMS WITH PRETERM BABIES

1. Immature lungs - difficult to ventilate and also more vulnerable to

injury by PPV;

2. Immature blood vessels in the brain that are prone to hemorrhage;

3. Thin skin & large BSA  Rapid heat loss;

4. Increased susceptibility to infection;

5. ↑ risk of hypovolemic shock related to small blood volume.

 INITIAL STEPS

• To provide warmth by placing the baby under a radiant heat source,

• Positioning the head in a “sniffing” position to open the airway,

• Clearing the airway if necessary with a bulb syringe or suction

catheter,

• Drying the baby, and

• Stimulating respiration.
 INITIAL STEPS

• The baby dried, placed skin-to-skin

with the mother, and covered with
dry linen to maintain temperature.

• Observation of breathing, activity,

and color should be ongoing.
 INITIAL STEPS (TEMPERATURE CONTROL)

•VLBW (<1500 g) preterm babies are

likely to become hypothermic despite
the use of traditional techniques for
decreasing heat loss.
 INITIAL STEPS (TEMPERATURE CONTROL)

Additional warming techniques :

• Prewarming the delivery room to 26°C,

• Covering the baby in plastic wrapping (food or

medical grade, heat-resistant plastic)

• Placing the baby on an exothermic mattress,

• Placing the baby under radiant heat .

 CLEARING THE AIRWAY

When Amniotic Fluid Is Clear (cont..)

• However, suctioning in the presence of secretions can decrease

respiratory resistance.

• Suctioning immediately following birth should be reserved for

babies who have obvious obstruction to spontaneous breathing or
who require PPV.
 CLEARING THE AIRWAY

When Meconium is Present

• Meconium-stained depressed infants are at increased risk to

develop Meconium Aspiration Syndrome (MAS).

• Tracheal suctioning has not been associated with reduction in the

incidence of MAS or mortality in these infants.
 CLEARING THE AIRWAY

When Meconium is Present (cont..)

• “Pea soup" or particulate meconium should be removed from the

lung before breathing is established to improve the survival of
neonates with meconium aspiration.

• Thin, watery meconium does not require suctioning.

• Chest physical therapy and postural drainage done every 30 min

for 2 hrs and hourly thereafter for the next 6 hrs may help remove
residual meconium from the lung.
 CLEARING THE AIRWAY

When Meconium is Present (cont..)

• All neonates born after meconium aspiration should be observed for

24 hrs because they can develop Persistent Fetal Circulation
syndrome.

• In the absence of randomized, controlled trials, there is insufficient

evidence to recommend a change in the current practice of performing
endotracheal suctioning of nonvigorous babies with meconiumstained
amniotic fluid.
 RESUSCITATION DRUGS

• Bradycardia is usually the result of inadequate lung inflation or

profound hypoxemia, and establishing adequate ventilation is the most
important step.

• If the HR remains < 60/min despite one minute of adequate

ventilation and chest compressions with 100% O2, adrenaline or volume
expansion or both are indicated.
 RESUSCITATION DRUGS

• IV is the preferred route: UVC is preferable to

intraosseous
• Recommended IV dose is 0.01-0.03
mg/kg/dose; rapid bolus followed by 1ml of 0.9% NS
flush
• Intratracheal dose is higher (0.05 to 0.1 mg/kg);
1:10,000 (0.1 mg/mL); may be considered while IV
access is being obtained; Follow with PPV – Flush not
recommended
• Can be repeated every 5 minutes, if HR remains <
60/min.
 RESUSCITATION DRUGS

• IV is the preferred route: UVC is preferable to

intraosseous
• Recommended IV dose is 0.01-0.03
mg/kg/dose; rapid bolus followed by 1ml of 0.9% NS
flush
• Intratracheal dose is higher (0.05 to 0.1 mg/kg);
1:10,000 (0.1 mg/mL); may be considered while IV
access is being obtained; Follow with PPV – Flush not
recommended
• Can be repeated every 5 minutes, if HR remains <
60/min.
 RESUSCITATION DRUGS

Administration :
Intravenous (recommended)
Endotracheal
Preparation and dosage:
Adrenaline vial 1ml = 1mg (1:1000 solution)
Dilute with NS to make 1:10,000 solution (1ml =
100 mcg)
IV : 0.1-0.3 ml/kg = 10-30 mcg/kg
ET : 0.5 – 1 ml/kg = 50-100 mcg/kg
Give rapidly – as quickly as possible
Can repeat every 3-5 minutes
 RESUSCITATION DRUGS

Volume Expansion

Detection of Hypovolemia

• measuring the arterial BP and

• by physical examination (i.e. pale skin color, have poor capillary refill
time, poor skin perfusion, extremities are cold, and pulses (radial and
posterior tibial) are weak or absent, and temperature).
 RESUSCITATION DRUGS

Volume Expansion (cont..)

• CVP measurements are helpful in detecting hypovolemia and in

determining the adequacy of fluid replacement.

• Normal CVP in neonates is 2-8 cm H2O.

• If CVP < 2 cm H2O, hypovolemia suspected.

 RESUSCITATION DRUGS

Volume Expansion (cont..)

Indications:
Bradycardia not improving with adrenaline
Placenta previa/ Abruption
Volume Expanders:
Normal saline (recommended)
Ringer lactate
Dosage: 10 ml/kg
Route : Umbilical vein
Rate: over 5-10 min , rapid infusion may cause IVH in <30 weeks
babies
 POST RESUSCITATION

• Babies who require resuscitation are at risk for

deterioration after their vital signs have returned to normal.

• Once adequate ventilation and circulation have been

established, the infant should be maintained in, or transferred
to an environment where close monitoring and anticipatory
care can be provided.
 GUIDELINES FOR WITHHOLDING AND
DISCONTINUING RESUSCITATION

• It is based on the physician's experience and desires of the parents.

• In making the decision, the physician must consider the probability

of neurologic damage and chances of a productive, useful life are poor,
consideration should be given to discontinuing all resuscitative efforts.
 WITHHOLDING RESUSCITATION

• It may be considered reasonable, when there have been conditions

with poor outcome (i.e. gestation, birth weight, or congenital
anomalies are associated with almost certain early death or
unacceptably high morbidity is likely among the rare survivors) and
opportunity for parental agreement, (eg <23 wk gestation; BW<400g;
trisomy 13)

• conditions with ↑ rate of survival, acceptable morbidity (with ≥ 25

wks gestation and with most congenital malformations), resuscitation
is always indicated.
 WITHHOLDING RESUSCITATION (cont..)

• Conditions with borderline survival, high morbidity rate and uncertain

prognosis, parental desires concerning initiation of resuscitation
should be supported.
 DISCONTINUING RESUSCITATIVE EFFORTS

• In a newly born baby with no detectable HR, resuscitation are

discontinued if the HR remains undetectable for 10 min.

• resuscitation efforts beyond 10 min with no HR should be considered

if presumed etiology of the arrest, gestation of the baby, and the
parental desire.
RESUSCITATION OF A
CHILD
 BASIC LIFE SUPPORT (BLS)

• It is the life support method used when there is limited access to

advanced interventions such as medications and monitoring devices.

• It utilizes CPR and cardiac defibrillation when an Automated External

Defibrillator (AED) is available.

• It is performed until the emergency medical services (EMS) arrives to

provide a higher level of care.
 BASIC LIFE SUPPORT (BLS)

• In every setting, high-quality CPR is the foundation of both BLS and

PALS interventions.

• High-quality CPR gives the child or the infant the greatest chance of
survival by providing circulation to the heart, brain, and other organs
until return of spontaneous circulation (ROSC).
DIFFERENCES IN BLS FOR INFANTS AND BLS FOR
CHILDREN
BASIC LIFE SUPPORT FOR INFANT
BASIC LIFE SUPPORT FOR CHILDREN