Resident Assessment for Simulation in Healthcare (RASH): Newborn Resuscitation
Date: Examiner: Examinee(s):
CRITICAL ACTIONS / SUSTAIN / IMPROVEAssess infant breathing and tone
Warm, clear airway, dry, stimulate
Determine HR/breathing difficulty
PPV for HR < 100, breathing issues
Apply SPO2 monitor
Reassess after 30 sec PPV
Chest compressions for HR < 60
Consider intubation
Place umbilical line
Give epi at proper dose/route
Debriefing Phases
1. Reaction—Blow off steam
2. Teaching—Follow critical actions to guide teaching using effective feedback techniques
3. Summary— What did you do well? How will you improve next time?
Rudolph JW et al. Debriefing as formative assessment: closing performance gaps in medical education. Acad Emerg Med. 2008 Nov;15(11):1010-6.
Didactic Material/Key Teaching Points
1. 90% of infants without any transition issues, 10% require some intervention (ie-PPV), 1% require extensive resuscitation (ie-chest compressions/epi).
2. Be prepared! Ensure EVERY delivery has at least one provider in the room who is NRP certified and capable of performing PPV, chest compressions, intubation and placement of an umbilical line with admin of meds. Ensure ALL equipment is available and working properly (ideally) before the infant is delivered. Check: warmer is on and warming, O2 is on and flowing, suction is working, laryngoscope is functional/bright, ensure resus bag/neopuff working w/adequate pressure.
3. NRP has evidence of improving infant outcomes (ie—better 5 min Apgar scores, dec admissions to NICU, etc.).
4. Risk factors for high-risk deliveries: maternal (age >40<16, poor SE status, smoker, drugs, diabetes, HTN, PROM, infections, previa); fetal (pre/post maturity, IUGR, macrosomia, multiple gestation, congenital anomalies); during birth (premature labor, prolapsed cord, abruption, breech, chorio, meconium, instrumented delivery, narcs to mother within 4 hrs of delivery).
5. Perform a rapid assessment:
a. Is the infant full-term?
b. Is the infant breathing or crying?
c. Does the infant have good muscle tone?
If yes, then no resus is needed and infant can be handed to mother and receive routine neonatal care. If the answer to any of these is no, then modified ABCD’s are performed.
a. Initial steps (provide warmth, clear Airway if necessary, dry, and stimulate)
b. Breathing (ventilations)
c. Chest compressions
d. Admin of Drugs such as epinephrine and/or volume expansion
6. Essentially infant is assessed and reassessed at 30 sec intervals and if not improving then proceed to the next step of the ABCD mnemonic. Once infant has spontaneous respirations AND a HR >100, resus efforts can be stopped.
7. One should monitor O2 sats with a pulse ox for any infant in distress. Normal to be in the 70-80% range for the 1st few minutes after birth. See chart below for target O2 sats. Attach to preductal location on the right upper extremity (wrist or palm) ASAP.
8. Apgar scores should NOT be used to guide resus, but can still be helpful to assess overall status. Take a 1 min, and 5 min then every 5 min up to 20 min if score remains < 7.
9. Warmth: dry with warm towels, place on radiant warmer. Use servo control of warmer via application of temp probe to infant’s abdomen with goal of temp at 36.5 (for term infant). Other methods: skin to skin, blankets, plastic bags, etc.
10. Airway: position infant to keep airway open. Consider rolled towel under infant’s shoulder to slightly extend neck. Suction mouth first then nares if infant in distress/obstructed. NO routine suctioning of meconium in vigorous infants!!
11. Stimulation: initiated promptly after birth. Safe methods: warm, dry, suction; flicking soles of feet; rubbing infant’s back.
12. Supplemental O2: 100% O2 is NOT required or recommended. Should start with blended O2. If not available, then start with room air! O2 concentration then adjusted to achieve target SpO2 via pulse ox monitoring listed in table below. HOWEVER, if HR < 60 after 90 sec or chest compressions being administered, use 100% O2 until infant HR > 100.
13. PPV: required if infant is gasping or apneic OR if HR<100 via auscultation or palpation of umbilical stump.
a. Self inflating bag, flow inflating bag (anesthesia bag), T-piece (Neopuff), LMA.
b. Ensure proper mask size and tight fit (“E”, “C” hold).
c. Initial pressure may require 30-40 cm H20 to inflate lungs.
d. Rate is 40-60 times/minute to achieve HR > 100.
e. TV goal is 4-5ml/kg and PEEP of 4-5cm H20.
f. Reevaluate breathing effort and HR every 30 sec.
g. Consider CPAP in preterm infants
14. Intubation: usually NOT necessary. Ensure proper ET tube sizes and depth. See NRP book table, Tochen’s rule, or app.
Indicated for:
a. Meconium suctioning in non-vigorous infants
b. BMV is ineffective or prolonged
c. Chest compressions are being performed.
15. Chest compressions: initiate for a HR < 60 AFTER 30 sec of PPV. Thumb technique or 2 finger technique acceptable but thumb encircling technique is preferred. Depress to depth of 1/3 of the AP diameter of the chest. Must always be accompanied by PPV. Compression rate is 90 per min with 30 ventilations---1 breath for every 3 compressions ratio. Reassess after 30 secs.
16. Drugs: rarely required. However if HR remains < 60 despite adequate PPV and chest compressions, then epi should be given.. Epi dose is 0.01-0.03 mg/kg IV of a 1:10,000 (0.1 mg/ml) solution. IV is always preferred to ET tube for epi. Repeat epi dose every 3-5 min. Also can consider volume expansion (10 ml/kg bolus of NS IV over 5-10min). Narcan use is NOT recommended.
17. Vascular access: meds should be given IV! Umbilical vein is the route of choice. Aseptically insert to a depth of 2-4cm.
18. If NO response, consider: meconium blockage, airway malformations, pneumothorax, diaphragmatic hernia, hyaline membrane dz, congenital heart dz, heart block, brain injury, resp depression from maternally administered narcotics. Consider discontinuation of efforts if no heart beat or resp effort after 10 min of resus.