EM Basic - Neonatal Resuscitation Program (NRP) 2.

Airway – Open airway and Clear secretions

Authors: Azif Safarulla MD, Jessica Gancar MD, George Hsu MD, Daniel McCollum MD.  Shoulder roll to open up airway and maintain sniffing
©2019 EM Basic LLC, Steve Carroll DO, and the authors above. May freely distribute with proper attribution
position
Scenario  8 – 10 Fr Suction catheter set to 80 to 100 mm Hg
- Pregnant mother in labor and en route to ER negative pressure
- Delivery is imminent  Bulb suction

Approach
3. Breathing – Provide ventilatory support
 Self-inflating bag or T piece resuscitator, set at PEEP of 5
Multidisciplinary team approach – ER, OB and NICU teams. Timely
notification of other teams is key. and Peak inspiratory pressure of 20 cms of H2O, adjust
Know your setting in terms of resources, pediatric tertiary care centers, flow rate to 10 LPM.
distances and mode of transport available if needed.  Mask (Appropriately sized to cover mouth and nose)
 Set FiO2, 21% for ≥ 35 week and 21 - 30% for <35 week
Initial Questions – Allows team to prepare appropriately  Orogastric tube to decompress abdomen
 One baby or multiple so as to decide on number of personnel  Endotracheal tube – 2.5, 3.0, 3.5 size
needed for stabilization.  Blade – Miller 00, 0 or 1
 Term or preterm, equipment chosen will vary depending on  CO2 detector
gestational age (GA)
 Pulse ox probe (Applied to right wrist for preductal
 Relevant maternal serology
saturations)
 Rupture of membranes? If yes, is fluid clear, bloody or
meconium stained.  EKG leads

Key difference in NRP: Ventilation is key. Still follows airway (A), 4. Circulation – Hemodynamic support
breathing (B), circulation (C) sequence compared to C-A-B sequence in  Umbilical venous catheter – 3.5 or 5 Fr
PALS and ACLS.  Insertion kit – cord tie, scalpel, forceps
 Epinephrine (1:10000 concentration)
IMPORTANT STEPS – Prepare for the worst case scenario  Normal saline

1. Initial Stabilization – Thermoregulation 5. Miscellaneous

 Warmer which is turned ON (Normal temperature is 36.5
 Pre resuscitation briefing
to 37.5⁰C)
 Assign roles to team members
 Warm towels and hat (Neonates have high surface area
and lose heat rapidly)  Team Include – Leader, Respiratory therapist, Auscultator
 Neowrap (for <32 week GA) (HR and breath sounds), Compressor, Line insertor, Meds,
 Transwarmer Recorder
 Closed Loop Communication
Once Baby is delivered, initial questions to be asked Intravenous access – Umbilical venous catheter
 Appears Term/Preterm  Think about placement once compressions started
 Respiratory effort – Crying/gasping/none  Clean and not sterile procedure
 Tone – Flexor (good) / extensor (bad)  Insert catheter till blood return obtained (around 4-5cm)
 Drugs given – Epinephrine, normal saline and dextrose
Ventilation is KEY. Airway – Breathing – Circulation sequence  Dose of epinephrine – 0.1 ml/kg for IV and 1ml/kg via
endotracheal route.
Objective measure of success of resuscitation - Heart Rate
Debrief
Heart Rate targets  VERY IMPORTANT, only way to get feedback and improve.
 ≥ 100 bpm - Resuscitation going well
 ≥60 and <100 bpm – needs positive pressure ventilation
 < 60 bpm – Needs Chest compressions in addition References:

Time intervals for monitoring Heart rate 1. American Academy of Pediatrics and American Heart
 Every 30 seconds Association. Textbook of Neonatal Resuscitation (NRP). 7th ed.
 Extends to 60 seconds when chest compressions ensue Chicago, IL: American Academy of Pediatrics (2016)
2. Ringer SA, Aziz K. Neonatal stabilization and postresuscitation
care. Clin Perinatol. 2012;39:901–183.
Targets for Oxygen Saturation (Preductal) 3. Perlman J, Kattwinkel J, Wyllie J, Guinsburg R. Velaphi S; Nalini
 60% within the 1st minute of life Singhal for the Neonatal ILCOR Task Force Group. Neonatal
 Takes around 10 minutes to reach 90 – 95% sats resuscitation: In pursuit of evidence gaps in knowledge.
Resuscitation. 2012;83:545–50
Corrective measures for improving ventilation 4. Kamlin CO, O’Donnell CP, Davis PG, Morley CJ. Oxygen
 M Adjust Mask to cover mouth and nose saturation in healthy infants immediately after birth. J Pediatr.
 R Reposition airway 2006;148:585–9
 S Suction mouth then nose 5. Remick, K., Gausche-Hill, M., Joseph, M.M. et al, Pediatric
 O Open mouth readiness in the emergency department. J Emerg
 P Pressure increase Nurs. 2019;45:e3–e18
6. Cincinnati Children’s Hospital UVC Placement on Sim Newbie
 A Alternate Airway
(Contact: steve@embasic.org)
If HR < 60 bpm, Compressions start
 Compressions and breaths coordinated at 3:1 ratio
Thermoregulation Endotracheal tube and Blade size

Sniffing Position Target Oxygen Saturations