10% of all newborns require some assistance breathing at birth o 1% require extensive resuscitative measures Rapid 4 characteristic assessment

upon birth o Meconium or not o Full-term o Respiration or cry o Muscle tone If answer to ALL 4 is yes, nothing else If answer to ANY is NO, must do A, then B, then C, then D Reanimation A) initial steps in stabilization o Warmth o Position o Aspiracion o Secar o Estimular Ventilacion Masaje cardiac Administrar epinefrina y/o expansores + intubacion Observation of breathing, FC, and color should be ongoing these are what we evaluate to decide whether we go from A-B , or B-C, etc. People o Person: initiate resuscitation, including ventilation and masaje o 1st or 2nd person: a complete resuscitation capability, including intubation and medication administration Pre-term = <37 SDG o Lungs harder to ventilate, more susceptible to damage o Immature blood vessels prone to hemorrhage o Thin skin and large surface area contribute to rapid heat loss o Increased susceptibility to infection o Increased risk of hypovolemic shock caused by small volumen circulante Initial steps A o Temp control Very low birth weight infants (>1500 g) preterm babies are likely to become hypothermic, so additional heating techniques are recommended Covered in plastic wrapping and placing under radiant heat Monitor temp closely to avoid hyperthermia o Posicion Aspiracion de Meconio o ET intubacion se recomienda inmediatamente seguiendo posicion de los pasos iniciales, si el RN no es vigoroso (no llanto, no tono muscular, FC <100), con succion mientras

retirar la sonda (use tube according to birth weight and/or SDG) 2.5, 3, 3.5, 4.0 (sondas are double the size if you need one, estiletes are ______________________? o RN vigorosos no mas requieren O2 libre, si hay cianosis pero respiracion y FC > 100 Revision de color, esfuerzo respiratorio, FC cada 30 minutos o Jaleo, apnea se indica necesidad ventilacion, mientras si sube o baja la FC nos puede indicar evidencia de mejora o empeora Healthy babies at term may take >10 minutes to achieve preductal ox sat of 95% and 1 hour for postductal sat of >95% o Central cyanosis = face, trunk, mucous membranes o ACrocyanosis = feet and hands only NORMAL finding at birth, therefore not a reliable indicator of hypoxemia but may indicate cold stress o Pallor, piel marmoeada may be sign of decreased cardiac output, severe anemia, hypovolemia, hypothermia, acidosis Positive-pressure ventilation: o If apnea or gasping, if FC <100 30 seconds after administering initial steps, or if we have persistent central cyanosis despite administration of supplementary oxygen, start ventilation o Initial breaths and assisted ventilation Term infants: initial ventilations (first 2 with all of hand)/inflations create an FRC The initial pressure average initial peak inflating pressures of 30-40 cm H20 usually successfully ventilate unresponsive RN At rate of 40-60 / minute (20-30 in 30 seconds) **primary measure of adequate ventilation is prompt improvement in FC, and **chest wall movement should be assessed if no improvement is made (check steps to move towards ventilacion ineficaz, if chest if not moving) Want to promptly achieve FC >100 x o Devices Ventilation options Self-inflating bag T-piece o Valved mechanical device used to control flow and limit pressure Flow-inflating bag Laryngeal mask near-term and full-term infants o Assisted ventilation of pre-term infants The inclusion of PEEP protects against lung injury and improves lung compliance and gas exchange Most apneic pre-term infants are ventilated with an initial inflation pressure of 20-25 cm H20

ET Tube Placement When suctioning meconium is needed Ventilacion ineficaz Ventilacion prolongada Medications (adrenalina, surfactant) Congenital diaph hernia or birth weight <1000 (extremely low BW) *Chest compressions performed**? Prompt increase in HR is the best indicator the tube is placed to provide effective ventilation; Exhaled CO2 detection is effective in infants No CO2 = esophageal intubation ET tube placement must be assessed visually during intubation and by confirmatory methods after intubation if the HR remains low and is not rising Chest compressions o Indicated for FC <60 despite adecuate ventilation with supplement O2 for 30 seconds o **B/c ventilation is the most effective action in neonatal resuscitation, ensure that ventilation is being delivered b4 starting chest compressions** o Lower 1/3 esternon; profundidad 1/3 diametro antero-posterior Two tecnicas Mejor is 2 dedo pulgares con manos encirculando b/c genera mejor presion y tiene mas control The 2-dedo solo metodo se recomienda cuando hay sola una persona, o cuando necesitamos aceso a umbilicus Slightly shorter compression/systole than relaxation/diastole 3:1 compressions por ventilaciones 90 compressions and 30 breaths to achieve 120 events per minute so each event = .5 seconds, with exhalation occurring during first compression after each ventilation Medications o Bradycardia: inadequate lung inflation or profound hypoxemia, so establishing adequate ventilation is the most important step to correct it o If HR stays <60 despite adequate vent with 100% oxygen and chest compressions, admin of adrenalina o expansores may be needed Adrenalina IV best method .01-.03 mg/kg per dose; if you dose around .1 mg/kg IV you can cause paro b/c of increased myocardial oxygen demand o Use .1 ml of adrenalina and .9 of ss0.9% in a 1 ml insulin syringe While IV access is being obtained, you can give up to .1 mg/kg in a 10 ml syringe through the ET tube Concentration we have to use is 1:10,000 (.1 mg/mL) Expansores

Choque signos y sintomas o Isotonic cristalloide preferable o 10 mL/kg; but be careful in premature infant giving too rapidly b/c can cause intraventricular hemorrhage Naloxone IV or IM; .1 mg/kg Only give if moms fentanyl during delivery caused resp depression in baby Withholding resuscitation o Almost certain early death with unacceptabley high mortality resuscitation not indicated (extreme premie <23 SDG or birth weight <400 g), anencephaly, trisomy 13 o High rate of survival and acceptable morbidity, resuscitation always indicated (SDG >= 25) and those with congenital malformations o Borderline cases should go with parental decisions Discontinuing o Infants without signs of life (no FC, esfuerzo resp) after 10 minutes of resuscitation have high mortality or severe neuro issues; so, discontinuation after 10 minutes may be justified if there are no signs of life. 90% RN OK sin ningun ayuda Ventilar pulmones con 02 lo mas importante Evalular, dedicir, actuar Categorias de accion a. Pasos inciales b. Ventilacion c. Compressiones, masajes toracias d. Adrenalina y/o expansores (Intubacion puede interferir in cualquier categoria) 68% O2 in utero; T d P 38% - so coming out cyanotic is normal; we evaluate color AFTER pasos iniciales

1) 2) 3) 4)

5) Primeras respiraciones son muy importantes y tienen que ser por lo menos 30-40 cm H20 para expulsar liquid alveolar y para ayudar a los arterioles dilator 6) Factores de Riesgo para Hipoxia a. PN: glicemias, oligo y poli, edades extremas, anemia maternal, SLE/systemic, embarazo multiple, enfermedad maternal (infeccion, DM, hipotiroidismo, IVU aguda) b. N: malformacion; pre- o post-madurez c. Post natal: aspiracion meconio y **Hipotermia d. T d P prolongado, T d P precipitado, Anestesicos generales, DCP, distocicos, hipertonia o atonia uterine, DPPNI

i. Asfixia leads to Apnea (which does NOT equal respiraciones irregulares) 1. Triada: Cianosis, Bradicardia, >15 segundos 2. Apnea a. Primaria: causada por hypoxia leve y corto; despues de primeros pasos OKo, si tiene que pasar a B, ya es secundaria b. Secundaria: quizas continuacion de primaria o ya in utero hypoxia 7) Equipo a. Fuente de calor (cuna de calor radiante ideal) b. Campos esteriles (4) c. Aspiracion i. Perilla de Hule (#5) must check for holes, fissures, esteril ii. Aspirador meconio iii. Sondas de aspiracion 5fr 12 fr (8 fr = K-31 = alimentacion) 1. Increase # increase diameter iv. Sonda de alimentacion 8fr v. Estetoscopio neonatal d. Ventilacion i. Bolsa y mascara con reservoirio (only for term) ii. Fuente de oxigeno con linea w/ 2 extremos (smooth end for baby) e. Intubacion i. Canulas endotraqueales (2.5, 3, 3.5, 4 diameter and length larger as number larger) ii. Tijeras de mayos rectos o omfalotomo iii. Laringoscopio / hojas rectas 0 = preterm; 1 = term; 00 = extreme preterm iv. Jeringas: 20, 10, 5, 1 mL v. Estilete vi. Pilas y focos vii. Extra: guantes, ligadura o umbilipinza, canalize stuff (yelcos, punzocats) f. Meds i. Adrenalina 1:10,000 ii. Cristaloide iii. SS0.9% iv. D10W v. Naloxona vi. H2CO3 8) Steps to Set up a. Encender cuna de calor (15-20 minutos antes) b. Ask for campos y guantes i. 1st campo over colchon ii. 2nd rolled up for Rosiere iii. Over roll tuck in

9)

10)

11) 12) 13)

iv. Used for receiving put on bed c. Check all material and leave by colchon: Tijeras, umbilipinzas, y perilla i. Let them fall; ask for scissors from nurse d. Lavado Ox e. Bata esteril, nuevos guantes f. Look to see head put 4th campos ready g. Observe while birthing your 4 things to see if reanimation is necessary ** A Pasos Iniciales ( 5 steps, 30 seconds maximum) a. Calor b. Posicion c. Perilla (comissura hacia cheek, then nose) d. Secar and remove campo humedo e. Estimular f. Evaluate: FC>100 OK (measure over 6 seconds); ER bien (llorar, elevar torax); color i. O2 flujo libre = 3-5 L / minute 1. Cianosis only is an indication (for first evaluation after pasos inciales) B if no ER, or FC is <100, automatic ventilation for 30 seconds; if just cyanotic try flujo libre first a. If, after B, FC<60 = ventilacion + masaje for 30 seconds b. If, after C, FC still <60 = intubar + adrenalina + ventilacion If we have F d R of infant for hypoglycemia that is not responding to our reanimacion, take a DxSx and for <40 mg/dL give bolo IV of 2 ml/kg peso If 3:4 things: Meconio, FC low, FR low = nino no vigoroso = intubate immediately and aspirate while withdrawingup to 2 timesfollow with nose aspiration **any times you have ventilated and they recover, you MUST give flujo libre de O2 while stabilizes

1) Ventilacion a. Partes de la bolsa auto-inflable b. 5-10 L / minute por la saliente estrecha + reservoirio = 100% O2 i. Pre-termino we only want 40% = sin reservorio (give 3 ciclos with 40% and if not OK, raise to 100%/put on reservoirio) c. Cada yema de dedo aplica 5 mm Hg presion / ml flujo / cm H20 i. We want for every 1 kg peso / 5 ml flujo (1 yema) 1. More than this = neumotorax: #1 cause of neumotorax iatrogenica en reanimacion o atelectrauma, biotrauma, o etc. d. Aparato en T con valvula nos da presion positive despues de espiracion para prevenir ese dano e. Valvula de seguridad/liberacion nos ayuda en prevenir dano por presiones aplicadas >30-40 cm H2O

i. 30-40 is what is required to liberate liquid from alveolus must use all 5 fingers / all hand for first two breaths unless premature (use all 5 yemas) f. Mascara anatomica i. SIZE: 00= preemie extreme; 0=preemie; 1 = term ii. Mask desde la barba hacia la nariz and hold it down g. Never cover thorax witih bolsa or hands b/c we must look for slight elevation h. Give 1, 2-3; 2, 2-3; 3, 2-3; etc. for 20 cada 30 segundos say out loud i. If thorax does not elevate i. 1ST: mask put on right ii. 2nd: obstruccion por secrecion o mala posicion de rosier 1. Put back in position 2. Check for obstruccion if necessary iii. 3rd: patologia requiere presion aumentada o bolsa defectuosa 1. First, close valvula de seguridad and try again a. Neumotorax b. Memb hialina c. Mom fentanyl d. Hemorragia pulmonary 2. Then, probably have defective bag iv. SOOOOO Ventilacion Ineficaz = INTUBATE j. Mientras >60, <100, keep ventilating k. After 2 cycles of ventilating must aspirate stomach with 8 fr NG sonda i. Nose-lobe; lobe-xifoid ii. Insert iii. Jeringa de 20 to aspirate; take off iv. Leave in sonda but in commissure!! v. Ventilate now vi. If still <100, ventilation prolongada = INTUBATE 2) Cardiac Massage a. Steps i. Site: entre apendice, xifoideo, y linea intermamaria (1/3 inferior del esternon) ii. Never take away fingers from site iii. Profundiad: 1/3 AP diameter iv. Coordinate with ventilation (3 compressions : 1 ventilation) = 1 ciclo de eventos por cada 2 segundos b. Complications i. 1st: fx costillas ii. Hepatic laceration 2nd (if take away fingers from site once you find it) c. 1 y, 2 y , 3 y 3) Once intubated and ventilating, you must review every 30 seconds while still ventilating 4) If no response once intubated + signs of choque = choque = pass expansores a. 10 ml/kg peso 5-10 minutos IV

5) If still no response, acidosis = H2CO3 a. 2 mEq/kg peso 6) May check sugar and admin D10W 2 mL/kg bolo IV over 5-10 minutos Intubacion 1) Equipo a. Laringoscopia (with hojas rectas #1 term; 0 prem; 00 prem extreme) b. Tubos endotraqueales/canulas (2.5, 3, 3.5, 4) i. Estilete: ask for # double the canula ii. I think sonda to go inside is size of canula c. Carnografo: CO2 monitorbest thing to monitor if tube is placed correctly i. FC also d. Sondas de aspiracion (5fr 12 fr) e. Rollo de tela micropor f. Tijeras g. Canula de Guedel: to maintain via aerea permeable h. Aspiracion de meconio i. Esteto, bolsa autoinflable, foco, pilas 2) Laringo a. Mango (grossor variable) i. Foco en cabeza de mango ii. Cuello (estrechamiento entre mas cerca del cuello, tenemos mas control) iii. Hoja goes in cilindro (vertical) and push it out from the bottom iv. Mango not esteril, but if we have disposable plastic ones we can use those v. Luz must be blanco y brillante vi. Never leave laringo open close with bland surface vii. Always leave on left side b/c we grab it with left hand 3) Mascarilla laringe: no tube in traquea 4) Canulas / ET tubes (2.5, 3, 3.5, 4) a. Never open til you intubate i. Must ask nurse to present it to you ii. Leave on right of patient b. Higher #, higher diameter and length c. Punta negra: guia de cuerdas: its designed to stop exactly 1.5 cm above the bifurcation i. If goes deeper = neumotorax on that side, atelectasia on left ii. If no black point, look for medida punta labio 1. Peso + 6 d. Never use canula with globo 5) Rectificacion that its OK position: steth for well ventilation, CO2, FC improvement, or RX of control is last resort If its already in place 6) Indications to Intubate (premature is NOT an indication)

a. b. c. d.

Aspiracion traqueal (meconio, pasos iniciales) Ventilacion ineficaz (AL INICIO DE VENTILACION) Ventilacion prolongada (despudes de 3 ciclos with FC still <100) Admin meds (prem extreme surfactant, adrenalina (once youve already done cardiac massage and FC still <60) must intubate first before giving adrenalina) e. Hernia diafragmatica congenita i. Morgagni's hernia: esofago ii. Bochdalek hernia: postero-latera 1. Most severe; hipoplasia pulmonary 2. Do pasos iniciales first, then reevaluate a. If FC OK (>80) but cyanotic and FR is low intubate b. If FC very very low <80, cannot intubate yet b/c youll

cause paro; must put in sonda 8fr, aspirate, give ciclo presion to increase FC, then intubate
7) Tamano del tubo a. 2.5; <1000; <28 SDG b. 3.0; 1000-2000; 28-34 c. 3.5; 2000-3000; 34-38 d. 4; >3000; >38 e. Divide SDG / 10 to get closest canula but if weight is not proportional to SDG, can adjust up or down 1 based on the weight 8) Anatomy a. Epiglottis = ondulando b. Valecula: fondo de saco entre lengua y epiglottis where you introduce hoja recta and pull towards feet c. If you see all RED = esofago d. Must be behind epiglottis in valecula to intubate 9) Complicacions a. Hypoxia (shouldnt taken longer than 20 seconds) b. Bradicardia/apnea reflejo vagal c. Neumotorax: if we get to right bronquio of ir all hand squeezing bag d. Contusion/laceracion: if secretions are blocking view, ask for sonda aspiracion (1/2 size of canula?? Or double? 5fr 12 fr) i. Never pega al labio superior ii. PUT IN CANULA FROM SIDE/COMISSURE e. Perforacion traqueal/esofagica f. Obstruccion = hipersecrecion in tubo; take out ventilator and ask for sonda size of canula?? g. Infeccion: must give antibiotics to everyone h. When take out, always aspirate extubation

Medications 1) Adrenalina: primera eleccion a. Ino+, crono+, VC perif, VD pulm y cerebral b. Increases VO2 en miocardio and can cause paro, therefore, we must intubate first c. Ampulas: 1:1000 (mex) and 1:10000 (mg:ml) d. .01 - .03 mg/kg/dosis == .1 ml/kg/dosis i. Dilute in 1 ml tube (.1 (.1 ml) adrenalina, .9 (.9ml) ml fisiologica) insulin syringe ii. If ET, give 10X dosis (1 ml/kg peso in 10 ml syringe) e. Best way is IV f. .30 1 minute tardia la accion (do masaje cardiac y ventilacion mientras) g. You can give it 3 times ET or IV, but must wait 3-5 minutes to give again h. Indication: Fc<60 post masaje cardiac or paro/asistolia post massage cardiac i. IF KID DOESNT RESPOND TO ADRENALINE CHOQUE 1. Expansores de volumen (fisiologica, LR, sangre O -) 10 ml/kg IV over 510 minutes 2. If DOESNT RESPOND = ACIDOSIS (give bicarb) a. Dosis: 2 mEq/kg/dosis i. 4.2% = .5 mEq/ml (if baby is 3 kgs, we give 6 mEq = 12 ml) ii. Can also use 7.5% (1 mEq/ml) b. Presentation: ampulas de 10 ml c. Pass 2 ml/minute 2) Naloxona a. .1 ml/kg/dosis IV or IM b. Comes in ampulas de .2 mg/ml c. D10W (D10W 2 mL/kg bolo IV over 5-10 minutos) 1) When we dont see trachea very well, we need to do maniobra de Sellick