Scenario Overview
A newborn is presented with a heart rate (HR) of less than 100 beats per minute after birth. Initial interventions such as endotracheal intubation (ETT), oxygen administration, pulse oximeter placement, and ECG monitoring have been performed. Despite these measures, the HR continues to drop below 60 beats per minute, prompting further evaluation and resuscitation measures.
Initial Assessment and Management Steps
Perform ABC Evaluation:
A: Airway Management: Ensure the ETT is placed correctly. Verify tube placement by checking for chest rise and bilateral breath sounds.
B: Breathing Support: Initiate positive pressure ventilation (PPV) using 100% oxygen if HR <100 bpm.
C: Circulation: Assess HR via auscultation or ECG.
Assess for Causes of Resuscitation Failure – DOPE Mnemonic:
D: Displaced ETT – Ensure the ETT is in the correct position, around 6-7 cm at the lip depending on gestational age and weight.
O: Obstructed ETT – Suction the airway or replace the ETT if obstruction is suspected.
P: Pneumothorax – Consider needle decompression if pneumothorax is suspected.
E: Equipment Failure – Ensure ventilation equipment is functioning correctly.
Advanced Resuscitation
Administer Chest Compressions:
Indicate if the HR remains below 60 bpm despite effective ventilation.
Technique: Use the two-thumb encircling technique, compressing the lower half of the sternum.
Rate: Perform compressions at a rate of 90 per minute.
Depth: Compress to one-third the anterior-posterior diameter of the chest.
Coordinate with Ventilation: Follow a 3:1 compression-to-ventilation ratio (i.e., 3 compressions followed by 1 ventilation, all within 2 seconds).
Avoid excessive ventilation to prevent hyperventilation, which can decrease cardiac output.
Reassess After 1 Minute of Compressions:
If the HR remains below 60 bpm, continue with compressions and increase ventilation to 40-60 breaths per minute.
Prepare for potential intravenous (IV) access through the umbilical vein (Umbilical Venous Catheter, UVC).
Monitoring Resuscitation Effectiveness – Mnemonic CARDIO
Check for Adequate Resuscitation:
C: Chest Movement – Verify if chest rise is adequate.
A: Airway – Reassess for obstruction.
R: Rate of ventilation – Adjust to 40-60 breaths/min if needed.
D: Depth of ventilation – Ensure deep enough ventilation to cause chest rise, a depth of 1/3 the anterior-posterior diameter.
IO: Inspired Oxygen – Make sure 100% oxygen is being used.
Administration of Medications
If no response to chest compressions and ventilation:
Administer epinephrine via UVC at 0.01-0.03 mg/kg, followed by a flush with normal saline.
Key Considerations for OSCE Exam
Communication: Clearly explain the steps and rationale to the examiner.
Technical Skill: Demonstrate proper technique for compressions, ventilation, and equipment use.
Teamwork and Leadership: Assign tasks to team members, asking questions like "Are we using 100% oxygen?" or "Is the chest moving with ventilation?"
Parental Communication
After resuscitation, update the parents on the situation, explaining the steps taken, current status, and prognosis.
This structured approach aligns with NCPR guidelines and will help ensure a systematic response in neonatal resuscitation scenarios.
Target Oxygen Saturation Levels
1 minute: 60%-65%
2 minutes: 65%-70%
3 minutes: 70%-75%
4 minutes: 75%-80%
5 minutes: 80%-85%
10 minutes: 85%-95%
Initial Oxygen Concentration for Positive Pressure Ventilation
Gestational age ≥ 35 weeks: Start with 21% oxygen.
Gestational age < 35 weeks: Start with 21%-30% oxygen.
This table helps guide the administration of oxygen to newborns during resuscitation to avoid hyperoxia and ensure the gradual achievement of normal oxygen saturation. The aim is to adjust the oxygen concentration based on the infant's age and monitor saturation levels.
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