Lesson 4: CHEST COMPRESSIONS

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1 Lesson 4: CHEST COMPRESSIONS Neonatal Resuscitation Program Slide Presentation Kit The American Academy of Pediatrics is not responsible for any changes or modifications to this program made by the Neonatal Resuscitation Training Team of Latter-day Saint Charities. This program, as modified, may not be distributed in the United States.

2 Chest Compressions Lesson content: Indications for chest compressions Performance of chest compressions Coordination of chest compression with positive-pressure ventilation Stopping chest compressions 4-2

3 Chest Compressions Chest Compressions Temporarily increase circulation Must be accompanied by ventilation Should use 100% oxygen 4-3

4 Chest Compressions: Indications Heart rate remains less than 60 beats per minute (bpm) despite 30 seconds of effective positivepressure ventilation 4-4

5 Chest Compressions: Compress the heart against the spine Increase intrathoracic pressure Circulate blood to vital organs, including the brain Click on the image to play video 4-5

6 One person compresses chest One person continues ventilation Chest Compressions: 2 People Needed 4-6

7 Comparison of Chest Compression Techniques Thumb Technique (Preferred) Less tiring Better control of compression depth 2-Finger Technique Better for small hands Provides access to umbilicus for medications 4-7

8 Chest Compressions: Positioning of Thumbs or Fingers Run your fingers along the lower edge of the rib cage until you locate the xyphoid Place your thumbs or fingers on the sternum, above the xyphoid and on a line connecting the nipples 4-8

9 Thumbs compress sternum Chest Compressions: Fingers support back Thumb Technique

10 Chest Compressions: Tips of middle finger and index or ring finger of one hand compress sternum Other hand supports back 2-Finger Technique 4-10

11 Apply pressure during compression on the sternum, releasing pressure to allow chest recoil and ventilation Chest Compressions: Pressure and Depth Depress sternum one third of the anteriorposterior diameter of chest 4-11

12 Chest Compressions: Compression Pressure and Depth Depress sternum one third of the anteriorposterior diameter of chest

13 Chest Compressions: Technique Duration of downward stroke shorter than duration of release 4-13

14 Chest Compressions: Complications Laceration of liver Broken ribs 4-14

15 Chest Compressions: Coordination With Ventilation Click on the image to play video 4-15

16 Chest Compressions: Coordination With Ventilation One cycle of 3 compressions and 1 breath takes 2 seconds The breathing rate is 30 breaths per minute and the compression rate is 90 compressions per minute. This equals 120 events per minute 4-16

17 After 30 seconds of compressions and ventilation, stop and check heart rate Chest Compressions: Stopping Compressions 4-17

18 Chest Compressions: Heart Rate Remains Less than 60 bpm Check adequacy of ventilation Consider intubation if not already done Insert an umbilical catheter to give epinephrine 4-18

19 Thumb Technique Click on the image to play video 4-19

20 Chest Compressions: 2-Finger Technique Click on the image to play video 4-20

21 Lesson 5: ENDOTRACHEAL INTUBATION Neonatal Resuscitation Program Slide Presentation Kit The American Academy of Pediatrics is not responsible for any changes or modifications to this program made by the Neonatal Resuscitation Training Team of Latter-day Saint Charities. This program, as modified, may not be distributed in the United States.

22 Endotracheal Intubation Lesson content: Indications for intubation Equipment selection and preparation Laryngoscope use and endotracheal tube insertion Determination of tube placement Suctioning meconium from trachea Positive-pressure ventilation via endotracheal tube 5-22

23 Endotracheal Intubation: Indications To suction trachea in presence of meconium when the newborn is not vigorous To improve efficacy of ventilation after several minutes of bag-and-mask ventilation or ineffective bag-and-mask ventilation To facilitate coordination of chest compressions and ventilation To administer epinephrine while IV access is being established 5-23

24 Endotracheal Intubation: Equipment Equipment should be clean, protected from contamination and Supplies 5-24

25 Characteristics of Endotracheal Tubes: Sterile, disposable Uniform diameter (not tapered) Centimeter marks and vocal cord guides helpful Uncuffed 5-25

26 Endotracheal Tube: Appropriate Size Select tube size based on weight and gestational age Consider shortening tube to 13 to 15 cm Stylet optional Tube Size (mm) Weight Gestational Age (inside diameter) (g) (wks) 2.5 Below 1,000 Below ,000-2, ,000-3, Above 3,000 Above

27 Preparation of Laryngoscope: Supplies The correct-sized laryngoscope blade: No. 0 for preterm and term newborns No. 1 for term newborns Check laryngoscope light Adjust suction source to 100 mm Hg Use large suction catheter (greater than or equal to 10F) for oral secretions Have small catheter for suctioning endotracheal tube 5-27

28 Preparation for Intubation Prepare resuscitation device and mask Turn on oxygen Get stethoscope Cut tape or prepare endotracheal tube stabilizer 5-28

29 Assisting During Intubation The assistant for the procedure should Ensure equipment available, prepared Correctly position baby, stabilize head Provide free-flow oxygen Provide suction Hand endotracheal tube to intubator Apply cricoid pressure if asked 5-29

30 Assisting During Intubation The assistant for the procedure should Provide positive-pressure ventilation between attempts Connect endotracheal tube to resuscitation device Auscultate heart rate to assess improvement Auscultate breath sounds and observe chest movement Help secure tube 5-30

31 Endotracheal Intubation: Upper Airway Anatomy 5-31

32 Endotracheal Intubation: Anatomic Landmarks 5-32

33 Endotracheal Intubation: Positioning the Newborn 5-33

34 Endotracheal Intubation: Always Hold the Laryngoscope in the Left Hand 5-34

35 Endotracheal Intubation: Step 1: Preparation for Insertion Stabilize the newborn s head in the sniffing position Deliver free-flow oxygen during the procedure Click on the image to play video 5-35

36 Endotracheal Intubation: Step 2: Insert Laryngoscope Slide the laryngoscope over right side of the tongue Push tongue to left side of mouth Advance blade until the tip lies just beyond the base of the tongue 5-36

37 Endotracheal Intubation: Step 3: Lift Blade Lift the blade slightly Raise the entire blade, not just the tip Visualize pharyngeal area Do not use rocking motion 5-37

38 Endotracheal Intubation: Step 4: Visualize Landmarks Look for landmarks. Vocal cords should appear as vertical stripes on each side of the glottis or as an inverted letter V Applying downward pressure on cricoid may help bring glottis into view Suction, if necessary, for visualization 5-38

39 Endotracheal Intubation: Step 5: Inserting Tube Insert the tube into the right side of the mouth with the curve of the tube lying in the horizontal plane If the cords are closed, wait for them to open Insert the tip of the endotracheal tube until the vocal cord guide is at the level of the cords Limit attempts to 20 seconds Click on the image to play video 5-39

40 Endotracheal Intubation: Step 6: Remove Laryngoscope Hold the tube firmly against the baby s palate while removing the laryngoscope Hold the tube in place while removing the stylet if one was used Click on the image to play video 5-40

41 Endotracheal Intubation Click on the image to play video 5-41

42 Suctioning Meconium via Endotracheal Tube Connect endotracheal tube to meconium aspirator and suction source Occlude suction port to apply suction Gradually withdraw endotracheal tube Repeat intubation and suction as necessary until newborn s heart rate indicates that positivepressure ventilation is needed Click on the image to play video 5-42

43 Suctioning Meconium via Endotracheal Tube Suction for only 3 to 5 seconds as tube is withdrawn If no meconium is recovered, proceed to resuscitation If meconium is recovered, check heart rate No significant bradycardia Reintubate, suction again if needed Significant bradycardia Administer positive-pressure ventilation 5-43

44 Endotracheal Intubation: Checking Tube Position Signs of correct tube position Improved vital signs (heart rate, color, and activity) Breath sounds over both lung fields but decreased or absent over stomach No gastric distention with ventilation 5-44

45 Endotracheal Intubation: Checking Tube Position Additional signs of correct tube placement Vapor in the tube during exhalation Chest movement with each breath Chest x-ray confirmation if the tube is to remain in place past initial resuscitation Direct visualization of tube passing between vocal cords 5-45

46 Endotracheal Intubation: Checking Tube Position The tube is not likely in the trachea if Newborn remains cyanotic and bradycardic No breath sounds over lungs Abdomen becomes distended Air noises over stomach No mist in endotracheal tube Chest not moving symmetrically with positivepressure breaths 5-46

47 Endotracheal Intubation: Tube Location in Trachea 5-47

48 Endotracheal Intubation: Tube Location in Trachea Tip-to-lip measurement Weight (kg) Depth of insertion (cm from upper lip) 1*

49 Endotracheal Intubation: Radiographic Confirmation Correct Incorrect 5-49

50 Endotracheal Intubation: Limiting Hypoxia During Intubation Pre-oxygenate with positive-pressure ventilation (unless intubating to suction meconium) Deliver free-flow oxygen during intubation Limit attempts to 20 seconds 5-50

51 Endotracheal Intubation: What can go wrong during intubation? Laryngoscope not inserted far enough You see the tongue around the blade Advance the blade farther 5-51

52 Endotracheal Intubation: What can go wrong during intubation? Laryngoscope inserted too far You see the walls of the esophagus surrounding the blade Withdraw the blade slowly until the epiglottis and glottis are seen 5-52

53 Endotracheal Intubation: Special Indications Extreme Prematurity Surfactant Administration Suspected Diaphragmatic Hernia A person experienced in endotracheal intubation should be immediately available to assist at every delivery. 5-53

54 Endotracheal Intubation: A person experienced in endotracheal intubation should be immediately available to assist at every delivery. 5-54

55 Endotracheal Intubation: What can go wrong during intubation Endotracheal tube inserted too far Breath sounds heard louder over right side of chest Withdraw ET tube slowly while listening for breath sounds QuickTime and a TIFF (LZW) decompressor are needed to see this picture. 5-55

56 Lesson 6: MEDICATIONS Neonatal Resuscitation Program Slide Presentation Kit The American Academy of Pediatrics is not responsible for any changes or modifications to this program made by the Neonatal Resuscitation Training Team of Latter-day Saint Charities. This program, as modified, may not be distributed in the United States.

57 Lesson content: Medications for Neonatal Resuscitation Indications for medications Indications for placement of umbilical venous catheter How to insert umbilical venous catheter How to give epinephrine When and how to administer volume expanders 6-57

58 Epinephrine Indications Epinephrine, a cardiac stimulant, is indicated when the heart rate remains below 60 beats per minute despite 30 seconds of assisted ventilation followed by 30 seconds of coordinated compressions and ventilation Total = 60 seconds Note: Epinephrine is not indicated before adequate ventilation is established. 6-58

59 Medication Administration Placing catheter in umbilical vein Preferred route for intravenous access 3.5F or 5F end-hole catheter Sterile technique via Umbilical Vein 6-59

60 Medication Administration via Umbilical Vein Insert catheter 2 to 4 cm Note free flow of blood when aspirated Use less depth in preterm newborns Insertion in liver may cause damage 6-60

61

62

63 Epinephrine: Effects, Repeated Dosing Increases strength and rate of cardiac contractions Causes peripheral vasoconstriction Repeat doses should be given via umbilical vein, if possible Repeat dose via umbilical vein if first dose given via endotracheal tube 6-63

64 Epinephrine Administration Dilute 1:1000 concentration to 1:10,

65 Epinephrine: Poor Response (Heart Rate < 60 bpm) Recheck effectiveness of Ventilation Chest compressions Endotracheal intubation Epinephrine delivery Consider possibility of Hypovolemia 6-65

66 Poor Response to Resuscitation: Hypovolemia Indications for volume expansion Baby is not responding to resuscitation AND Baby appears in shock (pale color, weak pulses, persistently low heart rate, no improvement in circulatory status despite resuscitation efforts) There may be a history of a condition associated with fetal blood loss (eg, extensive vaginal bleeding, abruptio placentae, placenta previa, twin-to-twin transfusion, etc) 6-66

67 Blood Volume Expansion Recommended: Normal saline Acceptable: Ringer s lactate 6-67

68 Blood Volume Expansion: Dose and Administration Recommended solution = Normal saline Acceptable solution = Ringer s lactate, Recommended dose = 10 ml/kg Recommended route = Umbilical vein Recommended preparation = Correct volume drawn into large syringe Recommended rate = Over 5 to 10 minutes 6-68

69 Expected Response: Volume Expanders Expected signs of volume expansion Heart rate increases Pulses stronger Pallor lessens Blood pressure increases Follow up if hypovolemia persists Repeat volume expanders (dose 10 ml/kg) 6-69

70 Medication Given: No Improvement 6-70

71 Medication Administration: Alternative Routes Endotracheal tube Intraosseous (more likely in outpatient setting) 6-71

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