Written by: Aaron Wibberley, MD (NUEM ‘22) Edited by: Vidya Eswaran, MD '20 Expert Commentary by: Spenser Lang, MD
Expert Commentary
Thanks to Dr. Wibberley and Dr. Eswaran for providing this infographic on a tough topic – neonatal resuscitations.
Usually, deliveries in the emergency department cause a dichotomy of emotions – initial anxiety, then relief and happiness. Most of our deliveries tend to be quick, precipitous, with hopefully just enough warning for us to grab gloves and remember where the baby warmer is. Unfortunately, when babies decide to struggle with their first few minutes of life, this becomes a lot more stressful for everyone.
Fair warning – though I am an emergency medicine physician, and prepared to deal with emergent situations of any age, I think there are very few of us who feel as comfortable with neonatal resuscitations as we do with critically ill trauma or cardiac arrest patients. Especially if your department sees very little pediatrics, it is completely normal to feel anxiety when imagining resuscitating a neonate, and even more so a pre-term baby. This is OK! In fact, this should motivate you to get familiar with NRP, and provides a perfect opportunity for spaced repetition throughout your career to enhance recall.
Here are my broad strokes steps for a fresh neonate requiring resuscitation.
#1: Know your resources! The first step in managing a neonatal resuscitation occurs far before the patient shows up in your department. Where is your baby warmer? Where are your teeny-tiny BVM’s? What’s the smallest ETT and intubating blade you stock, and where? I promise you, the hardest part of intubating this baby won’t be the actual mechanics of placing an ETT – it will be in the preparation and supply gathering. Don’t rely on your nurses to know everything when seconds count – know where this stuff is yourself.
#2: Call for help, early and often. Many emergency departments have some type of OB/imminent delivery response – hopefully this brings in a pediatrician well trained in neonatal resuscitation as well. Hopefully, this also brings a nurse who is used to placing IV’s in these itty bitty babies. If this doesn’t describe your hospital, call to start the transfer process, and move on to #3…
#3: Dry and stim. Nearly all babies respond to drying and stimulation. Please don’t start bagging a poor newborn before drying it off and giving it a good rub for 30-60 seconds (unless it’s extremely pre-term – try to avoid rubbing all the skin off of a 25-weeker, this is bad form.) At the same time, keep in mind that these babies will need some form of external thermoregulation so make sure the warmer is actually functioning.
#4: When in doubt, fix the breathing. As is obvious when scanning through NRP guidelines, 95% of managing a sick newborn lies in assisting the respirations. Poor tone? Fix the breathing. Initial HR below 100? Try to fix the breathing. Poor color? You get it. Don’t be afraid to escalate from blow by, to PEEP, to BVM. If the baby has little to no respiratory effort, a couple initial breaths via BVM can quickly improve the situation. But please, when you’re bagging a tiny neonate, use small breaths – this is not the typical 120 kg patient we are used to.
#5: In the short term, an IO is your friend. A UVC is golden, but not really possible in an active resuscitation. The good news is that most babies don’t need IV access in the short term – for my reasoning, see #3 and #4. The literature suggests that placing the neonatal IO in the proximal tibia, distal tibia, or distal femur can be safe and effective.
#6: This is the time to debrief. Whether a happy or a tragic ending, this is a rare and emotional event in the emergency department. Debrief with your team. Talk to whoever you talk to about this stuff – spouse, friend, coworker. We are champions of compartmentalization in the emergency department out of necessity, but don’t bear the entirety of these encounters on yourself – lean on those around you.
Spenser Lang, MD
Assistant Professor
Department of Emergency Medicine
University of Cincinnati
How To Cite This Post:
[Peer-Reviewed, Web Publication] Wibberly, A. Eswaran, V. (2020, Nov 9). Preterm Neonatal Resuscitation. [NUEM Blog. Expert Commentary by Lang, S]. Retrieved from http://www.nuemblog.com/preterm-neonatal-resuscitation
