5. PEDIATRIC EMERGENCIES
5.1 NEWBORN RESUSCITATION
Infants born in the prehospital setting are at greater risk of complications due to respiratory distress, hypoxia, prematurity, infection, acidosis and hypothermia. Anticipation, adequate preparation, accurate evaluation, and prompt initiation of resuscitation steps are critical to successful outcome of a neonatal resuscitation. It is essential to prevent heat loss in newborns: it is important to rapidly dry the infant, cover the head, and wrap the child to avoid a drop in body temperature.
Note: This statement is true for "unplanned", "unattended", "unprepared", "emergency" births by unhealthy women who have had very little, very poor quality, or no prenatal care during their pregnancies.This is an inaccurate statement for healthy women choosing to have a "planned", "low-risk", out-of-hospital (home or birthing center) birth attended by trained birth attendants, midwives, or physicians.
ASSESSMENT / TREATMENT PRIORITIES
1. Maintain universal blood and body fluid precautions
2. Maintain open airway, remove secretions and assist ventilations as needed. NOTE: The newborn should be evaluated for central cyanosis. (Remember: Peripheral cyanosis is common and is not a reflection of inadequate oxygenation). If central cyanosis is present in a breathing newborn during stabilization, early administration of 100% oxygen is important while the neonate is being assessed for need of additional resuscitative measures.
3. Evaluate heart rate by one of several methods: auscultate apical beat with a stethoscope or palpate the pulse by lightly grasping the base of the umbilical cord. NOTE: Pallor may be a sign of decreased cardiac output, severe anemia, hypovolemia, hypothermia or acidosis.
4. APGAR scoring system provides a mechanism for documenting the newborn's condition at specific intervals after birth. The five objective signs are assessed at one (1) and five (5) minutes of age. NOTE: The APGAR score should be documented but should not be used to determine need for resuscitation because resuscitative efforts, if required, should be initiated promptly after birth.
|
SIGN |
0 POINTS |
1 POINT |
2 POINTS |
HEART RATE |
ABSENT |
< 100 |
> 100 |
RESPIRATORY EFFORT |
ABSENT |
WEAK CRY |
STRONG CRY |
MUSCLE TONE |
FLACCID |
SOME FLEXION |
ACTIVE MOTION |
REFLEX IRRITABILITY |
NO RESPONSE |
GRIMACE |
COUGH, SNEEZE OR CRY |
COLOR |
BLUE, PALE |
BODY: PINK EXTREMITIES: BLUE |
FULLY PINK |
5. Establish pertinent medical history, including maternal prenatal care, medications or drug use, illness and time of rupture of membranes.
TREATMENT
BASIC PROCEDURES
1. Maintain universal blood and body fluid precautions
2. Maintain an open airway and suction the mouth, then nose. If meconium (brown stained fluid) is present, suction the hypopharynx (Contact ALS immediately if available for possible need of endotracheal intubation).
3. Dry the infant, place on a dry blanket, cover the head and keep the infant warm.
4. If the infant is ventilating adequately, administer free flow (blow-by) 100% oxygen at a minimum of 5 liters per minute close to the face. If ventilations are inadequate or if the chest fails to rise, reposition the head and neck, suction, and initiate positive pressure (bag-valve-mask) ventilations with high flow oxygen at 40-60 breaths per minute.
5. For heart rate 60 - 80 and rapidly rising:
- Continue manual ventilation
6. For heart rate less than 60, or 60-80 and not rapidly rising:
- Initiate CPR
7. Activate ALS Intercept if available
8. Initiate transport as soon as possible with or without ALS
9. Notify receiving hospital
INTERMEDIATE PROCEDURES
1. Maintain universal blood and body fluid precautions
2. Maintain an open airway and suction the mouth, then nose. If meconium (brown stained fluid) is present, suction the hypopharynx (Contact ALS immediately if available for possible need of endotracheal intubation).
3. Dry the infant, place on a dry blanket, cover the head and keep the infant warm.
4. If the infant is ventilating adequately, administer free flow (blow-by) 100% oxygen at a minimum of 5 liters per minute close to the face. If ventilations are inadequate or if the chest fails to rise, reposition the head and neck, suction, and initiate positive pressure (bag-valve-mask) ventilations with high flow oxygen at 40-60 breaths per minute.
5. For heart rate 60 - 80 and rapidly rising:
- Continue manual ventilation
6. For heart rate less than 60, or 60-80 and not rapidly rising:
- Initiate CPR
7. ALS STANDING ORDERS (heart rate less than 60 and inadequate ventilations)
a. Advanced Airway management if indicated.
8. Activate ALS Intercept if available
9. Initiate transport as soon as possible with or without Paramedics
10. Notify receiving hospital
PARAMEDIC PROCEDURES
1. Maintain universal blood and body fluid precautions
2. Maintain an open airway and suction the mouth, then nose. If meconium (brown stained fluid) is present, suction the hypopharynx. NOTE: If meconium is present, consider early endotracheal intubation and suctioning.
3. Dry the infant, place on a dry blanket, cover the head and keep the infant warm.
4. If the infant is ventilating adequately, administer free flow (blow-by) 100% oxygen at a minimum of 5 liters per minute close to the face. If ventilations are inadequate or if the chest fails to rise, reposition the head and neck, suction, and initiate positive pressure (bag-valve-mask) ventilations with high flow oxygen at 40-60 breaths per minute.
5. Cardiac monitor: dysrhythmia recognition if needed. Manage dysrhythmia per protocol.
6. Normal Newborn: initiate transport
7. ALS STANDING ORDERS
a. Newborn in distress and requiring emergency care:
- For heart rate 60-80 and rapidly rising:
- Continue manual ventilation and supplemental oxygen
- Cardiac Monitor: dysrhythmia recognition if not already done. Manage dysrhythmia per pediatric protocols
- For heart rate less than 60, or 60-80 and not rapidly rising:
- Initiate CPR
- Continue manual ventilation with supplemental oxygen
- Advanced airway management if not already done
- Cardiac Monitor: dysrhythmia recognition if not already done. Manage dysrhythmia per pediatric protocols
- If defibrillation is indicated: initial energy level: 2 joules/kg subsequent: 4 joules/kg.
- If synchronized cardioversion is indicated: 0.5-1.0 joules/kg
- Establish IV or IO access, if indicated while enroute (Note: NALS-trained EMT-Paramedics may utilize umbilical lines when necessary).
8. Initiate transport as soon as possible.
9. Contact Medical Control. The following may be ordered in addition to other appropriate pediatric procedures needed to treat specific newborn resuscitation emergencies:
a. Epinephrine 1:1,000 (0.1 mg/kg) ET; follow with 2.0 ml Normal Saline Solution; repeat every 3 - 5 minutes
b. Epinephrine 1:10,000 (0.01-0.03 mg/kg) IV push or intraosseous
c. Epinephrine Infusion: 1:1,000, 0.1-1.0 mg/kg/min.
d. Atropine 0.02 mg/kg ET, IV, IO
e. Naloxone HCL 0.1 mg/kg of a 1 mg/ml solution, IV, ET, or IO. May repeat every two (2) to three (3) minutes as needed. If perfusion is adequate may give subcutaneously (SQ) or intramuscularly (IM).
f. Dextrose 10%, 0.5 g/kg IV or IO.
g. Normal saline fluid challenge, 10 cc/kg IV or IO.
h. Lidocaine 2%, 1 mg/kg ET, IV, or IO.
10. Notify receiving hospital.
MoonDragon's EMS Index Page
HELPFUL PRODUCTS & FURTHER EDUCATION
-- by Phyllis A. Balch, James F. Balch - 2nd Edition
-- by Phyllis A. Balch, James F. Balch - 4th Edition
-- by Phyllis A. Balch
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