Why should an Emergency Physician be competent at neonatal resus?
Isn’t it someone else’s job? Babies get delivered in theatre or labour ward don’t they? WRONG- this paper from a couple of decades ago showed one ED delivering about 1 baby a month with a high rate of maternal and fetal complications. If a baby is being delivered in your ED or in an ambulance something has gone wrong somewhere. It may be as simple as poor estimation of the time to get to hospital but it may be associated with lack of antenatal care, maternal illness or trauma or poor maternal self-care. If a lot of babies are being born in your ED you need to start looking at whether there is something wrong with your obstetrics and midwifery resources.
It still sounds like somebody else’s problem. Can’t I just call a neonatal code blue and go make a cup of tea?
You can do this if you like. Personally I think letting someone else run a resus in my resus room without me is like calling a babysitter over to separate my sons when they’re fighting. She will probably do a good job but how are the kids going to look at me afterward? When she disarms the eldest will she put his cricket bat away in the right place? Will she know where to look for the crowbar to lever them apart? This is your resus room, your nursing colleagues nursing the baby and your residents and registrars looking on and trying to learn. Are you really going to abdicate responsibility for the case? And who exactly is the neonatal team in your hospital? If you’re in a top level tertiary centre with a neonatal ICU you may have a very different neonatal team from what you have in a regional general hospital. The local paediatrician may be the content expert in the room but there are paediatricians who live for resuscitating sick kids and there are paediatricians who spend their days dealing with developmental delay, psychiatric illness, coughs and colds and autism and who enjoy a neonatal resus like they enjoy getting a root canal, just like there are emergency physicians who live for resus and others who can see 25 fractured NOFs and dizzy/giddies in a day and go home thinking they had the shift of their life. The model we are trying to work toward in Bendigo ED is a collaborative one where the emergency physician and paediatrician work together to run neonatal resuscitations that occur in ED. Now this is an approach that requires a degree of trust on both sides and excellent communication but if emergency physicians and trauma surgeons can sort this stuff out (and they have done, in most places, by now) then so can emergency physicians and paediatricians.
Why is this important?
The neonatal resus team in a general hospital will likely include nurses from the Special Care Nursery and a paediatrician and paediatric registrar or resident. They will have considerable experience and expertise resuscitating newborns in labour ward and in theatre. Both of these environments are set up for them to carry out their routines in because they are there every day. Every day. The ED resus room is a place they come to as a team perhaps a few times a year and as individuals much less frequently. The equipment is not where they expect it to be. Everything is the wrong size. There is a drunk guy on their left swearing through the curtain. Worse still there are emergency physicians and emergency nurses everywhere, terrifying people who say bad words and seem comfortable in this horrible environment. If you are going to get the best out of this group of experts who have just come down to your ED you need to take charge of the room just like you have ben trained to do for every other crisis in ED. You need to make that team feel safe and wanted, you need to put them to work to solve your problem (the sick baby in your ED) and you need to integrate them into your own team.
No time for blogging now, the bat phone is ringing.
A 19 year old woman has just delivered a baby in the back of an ambulance. Mum seems unwell and has had no antenatal care. Bub is in poor condition. They are 4 minutes away.
How are you going to set up?
First of all, any extra information you can get now could be invaluable in a few minutes. Is the baby term? Is it breathing? Is there meconium? The likelihood is though that your information is coming second hand from ambulance control and you may not be able to get anything more. Resuscitating a flat neonate in ED is an uncommon thing so you want to be prepared. It makes sense to call your neonatal team now so that you have a chance of forming yourselves into a functioning team by the time the patient arrives. You need to call for the resuscitaire or find it and plug it in. In the absence of a resuscitaire you need some sort of firm, well lit surface with a source of heat and access to air, oxygen, pressure control and suction. You should identify your umbilical catheter pack and consider opening it. If your neonatal resus algorithm is not up in the wall then with luck it is laminated in the drawer of your resuscitaire. If not, print one off today and get it laminated.
Decision point 1: Has the baby started breathing yet?
The baby arrives. Remember that babies survive birth in massive numbers every day. The one critical thing the baby needs to do to make the transition from uterine to terrestrial life is to take a breath. So before you do anything else, look at the baby: is it crying (and therefore breathing) and wriggling or is it floppy and silent. If it is crying and wriggling it is exceedingly unlikely that you need to do anything further for it. If it is floppy and silent however then you need to give it some help.
Decision point 2: Is there meconium?
The next decision point is whether the baby is covered in sticky green/black/yellowy muck. Like most resus, neonatal resus has become simpler over the years. There used to be all sorts of complex decisions to make about meconium. Now, if the baby has not breathed and there is thick meconium, airway toilet comes before everything else. If the baby is already breathing, or if there is no mec, then you pretty much just follow the flowchart above.
Decision point 3: Is the baby very premature?
Now is not the time for a full assessment of gestational age but if the baby looks very premature you need to protect it from the environment fairly quickly. Very premature babies are not waterproof yet and will quickly run into trouble with heat and water loss through their skin. Current recommendations here are to cut a hole in the bottom of a zip-lock bag, big enough for the head to pass through and then put the baby in the bag with the head poking out and the big opening zipped up. Procedures may require further holes to be made in the bag to admit limbs or the umbilical cord. Some sort of hat or other covering should be put on the head of the baby. If the baby is very premature it is important to remember that very premature babies born outside of tertiary centres have an extremely low survival rate.
Proceeding through the algorithm.
Your baby is floppy, pale and not breathing. There is no meconium. It appears to be about term. It is time to get started on the algorithm. The great majority of babies will respond to the first steps of the algorithm and as you progress down it there is a diminishing return to be had from your efforts.
Before we go on, there are two things for the adult emergency physician to adjust to with the neonatal resus algorithm. The first is that it is all about ventilation, ventilation, ventilation rather than circulation (until it is not). The second is that each cycle of intervention-assessment-intervention should take 30 seconds only.
Put the baby under the heat lamps and stimulate it (flick the feet, rub it a bit, blow on its face) while ensuring the airway is open by putting the head in a sniffing position. Some babies with small jaws (for example those with Pierre-Robin sequence where a cleft palate leads to a set back tongue and an under-grown mandible) will not have breathed because their upper airway is obstructed.
Most babies will respond to this. Yours hasn’t.
Start some ventilation and get a sat probe and monitoring on. Start with 21% O2. Whether you ventilate with a self-inflating bag and PEEP valve or with an oxygen blending device like the Neo-Puff is up to you and your institution but I would strongly encourage getting to know the Neo-Puff if your resuscitaire is equipped with one. It will take you about 3 minutes of quiet time to get the hang of it. There is an inlet valve that is usually connected to an oxygen bottle and low volume flow meter attached to your resuscitaire, and an air blender attached to a medical air source. There is a knob to set the inspiratory pressure (default to 30 but be prepared to turn it up for the first few breaths), another knob with a “don’t-mess-with-this-knob” cover over it which sets the pop-off pressure (to guard against transient pressure rises above the set PIP, say when CPR is going on) and on the end of the circuit there is an adjustable PEEP valve which you occlude with your finger to create IPAP and which you release again to create EPAP. There is no on-switch because it is just a set of valves and gas pipes. To read more about the neopuff, check out this blogpost by Rick Frea, a respiratory therapist from Michigan.
Aim for about 60 breaths a minute counting a fast waltz in your head (1-2-3, 1-2-3, 1-2-3) and allowing inspiration on the “1” and expiration on the “2-3”.
Having started off the business of respiration most babies will again respond at this stage. Yours hasn’t.
Now we should have a heart rate available from the sat probe. We are looking for a good fast heart rate (well over 100) to reassure us that things are going well. If it is below 100 take steps to improve the quality of your ventilation. Reposition the airway, increase the PIP and provide some oxygen. If it is agonal or extremely slow at this point you may wish to start CPR early but the algorithm emphasises improving the ventilation as a first step. You may also wish to intubate the baby at this point if you have the skills although in the short term, face mask ventilation is usually quite adequate. Laryngeal mask airways may be a worthwhile investment for your ED if you think people are going to be reluctant to intubate a neonate.
Reassess the HR (in reality you have been watching it on the sat probe the whole time). If it above 60 keep doing what you are doing until it gets above 100 and then go on to post-resus care. If it is below 60 it is time to start CPR. You need to abandon your fast waltz because now the rhythm is that of the conga-line. I like to think of the episode of The Simpsons when Lisa tried to serve salad at the neighbourhood barbecue hosted by her father and everyone except her ended up conga-line dancing around the yard chanting “you don’t win friends with salad, you don’t win friends with salad”. Normal people probably count something like “one and two and three and breathe, one and two and three and breathe” to get the 3-to-1 compression to breath ratio right but I prefer the Simpsons.
Still less than 60? You need to get some IV/IO/UV access and give some adrenaline. Your kid is pale which should trigger you to think of ante-partum haemorrhage and hypovolaemia so a fluid bolus is indicated. Babies normally come out a horrible blue colour and become sort of bright red so a pale kid is not normal. Remember that the baby has spent the last 9 months in an environment about as well oxygenated as the top of Mt Everest. It should have a Hb of around 180g/L.
- This is something you need to learn by doing on a mannikin and not from a blogpost but here are some basic tips for the person trained to intubate larger humans.
- The distance to the larynx is much shorter than you are used to. If you just see a big whole you are holding a rigid oesophagoscope. Turn it into a laryngoscope by withdrawing it gently.
- Neonates are softer and more delicate than large humans. You can’t jam that laryngoscope in in the way you do to an adult and if you lift it with the kind of force you are used to applying in large adults you risk completing a mandibulectomy. Practice a few times on a good quality neonatal mannikin and you will get a feel for it. Also, your introducer, if you are using one, must not protrude beyond the end of the tube as it can easily puncture the trachea.
- The larynx is more anterior than you are used to. Cricoid or some variant on it will always be helpful to bring it into view.
- The epiglottis is larger and more troublesome. You may end up just picking it up with the tip of the blade (one of the reasons a straight Miller blade is helpful) to get it out of the way.
The umbilical cord in the first hours of life offers you one of the easiest IV access opportunities you will ever get but you don’t want to learn the technique on the day. The NEJM has a magnificent video on Umbi vein catheterisation but it is paywalled for subscribers. Try to get access to it if you can, it is very well done.
Here is our umber vein kit opened. It looks to me to be a bit more than you really want for urgent umbilical vein access.
We are looking at trimming it down to what you actually need which is more like this.
The first thing to do is to get a nice clean cut across the umbilical cord with a scalpel like so. You are cutting it down to within a cm or so of the skin.
The next trick is to identify the single umbilical vein and the two umbilical arteries. Do not expect them to be spurting. In the picture below the vein is on the left and the two arteries are on the right. The NEJM vid talks about using a sterile tie to hold the base of the cord. An alternative, as shown in this picture, is to hold the slippery cord with some dry gauze.
You need to dilate the vein a little with the very fine mosquito forceps. Then take your catheter and insert it into the vein to a depth of about 5cm. In a semi-elective setting these can be put much further in, acting as central lines, but in the emergency there is no way to know that the tip is not in the hepatic veins if pushed in more than 5 cm so we keep it a bit more shallow.
Ventilating a neonate
The volumes you want to use are small. This means you cannot just pop on the oxylog and turn the dials down low. The ratio of dead space to ventilation and the ratio of variability to volume is just too great with an adult machine. You will need to call SCBU to get the neonatal ventilator down. Here are some starting numbers for ventilating a neonate:
- Ti 0.4 sec
- RR 60
- IPAP 25
- PEEP 5
Aim to achieve:
- MV of 0.25-0.4L/kg/min
- Spo2 85-95% in a preterm baby and 90-95% in a term baby
- Tolerating an ETCO2 of 60mmHg.
After ABC comes DEFG: Don’t Ever Forget Glucose
Neonates have very little energy storage available.
Give 2mL/kg of 10% if hypoglycaemic.
What about drugs and doses and volumes. I can’t remember!!
Don’t try. This book, prepared by Dr Simon Craig and colleagues at Monash Children’s Emergency Department is available online and a fantastic resource for people who take care of sick kids. Every page opens to a different weight (in half kg increments in smaller kids and 1kg increments as they get bigger) and gives doses for everything from IM adrenaline for anaphylaxis to prostaglandin for a closing Ductus in congenital heart disease.
Enormous Thank You!!
Thanks to our teachers Dr Martina Moorkamp, Neonatologist from The Mercy Hospital in Melbourne and Dr Preeti Ramaswamy, our brand new Paediatric emergency physician at Bendigo for preparing the extraordinary day of neonatal education for us which allowed me to prepare this post.