EMS Protocol of the Week - Neonatal Care / Resuscitation

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The prehospital protocol for neonatal resuscitation is dense, so it doesn't serve to reproduce it all within the email. Read through the attachment for details, and realize that it serves as a reference for stepwise assessment (with target heart and respiratory rates) and interventions (with target compression/ventilation rates and medication dosages) for when our EMTs and paramedics are stuck in a high stress home environment with a neonate in extremis. Not a ton to add from an OLMC perspective, but recognize that this protocol is here for your reference as well, in case a crew calls looking for assistance.

The attached appendix also includes a review of APGAR scores for your review. 

That's RESUSCITATION...BABY.

And with that, hope you all have some wonderful holidays! If you can't wait for more protocol goodness, there's always www.nycremsco.org

Dave

POTD: Primary Hypothermia!

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With the turn of the weather and puffy jacket season in full throttle, let's review hypothermia. In this POTD, we're going to be focusing on primary (environmental) hypothermia, and not hypothermia due to secondary causes such as sepsis, hypothyroidism, metabolic derangements, or trauma. 



Hypothermia is defined as core temperature < 35C

 

  • between 1991-2011, an average of 1,300 deaths/year in the US attributed to environmental hypothermia

  • At risk populations: elderly, lack of shelter, alcohol/drug abusers, frequent exposure (winter sports)



The modified staging system for hypothermia classifies severity into 4 categories, of which the chart below summarizes and demonstrates the general clinical picture


Initial evaluation should include the following:

  • Basic vital signs including core temperature

  • BGM (hypoglycemia)

  • EKG (bradycardia, Osborne waves, arrhythmias)

  • Basic labs (hypokalemia)

  • lactate, CK (rhabdomyolysis)

  • coags and fibrinogen (DIC)

  • consider TSH, cortisol, 


Management of ABCs:

Airway/Breathing

  • Intubate as necessary, however encourage holding off intubation as patients are often hypotensive and prone to arrhythmias. Attempt rewarming and stabilization prior to hemodynamic stressors of intubation.

Circulation

  • bradycardia 

    • hypothermia itself causes bradycardia, thus the key to treating bradycardia is rewarming. Giving medications to speed up HR is generally not encouraged and can induced arrhythmias

  • hypotension 

    • again, often hypothermia induced, may also be secondary to bradycardia. Rewarming should improve pressures, and vasopressors generally discouraged as it can also induced arrhythmias

    • BUT - vasodilation can occur with rewarming, so if there is a drop in pressure, vasopressors should be considered

  • access 

    • if central access is needed, keep the guidewire shallow to prevent entry into the right ventricle. The hypothermic heart is incredibly sensitive to VT/VF, so don't go tickling that ventricle. Femoral access or midline access is preferred


EKG in hypothermia:

Patient may initially present with tachycardia, however as hypothermia sets in, everything gets slower. Just imagine taking a NSR rhythm stripe and click-dragging it horizontally. You often see bradycardia, prolonged QTC, prolonged PR, and the presence of Osborne waves. 

  • Osborne waves (also known as J waves) - a deflection at the junction of the QRS and ST segments, present usually temp < 30C. The size increases with worsening hypothermia

The most common dysrhythmia is atrial fibrillation, but cardiac arrest is due to eventual VF/VT or asystole

Management of hypothermia in the pulseless patient:

The famous phrase: "They aren't dead unless they're warm and dead" indeed is true. To be considered dead, the patient's core temperature should be ~32C before calling it.

ACLS: Modifications in setting of hypothermia

  • Delayed or intermittent CPR can be adequate due to low oxygen demand. Some say for T < 28, there can be pauses of <5 minutes CPR after every 5 minute interval of CPR if necessary. 

  • Medications may fail to metabolize and will accumulate in the system, therefore prolonged intervals between epinephrine pushes and limiting repeated doses are recommended. 

  • Similarly, defibrillation is poorly effective in T < 30C and repeated defibrillation may induce myocardial damage. 

    • Suggested treatment by AHA: Can attempt one defibrillation if VF/VT present, otherwise hold further defibrillations and all IV medications until core T > 30C

Internal Rewarming:

  • ECMO: The best option for sever hypothermia. It allows for better organ perfusion, active rewarming as much as 7-10C per hour, and allows you to stop compressions. As an ECMO center, we should definitely consider getting ECMO downstairs to cannulate.

  • Thoracic Lavage: achieved through placement of two chest tubes, left preferred over right if only able to place one tube. Can achieve 3-6C warming/hour. Use Belmont or warm tap water if available, and monitor appropriate ins and outs to prevent tension PTX from improperly draining tubes

  • Bladder Lavage: less effective, however is easier to implement. Use dedicated 3-way Foley catheter or consider instilling 300 cc warmed fluids, hold for 15 minutes, and draining bladder. Rinse and repeat.

Management of hypothermia in patient with pulse:

 

  • External rewarming: Removing cold/frozen clothes and fully wipe down of snow. Employ external rewarming with Arctic Sun (preferred due to direct contact with skin to improve rewarming), warm blankets or Bair Hugger. 

  • Respiratory rewarming: Warmth is typically lost through expirations. Therefore consider rewarming via respiratory support. In non-intubated patients, HFNC or CPAP/BIPAP with highest temperature settings. Intubated patients should have heated and humidified air set up with the ventilator (ask respiratory)

  • Fluid rewarming: hypothermia induced "cold diuresis," therefore patients often require volume resuscitation. Warm IV fluids, ideally crystalloid, should be administered. Keep in mind that this method prevents further dropping temperatures, but is ineffective for raising core temperature. 

  • Lavage can also be considered in moderate/severe hypothermia in patients with pulses - see above.


Resources:

https://emcrit.org/ibcc/hypothermia/

http://www.emdocs.net/em3am-hypothermia-2/

https://www.saem.org/about-saem/academies-interest-groups-affiliates2/cdem/for-students/online-education/m4-curriculum/group-m4-environmental/hypothermia

https://wikem.org/wiki/Accidental_hypothermia


POTD: Neonatal Resuscitation

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We’ll be going over a few high yield topics pertaining to NALS today. 

It’s 7:30 AM, and you’ve just unwrapped your BEC sandwich and taken your first sip of coffee. You’re settling into the morning getting ready for your 12 hour peds shift… until the phone rings, and you get a note: 

“Mother 38w delivered her baby at home 30 minutes ago. Baby is having labored breathing, and is bradycardic. EMS will be here in 2 minutes.”

Take a deep breath. First, remember the basics. If you’re in a facility that has Peds/NICU, call them immediately. Call respiratory. Call pharmacy. Call Hector. Use the resources available to you. 

The set up.

Get the warmer and set it to 25 C

  • Avoid hypothermia in these patients. The goal is > 36.5-37.5C

Grab the Broselow tape so that it’s available for immediate use.
Get the backboard.
Grab the code cart, zoll
Get a towel to warm and dry the baby.
Get your airway equipment ready:

  • Suction x 2, plugged in, ready to go

  • Oxygen: grab the neonatal BVM and plug it into the oxygen port

  • Airway equipment: have both DL/VL equipment,

    • LMA size 1

    • Pre-loaded tubes

      • 2.5 and 3.0 uncuffed tubes

    • Blades: 0 and 1

    • EtCO2

Access: IO gun + pink needles ready for use; umbilical vein catheters (future POTD)

Grab your PALS card or open up your PediStat app
Ultrasound

Assess the patient.

Pediatric assessment triangle:

  • Appearance – crying? Good tone? Tracking?

  • Breathing – nasal flaring? Stridor? Grunting? Head bobbing?

  • Circulation – Pallor? Cyanosis? Mottling?

Off the bat, there are two numbers you need to remember:
HR < 100→ initiate positive pressure ventilation (PPV)
HR < 60→ initiate CPR / epinephrine if this is sustained more than 30 seconds despite adequate ventilation.

  • NOTE: Bradycardia is almost always related to hypoxia, so atropine isn’t routinely indicated for these patients.

Remember, the most important part of neonatal resuscitation is positive pressure ventilation.


PPV.

If the patient is spontaneously breathing but labored, you can place them on CPAP.
Remember, the targeted SpO2 after birth is much lower for neonates, so see the box below. You’re more interested in ventilating than the oxygenation.
For gasping / apneic / HR < 100 patients, initiate PPV. You can use 5 on the PEEP valve.

  • Rate: 40-60 breaths / minute

MR SOPA mnemonic for ventilation tips:

  • Mask, right size

  • Reposition airway

  • Suctioning nares

  • Open mouth

  • Pressure increase to PEEP to ~5

  • Advanced airway: ETT / LMA

BGM.

They also have lower BGMs. Hypoglycemia for neonates is < 30 for a patient < 24 hours old. It’s recommended to give D10 bolus 2ml/kg if the patient is hypoglycemic.

You can give glucagon IM too: 0.03mg/kg max 1mg

CPR.

It’s recommended to secure an airway (supraglottic or ETT) prior to doing compressions) since most these codes are usually due to respiratory events.
The ideal ratio is3 compressions:1 breath

  • Goal is 90 compressions: 30 breaths in one minute

2 thumb compression technique (*preferred) or 2 finger technique
Pulse checks q1 min
Depth: ⅓ chest diameter

Epinephrine.

IV dosing: 0.01mg/kg q3-5min
ETT dosing: You can give epinephrine through the ETT too if you don’t have access yet! AHA recommends a larger dose 0.1mg/kg of 1:1000 ETT

  • Max dose is 10mg, and follow it with a saline flush

I highly recommend reviewing the following flowchart linked.

I hope this was a good refresher on some of the most important concepts. I would love to learn other tips that others have in managing these stressful situations!

References:

https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/neonatal-resuscitation 

https://emergencymedicinecases.com/neonatal-resuscitation/