NALS – Neonatal Resuscitation Algorithm (NALS)

Birth->

Somenewbornswithoutanyapparentriskfactorswillrequireresuscitation,includingassistedventilation.❷Unlikeadults,whoexperiencecardiacarrestduetotraumaorheartdisease,newbornresuscitationisusuallytheresultofrespiratoryfailure,eitherbeforeorafterbirth.➌Themostimportantandeffectiveactioninneonatalresuscitationistoventilatethebaby’slungs.❹Veryfewnewbornswillrequirechestcompressionsormedication.❺Prolongedlackofadequateperfusionandoxygenationcanleadtoorgandamage.❻Resuscitationshouldproceedquicklyandefficiently;however,ensurethatyouhaveeffectivelycompletedthestepsineachblockoftheNeonatalResuscitationProgramFlowDiagrambeforemovingtothenext.❼Teamwork,leadership,andcommunicationarecriticaltosuccessfulresuscitationofthenewborn.
Vigorous: Delayed cord clamped at 30-60 seconds post delivery.
Not vigorous ( or If anything not right) clamp immediately (though insufficient evidence)
Access:
Term?
Tone?
Breathing or crying?
Given term, good tone, breathing well, baby placed with mother for skin-skin warming. 
If secretions or meconium, provide suction (mouth before nose (“M” before “N”)
<32 weeks -> cover in polyethylene plasic (don’t dry). 
If HR not >100 @ 1 min, start PPV. 
HR – determine by ausculation (6 sec *10, tap it out). If can’t determine, use pulse ox or ECK monitor leads. Place pulse ox (pre-ductal : on R UE). Preductal O2 1 min 60&, up by 5% q min to 5 min. 
5 Initial Steps:
-warm
-position head/neck
-clear secretions
-dry
-stimulate
PPV: rate 40-60,  PIP 25 h20, PEEP 5, pop off pressure 40. 
Ck HR 15 sec after PPV, if increasing, cont. If not increasing, MR SOPA
HR: >100
HR 60 – 100 -> PPV
HR <60 (after 30 sec of PPV) -> chest compressions (fio2 to 100%). Compresssion rate 90-100
Epi indication:
30 sec of PPV
60 sec of CPR
If HR < 60 -> epi
epi:
IV 0.1ml/kg (1:10k) = 0.01mg/kg (up to 0.03)    (1:10k has 0.1mg/ml)
ET 1ml/kg = 0.1mg/kg
Umbilical Line: 
3.5 – 5 F tube
insert until blood return
After resus, theraputic cooling. At least prevent hyperthermia. Avoid bicarb
Reasonable to stop resus after 10 min w/ no APGAR 0 and no pulse given strong predcitor or mortality and morbidity. Review of interventions to ensure all were optimized. 
If MD bleievs there is no chance of survival, umane, compassonate, palliateive care provided. 
I
If PPV > min -> OG tube: 8F, 
Color change (yellow -> correct, stays blue -> redo)
Intubation: use uncuffed for neonate (newborn). 
<28 wks -> 2.5, 00
28-34 -> 3.0, 0
>3.4 -> 3.5, 1
Use Mechonium aspirator
laryngeal mask = LMA
Decompensation after intubation: DOPE
-Displaced
-Obstructed
-PTX
-Equipment
?How much of a risk is using 100% O2?
-higher risk of chronic lung dz and cerebral blod flow
If baby > 35 wks, use 21% O2
if baby <35 wks 21-30%
? flow inflating/ self inflating – spontaneous respirations
Somenewbornswithoutanyapparentriskfactorswillrequireresuscitation,includingassistedventilation.❷Unlikeadults,whoexperiencecardiacarrestduetotraumaorheartdisease,newbornresuscitationisusuallytheresultofrespiratoryfailure,eitherbeforeorafterbirth.➌Themostimportantandeffectiveactioninneonatalresuscitationistoventilatethebaby’slungs.❹Veryfewnewbornswillrequirechestcompressionsormedication.❺Prolongedlackofadequateperfusionandoxygenationcanleadtoorgandamage.❻Resuscitationshouldproceedquicklyandefficiently;however,ensurethatyouhaveeffectivelycompletedthestepsineachblockoftheNeonatalResuscitationProgramFlowDiagrambeforemovingtothenext.❼Teamwork,leadership,andcommunicationarecriticaltosuccessfulresuscitationofthenewborn.






Credit: Drs Wu, A. Ogunniyi, R. Pedigo, R. Fleischman on 
OB Sim Day at Harbor-UCLA
Ill-appearing neonate

  • For babies
    born precipitously in ED, always ask: 1) Term? 2) Good tone? 3)
    Breathing or crying?

    • If yes to
      all 3Qs, consider delaying cord clamping and hand baby to mother
      for skin-to-skin contact while keeping baby warm and dry.

      • Clamping of
        cord should be delayed 30-60 sec unless child requires immediate
        resuscitation

      • Associated
        with less IVH, NEC, better BPs and blood volume, but a/w more
        phototherapy requirement

    • If no to any
      of Qs, cut cord and begin resuscitation by:

      • Taking baby
        to warmer (make sure it’s on!, plastic bag from neck
        down) goal temp 36.5-37.5

      • Bulb
        syringe suction to clear secretions,

      • Dry,
        stimulate. Ventilate/oxygenate as needed.

      • Note time,
        document APGAR.

  • Cutaneous
    temp monitor on liver – largest organ provides most consistent
    measurement. Hypothermia increases risk of intraventricular
    hemorrhage, respiratory issues, hypoglycemia, and late onset sepsis.

  • Meconium
    aspiration no longer empirically intubated, treat similar to other
    babies with stimulation, suctioning, PPV as needed. Immediate
    intubation thought to delay resuscitation

Resuscitating a neonate: HR, RR, Pox

  • HR:
    Detecting HR difficult, 3 lead ECG best, umbilical cord stethoscope
    alternate but not as accurate

    • If
      bradycardic HR <60, start chest compressions, thumb encircling
      chest wall, 3:1.

    • If not
      already done, intubate baby

    • Epi 1:10,000
      concentration, dose 0.01 mg to 0.03 mg/kg IV, or 0.05 to 0.1 mg/kg
      via ETT

  • RR/Pulse
    ox     – low oxygen sat is normal in first few minutes of life.
    Increases by 5% every minute of life. Place monitor on R palm/wrist
    for pre-ductal measurement, reflects blood that is going to the
    brain.

    • Normal
      preductal (right hand) O2 Sat

    • Resuscitation
      with room air (FiO2 21%) initially

    • Give
      supplemental O2 – increase FiO2 if not achieving normal saturation
      or has a HR<100.

    • PPV using
      BVM to RR 40-60 for 30 sec, CPAP

    • If need for
      CPR, then intubated baby

  • Intubation:

ETT = [age/4+4]

Laryngoscope blade

<28 wks 2.5

Pre-term 0

28-34 wks 3.0

Term 1

34-38 wks 3.5

>38 wks 3.5 to 4

PEEP 5

Depth 3xETT size to lip


  • Why does baby
    need resuscitation?

    • Shock? Blood
      or volume? Give transfusion or IVF bolus as indicated, 10ml/kg,
      repeat prn

    • Uterine
      rupture or abruption?

    • Accident
      with umbilical cord?

    • Hypoglycemic?
      2ml/kg of D10 as initial bolus, then D10W maintenance IVF at
      80ml/kg per day.

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