Prehospital Stabilization of Unstable Neonates

This CE activity is approved by EMS World Magazine, an organization accredited by the Continuing Education Coordinating Board for Emergency Medical Services (CECBEMS) for 1 CEU. To take the CE test that accompanies this article, go to www.rapidce.com to take the test and immediately receive your CE credit. Questions? E-mail editor@EMSWorld.com.

Objectives

• Identify the neonatal period
• Describe the the stabilization of a neonatal patient's critical systems
• Explain the importance of limiting oxygen administration to the neonatal patient
• Explore the common causes of neonatal patient instability

Each year more than 3.9 million births occur in the United States, nearly 90% without incident.¹ Of the 10% of newborns who require assistance, fewer than 1% require resuscitation.² In 2013, the last year for which data is available, 98.6% of births occurred in hospitals, but that means more than 70,000 births a year occur at home or freestanding birth centers.¹
Considering less than 10% of these out-of-hospital births will require intervention, it is no surprise that paramedics rarely encounter these high-risk and high-stress emergencies. Keep in mind, though, that neonatal emergencies can develop well after birth.

A normal pregnancy lasts 40 weeks. Neonates born after 37 weeks are considered term, while those born before the 37th week we consider preterm.³ Once born, a child is considered a neonate for their first 28 days of life. However, when a child is born prematurely, the neonate period is extended to 28 days beyond their due date (when they would have been term). Understanding the neonatal period is important, as during this phase of life, the newborn is prone to unique emergencies and requires unique care if an emergency occurs.

Initial Stabilization

When managing an unstable neonate, begin stabilizing the critical systems and then seek to correct the underlying problem. While we often focus on initial stabilization, it is important to never forget identifying and correcting the underlying problem, as failure to do so may mean futile resuscitation efforts. The general approach to stabilization includes obtaining a history and physical and management of the ABCDs.

Medical History

While immediate stabilization of any newborn takes precedence over completion of a medical history, a history needs to be obtained as early as possible, as the patient’s and mother’s histories can play an important role in establishing a differential diagnosis. Key aspects of a maternal history include determining any instances of:

• Infections—hepatitis B, syphilis, HIV, group B streptococcus screens;
• Blood type compatibility with mother;
• Illnesses during pregnancy;
• Pregnancy-induced illnesses: diabetes, hypertension, preeclampsia.

In addition to inquiring about the mother’s pregnancy history, determine the neonate’s actual age and gestational age at birth. Remember, prematurely born infants may be “neonatal” well beyond 28 days of age. Also determine the patient’s birth weight and most recent weight; inquire about any difficulties following birth, such as respiratory distress, apnea spells and time on a ventilator; and ask about the patient’s recent feeding history. Sudden changes in how a neonate has been feeding may indicate a serious condition.

Physical Exam

A detailed physical exam is important in all patients, and the neonate is no exception. However, in the neonatal patient many presenting symptoms are generic to multiple illnesses, making the overall appearance of the patient as important as specific exam findings. Spontaneous movements and a flexed posture are pertinent positives and can be reassuring, while respiratory distress, cyanosis and flaccid extremities can be grave.

Complete a detailed head-to-toe exam. Assess the anterior and posterior fontanels—they should be flat and soft. Sunken fontanels can signify dehydration or fluid loss. Look at the mouth and mucous membranes of the eyes—dry mucous membranes suggest dehydration. Observe for signs of respiratory distress, such as nasal flaring or cyanosis. Inspect the chest closely for accessory muscle use, easily observed if the patient’s clothing is removed. Look for retractions along the clavicles and xiphoid process, as these typically appear before intracostal and subcostal retractions develop. Auscultate the chest, noting both lung sounds and heart tones. Murmurs are common in the first few hours after birth as the ductus arteriosus, which usually closes within 24 hours, may remain patent for up to a week.

As you examine the abdomen, both a large, distended abdomen and concave-appearing abdomen suggest a possible surgical emergency. Evaluate the tone and activity of the neonate’s extremities—the healthy neonate moves all extremities freely. Flaccid extremities are a grave finding, while a bicycling motion of the legs may suggest seizure. Acrocyanosis, a blue hue to the hands and feet only, is not in and of itself concerning, though it can be very distracting to the parent as well as the stressed provider. Acrocyanosis may appear while the neonate cries. Central cyanosis on the skin of the trunk or proximal extremities is more concerning.

Obtain a complete set of vital signs, including core temperatures, as a part of your physical exam. Vital signs will determine when you alter your patient care during neonatal stabilization. Pulse and respirations are the most important signs. A normal neonatal pulse is 110–160 bpm, and a pulse of less than 100 is an emergency. Neonatal patients breathe 40–60 times per minute, and because their tidal volume is so small (25 mL), breathing too slow or too fast can rapidly reduce their minute volume.
A neonate’s blood pressure is typically 65–76 mmHg systolic, with a mean arterial pressure equal to their gestational age.⁴ For example, a neonate of 41 weeks’ gestation would have a MAP of 41 mmHg. While determining blood pressure is important, it is not a priority during initial stabilization. Finally, determine the patient’s core body temperature. Both rectal and axillary temperatures are reasonable for determining core temperature, which should be between 36.2–37.7ºC.⁴ Neonates are susceptible to both hypothermia and fever, and both require correction.

Making sure to keep the neonate warm, follow ABCD to guide your stabilization. During this time it is important to remember two heart rates: 100 and 60. When heating is required, radiant heat is the most effective warming method. Avoid chemical hot packs if possible.⁴

Airway—Place the head in a neutral position (pad beneath the shoulders) while avoiding flexing or hyperextending the airway, both of which can lead to occlusion. Suction as necessary. Stimulate the neonate by flicking its feet or gently rubbing the sternum. Stimulation can trigger breathing and may be needed regularly, particularly when a neonate has been born prematurely.

Breathing—If the neonate has inadequate respirations, doesn’t respond to stimulation, is centrally cyanotic or has a heart rate below 100 bpm, then immediately begin positive-pressure ventilations with positive end expiratory pressure (PEEP). Typically a PEEP of 5 cm H₂O is adequate. CPAP may also be attempted to support breathing in the neonate with respiratory distress. Begin initial ventilations with room air. If pulse oximetry does not return to normal with room air, slowly titrate oxygen up from 21% to maintain a normal SpO2 of 90%–95%. When oxygen is increased, allow 1–2 minutes for SpO₂ to rise before increasing it again. Administering oxygen in concentrations greater than 60% for an extended period may be harmful.

When treating a neonate always obtain pulse oximetry readings in the right arm. This provides a preductal (ductus arteriosus) SpO₂ value. The preductal SpO₂ is typically 60%–65% at birth and rises to 85%–95% after about 10 minutes.² Persistently low SpO₂ levels may suggest a cardiac abnormality (discussed later).

When using a bag-valve mask on a neonate, ensure a pressure manometer is attached. Monitor your ventilations by controlling the pressure delivered with each breath (known as the peak inspiratory pressure or PIP) and avoid delivering a breath with a PIP greater than 20 cm H₂O.² Also ensure the use of an appropriately sized bag-valve mask. Neonates only require 4–6 mL of air per kilogram of body weight (that’s 28 mL for a 7-kg patient). The typical neonatal BVM holds 400–500 mL of air. Ventilate at a rate of 40–60 breaths per minute, delivering each breath over about one second and stopping when you see chest rise.

When endotracheal tube insertion is necessary, use an uncuffed tube. Endotracheal tubes are sized based on the neonate’s age and weight (see Table 1).² Neonatal ET tubes have a distal black line known as the vocal cord guide; when present this line should be placed at the vocal cords during insertion. When a black line is not present, you can estimate the tube depth at three times the tube’s internal diameter (e.g., 9 cm deep for a 3.0 ETT).

These narrow insertion depths leave a significant length of tube outside the neonate’s mouth after securing the tube. This long tube increases the risk of accidental dislodgement and accidental tube advancement (right mainstem bronchus intubation is a significant problem in neonatal care); control this risk by cutting the tube to a shorter length. Cut the tube at an angle, so other healthcare providers can easily see it was cut. In addition, this makes reinsertion of the BVM adapter easier.

Circulation—Whenever a neonate’s heart rate drops below 60 bpm, begin chest compressions and consider endotracheal intubation if the patient doesn’t improve after about two minutes. Perform chest compressions at a rate of at least 100 a minute. The two-thumb/encircling hands technique is the preferred compression method. Place both hands around the chest and, bringing both thumbs together just below the nipple line, compress the chest roughly one third the anterior-posterior diameter. Using two fingers promotes performing compressions with an inconsistent depth and pressure.² Current neonatal resuscitation program guidelines recommend a compression-to-ventilation ratio of 3:1 for a total of 120 events per minute (90 compressions and 30 ventilations).²

Venous access is typically most easily established using a manual intraosseous needle. Mechanical IO guns are best avoided in children less than 6–12 months of age and who cannot walk, as the bones are not yet strong enough for the pressures and vibrations of mechanical insertion. Use of mechanical IO access is associated with increased needle dislodgement. Intravenous access may be attempted with an IV needle if time allows, though considering paramedics rarely have the opportunity to place neonatal IVs, it is reasonable to try IO on the first attempt. When patients have evidence of shock or hypovolemia, begin fluid resuscitation with 10 mL/kg of 0.9% saline over 10–15 minutes. This may be repeated as necessary as long as there is no pulmonary edema.

Drugs—If the pulse remains below 60 bpm after chest compressions, administer 0.01–0.03 mg/kg (0.1–0.3 mL/kg) of epinephrine 1:10,000. While high-dose (1:1,000) epinephrine was once administered during neonatal resuscitation, it is no longer recommended, as it is not associated with improved outcomes. The easiest way to draw up epinephrine 1:10,000 from a prefilled syringe is by using a three-way stopcock and a 1-mL syringe (Figure 1).

Endotracheal intubation and fluid resuscitation may be required in critically ill neonates as part of or following initial resuscitation.⁴ As you move beyond initial stabilization, it’s important to begin looking for the cause of the neonate’s distress.

The Pediatric Assessment Triangle

Perform an initial assessment using the pediatric assessment triangle. This quick assessment, done in about 30 seconds, provides a foundation for your general impression of the patient’s acuity. The three parts to the assessment triangle are appearance, work of breathing and circulation to the skin.

Determine how the patient appears to be interacting with their environment. Neonates who are not active are concerning. Flaccid extremities signify a depressed neurological system. Next evaluate the patient’s work of breathing. Do not count respirations or listen to lung sounds; rather, expose the chest and evaluate if the patient needs an extra effort to breathe or if their breathing seems easy. Breathing effort that catches your attention is a problem—find the reason. Finally, gain a quick understanding of the patient’s circulatory status by looking at the skin to see if it is pale or cyanotic.

NEO SECRETS

The mnemonic NEO SECRETS is a helpful list of differential diagnoses that cause instability in the neonate (Figure 2).4 After providing initial stabilization for a critically ill neonate, seek to identify the underlying problem. Failure to rule in, or out, underlying problems can lead to the neonate deteriorating or ultimately their demise.

iNborn Errors in Metabolism

Inborn errors of metabolism won’t appear until after the neonate has attempted oral feeding. While newborn neonates are unlikely to have fed, prehospital providers may encounter recently discharged neonates who, in their first weeks of life, have deteriorating conditions for which 9-1-1 is requested. In these patients, parents may report a failure to properly suck on a nipple, increasing irritability, vomiting, increasing lethargy and foul-smelling urine and stool.⁴ Without intervention these patients tend to slowly and consistently deteriorate, though sudden collapse into shock is not common. While the prehospital care of metabolic imbalances is supportive in nature, monitory closely for hypoglycemia as a result of the poor feeding. Hypoglycemia of less than 45 mg/dL should be corrected with D10W or D5W.

Electrolyte Abnormalities

Abnormal electrolytes in neonatal patients are typically the result of an underlying illness rather than being a precipitating problem. However, failure to correct these abnormalities can limit the success of resuscitative efforts and may prove fatal.⁴ One of the most effective strategies for managing neonatal electrolytes is to ensure proper hydration. The critically ill neonate’s response to the antidiuretic hormone is depressed, and this places them at increased risk for fluid loss and dehydration, especially when ill.
The most common neonatal electrolyte abnormalities include hyponatremia, hyperkalemia and metabolic acidosis. Initial care for all of these is fluid replacement, making the initiation of intravenous access during prehospital care a critical intervention.4 Prehospital teams with laboratory equipment that can determine electrolyte levels should do so, but do not initiate specific electrolyte treatments without additional training or specific online medical control orders.

Overdose

While accidental overdoses occur commonly in toddlers, who can place unknown objects in their mouths, they are rather rare in neonates. However, neonates have immature hepatic and renal function and increased ratios of skin surface area to body mass. These lead to an increased risk of exposure and a decreased ability to metabolize and eliminate toxins, resulting in toxicity at much lower concentrations than older children.⁴ The two most common toxin exposure routes in neonates are oral (via mother’s milk) and dermal. The latter is a particularly great risk, especially as new parents rub drugs on a neonate’s skin to treat rashes and use rubbing alcohol (isopropyl alcohol or ethanol) following baths or to treat fevers.⁴

To screen for accidental overdoses, inquire about topical medicines or treatments parents may have used on the newborn, and also ask about any drugs, herbs, foods and alternative medicines they may have tried.

Narcotics and methadone can pass through the placenta to newborn neonates and via milk to feeding neonates. When narcotic overdose is suspected in a neonate whose mother has been abusing narcotics, do not administer naloxone as you would in an adult. Giving naloxone may cause withdrawal seizures in the neonate. Rather, assist the neonate with ventilations and intubate if necessary. The exception to this would be when the mother was knowingly administered narcotics for pain control during the preceding four hours of the birthing process, and there was no narcotic exposure prior to that. In these instances 0.1 mg/kg naloxone is indicated.²

Seizures

Tonic-clonic seizure activity commonly seen in adult patients is extremely rare in neonates. Rather, neonatal seizures often present with lip smacking, bicycling movements of the legs, tongue thrusting, staring spells and apnea.⁴ The most common causes of neonatal seizures include intracranial hemorrhages, infections, electrolyte abnormalities (sodium, calcium, glucose) and drug withdrawals.

When seizures are observed, focus on identifying and correcting the underlying cause, as idiopathic seizures and epilepsy are unlikely. If seizures continue after electrolyte imbalances are corrected, the drug therapy of choice is 20 mg/kg of IV phenobarbital.4 Only administer midazolam, diazepam or lorazepam with online medical control orders.

Endocrine Crisis

The two most commonly encountered neonatal endocrine disorders are hypoglycemia and hypocalcemia.⁴ Neonatal hypoglycemia occurs in roughly three of every 1,000 births.⁵ In the neonate, hypoglycemia is defined as a whole blood glucose of less than 45 mg/dcL and can occur in infants who are both large or small for their gestational age, premature, have low glycogen stores or whose mother has gestational diabetes.³ Less commonly, neonates can also develop hypoglycemia if they’re producing too much insulin or using glucose faster than it can be produced/consumed, such as during a serious infection.⁵ It is a best practice to screen all neonates for whom medical care has been requested for hypoglycemia, even when asymptomatic. Symptoms of neonatal hypoglycemia include abnormal cry, hypothermia, diaphoresis, jitteriness, lethargy, seizures, apnea, cardiac arrest, weak muscles, vomiting, tremors and sweating.^3,5

The initial treatment for hypoglycemia is 2–4 mL/kg of 10% dextrose. While 10% dextrose is available as an IV infusion, it can also be made by mixing 5 mL of D50W with 45 mL of sterile water. It is important to note that dextrose is mixed with sterile water and not normal saline. The unnecessary use of normal saline can alter the newborn’s sodium levels and cause additional unanticipated problems.

Symptomatic hypocalcemia (serum calcium less than 7 mg/dL or ionized calcium less than 1.1 mmol/L) may present with seizures, laryngospasm, stridor, a weak cry, jerking movements and a prolonged QT interval on an ECG.4 It’s necessary to confirm hypocalcemia prior to initiating treatment with 100–200 mg/kg of 10% calcium gluconate. Hypocalcemia is considered an endocrine crisis rather than an electrolyte imbalance, as its cause is typically endocrine rather than purely volume-related.

Cardiac Abnormalities

When neonates are born in a hospital, they are screened for cardiac abnormalities; often these can be found prior to birth via ultrasound. There are five cyanotic congenital heart defects: Truncus arteriosus, transposition of the great vessels, tricuspid atresia, tetralogy of Fallot and anomalous pulmonary venous return all present within the first few days of life and are immediately evaluated by pediatric cardiologists. However, as more families elect to have births occur at home, it is possible these cardiac abnormalities won’t be observed until the neonate becomes symptomatic and hemodynamically unstable. It is well beyond the scope of prehospital providers to diagnose specific cyanotic heart abnormalities; however, it is extremely important to provide appropriate management when they present.

Following birth the ductus arteriosus slowly begins to close. Because of the abnormal blood flow in these cardiac abnormities, these neonates depend upon continued blood flow through the ductus arteriosus. As blood flow through the ductus arteriosus decreases, cyanosis and shock develop. Even though these patients present cyanotic, high-flow oxygen is actually detrimental, as supplemental oxygen stimulates closure of the ductus arteriosus.

Suspect a cardiac abnormality when neonates suddenly develop shock and cyanosis anytime between 2–14 days of life. Intravenous fluid resuscitation is indicated. Avoid supplemental oxygen, and if ventilations are needed, do so with room air.

Recipe

When evaluating an unstable neonate, inquire how the caregivers are feeding the patient. When neonates are receiving formula, improper mixing can lead to electrolyte abnormalities. Thus, if the neonate is receiving formula, ask how it is being prepared. Improper mixing with either too little or too much water is dangerous.⁴ In particular new caregivers with limited income may try to “stretch” the formula by diluting it, and this can lead to severe hyponatremia.

Additionally, there are many formulas that offer supplements for the neonate, and some families add their own supplements too. Many of these are untested and unregulated. This lack of control can expose the neonate to a variety of abnormalities. When you identify that a neonate has received supplements of any sort, attempt to bring the supplement with the patient for the hospital to evaluate.

Enteric Emergencies

Neonates who present with feeding intolerance, bile in emesis or stool, and a tender, distended or discolored abdomen are considered to have a surgical emergency until they can be evaluated by physicians experienced in neonatal surgical care. Raise your index of suspicion when the patient also presents febrile. There are a variety of surgical emergencies the neonate may experience, and few can be diagnosed without an x-ray or CT scan. Many of these emergencies include intestinal necrosis, making them truly time-sensitive.

One enteric emergency prehospital providers can recognize and accurately diagnose is a diaphragmatic hernia. Diaphragmatic hernias present shortly after birth with a scaphoid abdomen and bowel sounds in the chest. A scaphoid abdomen is diagnosed when the abdomen is sunken below the flat line that extends from the chest wall to the pelvis. These neonates also commonly present with severe respiratory distress, as the intestines impair lung expansion. Avoid ventilating these patients until an endotracheal tube can be placed! Bag-mask ventilations can introduce air into the stomach and intestines, which will further limit lung expansion. Intubate these patients early, place a gastric tube and then provide rapid transport to a hospital with neonatal surgery capabilities.

Trauma

Sadly neonates are not immune from traumatic injuries, both accidental and intentional. Failure to complete a detailed physical exam on a neonate can result in missing evidence that their condition has resulted from trauma. Trauma may be suspected based on the story given, evidence on the scene or signs of bruising or other injury on examination. The musculoskeletal system is most commonly affected. Suspect serious internal organ injury when neonates present unstable with evidence of trauma. Head trauma may result from accidental injury as well as abuse. The most commonly injured organ is the liver, due to its relatively large size.
Tension pneumothorax is an uncommon complication of both neonatal trauma and hyperventilation of the neonatal patient. Simple pneumothorax occurs in less than 1%–2% of all neonates, with less than half of these developing symptoms.6 However, when it does occur, it produces profound shock commonly associated with bradycardia and is a life-threatening emergency that requires rapid intervention. Suspect a tension pneumothorax when an injured neonate has shock with absent breath sounds on one side and also has severe respiratory distress, or when shock suddenly develops in the neonate who is receiving artificial ventilation and then has absent breath sounds on one side. Often the affected side will appear expanded while the patient’s respirations slow.

Immediate needle chest decompression of the affected side is indicated when a tension pneumothorax is suspected—again, this is rare! When necessary, perform decompression with a 20- or 22-gauge needle at the second or third rib along the midclavicular line. To assist in positioning, consider raising the affected side by placing a rolled washcloth beneath the patient’s back. Since the needle only needs to be inserted a half-inch (or less), consider placing hemostats on the needle to prevent it from being inserted too deeply (Figure 3).⁶

Sepsis

Neonatal sepsis is not common, though it is a significant cause of neonatal instability, as it progresses rapidly and has a 25% mortality.³ Any fever greater than 38.0ºC is an indication for a thorough evaluation and hospital workup. Neonatal infections that present in the first seven days of life are assumed to be transmitted from the mother; when infections appear after the seventh day, they are often community-acquired. Prophylactic antibiotic care at birth does not prevent neonatal sepsis.⁴ Suspect sepsis when critically ill neonates have a fever in addition to any of the following: respiratory distress, shock, episodes of apnea or cyanosis, seizures, lethargy or petechiae. When sepsis is suspected, initiate IV/IO access and begin fluid resuscitation. The primary treatment of neonatal sepsis is the IV administration of two of the following antibiotics: ampicillin, 50 mg/kg; Rocephin, 50 mg/kg; gentamicin, 2.5–4 mg/kg based on weight.³

Blow-by Oxygen

There is no evidence that blow-by oxygen improves a neonate’s ventilations, pulse or SpO₂, and it results in the uncontrolled delivery of oxygen. Further, attempting blow-by oxygen to stimulate a newborn can delay necessary interventions.

Rather than attempting blow-by oxygen, provide ventilations when the pulse rate is below 100, and use a nasal cannula and pediatric oxygen regulator to determine the least amount of oxygen necessary to maintain oxygen saturations. By beginning with the least oxygen necessary, you can trend your patient over time. When patients require oxygen to be slowly increased every few minutes to maintain oxygen saturations, they are deteriorating in condition and need more intervention!

Transportation

It may be tempting to grab an unstable neonate and drive emergently to the closest emergency department while attempting to initiate care along the way. This strategy is likely dangerous for both the patient and the crew, as nobody is properly in seat belts during transport. Rather, initiate care and stabilize the patient to the best of your crew’s ability while on scene. Provide care and then initiate transport once your critical interventions are established (i.e., airway secured and IV/IO access in place). Stabilize the critical systems while looking for an underlying cause.

Once ready, transport the patient to an emergency department at a hospital with a neonatal intensive care unit. Transport directly to a hospital properly prepared to manage the patient rather than just the closest hospital; this is better for the patient’s long-term care. Only divert to the closest emergency department when you cannot stabilize the patient or when lifesaving interventions are required.

Conclusion

Acutely ill neonates are prone to rapid deterioration. When treating a neonate, complete a thorough assessment and begin interventions early. Stabilize the critical systems and then look to diagnose and correct the underlying problem. The most important prehospital intervention is often IV access and a fluid bolus. It is better to proactively intervene with small problems before they cause true instability in the patient.

References
1. Martin JA, Hamilton BE, et al. Births: Final Data for 2013. National Vital Statistics Reports, 2015 Jan 15; 64(1); www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_01.pdf.
2. Kattwinkel J, ed. Neonatal Resuscitation, 6th ed. American Academy of Pediatrics, 2011; https://reader.aappublications.org/nrp-neonatal-resuscitation-textbook-6th-edition-english-version/1.
3. Hashim MJ, Guillet R. Common issues in the case of sick neonates. Am Fam Physician, 2002 Nov 1; 66(9): 1,685–92.
4. Kim UO, Brousseau DC, Konduri GG. Evaluation and Management of the Critically Ill Neonate in the Emergency Department. Clin Ped Emerg Med, 2008 Sep; 9(3): 140–8.
5. Lee KG. Low blood sugar—newborns. MedlinePlus, www.nlm.nih.gov/medlineplus/ency/article/007306.htm.
6. Kim SK, Kim WH. Tension pneumothorax in a newborn after Cesarean-section delivery—A case report. Korean J Anesthesiol, 2010 Dec; 59(6): 420–4.