1. 2011 CPR Procedures Infant & Neonate RN, LPN and Respiratory Therapists

2. Objectives After completing this self-learning packet the reader will be able to: 1. Identify how infant and neonatal CPR techniques differ from those of older patients. 2. Apply the American Heart Association's performance guidelines to case scenarios requiring: -Infant one and two rescuer CPR -Infant Foreign Body Airway Obstruction (FBAO) Management -Neonatal CPR

3. A B C C A B (infants) A B C (neonates) or C A B (infants)  The guidelines 2010 identify specific difference in CPR techniques for infants and neonates.  Infants  Infants are defined as approximately 1 year of age or less.  Neonates  Neonates are identified as any infant during the initial hospitalization.  The differences in CPR techniques are outlined in the following program.

4. So, what else is important ?  Supplying ventilations to infants is extremely important as arrest is frequently due to asphyxia. BUT:  Ventilation - More is NOT better!  We over ventilate in volume and rate!  Blood flow to the lungs is decreased in an arrest, therefore, lower respiratory rates/volumes still maintain an adequate perfusion/ventilation ratio.  Hyperventilation is Harmful!  Forceful or excessively large breaths given by rescuers can exacerbate gastric distention. Not only can gastric distention cause vomiting and aspiration, it can restrict lung movement as it elevates the diaphragm.

5. So, what is important for infants and neonates? In a Cardiac Arrest Compressions are key!  Compressions need to be hard enough  Fast - appropriate to victim’s age  Started as soon as the cardiac arrest or imminent arrest is recognized  Maintained with minimal interruption

6. Initial Steps of Infant CPR  No longer will we be doing the A, B, Cs.  To emphasize initiation of early compressions, the steps are now C-A-B: 1. C - compressions 2. A - airway 3. B - breathing

7. Steps for Infant CPR for the Healthcare Provider (HCP) 1. Assess unresponsiveness and overview for absence of normal breathing. 2. Call for help and a defibrillator. 3. Check pulse. 4. If no pulse, begin CPR compressions. 5. After 30 compressions, open airway and give 2 breaths. 6. Continue CPR at a ratio of 30 compressions to 2 breaths for 2 minutes. 7. As soon as a defibrillator is available, assess for need to defibrillate.

8. Steps for Infant CPR for the Healthcare Provider (HCP) 1. Assess unresponsiveness and overview/observe for normal breathing. Tap victim, shout out, “Are you ok?” while simultaneously looking for any signs of normal breathing.

9. Steps for Infant CPR for the Healthcare Provider (HCP)  Assess unresponsiveness and overview/observe for normal breathing - DO NOT take the time to open the airway. DO NOT Look, Listen and Feel for breathing.  Abnormal breathing is frequently mistaken as presence of respirations. Cardiac arrest victims may present or initially have a short period of seizure like activity or agonal gasps - this should not be identified as normal breathing.

10. Steps for Infant CPR for the Healthcare Provider (HCP) 2. *. 2. Call for bystanders to get help and the defibrillator - do not leave the patient*. Note the time for recording on the code blue documentation form. * * If no one is present to activate the emergency response team, do CPR for 2 minutes and then call for help. 7911 In any of the Kaleida Hospitals, direct helpers to call 7911 and inform the operator of your location and Code Blue. The Code Cart with advanced equipment and defibrillator is essential.

11. Steps for Infant CPR for the Healthcare Provider (HCP) 3. 3.Check Pulse Use easily accessible central pulse point - in an infant the brachial pulse is used. Assess for no longer than 10 seconds for a definite pulse - if unsure, proceed as if pulse not present. 60  In an infant - a pulse must be 60 beats per minute or more to be considered adequate.  With a pulse less than 60 and signs of poor perfusion such as pallor, mottling or cyanosis - cardiac arrest may be imminent - chest compressions should be initiated.

12. Steps for Infant CPR for the Healthcare Provider (HCP) 4 4.Begin Chest Compressions to maintain forward blood flow  Just below the intermammary line.  Push Fast.  Push Hard enough - at least 1/3 the diameter of the chest or about 1 ½ inches in an infant.  At least a rate of 100 per minute.  Allow full re-expansion (or recoil) of chest wall between compressions.  Avoid the xiphoid process and ribs.  Place bed board under patient to facilitate chest compressions.

13. Chest Compressions in Infants 1 Rescuer - Use 2 fingers on the sternum, just below the intermammary line * 2 Rescuer - use 2 thumbs* encircling the infants chest - depress straight down - no squeeze of the chest is recommended * *increases coronary artery perfusion

14. Steps for Infant CPR for the Healthcare Provider (HCP) 5. 5. Following the first 30 chest compressions, begin rescue breathing. Deliver 2 breaths.  Use gentle head-tilt/chin-lift position to maintain open airway position - do NOT pause to check for breathing!  If the chest does not rise with ventilation attempt, reposition the head, make a better seal and try again.  HCP in employment situation should always have available and use a barrier device to deliver mouth to mouth ventilations.  Deliver only enough air to cause a visible chest rise-more is NOT better.  Deliver each breath over only 1 second.

15. Steps for Infant CPR for the Healthcare Provider (HCP)  Coordinate breathing and chest compressions: Continue CPR in cycles of 30 compressions to 2 ventilations (for 2 rescuers 15:2)  Pause no more often than every 5 cycles or 2 minutes for a 5 second pulse check

16. Ventilations in Infants  Ventilation when there is an advanced airway (example Endotracheal tube) in place: Do not interrupt compressions - Interpose one breath every 6 - 8 seconds for 8 - 10 breaths per minute.  For an apneic infant victim with a pulse of greater than 60, give one breath every 1 - 3 seconds or 12 - 20 breaths/minute.

17. Steps for Neonatal CPR for the Healthcare Provider (HCP)  For the purposes of CPR resuscitation - the guidelines identify a neonate as: Any infant during the initial hospitalization

18. Important Considerations in Neonatal CPR  Low birth weight infants may become hypothermic - make every effort to keep the newborn warm.  Suctioning of the nasopharynx can cause bradycardia during resuscitation. or  Insufficient or excessive oxygenation can be harmful to the newborn.  Bradycardia in a newborn is usually the result of inadequate lung inflation or profound hypoxemia.

19. Assisted Ventilation in the Neonate  Ventilation is the most effective action in neonatal resuscitation!  Assisted ventilation should be delivered at a rate of 40 - 60 breaths per minute to maintain a heart rate of greater than 100 beats /minute.

20. Steps for Neonatal CPR for the Healthcare Provider (HCP)  Assess unresponsiveness and overview for absence of normal breathing.  Call for help and a code cart/defibrillator.  Open the airway and deliver 2 breaths.  Check pulse.  If no adequate pulse, begin cycles of CPR compressions and ventilations. As soon as a defibrillator is available, assess for need to defibrillate.

21. Steps for Neonatal CPR for the Healthcare Provider (HCP) Checking pulse in a neonate:  Use easily accessible central pulse point - example brachial or in a newborn, umbilical pulse.  Assess for no longer than 10 seconds for a definite pulse. 60  In a neonate - a pulse must be 60 beats per minute or more to be considered adequate.  With a pulse of less than 60 despite adequate ventilation with supplemental oxygen for 30 seconds - chest compressions should be initiated.

22. Steps for Neonatal CPR for the Healthcare Provider (HCP) Begin Chest Compressions to maintain forward blood flow: Lower third of sternum Push Fast Push hard enough - at one third the dimension of the chest Allow full re-expansion (or recoil) of chest wall between compressions Do not compress the xiphoid process or ribs Use technique as in Infant CPR

23. Coordinating Chest Compressions and Ventilation in a Neonate  Ratio=3 compressions to 1 ventilation.  Rate=120 events per minute (90 compressions and 30 breaths).  Each compression or breath takes only 1/2 second.  Compressions and ventilations CANNOT be delivered simultaneously.

24. Foreign Body Airway Obstruction (FBAO) Infants  Management of choking is different for infants than adults and older children!  Definition=sudden onset of respiratory distress with coughing, gagging, stridor and or wheezing.  Mild=can cough forcefully or make some sounds-let the baby cough on her own.  Severe=victim unable to make sounds-use the steps outlined on the next slide.

25. FBAO - Conscious Infant  Pick up the infant (supporting head and neck on your forearm or thigh) and place the infant face down, with head lower than torso.  Using the heel of one hand on the infants upper back, perform 5 back blows (slaps).  Continue to support the infant’s head and neck, sandwich the infant between your arms turn the infant face up on opposite forearm or thigh.  Keep the infant’s head lower than the torso. Deliver 5 chest thrusts using 2 fingers (as in one rescuer infant CPR).

26. FBAO - Unconscious Infant For a choking baby who becomes unresponsive: Ask bystanders to call for help (if not done already). 1. Start CPR chest compressions (do not pause for pulse or breathing check). 2. After 30 compressions, open the airway and look for a foreign object. If a foreign object is seen-remove it. NO blind finger sweeps! 3. Attempt 2 breaths. 4. Continue with cycles of compressions and breaths.