1. Critical Neonate Rafat Mosalli MD

2. Objectives Describe the algorithm for neonatal resuscitation and Delivery room management Describe the algorithm for neonatal resuscitation and Delivery room management Approach to a infant with Respiratory distress Approach to a infant with Respiratory distress Describe the etiology and effect of birth asphyxia Describe the etiology and effect of birth asphyxia Describe common birth injuries Describe common birth injuries

3. Case 1 Scenario You are called to attend the delivery of a baby who is not born yet. You are called to attend the delivery of a baby who is not born yet. What should you do first What should you do first

4. Delivery Room Care: Resuscitation Detailed maternal hx, GA Preparation ( equipments and personals)

5. Case 1 Baby is 35 weeks delivered now, breathing fast,irregular, Nasal flaring,blue in color and intercostal Retractions? Baby is 35 weeks delivered now, breathing fast,irregular, Nasal flaring,blue in color and intercostal Retractions? how you would approach this newborn? how you would approach this newborn? What is your DD? What is your DD?

6. Case 1:ABCD first APGAR SCORE APGAR SCORE Resuscitation (NRP) Resuscitation (NRP) ABCD ABCD Postnatal resuscitation. Postnatal resuscitation.

8. (Or 21%-100%)

11. Differential Diagnosis RDS RDS TTN TTN Infection Infection MA MA

12. Respiratory Distress Syndrome (RDS) Surfactant Production? Surfactant Production? Complications Complications

13. Risk Factors Premature babies Premature babies Previous baby with RDS Previous baby with RDS Maternal diabetes Maternal diabetes Hypothermia Hypothermia Fetal Distress Asphyxia Fetal Distress Asphyxia Male sex Male sex Caucasian race Caucasian race Second twin Second twin C/S with out labor C/S with out labor

15. Signs of Respiratory Distress Grunting Grunting Tachypnea (RR >60/m) Tachypnea (RR >60/m) Nasal flaring, chest indrawing Nasal flaring, chest indrawing

16. Apnea Obstructive Apnea:No air flow but the chest wall movements continue Obstructive Apnea:No air flow but the chest wall movements continue Central Apnea: Central Apnea: Complete cessation of airflow and respiratory airflow and respiratory efforts with no chest wall movement Mixed Apnea (Is the most frequent type) Mixed Apnea (Is the most frequent type)

17. Cyanosis Deoxygenated hemoglobin is 5 g/dl Deoxygenated hemoglobin is 5 g/dl Types? Types? ACROCYANOSIS: blue color of the hands and feet with pink color of the rest of the body, common in delivery room and is usually NORMAL ACROCYANOSIS: blue color of the hands and feet with pink color of the rest of the body, common in delivery room and is usually NORMAL

18. Routine Delivery Room Care Other Routine Delivery Room Care Erythromycin eye drops? Erythromycin eye drops? Vitamin K IM? Vitamin K IM?

19. Case 2 You are called to attend a delivery for baby with Meconuim liquor? You are called to attend a delivery for baby with Meconuim liquor? What you do first? What you do first?

20. Meconium/Suction Meconium in Amniotic Fluid Infant Active Infant Depressed Absent or decreased respirations, decreased muscle tone OR HR <100 bpm Observe No stimulation intubate and Suction Trachea Resuscitate PRN

21. Depressed Meconium baby

22. MAS

23. Radiological appearance: Radiological appearance: 1-overexpanded lungs. 2-coarse air space infiltrates. 3-Wide spread consolidation. 4-+/-airleakage.

24. MAS and HIE ! The baby is born now and he is flat with Apgar score of ZERO? The baby is born now and he is flat with Apgar score of ZERO? How do you proceed? How do you proceed?

25. Meconium Aspiration Syndrome Complications: Severe Resp. failure Severe Resp. failure HIE HIE PPHN(persistent pulmonary hypertension) PPHN(persistent pulmonary hypertension) Pulmonary air leak Pulmonary air leak

26. Effect Of Asphyxia(HIE) CNS CNS CVS CVS Pulmonary Pulmonary Renal Renal Adrenal Adrenal GIT GIT Metabolic Metabolic Hematology Hematology

27. Treatment Resuscitation Resuscitation Post resuscitation: Post resuscitation:  Depend on severity(stage3 is the worst) Fluids restrictions Fluids restrictions O2 and ventilation O2 and ventilation Inotrops Inotrops Anti seizure medication Anti seizure medication

28. Primary Pulmonary Hypertension of the Newborn (PPHN) Severe hypoxemia, with out evidence of parenchymal lung or structural heart disease that also may cause right to left shunting. Severe hypoxemia, with out evidence of parenchymal lung or structural heart disease that also may cause right to left shunting. Often seen in term or post-term infants who are asphyxiated or meconium stained fluid Often seen in term or post-term infants who are asphyxiated or meconium stained fluid

29. Case2 You are called to assess the same baby with MAS because of worsning respiartory status and sudden desaturation,bradycardia and hypotension? You are called to assess the same baby with MAS because of worsning respiartory status and sudden desaturation,bradycardia and hypotension? What is your approach? What is your approach?

31. Treatment

32. Other Pulmonary Air Leaks Pulmonary Interstitial Emphysema (PIE) Pulmonary Interstitial Emphysema (PIE) Pneumomediastinum Pneumomediastinum Subcutaneous Emphysema Subcutaneous Emphysema Pneumopericardium Pneumopericardium

33. Pneumonia

34. Early Vs Late. Early Vs Late. Diagnosis is impossible from XR alone. Diagnosis is impossible from XR alone. frank lobar consolidation as seen in adults and older children is rare frank lobar consolidation as seen in adults and older children is rare More commonly, there is coarse opacity of one or more regions of the lung parenchyma More commonly, there is coarse opacity of one or more regions of the lung parenchyma

35. Transient Tachypnoea of the Newborn Typically, respiratory symptoms resolve within the first 24-hours of life, but occasionally can persist longer. Typically, respiratory symptoms resolve within the first 24-hours of life, but occasionally can persist longer. Typical radiologic features: Increased central vascular markings Hyperaeration Increased central vascular markings Hyperaeration Evidence of interstitial and pleural fluid Evidence of interstitial and pleural fluid Prominent interlobar fissures Prominent interlobar fissures

37. We Talked about! Algorithm for neonatal resuscitation and Delivery room management Algorithm for neonatal resuscitation and Delivery room management Approach & DD of an infant with Respiratory distress Approach & DD of an infant with Respiratory distress Effect of MAS and birth asphyxia Effect of MAS and birth asphyxia