Tulane Emergency Department Quick Guidelines for a NEWBORN BABY

  1. Turn on warmer (manual mode 37.0 degrees) as soon as EMS informs you that they are in route with an imminent delivery or recently delivered newborn. Call the NICU at 780-4583 and ask them to have the attending and neonatal transport team come to the ED STAT. Set up bed including neonatal code box.  When the baby is dried put a temperature probe on the baby, connect to the bed and switch to skin mode 37.0 degrees to start and turn up or down as the baby needs it. Use covered heel warmers (or a warming gel pad) and warm hats to help slowly warm the baby also.
  2. Basic Neonatal Resuscitation Protocols (NRP) should be followed. Below is a basic primer that is consistent with NICU policy:

A>    Dry with warm blankets and stimulate the infant to breathe in the first few seconds.

B>    If not breathing, use an appropriate size bag and mask to ventilate

C>    The seal is the most common error in establishing breathing, focus on mechanics, instead of jumping to intubation in the first 30 seconds.

D>    If the infant fails to responds to bag mask ventilation, intubate. Successful intubation should allow for ventilation. If the heart rate is depressed, you are more likely to get it back with successful ventilation followed by epinephrine (1/10,000 0.2 ml/kg/dose) down the endotracheal tube, than by any other intervention. The primary reason for cardiac depression in a newborn is almost always respiratory depression.  Thus chest compressions are generally reserved for infants who are progressing towards asystole and have perfusion that is inadequate to circulate the epinephrine (rather than just depressed due to hypoxia).

E>     Bicarbonate should be avoided except for arrhythmias 2o to acidosis (use 4.2%)

F>     Don’t worry about surfactant. The NICU attending will make that call.

  1. For access, focus on the UVC. The NICU team can get arterial access if it is needed later (often this is not done until the 2nd hour of life in the NICU). Use CBGs or VBGs for blood gas values to facilitate rapid turn-around and response cycles. Make sure to get a blood sugar in the first 30 minutes.
  2. Zosyn (80 mg/kg/1st dose) should be chosen for broad spectrum antibiotic coverage. The NICU does not use cephlosporins or aminoglycosides in the perinatal period (one is associated with increased mortality, the other with prolonged ductal patency).
  3. Common errors after initial stabilization include: Right main stem intubation: ETT should be lip to tip in cm = 6 cm + 1 cm for each kg of weight.  Cold stress: infants under 2 kg, should have a warming gel pad activated and placed beneath them as soon as they are stabilized. Rebound Hypoglycemia: the initial blood sugar in low birth weight infants is often elevated due to the stress of birth and perinatal events, but can drop an hour or two thereafter, it is important to start IV fluids (D10W at 80ml/kg/day) and check dextroses as appropriate. Dehydration: low birth weight infants have permeable skin and will have significant dehydration. The simplest two interventions are to cover them with saran wrap and normalize their temperature slowly (overheating is a terrible thing to do to a baby). Hyperoxia: wean to target saturations of 90-95%. Oxygen free radicals are bad for babies and worsen their outcomes.
  4. Studies show that parents need to see their baby as soon as possible after a baby is born in order to establish normal bonding. Every effort should be made for the mother to see her baby shortly after birth, even if she must be rolled to the room on a stretcher for a few moments prior the infant being transported out. A photo of the baby should be taken, (even if just by cell phone), and given to her.
  • NICU Code Meds and Drips

  • E.D. Quick Guidelines for the Newborn

  • Antibiotic Guidelines (Cheat-sheet)

  • Go to NICU Brain

  • Go to NICU Library

  • Go to NICU Vault (Guidelines)

  • Go to Follow Up Clinic

  • Dr Gordon believes in using the right tool for the job

  • Flow Diagram of Neonatal Resuscitation

  • NICU Common Med List (Cheat Sheet)

  • General NICU Formulary (limited)

  • Drug Reference Tool I

  • Drug Reference Tool II

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