Dr. Ariel Olicker, the medical director for Neonatal Critical Care Transport, joins the team for some practical conversation about understanding and being more comfortable with neonatal patients. Since traditional EMS doesn't encounter these patients regularly, the goal is to simplify understanding this patient category.
Prehospital Paradigm Podcast
Understanding the Neonatal Patients for EMS - Part 1
(upbeat music) - Welcome back everybody. It's a pre-hospital paradigm podcast. I'm Scott Wildenheim. Got the usual crew here. We got Caleb Ferron. We got Dr. John Hill. And a very special guest today. We have Dr. Ariel Olucker from University Hospitals, neonatology. You're an attending physician and assistant professor of pediatrics there. Welcome. - Thank you. - We wanted to do, there's been several field births and resuscitations that have gone on in various, both pre-hospital and certainly in the critical care. I know about that last situation with the pre-me. But we wanted to get you on and just kind of talk about all of this, you know, needle resuscitation stuff. And I think it's, it's kind of a, we really hope it never happens, but you know, you do EMS long enough, you're gonna deliver a baby. And then that on top of itself is stressful enough, but then to then subsequently turn around and then need to resuscitate the unwell baby. I mean, it's just, I guess borderline terrifying for most of us, right? And it's, I'm so, so glad you were, you know, anxious and willing to come on here and talk with us about these things. So again, thank you, thank you so much for coming on. - Thank you, I'm happy to be here. - Yeah, no, this is great. I mean, I guess where do we start? How do we identify that we're in trouble? John, I'll have you talk a little bit about, you know, the actual field birth in a little bit here, but how do we know when we're in trouble and we need to start actually resuscitating this, this newborn infant in the back of my ambulance and somebody's living room, where whatever situation we find ourselves in, I mean, what are some indicators that we're in trouble? - Yeah, so it's really easy to identify a well infant, right? So a well infant's gonna come out, they're going to cry. Usually they're gonna cry vigorously. They'll have good tone, they'll be kind of curled up, they'll want to stay curled up. They will, all babies start off blue and this is a big misconception. People think babies should come out pink and they don't, none of them do. So all babies will start off blue, but within the first couple of minutes, a well baby will start to pink up. So if you've got a baby who is crying and if you're not there for the delivery, you're probably gonna miss that blue stage or hopefully only miss that blue stage, but if you've got a baby who is pink and crying and kind of curled up and tight, that's generally a well baby. - That's good day. - Yeah. - Okay. - If you have a baby, babies don't necessarily have to cry. They usually cry on the white out when they're well, but they don't need to continuously cry. So if you get there and a baby's already been delivered and they're breathing nicely, but they're not crying, that's okay. - Okay. - A baby who's breathing nicely and pink and has good tone is still gonna be a well baby. The ones you need to worry about are gonna be those ones who a few minutes in are still not pink, so they're blue or they're kind of on their way from blue to pink. So kind of your purple baby, if you will. Babies who are not kind of tight and flexed, so the ones that are more extended or floppy. - Floppy, yeah, floppy. - Babies who obviously aren't breathing, those are gonna be the ones you're concerned about. - They're super, yeah. Well, good. And then I think one of the other, we touched on this a little bit when Dr. Yaski was on with, you know, needing the proper equipment is, you know, we can't be substituting in our adult stuff for this as we need very specific. - Most of it anyways, yeah. - Yeah, we need very specific, properly sized equipment for this, specifically for this population. I mean, there's a little more variance in our PEDs than certainly in our adults. I mean, you know, small adult versus regular adult, we can make it work in most cases. But this is a case where, you know, properly sized equipment is kind of a must, right? - Properly, you can go both ways on this. So some properly sized equipment is always gonna be a must. So when you're doing things like artificial airways, you're gonna wanna have the appropriate sized artificial airway. Too big isn't gonna go in, too small isn't gonna be able to be used to ventilators, right? Certainly having angiocath small enough to go into the newborn vein, things like that. Other things though, we can't expect you to carry everything, right? - Sure. - And so sometimes there is gonna be some creativity. So talking about things like using the umbilical cord for venous access. It'd be great if you had umbilical lines, but I can't expect EMS to carry umbilical lines. So we think about what can we do with what we have? So we've talked about things like using angiocaths or using feeding tubes or-- - That's sitting here, we're gonna get back to that, but yeah, absolutely. - So certainly you need to have some of the properly sized things that are irreplaceable, masks, tubes, vascular access, things like that. But other things, we can be a little creative with what we have and we can meet you where you are. - And I think to add to your point, Doc, is that we're also using different scales. I mean, we have the Apgar scale, we have maybe the bras well taped, so we're not using those on adults per se. So there are other things that are tailored to this as well. And I think that you made a good point there that they're gonna come out and it's probably not screaming at first, not pink yet, it takes a few minutes. So I think doing Apgar scales, it's important to remember that might not be perfect for the first one, but you need to trend that and do a second one and compare and see where the baby's progressing or digressing. - Yep, so we generally do them at one five and sometimes 10 minutes. Oftentimes, a well baby will have, so if we're gonna be technical, no baby will ever have an Apgar score of 10. I know people love to give people Apgar scores of 10. And the reason for that is, it takes much longer for the hands and the feet to turn pink. And so, for color, you always lose one for Acrocyanosis. So a blue baby is a zero, a baby with Acrocyanosis is a one, a completely pink baby is a two. And so that's why you never see us in the hospital ever give a 10. - Great of a 10, right? - But aside from that, you will oftentimes see in a well baby at one minute an Apgar score of nine. But if you don't, that's when you start to try them. And even sometimes, Apgar scores can even go down. Sometimes a baby will cry initially and then stop breathing. And those are babies who need some help. - What's your trigger for additional trending? So we're classically taught one in five minutes. - One in five. - And that's it. - It's like-- - You don't need any more. - And it's okay not to document 10 and 10. Like I'm saying, that's good. Don't do that because it's probably not normal to be 10 and 10. - If that second is trending down or if you think the overall clinical course is poor, that's the time to-- - And generally-- - And generally, if you're still resuscitating, you're still giving scores. And so the rule I think is if you score until your score is greater than seven, I believe. - Oh, okay. - But if you're still resuscitating, you're still gonna be giving scores. - I don't know that that has ever been said to me. - I've never heard that. - No, I don't know that's ever been said to me. So that's great, that's great information. - Yeah, no, I like that. - Yeah, score until sometime. - I would say if something changes too, right? So you do your initial, your birth, everything's fine. Baby starts to deteriorate, like we talked about vital signs. You're going vital signs for kids who don't need it or that it's gonna be abgar score, right? On top of pulse, right? We're talking about pulse knocks here in a little bit too. But making sure the patient has a good, strong, fast pulse, not a slow, brady pulse for kids, making sure their respirations are fast and moving adequate air. And then if there's a change, I don't think there's any reason not to re-score them as an abgar as part of their vital signs. - And you can do it later. So in general, you're recording vital signs, right? We don't do abgar scores in the moment. We do them after we're done with things. So we go back and we look at our resuscitation sheet and I'll go back and look. At this moment, I was giving breaths, but my heart rate was good. At this moment, I was giving breaths and my heart rate was 80, you know? And so we'll go back and do them afterwards. - And trending that seems intuitive, but I'm stressing that and I'm bringing that up 'cause I know that that's not taught to be that kind of a dynamic thought process. It's really like you must have these two points of information and it's essentially it, right? It's like for the newborn, especially classical textbook teachings and stuff like that. So it's good to hear that use it more dynamically and use it more intuitively based on your case presentation. - Yeah, and to take some of the pressure off of it, we take abgar scores with kind of a grain of salt. There's five components to it. Each one has up to two points that can be assigned, which is where you get your 10. There's heart rate, which is gonna be more objective. There's respirations, which has a little bit of subjectivity too, but it's gonna be more objective. There's color and this is where the subjective parts are gonna come in. There's color, which is gonna have some subjectivity to it. There's tone, which is gonna have some subjectivity to it. And there's reflex area ability, which is gonna have some subjectivity to it. And so we take a look at abgar scores, but in general, we take them with a little bit of a grain of salt. If you tell me that a baby's abgar is seven or you tell me a baby's abgar is eight, it doesn't mean all that much to me. If you tell me a baby's abgar is nine and a different baby's abgar is two, those are two different babies. - Yeah, those are wildly different cases, sir. - I like what you said about the color too. I mean, 'cause that's important. We talked a lot about field resuscitation not that long ago. I don't think I was on that episode, but I remember hearing the modeling versus, you know, lividity and it's important not everybody sees it the same way and I think that we need to see this color the same way. - By the same token, she has the opportunity to see well and unwell babies all the time, right? - We don't. - And she's going to be far better tuned to those subtle differences than we would, right? But yeah, it's great to wake up that subject. - Bigger for us though, as far as the paramedics go with the class and all that is that if you have a baby who's central cyanosis at first, not getting better, that's worse than somebody who's slowly pinking up and getting better. I mean, that's where we really need to step in and say that we gotta do something different. - All right, so. - Slowly pinking up and getting better is exactly what you're looking for. You don't necessarily even want to try for a baby to go straight from blue to pink. - Zero to 100 right now, it's just not gonna happen. - That's not your goal. Your goal is over the course of the first 10 minutes to get from deoxygenated to oxygenated. And so you actually have a good amount of time to get to a sack greater than 90. And so, and if you think about it, when you're resuscitating, you're focused right here, right? You're not focused on the rest of the baby. It's silly, but the sicker a baby is the less likely I am to know the stacks after I'm done resuscitating. - Oh, okay. - And so, you're focused right here. And you've generally got a mask right here. So you have a really good look at the area that you want to see get pink. And you can watch as your mouth starts to turn pink or not. And it's the best indicator of how well you're doing. - And I think display-- - In terms of color. - You know, race and background, I mean, even on a darker child that lips should still be a pretty good indicator of color. - Lips, and especially, I generally try to look at the tongue. - Tongue. - Tongue. You'd be surprised, even in more dark-skinned families, all babies actually come out pretty light. - As part of that airway management. In the, we're gonna frame this up in the adults, right? And in the adult side of things, 'cause clearly that's what EMS does the most, right? We may be very apt to go quickly to an advanced airway. Do we need to delay that? Or can we run out of kind of with the same gusto? Like we walk in, check up Paul's patient, not breathing. We might bag him four or five times before somebody's putting a super glottic in him or somebody's, you know, using that as a bridge while they're setting up endotracheal intubation. Do we need to drag our feet a little bit more on that? - You can have some patience. - Always is this, yeah. - You can have some patience. And if there's any skill as, you know, we were talking before we started, the newborn airway is gonna be different than the adult airway. And if nothing else, it's smaller and harder to see. It's also pretty delicate, it can be lacerated easily. Once you've lacerated an airway and you have a lot of blood back there, it's hard to see anything. - See anything, right? - Oftentimes the airways just have a lot of fluid back there for me, amniotic fluids and stuff. And as you suction things out, if you have a little patience, a lot of times once you sort of jumpstart a baby or get past what we call primary apnea. So primary apnea is a baby who comes out not breathing. Secondary apnea is a baby who comes out breathing and then stops. - Subsequently stops, okay. - So if you are able to bag and mask a baby past that primary apnea point, and sometimes you can, sometimes you can't. And a lot of this, some of it's gonna be breathing, some of it's also gonna be heart rate. But a lot of times we can bag and mask a baby past that initial primary apnea or that initial stunned period into a baby who can be transitioned to no support at all or considerably less support. And the less you have to instrument an airway, the better, the less likely we are to have swelling and it didn't even our little or babies when airways get traumatized. It can be traumatized for the long haul and cause issues that make us, I mean, thinking way down the line, you can get things like subglottic stenosis, which causes us issues extubating way later. - Sure, do you see that more intubations or like superglottics or let's say oral airways? - So everything subglottics and stenosis is gonna be with intubations. - Okay. - As far as the superglottics, so I would love for everyone to have the skill of good bag masking. The next thing that we'd love to have, everyone have the skill. - So would we. (laughing) - I can be VVM a lot. (laughing) - And we can look at it and talk about it. I would love for everyone. And even when we have our own residents, our greatest, our goal for them is not necessarily to make them good intubators, but we want them to be good bag maskers. You can bag mask a baby for a long time. But our next goal, especially for EMS, who doesn't have a lot of opportunity to resuscitate newborns or to intubate newborns, our next goal is to get them to be able to do something that is going to be easy, that they can do quickly and that they'll be confident with. And so superglottics is gonna be your easiest tool there. And so while it would be great to be able to have these babies intubated in the field, I'm happy if you can do superwattas. - Superglottic, yeah. - I love the point you made, because you can bag somebody much easier if you're doing proper technique and why fix it if it's not broken. If I'm bagging, if I'm getting good circulation, I'm not gonna go from that path. I've never intubated a baby in my career. It's been over 20 years, I've never done that. So I would definitely go with a subglottic airway. But I think, more importantly, as we go back to the equipment, using the BVM you have there and not this one is huge. 'Cause I don't wanna overpower those lungs and this is about all we have anymore. And to see these smaller ones, it makes so much more sense. - Yeah, I've got little ones. You can use big ones, you just have to be careful. - Very careful, the amount of air you're using. - Proper techniques, huge. And again, I think if you're able to get oxygenation, ventilation with that, why go from that? - And if you're confident putting in a superglottic airway, if you're confident placing an LMA or an eye gel, and you can get good chest rise and your baby's pinking up, that's all you need. - But I think like to your point, Scott, I mean, if we have an adult patient who collapsed on us and we're BVMing, we're going a couple of minutes and going right to an advanced airway, it's like-- - Our threshold for that is generally very low, right? And that was why I framed that up. - I would give a baby a moment to kind of turn around. Maybe sometimes just need a moment. You can give them a good few breaths and sometimes they will scream at you and-- - Tell you to stop. - Yeah, that's the best thing they can do. - Right, if you have a baby who's screaming and fighting, you're trying to put in the airway in the field, that's a baby who doesn't need an airway in the field. - Right, doesn't need it. - I think it'd be extremely rare that this child would have a cardiac event as opposed to respiratory event, though, right? I mean, we need to focus on the airway, not defibrillating because it's not going to probably need it. That is a huge, huge point. It is where NRP and newborn care differs from pediatric care and adult care. In pediatric care and adult care, when they go down, they're going down oxygenated, right? So those are people who were previously breathing and previously oxygenated who were going down with oxygenated blood. So when you're talking about lay BLS, and we did things like get rid of rescue breaths and lay BLS, that works because you're going down with oxygenated blood and you're circulating oxygenated blood. When a baby comes out, a baby is deoxygenated and you can do compressions forever. And if you circulate deoxygenated blood, you're not in any better spot than you were if you're not circulating at all. And so airway and breathing are the two most important parts of NRP and you usually don't have to go past that. If you can open up the airway, not necessarily with an advanced airway, you just need to generally open the airway. So clear the airway of secretions, get the airway open, get a baby into a good sniffing position and breathe for the baby. That's usually enough to bring your heart right back up on its own and you don't usually have to go from there. There's actually not in initial NRP, the defibrillator never comes into it at all. (laughing) - They're like, what's that thing? It's a big paper right? - There are instances when we do cardio work, but not generally in the delivery room. I've in my career never defibrillated in the delivery room. - Let's keep it that way. - Yeah, right. - Yeah. Once you do get past airway and breathing, if your heart rate still isn't coming up for you, the next part's actually to put in, you don't buy NRP, you don't necessarily need to, but the next step that makes the most sense is to put in the advanced airway at that point before you start compressions. - Sure. - And if you don't put in an advanced airway before you start compressions, there are several issues. You are oftentimes closing your airway by giving compressions, and so if you are trying to give compressions and breathe through a bag mask at the same time, you're often doing it through a closed airway. You can also, with your compressions, push out the air you're trying to push in, and so it's important to synchronize them. And so once you're to the point where airway and breathing isn't doing it for you and you have to move on in the steps, that's when you certainly want to put in an advanced airway. But if airway and breathing is doing it for you and the baby is just not developing their own respiratory drive, you're not going to want to transport giving bag mask ventilation. That's also when you're going to want to intubate it. - I think that'll separate paramount though between good providers and not, is that with adults we're jumping towards AEDs with PEDs, we need to focus in on airway period and just work the problem. - Focus in on airway, focus in on breathing. Most babies are never going to need compressions and the vast majority of babies will never need an AED. And then what is your threshold for the airway and breathing not working before you're transitioning? 'Cause of course, you know, a protocol and you know, our classic teaching, heart rate less than 60 star compressions. I'll tell you most providers, again, having not done many of them and I think they've, puff puff, nope, kids not making enough, heart rate's not coming up and they'd immediately go to the chest. - Or maybe they just suctioned and spagled, stimulated and-- - Correct, correct. - So I mean, like what is your kind of, your threshold for that? A couple minutes minimum kind of thing? - So if, are you looking at other indicators? - So if you're talking about compressions and RP is pretty specific on this, if you're talking about compressions, the first thing you want to get is effective ventilation. So it is, you move on to compressions when your heart rate is still less than 60 after 60 seconds of effective ventilation. It's not just 60 seconds though, it's 60 seconds of effective ventilation. - Got it. - So that means I have chest rise and fall or does that mean I have raising SPO2 levels? What is an effective ventilation? - You have chest rise and fall. So remember, if you don't have circulation, you're not gonna get rising, 'cause you have levels. - So I need mechanical ventilation. - Well, bad mask. - I need to see this. - Yes. - Yeah. - What's your heart rate threshold to give us, to start BVMing a patient? - Like if they drop below 100, if they drop below 80, at what point are you? - So we start bag masking if you are dropping below 100, but also just if you're not breathing. - You're not fair. - That's, I mean, that's one people forget, right? - Sure, they forget. - Well, if I'm breathing a baby's not breathing, baby should we breathing? - Yes. - At least as much as I am. (laughing) - She's, and if this was me, I'd be breathing pretty quick. (laughing) Because we talk about that too, and we're bagging, right? If you're breathing and you haven't braved for your patient, you should do it same here. If you're breathing a baby's not breathing, baby should be breathing or eating. - Yeah, baby should be breathing faster than you are, though, hopefully. - Yes. - How fast should we be bagging these patients? - You wanna do it, yeah, you wanna do it at a rate of 40 to 60 breaths per minute. - Which is very different than we do in the adult world. - Mm-hmm, it's very different. And so when we're teaching it, when we're teaching things like NRP, when you don't have an advanced airway, so when you're just doing it with a bag mask, people actually tend to breathe too fast. And it may honestly be different for people whose world mostly revolves around adults, actually, because you're used to breathing what, 12 to 20 times a minute? - Well, 12 to 16's ideal, but we end up probably more around 20 is probably what average people are, 'cause they're so excited. - They're excited, they're worried. - So it may honestly be that this isn't gonna be quite as big an issue for EMS as it is for pediatricians, say, but people do tend to even in a baby bag too fast. And so for us, in order to slow it down, sometimes, and when I'm leading codes, sometimes I feel like this is really my role, but I'll stand there and I'll say, breathe to three, breathe to three, breathe to three, when you're doing it with a bag mask. When you're intubated, it's a little bit different, or not intubated, I'm sorry, well, it's the same when you're intubated, but still bagging. - Yeah. - Once you start doing compressions, it changes a little bit, and it's one and two and three. Hold, breathe, one and two and three, and breathe, one and two and three and breathe. - Okay. - And that hold is the important part, because that would be where we would fail in the transition from the adult mindset, 'cause we would just continue with the chest compression. We wouldn't put that pause in there. I mean, that's beat into our heads on the adult side, is correct. - Well, we want to limit time off chest. - Time off chest, right, is hands on time. - The baby's chest is so compliant. - So compliant. - That if you try and give a breath while you were giving a compression, you'll just push your breath back out. - Yeah. - I mean, that's a simple little thing that I know would go overlooked, I mean, because we would fall back on what our experience is, right? And that's usually the adult population. - And hopefully we never see a Lucas on this. - Oh my goodness. - The Lucas will tell you no. But it comes back to knowing your equipment and knowing what is right for babies and not. - We talked a little bit off camera about, and actually we were looking with Lorentzoscope with a vastly oversized Lorentzoscope blade at-- - What size was that? - It was probably a two, but-- - I mean, I would use a one on her, it's not vastly oversized. - It looked gigantic, but yeah, 'cause I think that was the top one in that stack, so it says two, three, four over there. But you were saying that our anatomical, if we are to position where we need to take their airway and endotracheal innovation is the choice, whether we don't have a superglotic, and you've got here an eye gel, and you also have an LMA. But if you don't have either of those and or the decision is to intubate, you were kind of describing some of our usual landmarks that we train on aren't necessarily what we'll see when we go in. - The most, the one that you're looking for the most is gonna be what you're not gonna see. - I'm not gonna say it. - So, in general, the technique is gonna be similar, I think. - So softer. - Yeah, so-- - Miller blade versus a Mac, right? - Yes, we are using millers, so we're always using straight blades. So you're gonna wanna go in, and my general technique is I just go in deep. I assume that my blade is in the esophagus. You wanna pull up toward the corner of the wall, so you don't wanna rock toward your face, you wanna pull up toward the corner. And then I slowly back out, and you'll see the epiglottis flop down, just like it does in an adult, I assume. We were joking earlier, I've never intubated anybody with teeth. (all laughing) - A lot of our patients don't have teeth either. (all laughing) - For very different reasons, 'cause we took them out. - I mean, hopefully they had teeth before. - So they did, we just removed them to do the innovation. (laughs) So your epiglottis will flop down, and you'll see your airway, and it'll look more like a soft triangle, as opposed to that nice hard triangle you're used to seeing. But in older kids and adults, you are taught, or you've seen, that they have these nice, pearly white cords, and in infants, they don't. In infants, they're gonna be pink, just like the rest of the airway. If you're intubating a baby who's breathing, even ineffectively, you will be able to see the cords flapping open and shut just like you can in an adult. - You're probably paralyzing adult before you intubate them. - Not always necessarily, yes. - Pre-feel. - They do have-- - There's pockets that you RSI have. - But it's definitely not, it's not standard of care. It's not widely accepted, but-- - Got it, and we do it in the NICU for non-emergent intubation too. We don't do it in the delivery room. But if a baby is breathing, but not effectively, and you have to intubate, you will see the cords opening and shut, just like you would in somebody older, but they're not gonna be that nice, pearly white. They're gonna be pink. - I thought that was a phenomenal point. I never had been taught that. - Yeah, we both said we're gonna go back and check even. So I think our old mannequins absolutely have white cords, but that new one, I wanna check. I can't remember. - 90% sure they were painted. - Yeah, she doesn't. - No, no, so, yeah. Simple little thing to know, right? - Yeah, that's a big deal. - Do you carry enteric tubes that you can put down in the field? - Small ones. - Two and a half is probably the smallest that I have. - You could even go bigger than that. - The smallest that I think we would have, most would have is a two, two, five. - You could use a five and eight. Sometimes even a 10 and a bigger baby. But if you put down an OG tube. - Oh, I'm sorry, your question was OG. - Yeah. - OG, no. - Okay. - Don't, don't, don't. Just don't. - That's what I'm talking about. - Stop, stop, stop, stop it. - I should be. - I'm sorry. - Your tubes are pet peeve. - Well, we should be doing them. They're not out for. (laughing) - Well, when I was going to say. - I'm sorry, no, I misunderstood. They're talking about ET tubes. No. - They can't have a two, five tube down them. Well, you can, but. - I wouldn't. (laughing) - Let's not say we did, right? I'm sorry, your thought, though, was. And again, we've got a national audience, so, you know. - Some people are doing that. - Maybe somebody has it, but I misunderstood your question. - Or I know, I know, for example, our critical care transport team does have an entire tubes. And so if you put an entire tube down, you can leave that in. And so when you put in your blade and you go deep and you pull up, you can see, you can see your entire tube. And as you start to pull back and your esoph, and your epiglottis flops down, your entire tube's gonna go out of your field of view. And then you know you're looking at the airway. - What's your position? I know that nationally the position has changed, but cuffed versus uncuffed tubes. And have you seen any differences in your practice using them? Are you still inflating if you are using them, or just? - We are almost exclusively not using them. - Not you. - When babies go to the OR, they sometimes come back with cuff tubes. There is the very occasional baby who is between tube sizes who will put in a cuffed tube with the cuff down, just to give us a little bit more occlusion, just because our leak is so big that we need something there. But in general, at least our practice is that we use almost exclusively uncuffed tubes. And the reason is that pressure that you're putting on the trachea below the glottis is going to be at that point A, it's gonna be a pressure point. And we have tubes in sometimes for hours or days, but sometimes for weeks or months at a time. And that's a point that will eventually, if pressure is put on it for a long time. - And maybe even in the days to weeks area of long time, be a point that can scar down and cause a point of sublatic stenosis. And at that point, you have an abnormal airway, which is going to be a problem later. - That's a point, sure. - I think it's important, just talking differences in equipment, that if we do inflate, we have to be careful how much pressure we're putting in there. Don't blindly throw 10ccs in there, they won't accept it. And if you do, you're causing trauma. - I don't know that our cuff tubes, can you can't even 10ccs? - But you know, everyone's gonna take this revenge. - Some adults that have it. - They can accommodate a lot, but if you're throwing like this, a seven on an adult patient, you can usually get 10ccs than that. - Right. - We have a baby who just got a trick, who has pretty significant tracheal militia, so a kind of bigger floppy airway, and had no leak at all with two and a half ccs. - See that's just enough to start inflating the two brothers. (laughing) - Well, this is a total aside. When you set a leak on a kit, I'm thinking, yeah, I get leaks that are like 10s, 20s, 50s. Get above 50, that's probably a lot of leak, I'm thinking a leak for your kid. 50 is probably the whole volume of your entire hair. - Yeah, yeah. - That's been a leak for your patient. (laughing) - So I think-- - So your leaks are probably, you're talking smalls. - Are you talking about an MLs or percent? - MLs. - So when you think about babies and their title volumes, when I'm thinking about minimal event settings or a baby who just needs a ventilator because they're not breathing, so has lungs that can ventilate and oxygenate, my usual starting point for ventilation is gonna be five MLs per kilo. So if you think of your standard-- - That's even below, we do for adults, 'cause we totally start at six. Our goal is six to eight, six to eight. - Oh, okay. So if you think of your standard three kilo, just for round numbers, three kilo baby, your title volume's gonna be 15 MLs. - Yeah, wow. - If you think about your tiniest-- - That's my leak on my patient's super fun. (laughing) - If you think about your tiniest 500 gram 24 weeker, your title volume's gonna be two and a half MLs. - That's crazy to me. (laughing) That's crazy, that's more than what's in there. - Yeah, I mean, just to contextualize that, you know, it's two and a half MLs. That's your title, that's not-- - That's title volume for me. - That's title volume, right. - And now you see why that mask was, or that, that bag was too big? - Yeah. (laughing) But now actually that's, I'm glad you brought that up and talked about that 'cause to me, to contextualize that, that's a big deal. - Yeah, but in order to prevent airway trauma, so I think in adults, you're generally looking for no leak, right? - Ideally, but I mean, I accept leaks and vents all the time, right. I think I can, I expect it in a few MLs or tens of MLs is okay. And we see a lot of them, perhaps-- - By the way, you're not invasive. - Yeah, not invasive, of course. - I mean, this is gonna blow your mind. I'll see 1,200 MLs of title volume on a patient that's really working to breathe on a-- - On a basis, on a basis. - Yeah, on a bi-pager. - 'Cause they're taking a big shirt, right. - I don't think I have 1,200 MLs of patients. (laughing) - So you can see, and intermittently, I'll see leaks even to like 150, depending on how the mask is. - Yep, yep. - But it's typical, typical leaks of 10, 20, but again, that could be your whole volume. - So we're actually-- - That's nuts, yeah. - So, but you're looking to minimize your leak. - Of course, of course. - We're looking to minimize, sure, but we actually want some leak. If we don't have a leak at all, we're actually worried about that. - Sure. - And those are babies that we are worried as we get to that point about excavating. There are babies who have 100% leak on the vent, and before we go to straight up sizing the tube, we'll actually see what we can do with positioning the baby and positioning the vent tubing to see if we can kind of overcome our leak and still ventilate, just because we're trying as hard as we can to avoid airway trauma. - What I took from all of this is bag first, and then if we have graduated after at least a minute, if not more, that we're gonna put an advanced airway in. - Choose a super glottic-- - Super glottic, yep. - 'Cause that's what we'll have in the field. Or if you have a laryngeal mascara or whatever you have, and then transport. - Yeah, yes. - That's what I heard. - Yeah, I was-- - 'Cause even me, if I received this in the ED, I now know that I'm gonna leave that eye gel there. If I'm going down my ABCs, right, airways intact, we're ventilating and oxygen in the patient appropriately, I'm gonna transport to you to have you guys worry about advancing, putting in an ET tube, and not to disturb the lower, upper airway, but lower than the glottis. - But lower than the glottis. - Yeah, yeah. - Area, so that way it don't cost trauma. - If you can bring us a baby with a well-seeded, super glottic airway who has good chest rise, I'm happy. - Perfect. - Deal. (laughing) - Can do. (laughing) - Can do. - So kind of going back to your point, though, I mean, with an adult, a full arrest, seeing that we talked about field resuscitation in past episodes, sometimes they're staying, playing, sometimes they're just not. You were gonna talk a little bit about a normal delivery, and the stages of that. I think, you know, women have been giving birth naturally for thousands of years without any medical assistance, and things have been fine. - Yeah, they have been. - And I tell my guys all the time that I don't believe childbirth is a medical emergency, it's life, and there are small percent that might turn tail on you, but I think maybe if you talk through that, what is a load-and-go, and what is a kind of just, hey, let's get this airway, let's chill out, what point do we transport? - So let's go back, let's start with natural childbirth. Let's say you're called to a scene, and mom's crowning. You can have that conversation about what number child this is. If this is, they've had multiple kids, this is baby number four. Babies coming out a lot quicker than have never had a baby before, never passed a child through or the breath canal. Crowning, I would just stay there and work the scene, deliver baby. So they're gonna crown and to your shoulder, post to your shoulder, put baby on top of mom on skin to skin. I think the first step of any resuscitation for a newborn is going to take dry towels and vigorously rub that kid. That's the best thing you could-- - Tactile stimulation. - Tactile stimulation, you want to dry them off so that way they're no longer wet. You want to get them on skin to skin with mom or dad or whoever is gonna be a warm body to keep them warm because we've had a recent case where we didn't keep them warm, right? - Right, right. - And then keeping them dry. Just not playing with them but doing that stimulation so that way they'll take their first breath, they'll cry, they'll start to pink up as they start to really kind of move that air. And the crying baby would mean it's the best thing I can hear. - But wait, you haven't clamped the cord yet. - So do you want to talk about deletion? (laughing) - I'll set you a pregnancy. - I just think textbooks always tells you as soon as they baby, so you clamp, clamp, clamp. And it's like, whoa, whoa, whoa. - No, the new thing is delayed. - There's a body in it. - Body of evidence. - Body of evidence. Because we want more blood to go to baby. Let's pick baby up, dry 'em off, put 'em on mom, make sure baby's doing okay. Oh, crying, great, we can get our stuff out to, we should already have it out. But set up our clamps, we're gonna put our clamps on and then we're going to do most importantly, cut in between the two clamps. (laughing) - Yep. - So that way we can acclude the side. And then make sure the next step to that is you're not done. Baby might be doing okay, you want to watch baby, but then next thing is to then make sure that placenta gets fully delivered. - And old textbook was that every time we saw head, we would suction, mouth and nose. There is an importance, they're obligate, nasal breath. What are you suctioning first, but are you leaning away from, do we have to do that every time? Or are you doing that, what if you see maconial? - I can't do all this if you want. (laughing) - I wouldn't, you can, if baby's coming out and baby's heads out, you can suction if you have time. I wouldn't necessarily take the time if we're delivering. - NRP actually recommends against it now. - Okay. (laughing) - So I would deliver baby, get baby out, rub, again as you said. - Clear out your way there after you. - We've been doing this for a long time without our help. But if you keep in mind. - Yeah, and I kind of leaded that question, 'cause I know that recently they've changed their mindset on the suctioning, and it's really thrown some older paramedics for a little bit. - In our time, there has been a swing in that, usually. - So yeah, there's some evidence, and the reason NRP recommends against it is there is some evidence that there's actually more need for resuscitation when you try and suction at the perineums when the head is delivered, but the rest of the baby is not delivered. And so NRP recommends deliver, or recommend against suctioning in that situation. So deliver your whole baby. Keep in mind that once your baby is delivered but your court is not clamped, the baby is still attached to the placenta, and the placenta is still at that point an organ of respiration. So while the baby is getting, so placenta blood is baby blood, if you think of it that way. So while the baby is still connected, while you are doing your delayed court clamping, the baby is still getting the respiratory properties of the placenta while the placenta is still attached, and there are very few true contraindications to delayed court clamping. Pretty much the only really true contraindication to delayed court clamping is going to be an abrupted placenta, because at that point your placenta is not acting as, it's not acting as your organ of respiration, and it is bleeding. And so you are losing baby blood at that point. - I love that you brought that up because when you think about water births and people freak out that the baby's born in the water and the baby can't breathe, it's like, oh no, baby doesn't need breathe yet, just give it a minute. - Yeah. - Just went from outside water to inside water, right? As long as that placenta is still attached, the baby is still getting what it needs from its placenta. - I love that, yeah. - And so, as far as maconium goes, the guidelines on this have changed in the last several years. Between the last two editions of NRP, they've stayed the same, which I guess is nice. But the recommendation before I started, but long, not long before I started, was every baby with maconium got intubated for suction. - Deep suction? - Yeah, the same for us in the day, basically. - Yeah, yeah, certainly what I was trained in. - Yeah, so NRP at that time was every baby with maconium stained fluid gets intubated for deep suction. And that guideline has changed over time, and so around the time I started, every baby who was born vigorous did not get deep suction, but babies who were born not vigorous so you're not breathing baby or floppy baby, your baby with bad tone. Those were the babies who used to get still intubated for deep suction. Now, actually, every baby, even with maconium, comes out in the first step of NRP, even with maconium, is gonna be dry and stem. So the thought used to be that if you deep suctioned, you were going to prevent that maconium aspiration, and it was actually, I believe NRP came up with this new recommendation by looking at outcomes of resource-poor countries, where they didn't have the resources to intubate all these babies, and they had similar rates of maconium aspiration syndrome as we did with our intubating for deep suction. But with babies who have significant maconium aspiration syndrome, it's not that maconium that is present on the baby or in the mouth at the time of delivery. It's maconium that has been aspirated in-- - Chronic. - It's not chronic, per se. It's kind of sub-acute. But it's that maconium that's been aspirated before the baby has been delivered, and in sick babies, what can happen is those babies will gasp and they'll take in particulate maconium before they come out, and that's the maconium that's reaching down past your large airways into your smaller airways and really causing you issues. So certainly, bulb suction if you see an airway that is occluded by anything, but including maconium stained fluid, but your next step is gonna be dry and stem, and it's always gonna be dry and stem. - Is there anything else on a normal delivery? I mean, that was the high-level overview. - That's just high-level overview. That's how 99.9% of your deliveries are gonna go. They're gonna go the natural way. I think that's a whole separate issue. - About to say-- - What to talk about? - I think we could do a whole bit on abnormal breathing emergencies and why not. - Just because I'm that guy, let me ask you, and you'll probably be able to answer this question for me. - Probably not. - I have two patients down by ambulance. Can mom hold baby during transport? - Yes. - In this case? - They have to. - Skin to skin. - Skin to skin. - Right, and there's gonna be some people out there that'll butt heads with me on that because the baby should be secured in a car seat and locked down and it's like, hm, hm. - Have you ever been met a mom with a newborn baby? - That won't let her go? - I mean, take it one step further. You didn't make it to the hospital, you delivered in the squad. What are you gonna do? - Right, you're gonna have to stop, probably pull over. I mean, again, I hate seeing this unless it's a small percentile that this is a medical emergency. Let's just calm down. - I think you can go boil water. - I think you're crossing over to two thoughts here and that-- - Legality of transport. - Well, that secondary thing is our other edict to transport appropriately and safely in properly sized gear. But you're talking about, in the vast majority of those cases, not a newborn infant, we're talking about a patient, usually a pediatric, that's already gone home and is past this initial-- - And has an appropriately sized car seat? - That's a different case. In that case, the answer is, yeah, I understand mom, dad, whomever's gonna wanna hold the kid. That's a completely different set of circumstances, right? We're talking about this in the field delivery perspective. - But also, another part of resuscitation that we've sort of hit on a little bit, but kind of glossed over. So we talked about dry and stem, right? And babies come out wet. A big part of resuscitation is going to be getting your baby warm and keeping your baby warm. - They're all regulated. - And the best way to regulate temperature once your baby is dry is gonna be skin-discened with the mom. - No, I agree, 100% with that. And a head covering would help too. - Yep. (dramatic music) (gentle music) (gentle music) (gentle music) (gentle music) (gentle music) You [BLANK_AUDIO]