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Running A Neonatal "Mega-Code"


Dr. Reynolds
This program demonstrates how to perform critical procedures needed to resuscitate a newborn in distress. In this final segment, we will use the TeamSTEPPS approach to show you how all of these measures are put into action. Knowing how to perform these steps will give you the skills necessary to do everything you can for the distressed newborn.

Keep in mind that the scrubs of the team members are color-coded, to clarify who is doing what. The team leader is in green, the cardiac person is in burgundy, the equipment person is in gray, and the medication nurse is in blue scrubs.

Before performing a mega-code, it’s important to be as prepared as possible. Following these steps will help you be ready for the arrival of a baby who is unable to breathe, and whose heart rate is dangerously slow.
  1. Prior to delivery, find out the baby’s gestational age and estimated fetal weight from the obstetrician.
  2. Be sure to inquire about any maternal, obstetrical, or fetal concerns, as well as any maternal medications given, in particular magnesium and narcotic analgesia. If time permits, review the maternal chart.
  3. Introduce yourself and your team to the baby’s family.
  4. Double-check the equipment set-up, visually confirming the presence of a meconium aspirator; emergency medications such as epinephrine, normal saline, and naloxone; and an umbilical catheter tray.
  5. Huddle with your team.
  6. As the team leader, designate the team roles. You will need a cardiac person, an equipment person, and a medication nurse.
  7. Confirm with the medication nurse the likely 1:10,000 epinephrine dosage of 0.2 ml/kg and the likely normal saline bolus of 10 ml/kg based on the estimated fetal weight using a positive feedback response.
  8. Verify that the cardiac team member has a stethoscope and a watch or timer that displays seconds.
  9. Discuss how the cardiac team member will notify the team of the baby’s heart rate, including verbal notifications, tapping, and opening and closing their hand in time with the heartbeat.
  10. Alert the cardiac person that he will be responsible to provide chest compressions for a heart rate less than 60. The preferred technique is encircling the baby’s chest with the hands, placing the thumbs on the sternum. During the compressions, the cardiac person should repeat loudly, “One and two and three and breathe and.” This will synchronize the compressions with ventilation, which should be 90 compressions and 30 ventilations per minute.
  11. Confirm that the cardiac person will provide cricoid pressure using one finger, if necessary, during intubation. During all intubation attempts, the cardiac person will continue to listen to the heart rate, notifying the person intubating when it drops below 100, and below 60 during the intubation attempt.
  12. Communicate with the team member responsible for equipment about how the instruments and materials will be handled. This will include suction, the flow-inflating bag, endotracheal tube, stylet, pulse oximeter, tape, alcohol pads, 2 x 2 gauze pads, umbilical tray, and meconium aspirator.
After you have huddled with your team, you are now prepared for a neonatal mega-code — a blue, newly-born, full-term baby who is not moving, breathing, or crying, and has a heart rate less than 60. The following steps will walk you through a simulated mega-code so you can see the resuscitation training in action.
  1. This first step should last 30–60 seconds. You or the obstetrician will transfer the infant to the radiant warmer, placing the baby’s head near the edge of the bed, and the shoulders on the shoulder roll underneath the towels.
  2. Wipe the baby’s face with a towel. Use bulb suction inside the mouth, followed by the nose.
  3. At the same time, evaluate the color, tone, and breathing effort of the newborn.
  4. The cardiac person will obtain the heart rate by feeling the umbilical artery pulse, or by listening to the heart using a stethoscope. The rate should be displayed above the umbilical stump using hand motions, or by loudly tapping it out on the radiant warmer. The cardiac person should also call out the heart rate.
  5. The equipment person should pat the baby dry and stimulate him by flicking the heels and rubbing the back.

    If the baby continues to be unresponsive, blue, unable to breathe or cry, and his heart rate is less than 60, the equipment person will hand you the flow-inflating bag and mask.
  6. Apply the mask in drawbridge mouth-opening fashion, ensuring that the neck is not hyperflexed or hyperextended.
  7. Begin positive pressure mask ventilation, and look for symmetric chest rise.
  8. While you are doing this, the equipment person should prepare for intubation.
  9. While continuing to provide tactile stimulation, the equipment person should place the pulse oximeter on the baby’s right hand or wrist, if time permits. The cardiac person should continue to provide a visible indicator of the heartbeat while reporting the heart rate out loud. To ensure effective communication, you should repeat the heart rate back to them.
  10. If, at this point, the baby is still unresponsive after 30–60 seconds of positive pressure ventilation, notify the team to prepare for intubation. Follow the steps in the “Intubation and Placing an Endotracheal Tube” segment of this program.
  11. After intubation and 30–60 seconds of positive pressure ventilation, if the baby still isn’t breathing or moving, and the heart rate is less than 60, have the cardiac person begin chest compressions by encircling the baby’s chest with their hands and placing their thumbs on the sternum. The equipment team member should increase the oxygen level to 100%. During compressions, the cardiac person will repeat, “One and two and three and breathe and” so that there are 90 compressions and 30 ventilations per minute. Compressions will stop when you direct the cardiac person to do so. They will then check the heart rate. Ask the medication nurse to draw up epinephrine and normal saline boluses after reconfirming the weight as determined during the huddle. The equipment person should now take over the ventilations, confirming that they have hold of the flow-inflating bag before you let go of it. The equipment and cardiac team members must synchronize chest compressions with ventilations in a 3:1 ratio. 
  12. Prepare to insert an umbilical venous catheter to facilitate the administration of medications. Pause chest compressions during line insertion. The cardiac person may also need to switch to the 2-finger technique to allow room for umbilical line insertion. The equipment person will continue to provide positive pressure ventilation, synchronized with the chest compressions, or at a rate of forty to sixty breaths per minute when chest compressions are paused. The medication nurse will draw up 1:10,000 epinephrine, a normal saline bolus, and 3–5 ml saline flushes.
  13. If the baby continues to be unresponsive, and the heart rate is less than 60, repeat epinephrine. Confirm that all other measures have been properly executed, and that the endotracheal tube is properly placed in the trachea and inserted to the correct depth, which is calculated in centimeters by adding 6 to the amount of kilograms the baby weighs. For example, if the newborn is 3 kg, the tube should be inserted 9 cm relative to the baby’s gums or lips.
  14. If everything has been done correctly but the baby still remains unresponsive, a needle thoracentesis may be required. Try to identify the side of the chest with decreased breath sounds. If you cannot, start with the right side to avoid the baby’s heart. Proceed with the thoracentesis, following the steps discussed in the “Performing a Needle Thoracentesis” segment of this program.
As you train to care for an unresponsive baby, you become better equipped to lead your team in saving the lives of newborns who need critical care resuscitation.

We hope you and your patients will benefit from this training. Thank you for being a part of the “How to” Newborn Resuscitation program.