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Newborn Life Support Provider Course Resuscitation and ECC Skill

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					                     Newborn Life Support Provider Course
                      Resuscitation and ECC Skill Station
         Guide to teaching the resuscitaire, equipment familiarisation
                     and chest compressions skill station


Introduction

This guide is to help you plan your teaching session based on the structure of set,
dialogue and closure. After reading this guide you should understand the importance of
prior preparation. Remember – Prior preparation prevents poor performance.

Key teaching objectives

  •   Candidates will realise the need to be familiar with equipment in their hospital
  •   Candidates will understand the strengths and weaknesses of a resuscitaire
  •   Candidates will learn how to give chest compressions
  •   Candidates will learn how to deliver breaths and chest compressions working in pairs

Equipment per station

For specific teaching

  •   Resuscitaire with functioning gas supply, pressure relief valve & T-piece circuit.
  •   3 towels/baby wraps, with plastic bag & hat (to show preterm thermal care)
  •   Two manikins – preferably non-intubatable Laerdal BLS manikins (catalogue no. 14 00
      10)
  •   (alternatively one BLS and one Intubatable Laerdal ALS manikin (catalogue no. 08 00
      11)
  •   Round soft silicone Laerdal masks (or similar) – size 00, 0/1 and 2 – one of each

As part of normal resuscitaire equipment –
use of the following items will be taught in airway station

  •   Guedel airways 0 (6 cm), 00 (5 cm) & 000 (4 cm) – one of each
  •   Paediatric Yankauer sucker and wide bore (12 or 14 FG) suction catheter
  •   (Laryngoscopes with large and small blades)
  •   (Tracheal tubes with standard 15 mm connector sizes 2.5, 3.0, 3.5 – one of each)
  •   (Paediatric / neonatal stethoscope)
  •   (Syringes)
  •   (Umbilical line)
  •   (Disposable gloves)




NLS PROVIDER COURSE - RESUSCITATION AND ECC SKILL STATION         August 2006 (Revised July 2008)
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Environment

The room needs to be big enough to accommodate the resuscitaire, the group of candidates
and 2 instructors. The resuscitaire should be offset to the group who should form a semicircle
around it either standing or sitting. You must be familiar with the equipment you are
demonstrating. Find out what is available before the session.

Set

Introduce yourself and explain that this workshop will be in two parts. The first section is run
as a workshop to familiarise them with the resuscitaire and the second as a skill station to
teach them chest compression, allowing them to practise delivering breaths and chest
compressions as a team.

Plan

Part 1

Emphasise the need for candidates to familiarise themselves with their local equipment. Take
them through the resuscitaire logically:

  •    Power, heat, clock (sometimes clockwork with key), light
  •    Oxygen / air supply (mains and bottle)
  •    Gas flow controls
  •    Pressure limiting devices
  •    Suction control
  •    Means of ventilating babies
  •    Horizontal resuscitation area with removable sides (some people need to remove them
       to perform chest compressions and short people may need a stand as well - a variable
       height system is very useful but is rarely right for everyone)
  •    Shoulder support if present (meant to accommodate the occiput but allowing the baby to
       slip down causes the neck to extend and results in occlusion of the airway)
  •    Drawers with further equipment
  •    Shelf for putting equipment on

Discuss the need for identifying and familiarising equipment used at their base or in the
community. Identify any questions and answer them. Bring to a close and move onto Part 2.




NLS PROVIDER COURSE - RESUSCITATION AND ECC SKILL STATION            August 2006 (Revised July 2008)
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Part 2

Teach chest compression. This can be done as a four stage technique, making sure that
the candidates all have an opportunity to practise in pairs.


1st Stage      Perform chest compressions and breaths with the hand encircling technique.
               Use a 3:1 ratio with the other instructor.


2nd Stage      Explain and demonstrate the two ways of delivering external chest compression
               emphasising the landmarks and that the two-handed approach, encircling the
               chest, is the more effective. Emphasise yet again that compressions are
               pointless without adequate lung inflation – i.e., visible chest movement.


3rd Stage      Get the group to talk you or the first pair through the process.


4th Stage      Bring candidates up in pairs to deliver mask inflations and compressions
               getting them used to working together. A rapid compression stroke should be
               followed by a slightly longer relaxation phase in which the chest is allowed to
               spring back to shape. Both candidates should perform each activity.
               Use this opportunity to emphasise head position. Some candidates will have
               done the airway station already so check their technique. Others will have that
               to come so will learn the necessary practical skills subsequently. Ensure that
               each candidate practises and performs the manoeuvres and gains confidence.
               Correct any poor technique. Always use the standard manikin in the initial
               phases, as the NLS manikin will ventilate in ANY position.


Notes:

Importance of relaxation phase
Compression of the chest pushes blood from the ventricles into the aorta and the pulmonary
artery. Elastic recoil of the chest wall during the relaxation phase pulls blood into the
ventricles from the atria. Reiterate that the aim of chest compression in newborn resuscitation
is different from that in resuscitation of adults. In adults the aim is to maintain carotid artery
perfusion to ensure brain oxygenation as well as coronary artery perfusion to assist
cardioversion, but in the newborn the object is to achieve adequate coronary artery perfusion
with oxygenated blood to help 'bump start' the heart.
Carotid artery perfusion occurs during systole (i.e. during the compression phase) but both
coronary artery perfusion and ventricular refilling occur during diastole - i.e. during the
relaxation phase of chest compressions. The relaxation phase is thus just as important as the
compression phase. If you attempt too fast a rate you may not be allowing enough time for
the ventricles to refill between each compression and you may also be compromising coronary
artery perfusion.
Remind them again that we are trying to perfuse the coronary arteries with oxygenated blood
and therefore periodic effective inflation of the chest is absolutely essential to the process.




NLS PROVIDER COURSE - RESUSCITATION AND ECC SKILL STATION            August 2006 (Revised July 2008)
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Quality not quantity
Candidates will almost certainly ask for guidance on a rate of compressions and a ratio of
compressions to inflations. Explain that there is no scientific basis for any specific
recommendations. Aiming at any specific rate is probably unnecessary as one is trying.
merely to deliver a small quantity of oxygenated blood to the coronary arteries and not trying
to maintain a flow of oxygenated blood to the brain.
For those who insist on having numbers the situation is as follows. Most guidelines appear to
have been based on an unproven assumption that it is important to approximate the normal
heart rate (140) and respiratory rate (40) of the unstressed newborn. However, with a clear
airway, babies in primary apnoea resuscitate themselves very adequately with gasping
breaths at a rate of about six per minute using a heart rate of around sixty per minute.
We teach the current ILCOR guidelines on this course. These state: “Use a 3:1 ratio of
compressions to ventilations, aiming to achieve approximately 120 events per minute, i.e.
approximately 90 compressions and 30 breaths. However, the quality of the compressions
and breaths are more important than the rate.”
(Those who have done other life support courses including APLS and EPLS will notice that
this is different to the 15:2 ratio suggested for children with professional rescuers. There is no
logical explanation for this difference nor any clear indication as to when a baby, requiring 3:1,
becomes a child requiring 15:2. A logical approach may be to maintain the neonatal ratio of
3:1 in the delivery room, at birth, the postnatal ward and during any stay in the NICU/SCBU)


In the final analysis what is needed are good quality compressions - with a long enough
relaxation phase to ensure ventricular filling and coronary artery perfusion -
interspersed with good quality, effective reinflations of the chest. The exact rate and
ratio are less important though an agreed ratio makes it easier when more than one
person is involved in the resuscitation.


Closure

Ask for and answer any questions.
Summarise what has been covered and the main points, stressing out that they should now all
be confident in providing compressions and emphasising that they will only be effective if the
airway and breathing has been managed effectively.




NLS PROVIDER COURSE - RESUSCITATION AND ECC SKILL STATION            August 2006 (Revised July 2008)
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