Newborn’s Heart Rate Determination

We are often drawn to new techniques and methods. While we may become enamored with exotic management strategies (ex, ECMO in the ED, Delayed Sequence Intubation), focusing on the basics is vitally important to the successful management of even the most critically ill. Often it is simple strategies that are most effective – like methods to Avoid Oxygen Desaturations or to Optimize Chest Compressions. We must, however, recognize our own limitations. The mere act of accurately palpating a pulse (something that should be relatively simple) is extremely challenging and we cannot afford to be inaccurate. This is particularly true when involved in the resuscitation of a newborn! Thanks to Dr. Elise Alves Graber (one of the stellar PEM fellows at CMC), I was reminded of this. Let’s quickly review something simple, but very critical – Newborn’s Heart Rate Determination:

Newborn’s Heart Rate Importance

  • The Transition from intrauterine to extrauterine life is tough! (some of us are still struggling with it.)
    • Fortunately, the majority of newborns do it successfully with little help.
    • ~10% do require assistance though!
  • Determination of Heart Rate is an important aspect of Neonatal / Newborn Resuscitation.
    • Determination of the heart rate within the 60 seconds of life is recommended.
    • If Heart Rate < 100 bpm, then respiratory assistance (ex, PPV) is needed.
    • If Heart Rate < 60 bpm after 30 seconds of PPV, then Chest compressions are indicated.
    • Chest compressions can be stopped AFTER 60 seconds, if the heart rate has improved.
    • Heart rate is the best “measure” of the newborn’s response to resuscitation.
  • Unfortunately, trained providers’ ability to determine the heart rate is NOT reliable! [Chitkara, 2013]

Newborn’s Heart Rate Determination

  • The Heart Rate can be assessed in several ways. [Trevisanuto, 2019; Phillipos, 2016]
    • Palpation of the umbilical stump (the way I was taught)
    • Palpation of peripheral pulses
    • Auscultation of the precordium with a stethoscope
    • Pulse Oximetry
    • Three-lead ECG / Cardiac Monitor
  • Not all methods are consistent. [Trevisanuto, 2019; Phillipos, 2016; Chitkara, 2013; Katheria, 2012]
    • Rapid and reliable acquisition of the heart rate is challenging!
    • Use of Palpation or Auscultation is inaccurate and leads to errors.
    • While these may still be used, Human Factors may undermine their reliability… and an unreliable method can have devastating consequences.
    • Pulse oximetry is more precise (and offer continuous information), but is affected by poor peripheral perfusion in newborns.
  • Current Recommendation is to use 3-lead cardiac monitor as a more objective measure of heart rate. [Trevisanuto, 2019; Mizumoto, 2012]
  • But, it is not that simple either: [Agrawal, 2019]
    • Attaching electrodes to wet newborn skin
    • Electrodes can damage premature skin
    • Muscle twitching can produce artifacts
    • Cardiac monitoring is not available everywhere
    • May detect electrical activity despite lack of perfusing pulse (i.e., Pulseless Electrical Activity – PEA)
    • Attaching electrodes can be delayed by the initial attempts to dry and stimulate the child.
      • One method may help eliminate this issue [Gulati, 2018]
      • Prearranging the electrodes such that they adhere to the neonate’s posterior thorax once placed supine on the warmer shortens the time to determination of heart rate.
  • Other options:
    • Portable Doppler Ultrasound [Agrawal, 2019; Phillipos, 2016]
      • May be able determine heart rate faster than cardiac monitor.
      • Audible heart rate is able to be interpreted by all care providers.
      • Detects flow, so may distinguish PEA.
    • A mobile application (Neo Tap Advanced Support) [Cavallin, 2019; Binotti, 2019]
      • Calculates the heart rate based on provider tapping the screen in unison with the palpated or auscultated heart rate.
      • Removes the need for provider to do math (and doing math can be difficult).
    • There are various other new technologies being evaluated (so something more easily used and more reliable could just be on the horizon). [Kevat, 2017; Phillipos, 2016]

Moral of the Morsel

  • Not a Simple Task! Determination of the newborn’s heart rate is critical… and challenging to do (even for experienced providers).
  • Don’t let your pride get in the way! When fast and reliable matter… your ability to palpate the pulse is not the best option.
  • Get the Monitor Set Up EARLY! Or… if you have a portable doppler ultrasound… just be ready to determine that heart rate within 60 seconds!

References

Trevisanuto D1, Galderisi A1. Neonatal Resuscitation: State of the Art. Am J Perinatol. 2019 Jul;36(S 02):S29-S32. PMID: 31238355. [PubMed] [Read by QxMD]
Agrawal G1, Kumar A1, Wazir S1, Kumar NC2, Shah P3, Nigade A4, Nagar N5, Kumar S1, Kumar K5. A comparative evaluation of portable Doppler ultrasound versus electrocardiogram in heart-rate accuracy and acquisition time immediately after delivery: a multicenter observational study. J Matern Fetal Neonatal Med. 2019 Aug 27:1-8. PMID: 31409165. [PubMed] [Read by QxMD]
Cavallin F1, Binotti M2, Ingrassia PL3, Genoni G4, Rizzollo S4, Monzani A4, Trevisanuto D5. Impact of a mobile application for heart rate assessment in simulated neonatal resuscitation: a randomised controlled cross-over study. Arch Dis Child Fetal Neonatal Ed. 2019 May 17. PMID: 31101662. [PubMed] [Read by QxMD]
Binotti M1,2, Cavallin F3, Ingrassia PL2, Pejovic NJ4,5,6, Monzani A7, Genoni G7, Trevisanuto D8. Heart rate assessment using NeoTapAdvancedSupport: a simulation study. Arch Dis Child Fetal Neonatal Ed. 2019 Jul;104(4):F440-F442. PMID: 30262463. [PubMed] [Read by QxMD]
Gulati R1, Zayek M2, Eyal F2. Presetting ECG electrodes for earlier heart rate detection in the delivery room. Resuscitation. 2018 Jul;128:83-87. PMID: 29614329. [PubMed] [Read by QxMD]
Kevat AC1,2,3, Bullen DV3, Davis PG1,2, Kamlin CO1,2. A systematic review of novel technology for monitoring infant and newborn heart rate. Acta Paediatr. 2017 May;106(5):710-720. PMID: 28199732. [PubMed] [Read by QxMD]
Phillipos E1, Solevåg AL, Pichler G, Aziz K, van Os S, O’Reilly M, Cheung PY, Schmölzer GM. Heart Rate Assessment Immediately after Birth. Neonatology. 2016;109(2):130-8. PMID: 26684743. [PubMed] [Read by QxMD]
Yamada NK1, Yaeger KA2, Halamek LP2. Analysis and classification of errors made by teams during neonatal resuscitation. Resuscitation. 2015 Nov;96:109-13. PMID: 26282500. [PubMed] [Read by QxMD]
Louis D1, Sundaram V, Kumar P. Pulse oximeter sensor application during neonatal resuscitation: a randomized controlled trial. Pediatrics. 2014 Mar;133(3):476-82. PMID: 24534410. [PubMed] [Read by QxMD]
Chitkara R1, Rajani AK, Oehlert JW, Lee HC, Epi MS, Halamek LP. The accuracy of human senses in the detection of neonatal heart rate during standardized simulated resuscitation: implications for delivery of care, training and technology design. Resuscitation. 2013 Mar;84(3):369-72. PMID: 22925993. [PubMed] [Read by QxMD]
Katheria A1, Rich W, Finer N. Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation. Pediatrics. 2012 Nov;130(5):e1177-81. PMID: 23090347. [PubMed] [Read by QxMD]
Mizumoto H1, Tomotaki S, Shibata H, Ueda K, Akashi R, Uchio H, Hata D. Electrocardiogram shows reliable heart rates much earlier than pulse oximetry during neonatal resuscitation. Pediatr Int. 2012 Apr;54(2):205-7. PMID: 22044505. [PubMed] [Read by QxMD]

Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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2 Responses

  1. Sean. Another great article, thanks for keeping them coming. Given how much our practice has changed with POCUS, the best way of checking the pulse (and other critical items) is to take a quick look at the newborn’s heart and lungs. While the more experience the better one becomes, even novices can place their smallest available probe almost anywhere on the chest (depending on what geography is available in a crowded resuscitation) to determine the pulse, adequacy of squeeze, presence of 4 chambers for cardiac and sliding/no sliding and presence of absence of B lines for lungs. This would take about a minute and is far more accurate than the oversized adult stethoscope used in the cacophony we generally find ourselves in.

    • Sean M. Fox says:

      John,
      Thank you for your comment!
      Yes… doppler ultrasound and other avenues are proving to be more useful than the “grab the umbilical stump” to determine a newly born child’s heart rate. During the resuscitation of the newly born, I don’t think we need to focus of anatomy as much as what the actual heart rate is (>100 bpm, <100 bpm, <60bpm?)... but yes, structural information will also prove too be useful... once the initial resuscitation has gotten under control.

      Have a wonderful day,
      sean

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