Tiny Tips: How ready is this child?

Not many neonates are delivered in the Emergency Department, but those rare babies who greet the world for the first time under the fluorescent lights of the resuscitation bay are precisely those who warrant urgent and concise communication about their clinical status to our obstetric, paediatric, and neonatologist colleagues.

The Apgar score is an assessment tool designed for precisely this kind of communication. Developed by Virginia Apgar, an American obstetrical anaesthesiologist, the Apgar score was first published in 1952. Dr Apgar’s goal was to quickly determine and communicate the resuscitation needs of the neonate.^1,2 The assessment is initially completed at 1 minute after delivery, with low scores indicating a need for resuscitation. Subsequent re-assessment at 5-minute intervals allows practitioners to track the success of their interventions.²

The Apgar score comprises assessments of heart rate, respiratory effort, muscle tone, reflex irritability, and skin colour, but that can be a little tough to remember when a brand-new baby is slipping and sliding his way into your hands, or – worse yet – into the pant-leg of a new mother in your ED.^1,2

Though Apgar isn’t an acronym itself, somebody much smarter than me created a backronym – an acronym devised after the fact – to help us remember the components of the Apgar score. Many learners now use this backronym, APGAR: Appearance, Pulse, Grimace, Activity, and Respiration.

I prefer to ask myself How Ready Is This Child? The H stands for heart rate, R for respirations, I for irritability, T for tone, and C for colour. Each category corresponds to a component of the Apgar score and yields a score of 0, 1, or 2 with composite scores of greater than 7 being normal, those between 4 and 6 intermediate, and those less than 4 signaling the need for emergent resuscitation.^1,2

Hopefully, you won’t experience too many ED deliveries during your training and career, but next time you do, ask yourself: How Ready Is This Child to transition from foetal to extra-uterine life?

(Pssst…if you’re feeling a little nervous about what you’d do for a baby with an Apgar less than 7, check out this CrackCast episode!)

This blog post was uploaded by Chitbhanu Singh (CanadiEM Junior Editor).

References:

The Apgar Score. Advances in Neonatal Care. 2006;6(4):220-223. doi: 10.1016/j.adnc.2006.04.008

Kearney R, Lo M. Neonatal Resuscitation. In: Rosen’s Emergency Medicine: Concepts and Clinical Practice. Saunders W.B.; 2017:2032-2041.

Reviewing with the staff

Having a child that is born \'flat\' can make a precipitous ED delivery even more stressful. Stress can make it difficult to remember all of the components of specific assessment scores like the Apgar score in the heat of the moment. I find that the APGAR mnemonic, while prolific and simple, can be a bit difficult to mobilize due to relatively non-sensical assessment points such as \'Grimace.\' \'How Ready Is This Child?\' is a great mnemonic because the items are very directly related to their assessments and because it is intuitive - we use the Apgar score answer the question \'How Ready Is This Child?\' Bottom line: I think this is a reasonable and useful approach to coming up with an Apgar score.