I. Epidemiology A. Five million neonatal deaths per year worldwide 1. Birth Asphyxia accounts for 19% of neonatal deaths B. Newborns requiring respiratory assistance at birth: 10% C. Newborns requiring extensive Resuscitation at birth: 1% D. Early Resuscitation is key (intervene at primary apnea) 1. Primary apnea (initial) responds to simple measures a. See Neonatal Airway Assessment 2. Secondary apnea requires PPV and other interventions a. Does not respond to continued stimulation b. Associated with prolonged Resuscitation c. Associated with poorer outcomes d. Associated with decreased Heart Rate and BP II. Transition from fetal circulation at birth A. Alveolar fluid is absorbed by lung B. Umbilical vessels are clamped 1. Increases systemic Blood Pressure C. Pulmonary circulation increases 1. Pulmonary vessel vasodilation 2. Ductus arteriosus vasoconstriction III. Approach A. Initial questions to consider 1. Is the newborn clear of meconium? 2. Is the newborn breathing or crying? 3. Does the newborn have good muscle tone? 4. Is the skin pink centrally? 5. Is this baby consistent with term gestation? B. Consider Neonatal Distress Causes C. Step by step assessment 1. Neonatal Airway Assessment a. Includes general measures performed for all infants b. Includes warming, suctioning, drying, stimulation 2. Neonatal Breathing Assessment a. Positive Pressure Ventilation for apnea 3. Neonatal Circulation Assessment a. Positive Pressure Ventilation for Heart Rate <100 b. Chest Compressions for Heart Rate <60 c. Epinephrine for persistent Heart Rate <60 4. Neonatal Perfusion Assessment a. Free flow Oxygen at 100% for central cyanosis IV. References A. (1995) World Health Report, WHO B. Kattwinkel (2000) Neonatal Resuscitation, AAP-AHA
Transcript
I. Epidemiology
A. Five million neonatal deaths per year worldwide1. Birth Asphyxia accounts for 19% of neonatal deathsB. Newborns requiring respiratory assistance at birth: 10%
C. Newborns requiring extensive Resuscitation at birth: 1%D. Early Resuscitation is key (intervene at primary apnea)
1. Primary apnea (initial) responds to simple measures
a. See Neonatal Airway Assessment2. Secondary apnea requires PPV and other interventions
a. Does not respond to continued stimulationb. Associated with prolonged Resuscitationc. Associated with poorer outcomesd. Associated with decreased Heart Rate and BP
II. Transition from fetal circulation at birth
A. Alveolar fluid is absorbed by lungB. Umbilical vessels are clamped
A. Initial questions to consider1. Is the newborn clear of meconium?2. Is the newborn breathing or crying?3. Does the newborn have good muscle tone?4. Is the skin pink centrally?5. Is this baby consistent with term gestation?B. Consider Neonatal Distress Causes
C. Step by step assessment1. Neonatal Airway Assessment
a. Includes general measures performed for all infantsb. Includes warming, suctioning, drying, stimulation
2. Neonatal Breathing Assessment
a. Positive Pressure Ventilation for apnea3. Neonatal Circulation Assessment
a. Positive Pressure Ventilation for Heart Rate <100b. Chest Compressions for Heart Rate <60c. Epinephrine for persistent Heart Rate <60
4. Neonatal Perfusion Assessment
a. Free flow Oxygen at 100% for central cyanosisIV. References
A. (1995) World Health Report, WHOB. Kattwinkel (2000) Neonatal Resuscitation, AAP-AHA
I. Background
A. Performed immediately after delivery for all newborns
B. Entire initial assessment should not exceed 30 secondsC. Newborns need only these steps in 90% of cases
II. Protocol
A. Place infant under radiant heaterB. Meconium suctioning via Endotracheal Tube (if needed)
1. Indications (perform before too many respirations)
a. Thick meconium stained andb. Not vigorous (depressed tone, respirations, pulse)
2. Technique
a. Cords visualized with laryngoscopeb. Clear mouth with 12-14F suction catheter if neededc. Insert ET Tube to below cords, suction and withdrawd. Repeat insertion as needed to clear below cordsC. Suction mouth, then nose
1. Suctioning at perineum with delivery of head is no longer recommended as of 2010 (even for thick meconium)
D. Dry thoroughlyE. Remove wet linenF. Position with slight neck extension (sniffing position)
1. Consider small rolled blanket under ShouldersG. Provide tactile stimulation1. Drying and suctioning are usually sufficient2. Additional measures
a. Flick soles of feetb. Gently rub back
3. Do not delay Resuscitation for continued apnea
a. Response to stimulation should be within secondsb. Immediately move to next step if no responsec. Secondary apnea will not respond to stimulation
4. Avoid harmful measures
a. Do not shake, slap or squeeze infantb. Do not forcefully flex thighs onto AbdomenH. Assess need for further Resuscitation
1. Infant not breathing or Heart Rate less than 100
a. Resuscitation: See subsequent assessment below2. Central Cyanosis
a. Administer free-flow oxygen starting at 21% and titrating upb. See Neonatal Perfusion Assessment
3. No identified problems
a. Baby may be placed on mothers chest and observed
I. Background
A. Positive Pressure Ventilation (PPV) is single most important step in newborn CPR
II. Protocol
A. Spontaneous Respirations1. Neonatal Circulation AssessmentB. No Respirations or gasping (secondary apnea) or Heart Rate<100/min
1. Positive Pressure Ventilations with Oxygen starting at 21% and titrating up
2. Provide ventilations at rate of 40-60 per minute
a. Count as "Breath - two - three"b. During CPR, Compressions to PPV ratio is 3:1
3. Peak inspiratory pressure (PIP)
a. Started at 20-25cm H2Ob. Some infants may require 30-40 cm H2O
4. Ventilate for 15-30 seconds before next assessment
a. Continue PPV until Heart Rate >100/min and adequate spontaneous respirations
III. Management: Inadequate Positive Pressure Ventilation (no chest rise, no increase in Heart Rate)
A. Adjust mask to obtain adequate sealB. Adjust head and neck position to reposition airway (sniffing position is ideal)C. Suction mouth and nose for secretionsD. Open mouth slightly and move jaw forward
1. Place index and middle finger inside mouth hooking behind central lower gums and gently lift upward
E. Increase peak inspiratory pressure (PIP) enough to move chest (may require 30-40 cm H2O)
1. May require blocking pop-off valveF. Consider intubation (see below)
IV. Management: Pediatric intubation
A. Indications1. Prolonged Positive Pressure Ventilations >2-3 minutes2. Ineffective Bag Valve Mask ventilation3. Tracheal suctioning for thick meconium in a non-vigorous newborn4. Diaphragmatic Hernia suspected5. Birth weight below 1500 grams (EGA under 30-31 weeks)
B. Devices1. Endotracheal Tube intubation
a. Weight 1 kg: 2.5 mm Endotracheal Tubeb. Weight 2 kg: 3.0 mm Endotracheal Tubec. Weight 3 kg: 3.5 mm Endotracheal Tube
2. Laryngeal mask airway (LMA) size 1 (gestational age >34 weeks or weight >2kg)
C. Confirmation1. Exhaled carbon dioxide detector or end-tidal CO2 (etCO2) monitor
changes from purple to yellow if in tracheaV. References
A. Kattwinkel (2000) Neonatal Resuscitation, AAP-AHAB. Kattwinkel (2010) Neonatal Resuscitation, AAP-AHAC. Raghuveer (2011) Am Fam Physician 83(8): 911-
I. Protocol
A. Heart Rate over 100/min1. Proceed to Neonatal Perfusion AssessmentB. Heart Rate under 100/min1. Positive Pressure Ventilation
a. See Neonatal Breathing Assessmentb. Continue Positive Pressure Ventilation until Heart Rate>100/min
and adequate spontaneous respirationsc. Re-evaluate Heart Rate every 30 seconds
2. Heart Rate under 60/min after 30 seconds of PPV
a. Positive Pressure Ventilation with 100% Oxygenb. Perform Chest Compressions
i. Depress chest one third of AP chest diameterc. CPR Sequence
i. Count: One and Two and Three and Breathii. Compression to breath ratio of 3:1
i. Compress at rate of >90 beats per minuteii. Breath at rate of 30 breaths per minute
d. Reassess 45-60 seconds after starting compressions
i. Epinephrine for persistent Heart Rate <60/min after 60 seconds of compressions (and 90 seconds of PPV)
e. Additional measures for prolonged Resuscitation beyond 2-3 minutes
i. Consider Orogastric Tube to decompress Stomachii. Consider Endotracheal Intubation
3. Heart Rate under 100/min after 30 seconds of PPV
a. Continue Positive Pressure Ventilation until Heart Rate >100/min and adequate spontaneous respirations
4. Heart Rate over 100/min
a. Go back to Neonatal Breathing AssessmentII. Management: Epinephrine
A. Indication1. Persistent Heart Rate <60/min after 60 seconds of compressions (and
90 seconds of PPV)B. Dosing (use of 1:10,000 Epinephrine)
1. Umbilical Venous Catheter: 0.01 to 0.03 mg/kg (0.1 to 0.3 ml/kg) of 1:10,000 Epinephrine
2. Endotracheal Tube: 0.05 to 0.10 mg/kg (0.5 to 1 ml/kg) of 1:10,000 Epinephrine
3. May repeat every 3-5 minutes for Heart Rate <60/minIII. Management: Pediatric Fluid Resuscitation
A. Indication1. Suspected blood loss
B. Crystalloid (NS or LR) 10 ml/kg over 5-10 minutes1. Umbilical Vein Catheter is most common site for delivery2. May repeat for a second dose
C. Other fluids for Resuscitation1. Colloid Solution2. Packed Red Blood Cells
IV. References
A. Kattwinkel (2000) Neonatal Resuscitation, AAP-AHAB. Kattwinkel (2010) Neonatal Resuscitation, AAP-AHAC. Raghuveer (2011) Am Fam Physician 83(8): 911-8
I. Device: Flow-inflating bag (Anesthesia Bag)
A. Mechanism1. Requires compressed oxygen source to fillB. Advantages1. Preferred for Newborn Resuscitation2. Lung compliance can be felt on squeezing bag3. Can deliver free-flow 100% oxygenC. Disadvantages1. Requires a tight facial seal2. Higher risk of over-inflating lung (use manometer)3. Technically more difficult to learn to useD. Technique1. Set oxygen supply flowmeter to 5-10 L/min2. Adjust bag volume with flow-control valve
II. Device: Self-inflating bag (Bag-valve mask or Ambu Bag)
A. Mechanism1. Bag fills spontaneously after being squeezedB. Advantages1. Does not require an oxygen source2. Easier to learn to useC. Disadvantages1. Can not deliver free flow oxygenD. Oxygen Delivery with ventilation (Bag-Valve Mask)1. No Oxygen Source
a. Delivers 21% Oxygen (Room air)2. Without Oxygen Reservoir
a. Delivers 30-80% Oxygen at 10 LPM flow3. With Oxygen Reservoir (required for high oxygen flow)
a. Delivers 60-95% Oxygen at 10-15 LPM flowE. Pop-Off Valves (Bag Valve Mask)
1. Usually set at 30-45 cm H2O2. Pop-off should be easily occluded on bags
a. Higher pressures are needed during CPR3. Occlusion of the pop off valve
a. Depress valve with finger during ventilation orb. Twist the pop-off valve into closed position
III. Precautions
A. Do not use Bag Valve Mask to deliver free flow oxygenIV. Technique
A. Tidal Volume1. Term Newborns
a. Administer 5-8 ml/kg (15 to 25 ml per ventilation)b. Bag volume: 200 to 750 ml (usually >450 ml)
2. Adults and older children
a. Administer 10-15 ml/kgB. Hold mask over face with one hand
1. Mask should fit snugly
a. Covers mouth, nose and chinb. Should not cover eyes
2. Thumb over nose3. Support jaw with middle or ring finger4. Avoid submental pressure (risk of airway obstruction)
C. Head Tilt - chin lift (Avoid if trauma!)1. Infants/Toddlers
a. Neutral sniffing position without hyperextension2. Children >2yo
a. Anterior displacement of c-spineb. Folded towel under neck and headD. Observe for adequate ventilation
1. Adequate chest riseV. Troubleshooting
A. No chest rise:1. Reposition head2. Ensure mask is snug3. Lift the jaw4. Consider suctioning airway5. Consider equipment failure (always test before use)
a. Test bag with hand occluding patient outletb. Check for bag leakc. Check flow-control valved. Check that oxygen line is connectedB. Avoid Stomach inflation and gastric distention
1. Apply cricoid pressure (Sellick maneuver)
a. In unconscious infant or child2. Consider NG suction
C. Sudden decrease in lung compliance1. Right main Bronchus intubation2. Obstructed Endotracheal Tube3. Pneumothorax
I. Protocol
A. Heart Rate over 100/min1. Proceed to Neonatal Perfusion AssessmentB. Heart Rate under 100/min1. Positive Pressure Ventilation
a. See Neonatal Breathing Assessmentb. Continue Positive Pressure Ventilation until Heart Rate>100/min
and adequate spontaneous respirationsc. Re-evaluate Heart Rate every 30 seconds
2. Heart Rate under 60/min after 30 seconds of PPV
a. Positive Pressure Ventilation with 100% Oxygen
b. Perform Chest Compressions
i. Depress chest one third of AP chest diameterc. CPR Sequence
i. Count: One and Two and Three and Breathii. Compression to breath ratio of 3:1
i. Compress at rate of >90 beats per minuteii. Breath at rate of 30 breaths per minute
d. Reassess 45-60 seconds after starting compressions
i. Epinephrine for persistent Heart Rate <60/min after 60 seconds of compressions (and 90 seconds of PPV)
e. Additional measures for prolonged Resuscitation beyond 2-3 minutes
i. Consider Orogastric Tube to decompress Stomachii. Consider Endotracheal Intubation
3. Heart Rate under 100/min after 30 seconds of PPV
a. Continue Positive Pressure Ventilation until Heart Rate >100/min and adequate spontaneous respirations
4. Heart Rate over 100/min
a. Go back to Neonatal Breathing AssessmentII. Management: Epinephrine
A. Indication1. Persistent Heart Rate <60/min after 60 seconds of compressions (and
90 seconds of PPV)B. Dosing (use of 1:10,000 Epinephrine)
1. Umbilical Venous Catheter: 0.01 to 0.03 mg/kg (0.1 to 0.3 ml/kg) of 1:10,000 Epinephrine
2. Endotracheal Tube: 0.05 to 0.10 mg/kg (0.5 to 1 ml/kg) of 1:10,000 Epinephrine
3. May repeat every 3-5 minutes for Heart Rate <60/minIII. Management: Pediatric Fluid Resuscitation
A. Indication1. Suspected blood loss
B. Crystalloid (NS or LR) 10 ml/kg over 5-10 minutes1. Umbilical Vein Catheter is most common site for delivery2. May repeat for a second dose
C. Other fluids for Resuscitation1. Colloid Solution2. Packed Red Blood Cells
I. Technique: General
A. Compressions1. Compressions are the mainstay of Resuscitation and trump all
medications in survival benefit2. Compressions should be started immediately for an unresponsive,
apneic patient
a. Health care providers check for pulse (<10 seconds), but other rescuers start compressions without delay
b. If any doubt about palpable central pulses, begin cardiac compressions
3. Compressions should be interrupted only briefly (<10 seconds)4. Compressions should be hard and fast
a. To avoid Fatigue and maintain adequate compressions, compressor switches with Ventilator every 2 minutes
5. Active Compression-Decompression devices (ACD-CPR, e.g. Lucas ) can be considered where available, however insufficient evidence in 2010
a. ACD-CPR anecdotally can sustain adequate cerebral circulation for patients to alert despite lethal rhythm
b. ACD-CPR anecdotally may adequately sustain patients in lethal rhythm to transfer inter-hospital to a catheter lab
B. Ventilations1. Ventilations should last 1 second per breath and demonstrate visible
chest rise2. Untrained rescuers perform only compressions and no ventilations until
EMS arrives3. Place Advanced Airway when able
a. Can maintain airway with 2 intranasal and an Oral Airway until Advanced Airway available
4. Advanced Airway in position and confirmed
a. Ventilations every 6-8 seconds (8-10 per minute) asynchronous to compressions
C. Defibrillation1. Attach and use the AED or manual Defibrillator as soon as available2. Successful conversion from Ventricular Fibrillation and Pulseless
Ventricular Tachycardia is directly related to earliest timing of Defibrillation
3. Defibrillation requires briefly clearing the patient for each shock
a. Interruption of compressions should be minimized (<10 seconds)b. Use of an Active Compression-Decompression device (ACD-CPR,
e.g. Lucas ) may be continued through Defibrillation (need not be paused)
II. Technique: Newborns
A. Sternal Compressions: Same as for infants except for alternative technique using 2 thumbs
1. General
a. Depress one third chest depth (1.5 inches or 4 cm)b. Do not lift fingers from chest between compressions
2. Technique 1: Thumbs depress Sternum
a. Hands encircle torsob. Fingers support spinec. Preferred (less tiring)
3. Technique 2: Two fingers depress Sternum
a. Use Index, Middle Finger placed below nipple levelb. Preferred for larger newbornsB. Compression rate at least 100 times per minute
C. Compression to ventilation ratio1. One rescuer: 30:22. Two health care providers: 15:2 (compressor switches
with Ventilator every 2 minutes)
III. Technique: Infants (age under 1 year)
A. Sternal Compressions1. Use Index, Middle Finger placed below nipple level2. Depress 1/3 of chest depth (1.5 inches or 4 cm)
a. Do not lift fingers from chest between compressionsB. Compression rate ast least 100 times/minute
C. Compression to Ventilation Ratio1. One rescuer: 30:22. Two health care providers: 15:2 (compressor switches
with Ventilator every 2 minutes)IV. Technique: Children (1 to 8 years)
A. Sternal Compressions1. Use heel of one hand placed above center of chest (superior to xiphoid)2. Depress at least 1/3 of chest depth (2 inches or 5 cm)
B. Compression rate at least 100 times/minuteC. Compression to Ventilation Ratio
1. One rescuer: 30:22. Two health care providers: 15:2 (compressor switches
with Ventilator every 2 minutes)V. Technique: Adults
A. Sternal Compressions1. Use heel of two hands placed above center of chest (superior to
xiphoid)2. Depress chest 2 inches or 5 cm
B. Compression rate at least 100 times/minuteC. Compression to Ventilation Ratio
1. One or two rescuers: 30:2 (compressor switches with Ventilator every 2 minutes)
VI. Monitoring: Quantitative Waveform Capnography (PETCO2) - indications of quality compressions
A. PETCO2 should exceed 20 mmHg during diastole (relaxation phase)B. PETCO2 should show a pulsatile waveform that coincides with compressionsC. PETCO2 >40 mmHg (typically abrupt onset) suggests return of spontaneous
circulation (ROSC)VII. Prognosis: Adults after CPR
A. Criteria1. Witnessed arrest2. Initial rhythm
a. Ventricular Tachycardia orb. Ventricular Fibrillation
3. Pulse regained in first 10 minutes of compressionB. Interpretation: Any of three criteria above met
1. Predicts survival to hospital dischargeC. References
1. van Walraven (2001) JAMA 285:1602-6VIII. References
A. Cardiopulmonary Resuscitation Guidelines1. http://www.circulationaha.org2. (2010) Guidelines for CPR and ECC3. (2005) Circulation 112(Suppl 112):IV4. (2000) Circulation, 102(Suppl I):86-9
I. Definition
A. Natural Catecholamine with Alpha and beta activityII. History
A. Medical case report in 1923 on intracardiac Adrenaline1. Shown to reverse "Acute heart paralysis"
III. Pathophysiology
A. Alpha Adrenergic Agonist Effects1. Most important for Cardiac Arrest2. Vasoconstriction
a. Increases Systemic Vascular Resistanceb. Increases Systolic and Diastolic Blood Pressure
3. Increases Vital Organ Perfusion
a. Increases Myocardial perfusionb. Increases Cerebral perfusion
4. Decreases Non-Vital Organ Perfusion
a. Decreases splanchnic and intestinal perfusionb. Decreases renal perfusionc. Decreases skin perfusionB. Beta Adrenergic Agonist effects (Under 0.3 ug/kg/min)
1. Increases myocardial contractility2. Increases Heart Rate3. Relaxes Bronchial smooth muscle (bronchodilation)C. Epinephrine has a short half-life: ~2 minutes
IV. Indications
A. Initial Resuscitation Management (bolus)1. Cardiac Arrest
a. Vasopressin may be used instead in some protocols2. Symptomatic Bradycardia unresponsive to
a. Oxygenationb. Ventilation
3. Hypotension not related to volume depletionB. Post-Resuscitation Stabilization (Infusion)1. Poor systemic perfusion or Hypotension despite
a. Intravascular volume replacement ANDb. Stable rhythm
2. Significant BradycardiaV. Newborn Dosing (refractory and persistant Bradycardia)
A. Epinephrine (1:10,000) 0.1 to 0.3 ml/kg by IV or ETB. Do not use the 1:1000 concentration in newborns
VI. Dosing: Pediatric
A. Symptomatic Bradycardia (with a pulse)1. Dose: 0.01 mg/kg IV/IO (0.1 ml/kg of 1:10,000 Epi)
B. Pulseless Cardiac Arrest1. Initial regular dose Epinephrine
a. Dose: 0.01 mg/kg IV/IO (0.1 ml/kg of 1:10,000 Epi)2. Subsequent High Dose Epinephrine (if no effect above)
a. Dose: 0.1 mg/kg IV/IO (0.1 ml/kg of 1:1000 Epi)b. Maximum dose: 0.2 mg/kg
3. Repeat dose every 3-5 minutesC. Endotracheal Administration
1. Adults and children: 0.1 mg/kg (0.1 ml/kg of 1:1000)2. Newborn: 0.1 mg/kg (1 ml/kg of 1:10,000)
VII. Dosing: Adults
A. Symptomatic Bradycardia1. Infusion: 2-10 ug/min (See below)
B. Pulseless Arrest1. Rhythms
a. Asystoleb. Pulseless Electrical Activityc. Ventricular Fibrillation
2. Initial
a. IV: 1 mg (10 ml of 1:10,000 Epi) IV pushb. Endotracheal: 2.5 ml of 1:1000 Epi in 10 ml NS
3. Repeat every 3-5 minutes4. Consider increasing dose to 3 or 5 mg (0.1 mg/kg)
VIII. Dosing: Pediatric Infusion (Same as Isoproterenol preparation)
A. Preparation1. Draw up "x" mg of Epinephrine2. Where "x" = 0.6 x WeightKg3. Add enough D5W or NS to Epinephrine for 100 ml total4. At this dilution
a. Infusion rate of 1 ml/h provides 0.1 ug/kg/hB. Start Dose: 20 ml/hour until Tachycardia
1. Indicates drug has entered circulationC. Titrate Dose
1. Decrease to desired rate (0.1 - 1.0 ug/kg/min)2. Adjust infusion rate every 5 min to desired effect
IX. Dosing: Adult Infusion for Cardiac Arrest
A. Preparation1. Draw up 30 mg of Epinephrine (30 ml of 1:1000)2. Add Epinephrine to 250 ml Normal Saline or D5W
B. Start Dose: 100 ml/hC. Titrate to desired effect
X. Dosing: Adult Infusion for symptomatic Bradycardia
A. Preparation1. Draw up 1 mg Epinephrine (1 ml of 1:1000)2. Add Epinephrine to 500 ml Normal Saline or D5W
B. Start Dose: 1 ug/minC. Titrate Dose to desired effect (2-10 ug/min)
XI. Precautions
A. Carefully check concentration (1:1000 OR 1:10,000)B. Observe for side effects after Resuscitation
1. Supraventricular Tachycardia2. Ventricular Tachycardia3. Severe Hypertension
C. Extravasation into tissues1. may causes local ischemia or necrosis
D. Can exacerbate Myocardial IschemiaE. Do not mix with alkaline solutions
Protocol: Evaluate Central Color
A. Pink or only peripheral cyanosis (acrocyanosis)1. Observe and monitorB. Central Cyanosis1. Use Blow-By Oxygen until pink2. Re-evaluate status periodically
a. Neonatal Breathing Assessmentb. Neonatal Circulation Assessment
I. Background
A. Positive Pressure Ventilation (PPV) is single most important step in newborn CPR
II. Protocol
A. Spontaneous Respirations1. Neonatal Circulation AssessmentB. No Respirations or gasping (secondary apnea) or Heart Rate<100/min1. Positive Pressure Ventilations with Oxygen starting at 21% and titrating
up2. Provide ventilations at rate of 40-60 per minute
a. Count as "Breath - two - three"b. During CPR, Compressions to PPV ratio is 3:1
3. Peak inspiratory pressure (PIP)
a. Started at 20-25cm H2Ob. Some infants may require 30-40 cm H2O
4. Ventilate for 15-30 seconds before next assessment
a. Continue PPV until Heart Rate >100/min and adequate spontaneous respirations
III. Management: Inadequate Positive Pressure Ventilation (no chest rise, no increase in Heart Rate)
A. Adjust mask to obtain adequate sealB. Adjust head and neck position to reposition airway (sniffing position is ideal)C. Suction mouth and nose for secretionsD. Open mouth slightly and move jaw forward
1. Place index and middle finger inside mouth hooking behind central lower gums and gently lift upward
E. Increase peak inspiratory pressure (PIP) enough to move chest (may require 30-40 cm H2O)
1. May require blocking pop-off valveF. Consider intubation (see below)
IV. Management: Pediatric intubation
A. Indications1. Prolonged Positive Pressure Ventilations >2-3 minutes
2. Ineffective Bag Valve Mask ventilation3. Tracheal suctioning for thick meconium in a non-vigorous newborn4. Diaphragmatic Hernia suspected5. Birth weight below 1500 grams (EGA under 30-31 weeks)
B. Devices1. Endotracheal Tube intubation
a. Weight 1 kg: 2.5 mm Endotracheal Tubeb. Weight 2 kg: 3.0 mm Endotracheal Tubec. Weight 3 kg: 3.5 mm Endotracheal Tube
2. Laryngeal mask airway (LMA) size 1 (gestational age >34 weeks or weight >2kg)
C. Confirmation1. Exhaled carbon dioxide detector or end-tidal CO2 (etCO2) monitor
changes from purple to yellow if in trachea
I. Protocol
A. Heart Rate over 100/min1. Proceed to Neonatal Perfusion AssessmentB. Heart Rate under 100/min1. Positive Pressure Ventilation
a. See Neonatal Breathing Assessmentb. Continue Positive Pressure Ventilation until Heart Rate>100/min
and adequate spontaneous respirationsc. Re-evaluate Heart Rate every 30 seconds
2. Heart Rate under 60/min after 30 seconds of PPV
a. Positive Pressure Ventilation with 100% Oxygenb. Perform Chest Compressions
i. Depress chest one third of AP chest diameterc. CPR Sequence
i. Count: One and Two and Three and Breathii. Compression to breath ratio of 3:1
i. Compress at rate of >90 beats per minuteii. Breath at rate of 30 breaths per minute
d. Reassess 45-60 seconds after starting compressions
i. Epinephrine for persistent Heart Rate <60/min after 60 seconds of compressions (and 90 seconds of PPV)
e. Additional measures for prolonged Resuscitation beyond 2-3 minutes
i. Consider Orogastric Tube to decompress Stomachii. Consider Endotracheal Intubation
3. Heart Rate under 100/min after 30 seconds of PPV
a. Continue Positive Pressure Ventilation until Heart Rate >100/min and adequate spontaneous respirations
4. Heart Rate over 100/min
a. Go back to Neonatal Breathing AssessmentII. Management: Epinephrine
A. Indication1. Persistent Heart Rate <60/min after 60 seconds of compressions (and
90 seconds of PPV)B. Dosing (use of 1:10,000 Epinephrine)
1. Umbilical Venous Catheter: 0.01 to 0.03 mg/kg (0.1 to 0.3 ml/kg) of 1:10,000 Epinephrine
2. Endotracheal Tube: 0.05 to 0.10 mg/kg (0.5 to 1 ml/kg) of 1:10,000 Epinephrine
3. May repeat every 3-5 minutes for Heart Rate <60/minIII. Management: Pediatric Fluid Resuscitation
A. Indication1. Suspected blood loss
B. Crystalloid (NS or LR) 10 ml/kg over 5-10 minutes1. Umbilical Vein Catheter is most common site for delivery2. May repeat for a second dose
C. Other fluids for Resuscitation1. Colloid Solution2. Packed Red Blood Cells
I. Epidemiology
A. Five million neonatal deaths per year worldwide1. Birth Asphyxia accounts for 19% of neonatal deathsB. Newborns in United States: 4 million births per year1. Newborns requiring respiratory assistance at birth: 10%2. Newborns requiring extensive Resuscitation at birth: 1%3. Newborns developing severe hypoxic-ischemic encephalopathy: 0.2%
a. Mortality ranges between 6-30%b. Cerebral Palsy and other long-term disabilities in survivors: 20-
30%C. Early Resuscitation is key (intervene at primary apnea)
1. Primary apnea (initial) responds to simple measures
a. See Neonatal Airway Assessment2. Secondary apnea requires PPV and other interventions
a. Does not respond to continued stimulationb. Associated with prolonged Resuscitationc. Associated with poorer outcomesd. Associated with decreased Heart Rate and BP
II. Physiology: Transition from fetal circulation at birth
A. Alveolar fluid is absorbed by lungB. Umbilical vessels are clamped
A. Prepare equipment and providers before delivery (see prevention below)B. Initial questions to consider
1. See Newborn History2. Is the newborn clear of meconium?3. Is the newborn breathing or crying?4. Does the newborn have good muscle tone?5. Is the skin pink centrally?6. Is this baby consistent with term gestation?C. Consider Neonatal Distress Causes
D. Step by step assessment (timer started at delivery)1. Neonatal Airway Assessment
a. Includes general measures performed for all infantsb. Includes warming, suctioning, drying, stimulationc. Endotracheal suctioning if thick meconium AND only if non-
vigorous infant2. Neonatal Breathing Assessment
a. Positive Pressure Ventilation (PPV) for apnea, gasping or Heart Rate <100/min
i. Rate of 40-60/min for 30 secii. Peak inspiratory pressure (PIP) started at 20-25cm H2O
(may require 30-40 cm H2O)b. Apply O2 Sat monitor if PPV needed
c. Endotracheal Tube intubation or laryngeal mask airway (LMA) if PPV for >2-3 minutes (confirm wirh etCO2)
3. Neonatal Circulation Assessment
a. Positive Pressure Ventilation for continued Heart Rate <100/min or apnea
b. Chest Compressions for Heart Rate <60/min after 30 seconds of PPV
i. Rate - 3:1 compressions to breathsii. Reassess 45-60 seconds after starting compressions
c. Epinephrine for persistent Heart Rate <60/min after 60 seconds of compressions (and 90 seconds of PPV)
i. Umbilical Venous Catheter: 0.01 to 0.03 mg/kg (0.1 to 0.3 ml/kg) of 1:10,000 Epinephrine
ii. Endotracheal Tube: 0.05 to 0.10 mg/kg (0.5 to 1 ml/kg) of 1:10,000 Epinephrine
4. Neonatal Perfusion Assessment
a. Central Cyanosis: Free flow Oxygen starting at 21% or blended and titrating up
b. Blood loss suspected: Normal Saline 10 cc/kg bolus (consider pRBC when available)
5. Post-Resuscitation after extensive efforts for severe event
a. Intravenous Dextrose infusion (prevent Hypoglycemia)b. Developing severe hypoxic-ischemic encephalopathy in
newborns >36 weeks
i. Offer therapeutic Hypothermia protocol (started within 6 hours of event at NICU)IV. Management: Indications to
Discontinue Resuscitation Efforts
A. No detectable Heart Rate after 10 minutes of full Resuscitation effortsB. Lethal anomalies (Informed consent with parents if withholding care)
1. Very premature (gestational age <23 weeks or weight <400 grams)2. Anencephaly3. Trisomy 13 Syndrome
V. Prevention
A. Prepare for complicated deliveries1. NRP-certified Resuscitation team available at all times
2. NRP-certified physician present for high-risk deliveriesB. Hospital delivery rooms stocked with adequate equipment
1. Pulse oximeter2. Fully working warmer3. Oxygen supply with air oxygen blender4. Suction device5. Positive Pressure Ventilation device (e.g. Anesthesia Bag, ambu-bag, T-
piece device)6. Endotracheal Tubes, laryngeal mask airway, working laryngoscope,
CO2 Detection device7. Resuscitation medications (e.g. Epinephrine, normal saline)
VI. Precautions: Major changes in neonatal Resuscitation as of 2010
A. Perineal suctioning for meconium is no longer recommendedB. Do not endotracheal suction vigorous infants despite thick meconium presenceC. Monitor Resuscitation efforts with pulse oximetryD. End Tidal CO2 (etCO2) detector or monitor to confirm proper Endotracheal
Tube placementE. Laryngeal mask airway (LMA) size 1 may be used instead of ET for ventilation
in infants >2kg or >34 weeks gestationF. Naloxone and Sodium Bicarbonate are no longer recommended in
newboen ResuscitationG. Consider therapeutic Hypothermia protocol in newborns >36 weeks with
developing severe hypoxic-ischemic encephalopathyVII. Preparations: Medications no longer recommended in Newborn
Resuscitation (listed for completeness)
A. Sodium Bicarbonate (Use only 4.2% solution)1. Not recommended as worse outcomes with use2. Primary treatment of acidosis is by maximizing ventilation, not with
bicarbonate3. Dose: 4 ml/kg (2 meq/kg of 4.2%) very slowly via large vessel
(Umbilical Vein Catheter)B. Naloxone
1. Not recommended as of 2010 as no evidence for improved outcomes with use
2. Primary treatment of apnea is with Positive Pressure Ventilation3. Dose: 0.1 mg/kg of 1.0 mg/ml IV, ET, IM or SQ4. Indications (old)
a. Respiratory depression despite PPV (with normal Heart Rate and color)
b. Maternal Narcotic Analgesics within 4 hoursVIII. References
A. (1995) World Health Report, WHOB. Kattwinkel (2000) Neonatal Resuscitation, AAP-AHAC. Kattwinkel (2010) Neonatal Resuscitation, AAP-AHA
