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 . Does not respond to continued stimulation a. Associated with prolonged Resuscitation b. Associated with poorer outcomes c. Associated with decreased Heart Rate and BP II. Transition from fetal circulation at birth . Alveolar fluid is absorbed by lung A. Umbilical vessels are clamped 1. Increases systemic Blood Pressure B. Pulmonary circulation increases 1. Pulmonary vessel vasodilation 2. Ductus arteriosus vasoconstriction III. Approach . 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? A. Consider Neonatal Distress Causes B. Step by step assessment 1. Neonatal Airway Assessment . Includes general measures performed for all infants a. Includes warming, suctioning, drying, stimulation 2. Neonatal Breathing Assessment Positive Pressure Ventilation for apnea 3. Neonatal Circulation Assessment Positive Pressure Ventilation for Heart Rate <100 a. Chest Compressions for Heart Rate <60 b. Epinephrine for persistent Heart Rate <60 4. Neonatal Perfusion Assessment Free flow Oxygen at 100% for central cyanosis IV. References . (1995) World Health Report, WHO A. Kattwinkel (2000) Neonatal Resuscitation, AAP-AHA

I.

Background A. Performed immediately after delivery for all newborns B. Entire initial assessment should not exceed 30 seconds C. Newborns need only these steps in 90% of cases II. Protocol Place infant under radiant heater A. Meconium suctioning via Endotracheal Tube (if needed) 1. Indications (perform before too many respirations) a. Thick meconium stained and b. Not vigorous (depressed tone, respirations, pulse) 2. Technique . Cords visualized with laryngoscope a. Clear mouth with 12-14F suction catheter if needed b. Insert ET Tube to below cords, suction and withdraw

. . . I.

c. Repeat insertion as needed to clear below cords B. Suction mouth, then nose 1. Suctioning at perineum with delivery of head is no longer recommended as of 2010 (even for thick meconium) C. Dry thoroughly D. Remove wet linen E. Position with slight neck extension (sniffing position) 1. Consider small rolled blanket under Shoulders F. Provide tactile stimulation 1. Drying and suctioning are usually sufficient 2. Additional measures . Flick soles of feet a. Gently rub back 3. Do not delay Resuscitation for continued apnea . Response to stimulation should be within seconds a. Immediately move to next step if no response b. Secondary apnea will not respond to stimulation 4. Avoid harmful measures Do not shake, slap or squeeze infant a. Do not forcefully flex thighs onto Abdomen G. Assess need for further Resuscitation 1. Infant not breathing or Heart Rate less than 100 Resuscitation: See subsequent assessment below 2. Central Cyanosis Administer free-flow oxygen starting at 21% and titrating up a. See Neonatal Perfusion Assessment 3. No identified problems Baby may be placed on mothers chest and observed Background A. Positive Pressure Ventilation (PPV) is single most important step in newborn CPR II. Protocol . Spontaneous Respirations 1. Neonatal Circulation Assessment A. 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) . Started at 20-25cm H2O a. Some infants may require 30-40 cm H2O 4. Ventilate for 15-30 seconds before next assessment . Continue PPV until Heart Rate >100/min and adequate spontaneous respirations 5. Monitoring: Continuous pulse oximetry (targeted pulse oximetry values) . At 1 minute of life: >60% a. At 3 minutes of life >70% b. At 5 minutes of lifer >80% c. At 10 minutes of life >85% 6. Consider Orogastric Tube for prolonged PPV 7. Perform Neonatal Circulation Assessment Management: Inadequate Positive Pressure Ventilation (no chest rise, no increase in Heart Rate) . Adjust mask to obtain adequate seal A. Adjust head and neck position to reposition airway (sniffing position is ideal) B. Suction mouth and nose for secretions

III.

D. E.

A. .

B. V.

C. Open mouth slightly and move jaw forward 1. Place index and middle finger inside mouth hooking behind central lower gums and gently lift upward Increase peak inspiratory pressure (PIP) enough to move chest (may require 30-40 cm H2O) 1. May require blocking pop-off valve Consider intubation (see below) IV. Management: Pediatric intubation . Indications 1. Prolonged Positive Pressure Ventilations >2-3 minutes 2. Ineffective Bag Valve Mask ventilation 3. Tracheal suctioning for thick meconium in a non-vigorous newborn 4. Diaphragmatic Hernia suspected 5. Birth weight below 1500 grams (EGA under 30-31 weeks) Devices 1. Endotracheal Tube intubation Weight 1 kg: 2.5 mm Endotracheal Tube a. Weight 2 kg: 3.0 mm Endotracheal Tube b. Weight 3 kg: 3.5 mm Endotracheal Tube 2. Laryngeal mask airway (LMA) size 1 (gestational age >34 weeks or weight >2kg) Confirmation 1. Exhaled carbon dioxide detector or end-tidal CO2 (etCO2) monitor changes from purple to yellow if in trachea References . Kattwinkel (2000) Neonatal Resuscitation, AAP-AHA A. Kattwinkel (2010) Neonatal Resuscitation, AAP-AHA B. Raghuveer (2011) Am Fam Physician 83(8): 911Protocol A. Heart Rate over 100/min 1. Proceed to Neonatal Perfusion Assessment B. Heart Rate under 100/min 1. Positive Pressure Ventilation a. See Neonatal Breathing Assessment b. Continue Positive Pressure Ventilation until Heart Rate>100/min and adequate spontaneous respirations c. Re-evaluate Heart Rate every 30 seconds 2. Heart Rate under 60/min after 30 seconds of PPV . Positive Pressure Ventilation with 100% Oxygen a. Perform Chest Compressions i. Depress chest one third of AP chest diameter b. CPR Sequence . Count: One and Two and Three and Breath i. Compression to breath ratio of 3:1 i. Compress at rate of >90 beats per minute ii. Breath at rate of 30 breaths per minute c. Reassess 45-60 seconds after starting compressions . Epinephrine for persistent Heart Rate <60/min after 60 seconds of compressions (and 90 seconds of PPV) d. Additional measures for prolonged Resuscitation beyond 2-3 minutes . Consider Orogastric Tube to decompress Stomach i. Consider Endotracheal Intubation 3. Heart Rate under 100/min after 30 seconds of PPV . Continue Positive Pressure Ventilation until Heart Rate >100/min and adequate spontaneous respirations 4. Heart Rate over 100/min Go back to Neonatal Breathing Assessment II. Management: Epinephrine

I.

Indication

1. Persistent Heart Rate <60/min after 60 seconds of compressions (and 90 seconds of PPV) A. 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/min III. Management: Pediatric Fluid Resuscitation . Indication 1. Suspected blood loss A. Crystalloid (NS or LR) 10 ml/kg over 5-10 minutes 1. Umbilical Vein Catheter is most common site for delivery 2. May repeat for a second dose B. Other fluids for Resuscitation 1. Colloid Solution 2. Packed Red Blood Cells IV. References . Kattwinkel (2000) Neonatal Resuscitation, AAP-AHA A. Kattwinkel (2010) Neonatal Resuscitation, AAP-AHA B. Raghuveer (2011) Am Fam Physician 83(8): 911-8 I. Device: Flow-inflating bag (Anesthesia Bag) A. Mechanism 1. Requires compressed oxygen source to fill B. Advantages 1. Preferred for Newborn Resuscitation 2. Lung compliance can be felt on squeezing bag 3. Can deliver free-flow 100% oxygen C. Disadvantages 1. Requires a tight facial seal 2. Higher risk of over-inflating lung (use manometer) 3. Technically more difficult to learn to use D. Technique 1. Set oxygen supply flowmeter to 5-10 L/min 2. Adjust bag volume with flow-control valve II. Device: Self-inflating bag (Bag-valve mask or Ambu Bag) Mechanism 1. Bag fills spontaneously after being squeezed A. Advantages 1. Does not require an oxygen source 2. Easier to learn to use B. Disadvantages 1. Can not deliver free flow oxygen C. Oxygen Delivery with ventilation (Bag-Valve Mask) 1. No Oxygen Source a. Delivers 21% Oxygen (Room air) 2. Without Oxygen Reservoir . Delivers 30-80% Oxygen at 10 LPM flow 3. With Oxygen Reservoir (required for high oxygen flow) . Delivers 60-95% Oxygen at 10-15 LPM flow D. Pop-Off Valves (Bag Valve Mask) 1. Usually set at 30-45 cm H2O 2. Pop-off should be easily occluded on bags . Higher pressures are needed during CPR 3. Occlusion of the pop off valve . Depress valve with finger during ventilation or a. Twist the pop-off valve into closed position III. Precautions

Do not use Bag Valve Mask to deliver free flow oxygen IV. Technique . Tidal Volume 1. Term Newborns . Administer 5-8 ml/kg (15 to 25 ml per ventilation) a. Bag volume: 200 to 750 ml (usually >450 ml) 2. Adults and older children . Administer 10-15 ml/kg A. Hold mask over face with one hand 1. Mask should fit snugly . Covers mouth, nose and chin a. Should not cover eyes 2. Thumb over nose 3. Support jaw with middle or ring finger 4. Avoid submental pressure (risk of airway obstruction) B. Head Tilt - chin lift (Avoid if trauma!) 1. Infants/Toddlers . Neutral sniffing position without hyperextension 2. Children >2yo . Anterior displacement of c-spine a. Folded towel under neck and head C. Observe for adequate ventilation 1. Adequate chest rise V. Troubleshooting . No chest rise: 1. Reposition head 2. Ensure mask is snug 3. Lift the jaw 4. Consider suctioning airway 5. Consider equipment failure (always test before use) . Test bag with hand occluding patient outlet a. Check for bag leak b. Check flow-control valve c. Check that oxygen line is connected A. Avoid Stomach inflation and gastric distention 1. Apply cricoid pressure (Sellick maneuver) . In unconscious infant or child 2. Consider NG suction B. Sudden decrease in lung compliance 1. Right main Bronchus intubation 2. Obstructed Endotracheal Tube 3. Pneumothorax I. Protocol A. Heart Rate over 100/min 1. Proceed to Neonatal Perfusion Assessment B. Heart Rate under 100/min 1. Positive Pressure Ventilation a. See Neonatal Breathing Assessment b. Continue Positive Pressure Ventilation until Heart Rate>100/min and adequate spontaneous respirations c. Re-evaluate Heart Rate every 30 seconds 2. Heart Rate under 60/min after 30 seconds of PPV . Positive Pressure Ventilation with 100% Oxygen a. Perform Chest Compressions i. Depress chest one third of AP chest diameter b. CPR Sequence . Count: One and Two and Three and Breath i. Compression to breath ratio of 3:1 i. Compress at rate of >90 beats per minute

Breath at rate of 30 breaths per minute Reassess 45-60 seconds after starting compressions . Epinephrine for persistent Heart Rate <60/min after 60 seconds of compressions (and 90 seconds of PPV) d. Additional measures for prolonged Resuscitation beyond 2-3 minutes . Consider Orogastric Tube to decompress Stomach i. Consider Endotracheal Intubation 3. Heart Rate under 100/min after 30 seconds of PPV . Continue Positive Pressure Ventilation until Heart Rate >100/min and adequate spontaneous respirations 4. Heart Rate over 100/min . Go back to Neonatal Breathing Assessment II. Management: Epinephrine . Indication 1. Persistent Heart Rate <60/min after 60 seconds of compressions (and 90 seconds of PPV) A. 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/min III. Management: Pediatric Fluid Resuscitation . Indication 1. Suspected blood loss A. Crystalloid (NS or LR) 10 ml/kg over 5-10 minutes 1. Umbilical Vein Catheter is most common site for delivery 2. May repeat for a second dose B. Other fluids for Resuscitation 1. Colloid Solution 2. Packed Red Blood Cells c. I. Technique: General A. Compressions 1. Compressions are the mainstay of Resuscitation and trump all medications in survival benefit 2. 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 . 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 . ACD-CPR anecdotally can sustain adequate cerebral circulation for patients to alert despite lethal rhythm a. ACD-CPR anecdotally may adequately sustain patients in lethal rhythm to transfer inter-hospital to a catheter lab B. Ventilations 1. Ventilations should last 1 second per breath and demonstrate visible chest rise 2. Untrained rescuers perform only compressions and no ventilations until EMS arrives

ii.

3. Place Advanced Airway when able . Can maintain airway with 2 intranasal and an Oral Airway until Advanced Airway available 4. Advanced Airway in position and confirmed . Ventilations every 6-8 seconds (8-10 per minute) asynchronous to compressions C. Defibrillation 1. Attach and use the AED or manual Defibrillator as soon as available 2. 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 . Interruption of compressions should be minimized (<10 seconds) a. Use of an Active Compression-Decompression device (ACDCPR, e.g. Lucas ) may be continued through Defibrillation (need not be paused) II. Technique: Newborns . Sternal Compressions: Same as for infants except for alternative technique using 2 thumbs 1. General . Depress one third chest depth (1.5 inches or 4 cm) a. Do not lift fingers from chest between compressions 2. Technique 1: Thumbs depress Sternum . Hands encircle torso a. Fingers support spine b. Preferred (less tiring) 3. Technique 2: Two fingers depress Sternum . Use Index, Middle Finger placed below nipple level a. Preferred for larger newborns A. Compression rate at least 100 times per minute B. Compression to ventilation ratio 1. One rescuer: 30:2 2. Two health care providers: 15:2 (compressor switches with Ventilator every 2 minutes) III. Technique: Infants (age under 1 year) . Sternal Compressions 1. Use Index, Middle Finger placed below nipple level 2. Depress 1/3 of chest depth (1.5 inches or 4 cm) . Do not lift fingers from chest between compressions A. Compression rate ast least 100 times/minute B. Compression to Ventilation Ratio 1. One rescuer: 30:2 2. Two health care providers: 15:2 (compressor switches with Ventilator every 2 minutes) IV. Technique: Children (1 to 8 years) . Sternal Compressions 1. 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) A. Compression rate at least 100 times/minute B. Compression to Ventilation Ratio 1. One rescuer: 30:2 2. Two health care providers: 15:2 (compressor switches with Ventilator every 2 minutes) V. Technique: Adults . Sternal Compressions 1. Use heel of two hands placed above center of chest (superior to xiphoid) 2. Depress chest 2 inches or 5 cm A. Compression rate at least 100 times/minute

B. 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 . PETCO2 should exceed 20 mmHg during diastole (relaxation phase) A. PETCO2 should show a pulsatile waveform that coincides with compressions B. PETCO2 >40 mmHg (typically abrupt onset) suggests return of spontaneous circulation (ROSC) VII. Prognosis: Adults after CPR . Criteria 1. Witnessed arrest 2. Initial rhythm . Ventricular Tachycardia or a. Ventricular Fibrillation 3. Pulse regained in first 10 minutes of compression A. Interpretation: Any of three criteria above met 1. Predicts survival to hospital discharge B. References 1. van Walraven (2001) JAMA 285:1602-6 VIII. References . Cardiopulmonary Resuscitation Guidelines 1. http://www.circulationaha.org 2. (2010) Guidelines for CPR and ECC 3. (2005) Circulation 112(Suppl 112):IV 4. (2000) Circulation, 102(Suppl I):86-9 I. . . Definition A. Natural Catecholamine with Alpha and beta activity II. History Medical case report in 1923 on intracardiac Adrenaline 1. Shown to reverse "Acute heart paralysis" III. Pathophysiology Alpha Adrenergic Agonist Effects 1. Most important for Cardiac Arrest 2. Vasoconstriction a. Increases Systemic Vascular Resistance b. Increases Systolic and Diastolic Blood Pressure 3. Increases Vital Organ Perfusion . Increases Myocardial perfusion a. Increases Cerebral perfusion 4. Decreases Non-Vital Organ Perfusion . Decreases splanchnic and intestinal perfusion a. Decreases renal perfusion b. Decreases skin perfusion A. Beta Adrenergic Agonist effects (Under 0.3 ug/kg/min) 1. Increases myocardial contractility 2. Increases Heart Rate 3. Relaxes Bronchial smooth muscle (bronchodilation) B. Epinephrine has a short half-life: ~2 minutes IV. Indications Initial Resuscitation Management (bolus) 1. Cardiac Arrest . Vasopressin may be used instead in some protocols 2. Symptomatic Bradycardia unresponsive to . Oxygenation a. Ventilation 3. Hypotension not related to volume depletion A. Post-Resuscitation Stabilization (Infusion) 1. Poor systemic perfusion or Hypotension despite

A. . . B. VII. A. .

VIII.

. B. IX.

A.

A.

Intravascular volume replacement AND a. Stable rhythm 2. Significant Bradycardia V. Newborn Dosing (refractory and persistant Bradycardia) . Epinephrine (1:10,000) 0.1 to 0.3 ml/kg by IV or ET A. Do not use the 1:1000 concentration in newborns VI. Dosing: Pediatric . Symptomatic Bradycardia (with a pulse) 1. Dose: 0.01 mg/kg IV/IO (0.1 ml/kg of 1:10,000 Epi) Pulseless Cardiac Arrest 1. Initial regular dose Epinephrine 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) Dose: 0.1 mg/kg IV/IO (0.1 ml/kg of 1:1000 Epi) a. Maximum dose: 0.2 mg/kg 3. Repeat dose every 3-5 minutes 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) Dosing: Adults . Symptomatic Bradycardia 1. Infusion: 2-10 ug/min (See below) Pulseless Arrest 1. Rhythms Asystole a. Pulseless Electrical Activity b. Ventricular Fibrillation 2. Initial IV: 1 mg (10 ml of 1:10,000 Epi) IV push a. Endotracheal: 2.5 ml of 1:1000 Epi in 10 ml NS 3. Repeat every 3-5 minutes 4. Consider increasing dose to 3 or 5 mg (0.1 mg/kg) Dosing: Pediatric Infusion (Same as Isoproterenol preparation) . Preparation 1. Draw up "x" mg of Epinephrine 2. Where "x" = 0.6 x WeightKg 3. Add enough D5W or NS to Epinephrine for 100 ml total 4. At this dilution Infusion rate of 1 ml/h provides 0.1 ug/kg/h A. Start Dose: 20 ml/hour until Tachycardia 1. Indicates drug has entered circulation Titrate Dose 1. Decrease to desired rate (0.1 - 1.0 ug/kg/min) 2. Adjust infusion rate every 5 min to desired effect Dosing: Adult Infusion for Cardiac Arrest . Preparation 1. Draw up 30 mg of Epinephrine (30 ml of 1:1000) 2. Add Epinephrine to 250 ml Normal Saline or D5W Start Dose: 100 ml/h B. Titrate to desired effect X. Dosing: Adult Infusion for symptomatic Bradycardia . Preparation 1. Draw up 1 mg Epinephrine (1 ml of 1:1000) 2. Add Epinephrine to 500 ml Normal Saline or D5W Start Dose: 1 ug/min B. Titrate Dose to desired effect (2-10 ug/min) XI. Precautions . Carefully check concentration (1:1000 OR 1:10,000) A. Observe for side effects after Resuscitation 1. Supraventricular Tachycardia

2. Ventricular Tachycardia 3. Severe Hypertension B. Extravasation into tissues 1. may causes local ischemia or necrosis C. Can exacerbate Myocardial Ischemia D. Do not mix with alkaline solutions Protocol: Evaluate Central Color A. Pink or 1. B. 1. 2. only peripheral cyanosis (acrocyanosis) Observe and monitor Central Cyanosis Use Blow-By Oxygen until pink Re-evaluate status periodically a. Neonatal Breathing Assessment b. Neonatal Circulation Assessment

Background A. Positive Pressure Ventilation (PPV) is single most important step in newborn CPR II. Protocol . Spontaneous Respirations 1. Neonatal Circulation Assessment A. 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) . Started at 20-25cm H2O a. Some infants may require 30-40 cm H2O 4. Ventilate for 15-30 seconds before next assessment . Continue PPV until Heart Rate >100/min and adequate spontaneous respirations 5. Monitoring: Continuous pulse oximetry (targeted pulse oximetry values) . At 1 minute of life: >60% a. At 3 minutes of life >70% b. At 5 minutes of lifer >80% c. At 10 minutes of life >85% 6. Consider Orogastric Tube for prolonged PPV 7. Perform Neonatal Circulation Assessment III. Management: Inadequate Positive Pressure Ventilation (no chest rise, no increase in Heart Rate) . Adjust mask to obtain adequate seal A. Adjust head and neck position to reposition airway (sniffing position is ideal) B. Suction mouth and nose for secretions C. Open mouth slightly and move jaw forward 1. Place index and middle finger inside mouth hooking behind central lower gums and gently lift upward D. Increase peak inspiratory pressure (PIP) enough to move chest (may require 30-40 cm H2O) 1. May require blocking pop-off valve E. Consider intubation (see below) IV. Management: Pediatric intubation . Indications 1. Prolonged Positive Pressure Ventilations >2-3 minutes 2. Ineffective Bag Valve Mask ventilation 3. Tracheal suctioning for thick meconium in a non-vigorous newborn

I.

4. Diaphragmatic Hernia suspected 5. Birth weight below 1500 grams (EGA under 30-31 weeks) A. Devices 1. Endotracheal Tube intubation Weight 1 kg: 2.5 mm Endotracheal Tube a. Weight 2 kg: 3.0 mm Endotracheal Tube b. Weight 3 kg: 3.5 mm Endotracheal Tube 2. Laryngeal mask airway (LMA) size 1 (gestational age >34 weeks or weight >2kg) B. Confirmation 1. Exhaled carbon dioxide detector or end-tidal CO2 (etCO2) monitor changes from purple to yellow if in trachea . Protocol A. Heart Rate over 100/min 1. Proceed to Neonatal Perfusion Assessment B. Heart Rate under 100/min 1. Positive Pressure Ventilation a. See Neonatal Breathing Assessment b. Continue Positive Pressure Ventilation until Heart Rate>100/min and adequate spontaneous respirations c. Re-evaluate Heart Rate every 30 seconds 2. Heart Rate under 60/min after 30 seconds of PPV . Positive Pressure Ventilation with 100% Oxygen a. Perform Chest Compressions i. Depress chest one third of AP chest diameter b. CPR Sequence . Count: One and Two and Three and Breath i. Compression to breath ratio of 3:1 i. Compress at rate of >90 beats per minute ii. Breath at rate of 30 breaths per minute c. Reassess 45-60 seconds after starting compressions . Epinephrine for persistent Heart Rate <60/min after 60 seconds of compressions (and 90 seconds of PPV) d. Additional measures for prolonged Resuscitation beyond 2-3 minutes . Consider Orogastric Tube to decompress Stomach i. Consider Endotracheal Intubation 3. Heart Rate under 100/min after 30 seconds of PPV . Continue Positive Pressure Ventilation until Heart Rate >100/min and adequate spontaneous respirations 4. Heart Rate over 100/min . Go back to Neonatal Breathing Assessment II. Management: Epinephrine . Indication 1. Persistent Heart Rate <60/min after 60 seconds of compressions (and 90 seconds of PPV) A. 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/min III. Management: Pediatric Fluid Resuscitation . Indication 1. Suspected blood loss A. Crystalloid (NS or LR) 10 ml/kg over 5-10 minutes 1. Umbilical Vein Catheter is most common site for delivery 2. May repeat for a second dose I.

B. Other fluids for Resuscitation 1. Colloid Solution 2. Packed Red Blood Cells I. Epidemiology A. Five million neonatal deaths per year worldwide 1. Birth Asphyxia accounts for 19% of neonatal deaths B. Newborns in United States: 4 million births per year 1. 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: 2030% C. Early Resuscitation is key (intervene at primary apnea) 1. Primary apnea (initial) responds to simple measures . See Neonatal Airway Assessment 2. Secondary apnea requires PPV and other interventions . Does not respond to continued stimulation a. Associated with prolonged Resuscitation b. Associated with poorer outcomes c. Associated with decreased Heart Rate and BP II. Physiology: Transition from fetal circulation at birth Alveolar fluid is absorbed by lung A. Umbilical vessels are clamped 1. Increases systemic Blood Pressure B. Pulmonary circulation increases 1. Pulmonary vessel vasodilation 2. Ductus arteriosus Vasoconstriction III. Protocol Prepare equipment and providers before delivery (see prevention below) A. Initial questions to consider 1. See Newborn History 2. 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? B. Consider Neonatal Distress Causes C. Step by step assessment (timer started at delivery) 1. Neonatal Airway Assessment . Includes general measures performed for all infants a. Includes warming, suctioning, drying, stimulation b. Endotracheal suctioning if thick meconium AND only if nonvigorous infant 2. Neonatal Breathing Assessment . Positive Pressure Ventilation (PPV) for apnea, gasping or Heart Rate <100/min i. Rate of 40-60/min for 30 sec ii. Peak inspiratory pressure (PIP) started at 20-25cm H2O (may require 30-40 cm H2O) a. Apply O2 Sat monitor if PPV needed b. Endotracheal Tube intubation or laryngeal mask airway (LMA) if PPV for >2-3 minutes (confirm wirh etCO2) 3. Neonatal Circulation Assessment . Positive Pressure Ventilation for continued Heart Rate <100/min or apnea a. Chest Compressions for Heart Rate <60/min after 30 seconds of PPV . Rate - 3:1 compressions to breaths

Reassess 45-60 seconds after starting compressions b. Epinephrine for persistent Heart Rate <60/min after 60 seconds of compressions (and 90 seconds of PPV) . Umbilical Venous Catheter: 0.01 to 0.03 mg/kg (0.1 to 0.3 ml/kg) of 1:10,000 Epinephrine i. Endotracheal Tube: 0.05 to 0.10 mg/kg (0.5 to 1 ml/kg) of 1:10,000 Epinephrine 4. Neonatal Perfusion Assessment . Central Cyanosis: Free flow Oxygen starting at 21% or blended and titrating up a. Blood loss suspected: Normal Saline 10 cc/kg bolus (consider pRBC when available) 5. Post-Resuscitation after extensive efforts for severe event . Intravenous Dextrose infusion (prevent Hypoglycemia) a. Developing severe hypoxic-ischemic encephalopathy in newborns >36 weeks . Offer therapeutic Hypothermia protocol (started within 6 hours of event at NICU) IV. Management: Indications to Discontinue Resuscitation Efforts . No detectable Heart Rate after 10 minutes of full Resuscitation efforts A. Lethal anomalies (Informed consent with parents if withholding care) 1. Very premature (gestational age <23 weeks or weight <400 grams) 2. Anencephaly 3. Trisomy 13 Syndrome V. Prevention . Prepare for complicated deliveries 1. NRP-certified Resuscitation team available at all times 2. NRP-certified physician present for high-risk deliveries A. Hospital delivery rooms stocked with adequate equipment 1. Pulse oximeter 2. Fully working warmer 3. Oxygen supply with air oxygen blender 4. Suction device 5. Positive Pressure Ventilation device (e.g. Anesthesia Bag, ambu-bag, T-piece device) 6. Endotracheal Tubes, laryngeal mask airway, working laryngoscope, CO2 Detection device 7. Resuscitation medications (e.g. Epinephrine, normal saline) VI. Precautions: Major changes in neonatal Resuscitation as of 2010 . Perineal suctioning for meconium is no longer recommended A. Do not endotracheal suction vigorous infants despite thick meconium presence B. Monitor Resuscitation efforts with pulse oximetry C. End Tidal CO2 (etCO2) detector or monitor to confirm proper Endotracheal Tube placement D. Laryngeal mask airway (LMA) size 1 may be used instead of ET for ventilation in infants >2kg or >34 weeks gestation E. Naloxone and Sodium Bicarbonate are no longer recommended in newboen Resuscitation F. Consider therapeutic Hypothermia protocol in newborns >36 weeks with developing severe hypoxic-ischemic encephalopathy VII. Preparations: Medications no longer recommended in Newborn Resuscitation (listed for completeness) . Sodium Bicarbonate (Use only 4.2% solution) 1. Not recommended as worse outcomes with use 2. Primary treatment of acidosis is by maximizing ventilation, not with bicarbonate 3. Dose: 4 ml/kg (2 meq/kg of 4.2%) very slowly via large vessel (Umbilical Vein Catheter) A. Naloxone

i.

1. Not recommended as of 2010 as no evidence for improved outcomes with use 2. Primary treatment of apnea is with Positive Pressure Ventilation 3. Dose: 0.1 mg/kg of 1.0 mg/ml IV, ET, IM or SQ 4. Indications (old) Respiratory depression despite PPV (with normal Heart Rate and color) a. Maternal Narcotic Analgesics within 4 hours VIII. References . (1995) World Health Report, WHO A. Kattwinkel (2000) Neonatal Resuscitation, AAP-AHA B. Kattwinkel (2010) Neonatal Resuscitation, AAP-AHA