›If the heart rate is not rising or the chest is not moving, perform the ventilation corrective steps in order
›Mask readjustment to obtain a seal
›Reposition the airway to neutral
›Suction the mouth and nose
›Open the mouth
›Pressure increase in 5 to 10 cmH2O steps to a maximum around 40 cmH2O
›Airway alternative with a tracheal tube or a size 1 laryngeal mask
›Provide continuous positive airway pressure of 5 to 8 cmH2O, rather than intubation, for the spontaneously breathing preterm newborn with distress but an adequate heart rate
›Place an advanced airway when ventilation is prolonged or ineffective, before chest compressions, or for a diaphragmatic hernia
›Tube size 2.5 mm below 28 weeks, 3.0 mm at 28 to 34 weeks, 3.5 mm at 34 to 38 weeks, and 3.5 to 4.0 mm above 38 weeks
›Limit each intubation attempt to about 30 seconds and reoxygenate with mask ventilation between attempts
›Confirm placement with a rising heart rate, exhaled carbon dioxide detection, chest rise, and equal breath sounds
›A size 1 laryngeal mask is the rescue airway at 34 weeks or more or about 2000 grams when face-mask and intubation both fail
›Premedication for intubation applies only to non-emergent intubation of a stable newborn, never to emergent delivery-room intubation where loss of respiratory drive in a failed airway is lethal
›Atropine 20 mcg/kg intravenously
›Fentanyl 1 to 3 mcg/kg intravenously by slow push
›Vecuronium 0.1 mg/kg or rocuronium 1 mg/kg intravenously
›Verify against current pediatric guideline before use
›Avoid routine sustained lung inflations beyond 5 seconds, which have not improved outcomes and were associated with early mortality in preterm infants
›For congenital diaphragmatic hernia, avoid face-mask positive pressure ventilation, intubate immediately, ventilate gently with peak pressure below 25 cmH2O, and place a large-bore orogastric tube to continuous suction
›Mask ventilation distends the intrathoracic bowel, worsens lung compression and mediastinal shift, and can precipitate arrest
›Accept a preductal saturation of 80 to 95 percent with permissive hypercapnia while pH stays above 7.20
›Indications and prerequisites
›Heart rate remains below 60 per minute after at least 30 seconds of positive pressure ventilation that visibly inflates the chest
›Secure an advanced airway and increase oxygen to 100 percent before or as compressions begin
›Technique
›Two-thumb encircling-hands technique on the lower third of the sternum
›Compress to one-third of the anteroposterior chest diameter with full recoil between compressions
›A 3 to 1 ratio giving 90 compressions and 30 breaths, about 120 events each minute
›Compress from the head of the bed once the airway is secure so umbilical access stays available
›Reassessment
›Check the heart rate after 60 seconds of coordinated compressions and ventilation using electrocardiogram leads
›Continue until the heart rate is 60 per minute or more, then resume ventilation alone at 40 to 60 per minute
›Keep interruptions for reassessment brief
›Oxygen and ratio caveats
›The 3 to 1 ratio with 100 percent oxygen is specific to the newborn whose arrest is respiratory in origin
›Use higher pediatric ratios only if the arrest is known to be cardiac
›A shockable rhythm is exceptional in the newborn; if confirmed ventricular fibrillation or pulseless ventricular tachycardia, defibrillate at 2 J/kg
›Verify against current pediatric guideline before use
›Wean from 100 percent oxygen as soon as the heart rate recovers and the preductal saturation reaches target, to limit oxidative injury
Vascular access and epinephrine
›Establish emergency low-lying umbilical venous access as the preferred route when medications are needed
›Insert a 3.5 or 5 French catheter 2 to 4 cm until blood returns freely; a deeper line risks portal or hepatic infusion
›Intraosseous access is an acceptable alternative if umbilical access is not possible
›Epinephrine when the heart rate remains below 60 per minute despite 60 seconds of coordinated compressions and effective ventilation through an advanced airway
›Intravenous or intraosseous dose 0.01 to 0.03 mg/kg, which is 0.1 to 0.3 ml/kg of the 0.1 mg/ml concentration
›Follow each dose with a 0.5 to 1 ml isotonic flush
›Repeat every 3 to 5 minutes while the heart rate stays below 60 per minute
›Reassess the heart rate about 60 seconds after each dose
›Verify against current pediatric guideline before use
›Tracheal dose 0.05 to 0.1 mg/kg, which is 0.5 to 1 ml/kg of the 0.1 mg/ml concentration, only while access is being obtained
›The tracheal route is less reliable and is not repeated in place of an intravenous dose once a line is in
›Verify against current pediatric guideline before use
›Use the 0.1 mg/ml concentration only; the 1 mg/ml concentration must never be given by these routes
›If the heart rate remains below 60 per minute after the first epinephrine dose, treat it as a therapy-not-working problem
›Confirm the tracheal tube is in the trachea and patent with a carbon dioxide detector and breath sounds
›Confirm compression depth is one-third of the chest and the rate and ratio are correct
›Confirm the oxygen is 100 percent and the gas source is connected
›Exclude pneumothorax, hypovolemia, and diaphragmatic hernia
›Give volume expansion if blood loss is suspected and consider a second site of access
›Drugs with no role in the acute delivery-room algorithm, dosed here only because a clinician who elects to use one needs the number
›Sodium bicarbonate is not recommended during brief resuscitation; in a prolonged arrest with documented metabolic acidosis despite adequate ventilation and circulation, 1 to 2 mmol/kg of the 0.5 mmol/ml solution may be given by slow intravenous push
›Rapid administration causes a hyperosmolar load, intraventricular hemorrhage, and myocardial depression, and it raises carbon dioxide unless ventilation is adequate
›Verify against current pediatric guideline before use
›Calcium gluconate 100 mg/kg, which is 1 ml/kg of the 100 mg/ml solution, by slow intravenous push only for documented hypocalcemia, hyperkalemia, or hypermagnesemia with cardiac compromise
›Verify against current pediatric guideline before use
›Atropine and routine vasopressor boluses have no role in the initial newborn algorithm
Volume expansion, dextrose, and adjunct drugs
›Volume expansion when there is a poor response to resuscitation with a history or signs of blood loss such as pallor, weak pulses, or persistent low heart rate
›Isotonic crystalloid 10 ml/kg intravenously over 5 to 10 minutes, repeated once if the response is inadequate
›Emergency O-negative packed red cells 10 ml/kg for known significant hemorrhage
›In the preterm newborn, infuse over 15 to 30 minutes, since rapid volume swings cause intraventricular hemorrhage
›Avoid routine volume in the absence of blood loss, because it does not help the primarily asphyxiated heart and adds afterload and hemorrhage risk
›Verify against current pediatric guideline before use
›Dextrose for documented hypoglycemia below 2.6 mmol/l after resuscitation
›Dextrose 10 percent 2 ml/kg, which is 200 mg/kg, by slow intravenous push
›Follow with a dextrose 10 percent infusion delivering 5 to 8 mg/kg per minute and recheck glucose in 30 minutes
›Avoid boluses of dextrose more concentrated than 12.5 percent through a peripheral or low umbilical line
›Verify against current pediatric guideline before use
›Naloxone is not recommended as part of newborn resuscitation; airway and ventilation are the treatment for opioid-related respiratory depression
›If used later for isolated respiratory depression with a secure airway, the historical dose is 0.1 mg/kg intravenously or intramuscularly
›Do not give naloxone to the newborn of an opioid-dependent mother, since it precipitates severe withdrawal and seizures
›Verify against current pediatric guideline before use
›Prostaglandin E1 to maintain ductal patency when a ductal-dependent congenital heart lesion is suspected
›Infusion 0.01 to 0.05 mcg/kg per minute, starting at the higher end and titrating down toward 0.01 mcg/kg per minute once the duct opens
›Anticipate apnea, hypotension, and fever, and have airway equipment at the bedside before starting
›Verify against current pediatric guideline before use
›Surfactant deficiency in the intubated preterm newborn
›Poractant alfa 200 mg/kg by the tracheal route
›Alternative beractant 100 mg/kg, which is 4 ml/kg
›Verify against current pediatric guideline before use
›Seizures after hypoxic-ischemic injury, electrographic or clinical
›Phenobarbital 20 mg/kg intravenous loading dose
›A further 10 mg/kg if seizures persist, to a total of 40 mg/kg
›Verify against current pediatric guideline before use
›Empiric antibiotics after cultures when early-onset sepsis is suspected, with an age-appropriate neonatal regimen
›Ampicillin 50 mg/kg intravenously every 8 hours in the first week of life, with more frequent dosing as postnatal age increases
›Add gentamicin 4 to 5 mg/kg intravenously every 24 to 36 hours, since ampicillin alone does not cover gram-negative organisms in this age group
›Use cefotaxime 50 mg/kg intravenously every 8 to 12 hours rather than ceftriaxone in the neonate, because ceftriaxone displaces bilirubin and precipitates with calcium
›Verify against current pediatric guideline before use
›Persistent pulmonary hypertension at 34 weeks or more with a preductal to postductal gradient and echocardiographic confirmation
›Inhaled nitric oxide starting at 20 parts per million
›Wean in steps of 5 parts per million once oxygenation improves and do not stop abruptly, since rebound pulmonary hypertension can occur
›Verify against current pediatric guideline before use
Oxygen use and saturation targets
›Titrate oxygen to the preductal saturation measured on the right hand or wrist, checked against the minute-specific target
›1 minute 60 to 65 percent
›2 minutes 65 to 70 percent
›3 minutes 70 to 75 percent
›4 minutes 75 to 80 percent
›5 minutes 80 to 85 percent
›10 minutes 85 to 95 percent
›Set the starting concentration and adjust in steps
›21 percent for 35 weeks or more
›21 to 30 percent below 35 weeks
›Increase to 100 percent oxygen whenever chest compressions are given, then wean promptly once the heart rate is above 60 per minute and the saturation is in range
›Both extremes cause harm
›Hyperoxia in the term newborn delays the first breath and increases mortality and markers of oxidative stress
›Hyperoxia in the preterm newborn contributes to retinopathy of prematurity, chronic lung disease, and brain injury
›Sustained hypoxia perpetuates pulmonary vasoconstriction and acidosis
›Targets shift in specific physiology and must not be applied blindly
›Suspected ductal-dependent cyanotic heart disease tolerates a preductal saturation of 75 to 85 percent, and driving toward 95 percent can close the duct and precipitate collapse
›Congenital diaphragmatic hernia is managed to a preductal saturation of 80 to 95 percent with permissive hypercapnia to limit ventilator injury
›Established persistent pulmonary hypertension is kept in the low to mid 90s preductally to avoid both hypoxic vasoconstriction and hyperoxic injury
›During therapeutic hypothermia, avoid hyperoxia and keep the saturation in the low to mid 90s
›Once stable, wean to the lowest oxygen concentration that maintains the target rather than leaving a fixed setting
Post-resuscitation care and therapeutic hypothermia
›Move to intensive monitoring after return of an adequate heart rate, anticipating deterioration in the first hours
›Continuous heart rate, preductal and postductal saturation, blood pressure, and temperature
›Serial glucose every 1 to 2 hours targeting 2.6 to 5.0 mmol/l
›Serial blood gas and lactate to confirm the acidosis is resolving
›Serial neurologic examination with Sarnat staging and, where available, amplitude-integrated electroencephalography
›Maintain normal physiology
›Ventilate to PaCO2 40 to 55 mmHg and avoid hypocapnia below 35 mmHg, which reduces cerebral perfusion and worsens injury
›A higher PaCO2 is accepted in congenital diaphragmatic hernia and severe lung disease provided the pH stays above 7.20
›Treat hypotension to maintain perfusion, using volume only for demonstrated hypovolemia and otherwise a vasoactive infusion
›Dopamine 5 mcg/kg per minute titrated in steps of 2.5 to 5 mcg/kg per minute to a maximum of 20 mcg/kg per minute, guided by perfusion rather than a single blood pressure number
›Verify against current pediatric guideline before use
›Restrict maintenance fluids initially, anticipating acute kidney injury and inappropriate antidiuresis
›Treat seizures promptly with phenobarbital 20 mg/kg
›Initiate therapeutic hypothermia for the newborn 36 weeks or more with moderate to severe encephalopathy within 6 hours of birth
›Target core temperature 33.5 degrees Celsius, range 33 to 34, for 72 hours, then rewarm by no more than 0.5 degrees Celsius per hour
›Begin passive cooling immediately, turning off the warmer, while eligibility and transport are arranged
›Do not overshoot below 32 degrees Celsius and do not allow rebound hyperthermia during rewarming
›Delay enteral feeds during active cooling and address pain and shivering, since stress raises metabolic rate and undermines cooling
›Arrange brain magnetic resonance imaging at day 4 to 7 after rewarming for prognosis, not as an acute study
Withholding, discontinuing, and iatrogenic harm avoidance
›Non-initiation of resuscitation is reasonable for confirmed gestational age below 22 weeks or birth weight below approximately 350 grams, anencephaly, or confirmed trisomy 13 or 18
›Gestational age 22 to 24 weeks is a shared-decision zone that depends on antenatal counseling and family values
›Where there is genuine uncertainty about gestational age or the prognosis, begin resuscitation and reassess
›Discontinuation is reasonable when there is no detectable heart rate after 20 minutes of resuscitation that has included adequate ventilation, compressions, and epinephrine
›An Apgar of 0 at 10 minutes strongly predicts death or severe disability but is not absolute, and the decision is individualized to etiology, gestation, and access to hypothermia
›Involve the family and the senior clinician and document the rationale and the times
›Walk the routine emergency interventions and state how each is modified for the newborn
›Intubation is high value but each attempt causes hypoxia and bradycardia, so limit attempts to about 30 seconds, reoxygenate between, and use a laryngeal mask rescue at 34 weeks or more
›Sedation and neuromuscular blockade are withheld for emergent delivery-room intubation, because loss of respiratory drive in a failed airway is lethal
›Fluid loading is reserved for demonstrated blood loss; routine boluses do not help the asphyxiated heart and cause intraventricular hemorrhage in the preterm newborn
›Oxygen is titrated to the minute-specific target; both hyperoxia and prolonged hypoxia cause measurable harm
›Vasopressors have no place in the initial algorithm, where epinephrine with ventilation and compressions is the treatment, and an infusion belongs to the post-resuscitation phase
›Mechanical circulatory support in the newborn is extracorporeal membrane oxygenation at a specialist center, not a delivery-room option, and an intra-aortic balloon pump has no neonatal role
›Anticoagulation is avoided in the acute phase given the high baseline risk of intracranial and pulmonary hemorrhage
›Fibrinolysis is contraindicated because of the intraventricular hemorrhage risk, especially in the preterm newborn
›Analgesia is not given during the acute resuscitation but is addressed once stabilized, particularly during therapeutic hypothermia
›Treat a sudden deterioration on positive pressure ventilation as tension pneumothorax until excluded
›Transilluminate the chest and perform lung ultrasound
›Needle decompression with a 20 gauge catheter at the second intercostal space in the midclavicular line, or the fourth to fifth intercostal space in the anterior axillary line, then a chest drain
›Read the rhythm correctly
›Newborn bradycardia is hypoxic in origin and is treated with ventilation, not atropine or pacing
›A wide-complex or refractory rhythm should prompt a search for hyperkalemia from hemolysis or renal anomaly and for profound acidosis
›A narrow-complex tachycardia above 220 per minute is supraventricular tachycardia, treated with vagal maneuvers or adenosine 0.1 mg/kg by rapid intravenous push, increased to 0.2 mg/kg if needed, rather than the resuscitation algorithm
›Dextrose and any bicarbonate shift potassium, and ionized calcium must be corrected before interpreting the QT interval