Neonatal Resuscitation


It is October and all of the stores have their scariest Halloween devices out… but nothing will make you loose your breath more quickly than a woman delivering precipitously in your ED! When you are awoken from your regular workflow by this announcement, what should you consider?
1. Three Key Questions to ask of your pregnant patients: These help you know what resources you will need.
⇒ “How many babies are in your belly?” (hopefully she knows)
⇒ “When is your duedate?” (again… hopefully she knows)
⇒ “What color is the fluid?”

2. Three Key Characteristics of the baby to assess: (if all three are present, everyone’s job just got easier – the child won’t need resuscitation)
⇒ Term Gestation and appearance?
⇒ Crying and vigorous?
⇒ Good muscle tone?

On the other hand… the child is being born in the ED, which increases the likelihood of those three characteristics not being present – now what do you do?

3. Three Simple Maneuvers to start with: (do these for 30 seconds then assess HR and Respiratory effort)
Warm and Dry (Cold stress is a big concern – Large Surface Area : Mass leads to rapid heat loss, which is worsened by the amniotic fluid on them)
Clear the airway (bulb suction or even suction catheter) and ensure the airway is in good positioning (sniffing position)
Stimulate (Time to wake up baby!! – the first two will help, but also rub their spine and flick their feet)

4. Two Magic Numbers for Neonatal Resuscitation:
HR < 100 (or persistent central cyanosis or apnea) = positive pressure ventilation
HR < 60 = chest compressions +/- epinephrine
⇒ After the first 30 seconds, assess HR and Respiratory effort. Use the umbilical cord to count the HR. Remember that bradycardia is most likely due to hypoxia, so PPV will be the first step if HR < 100 (or apneic or cyanotic) at the 30 second time mark.
⇒ After another 30 seconds of PPV, reassess; HR < 60, then chest compressions!

5. Three Special Circumstances:
⇒ Mecomium presence?
(1) If the infant is depressed, then use meconium aspirator (aspirate the airway via the ETT)
(2) If the infant is vigorous, then resuscitate as usual (dry, clear airway, assess circulation/color)

⇒ Infant who is <28wks GA:
(1) Do not dry with towels as you would an older neonate
(a) Their skin is too fragile and sticky… you’ll waste too much time also
(b) Place the child in a food grade polyethylene bag (Zip Lock bag), to prevent heat loss and avoid losing valuable time during the resuscitation.
(2) Extreme prematurity (<23 wks or <400 grams) – which may be hard to figure out in the ED… but if it is known, then:
(a) There is an “unacceptably high morbidity” in the rare survivor
(b) Resuscitation efforts may be withheld
(c) Make sure you consider the family’s comfort

⇒ For infants not responding to resuscitation, TRANSILLUMINATE the chest to determine if there is a pneumothorax… which you can then aspirate (more on this later).


Kattwinkel et al. Neonatal Resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics: 126 (5); pp. e1400-e1413.

Sean 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 renown 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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