Neonatal Resuscitation

Initial Steps & Assessment - Golden Start Spark

• Golden Minute: Act within the first 60 seconds.
• Initial Steps (📌 WDS):
  • Warm: Under radiant warmer, prevent heat loss.
  • Dry: Thoroughly dry infant.
  • Stimulate: Gently rub back or flick soles.
• Airway Management:
  • Position: Head in "sniffing" position to open airway.
  • Clear Secretions: Only if copious & obstructing (mouth then nose).
• Rapid Assessment:
  • Respirations: Apnea, gasping, or labored breathing?
  • Heart Rate (HR): Auscultate or palpate umbilical pulse. Critical if < 100 bpm.
• If apneic/gasping or HR < 100 bpm after initial steps → Start Positive Pressure Ventilation (PPV).

⭐ Target Pre-ductal SpO2 after birth:

• 1 min: 60-65%
• 2 min: 65-70%
• 3 min: 70-75%
• 4 min: 75-80%
• 5 min: 80-85%
• 10 min: 85-95%

Ventilation & Compressions - Pump & Thump Time

• Positive Pressure Ventilation (PPV):
  • Indications: Apnea/gasping, or Heart Rate (HR) < 100/min after initial steps.
  • Rate: 40-60 breaths/min ("Breathe-two-three...").
  • Initial FiO₂: Room air (21%) for term (≥35 wks); 21-30% for preterm (<35 wks).
  • Monitor: Chest rise, HR, SpO₂.
  • If PPV ineffective (no chest rise/HR ↑): 📌 MR. SOPA corrective steps.
• Chest Compressions (CC):
  • Indication: HR < 60/min despite 30 seconds of effective PPV.
  • Technique: Two-thumb encircling hands (preferred); lower third of sternum.
  • Depth: 1/3 Antero-Posterior (AP) diameter of chest.
  • Ratio (CC:Ventilation): 3:1 (90 compressions + 30 breaths = 120 events/min).
  • Coordinate: "One-and-Two-and-Three-and-Breathe-and..."
  • Oxygen: Increase FiO₂ to 100% when starting CC.
  • Reassess HR every 60 seconds. Stop CC if HR ≥ 60/min.

⭐ The six corrective steps for ineffective PPV are crucial: 📌 Mask adjustment, Reposition airway, Suction mouth then nose, Open mouth, Pressure increase, Alternative airway (ETT/LMA).

Medications & Special Situations - Rx Rescue Rangers

• Epinephrine (Adrenaline): For HR < 60 bpm despite effective PPV & chest compressions.
  • IV/IO (preferred): 0.01-0.03 mg/kg (0.1-0.3 mL/kg of 1:10,000 solution).
  • ET (if no IV/IO): 0.05-0.1 mg/kg (0.5-1 mL/kg of 1:10,000 solution). Repeat q 3-5 min.
• Volume Expanders: For suspected hypovolemia (pallor, weak pulse, poor response).
  • Normal Saline (0.9% NaCl) or O-negative blood.
  • Dose: 10 mL/kg IV/IO over 5-10 min. May repeat.
• Naloxone: ⚠️ Limited role. For respiratory depression post maternal opioids (within 4h delivery).
  • Dose: 0.1 mg/kg IV/IO/IM. Ensure adequate ventilation established first.
  • Contraindicated: Infants of opioid-dependent mothers (risk of neonatal withdrawal seizures).
• Glucose: For hypoglycemia (screen if prolonged resuscitation/at-risk infant).
  • Target: Maintain blood glucose > 45 mg/dL.
  • Treatment: IV D10W 2 mL/kg bolus.
• Special Situations:
  • Meconium-Stained Amniotic Fluid (MSAF):
    • Non-vigorous infant: Clear mouth/nose. If HR <100 bpm/apnea, start PPV. Intubate for tracheal suction only if airway obstruction suspected after PPV initiation.
  • Preterm Infants (<35 wks): ↑ Hypothermia risk (thermal mattress, plastic wrap, hat). Gentle ventilation. Judicious O2 (target SpO2).
  • Persistent Bradycardia/Asystole: Ensure effective ventilation & compressions. Epinephrine, volume. Consider underlying causes (e.g., pneumothorax).
  • Congenital Diaphragmatic Hernia (CDH): Immediate intubation, NG/OG tube. Avoid bag-mask ventilation.
  • Choanal Atresia: Oral airway or intubation.

⭐ The preferred route for epinephrine administration during neonatal resuscitation is intravenous or intraosseous.

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High‑Yield Points - ⚡ Biggest Takeaways

• Initial steps: Dry, warm, position, suction (if needed), stimulate.
• PPV if apnea/gasping or HR <100 bpm after initial steps.
• Chest compressions if HR <60 bpm despite 30s effective PPV (ratio 3:1).
• Epinephrine if HR <60 bpm despite effective PPV & compressions.
• Target pre-ductal SpO2: 1 min (60-65%), 5 min (80-85%), 10 min (85-95%).
• MSAF & non-vigorous: Routine intubation for suctioning NOT recommended; initiate PPV if needed.