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HIGH-YIELD FACTS

  • The vast majority of newly-born term infants will respond adequately to tactile stimulation and warming. Very few will require significant resuscitation.

  • Neonatal resuscitation is focused chiefly on respiratory support, not on cardiac support, unlike resuscitation for adults.

  • Healthy term newborns may take 10 minutes or longer to reach normal extra-uterine oxygen saturations.

  • The use of preductal pulse oximetry is recommended because skin color may correlate poorly with oxygen saturation.

  • The use of 3-lead electrocardiogram (ECG) is the best secondary method to rapidly and accurately monitor the heart rate.

  • The use of oxygen/air blenders is recommended to decrease exposure to 100% oxygen which has been increasingly shown to have toxic effects.

  • When meconium-stained amniotic fluid is present, mouth and nasal suctioning after delivery of the head is not recommended for vigorous infants.

  • Chest compressions are only initiated if there is no pulse or if the heart rate remains less than 60 beats/min after adequate positive-pressure ventilation (PPV) for 30 seconds.

  • The ratio of chest compressions to ventilations during resuscitation should be 3:1, with 90 compressions and 30 ventilations per minute.

  • Chest compressions are performed using the two-thumb–encircling hand technique.

  • Auscultating for heart rate is more accurate than palpation of the umbilical cord base.

  • The umbilical vein is the best site for intravenous (IV) access, but intraosseous access may be considered in the emergency department setting.

  • Only isotonic crystalloid or packed red blood cells should be used for initial volume resuscitation.

  • Epinephrine is indicated for a heart rate less than 60 beats/min after 30 seconds of adequate ventilation and chest compressions.

  • The dose of epinephrine for the newly born infant is 0.1 to 0.3 mL/kg of 1:10,000 solution given intravenously. Higher doses are not recommended.

  • Therapeutic hypothermia instituted after resuscitation may improve neurologic outcomes for term infants with hypoxic-ischemic encephalopathy (HIE).

BACKGROUND

Of the nearly 4 million infants born in the United States each year, more than 90% successfully transition from intrauterine life with little or no intervention. Roughly 10% require some assistance and 1% require more extensive resuscitation.1 Because of the large number of births nationwide, it is inevitable that the emergency medicine practitioner will eventually be faced with a newly born infant who may require resuscitation. As in any critical situation in medicine, preparation and anticipation play a key role in neonatal resuscitation. This includes equipment (Table 22-1) and personnel to be ready as soon as a newly born infant presents to the emergency department. Current American Heart Association (AHA) and American Academy of Pediatrics (AAP) guidelines recommend that at least one skilled provider should attend every birth in the delivery room and at least two skilled providers should be present for deliveries in the higher risk emergency department setting.2

TABLE 22-1Neonatal Resuscitation Quick Checklist

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