Code pink in labour and delivery, and you are the only doctor in the hospital tonight. Time for a rapid review of neonatal resuscitation…
The biggest changes are:
- We no longer intubate and suction for meconium. The resuscitation proceeds identically whether or not meconium is present
- Heart rate is monitored using ECG leads, rather than the classic palpation of the umbilicus
- CPAP is added as an option for laboured breathing or persistent cyanosis
- The first 30 second assessment has been removed because it was unrealistic. The goal is to just get an initial assessment and initial maneuvers done in the first minute.
Call for help. Hopefully the code pink activated the pediatrician already. I like to bring a second ED doc if they happen to be around, if just for moral support.
Make sure the proper equipment is available. The baby should be in a warmer. You need appropriately sized lines and tubes. The unusually small doses take longer to draw up, so now is a good time to get a spare nurse to start drawing up the correct epinephrine dose.
The first step of neonatal resuscitation asks three questions to determine if the baby is ok: Is this a term gestation, is there good tone, and is the baby breathing or crying? Presumably at least one answer was no, which is why you are at a code pink.
Identify yourself and ask where the team is in the algorithm (it probably took you some time to run up a few flights of stairs). We will assume you got there immediately.
Stimulate, position, warm. Dry with towels, position and clear the upper airway, stimulate with gentle rubbing or heel flicks. (In the premature infant, less than 28 weeks, do not towel dry as the skin is very fragile. Instead, maintain warmth by wrapping in plastic or placing the child in a plastic bag.) Make sure that the radiant warmer has been turned on, because the baby needs to be kept warm whether or not further resuscitation is required.
30 seconds in: Evaluate HR, Respiration, Color, Tone
- If HR <100 or apneic → BVM at 30-60/min and apply an O2 sat probe. Consider ECG monitoring for more accurate HR assessment. Start the resuscitation with room air rather than 100% oxygen
- If isolated central cyanosis or laboured breathing → Position and clear the airway, provide 100% O2, and apply the O2 sat probe. CPAP is an option
60 seconds in: Re-evaluate HR, Respiration, Color, Tone
- If HR between 60 and 100 → Continue BVM ventilation. If there is any difficulty with BVM ventilation place an LMA or intubate
- If HR <60 → Start chest compressions (3:1 with respirations, 90 compression and 30 breaths per minute) and intubate. Change to 100% oxygen. Now is the time to start on venous access, either an IV or an umbilical vein catheter
90 seconds in: Re-evaluate HR, Respiration, Color, Tone
- If HR <60 → add epinephrine (0.01mg/kg = 0.1ml/kg of 1:10,000 iv, io, umbilical). For me, endotracheal epinephrine is a distant second choice (0.03mg/kg = 0.3ml/kg of 1:10,000 ETT)
120 seconds in: Re-evaluate HR, Respiration, Color, Tone
- If HR <60 → add a fluid bolus (NS 10ml/kg slow push over 5-10min) and assess for pneumothorax
If the child is not getting better at this point, it is time to move beyond the basic NRP algorithm (or pray that the pediatrician will arrive soon).
Is this primarily a ventilation problem?
Airway obstruction? (meconium, choanalatresia, Robin syndrome)
- Options: suction, intubate if not done, attempt prone positioning for BVM, nasal ETT or airway, LMA, tracheostomy
Lung problem? (pneumothorax, congential diaphgramatic hernia, pulmunary hypoplasia, right main stem intubation)
- Pneumothorax diagnosis by ultrasound, transillumination, or CXR → aspirate with 18 gauge catheter or place a 10F chest tube
- Diaphragmatic hernia (probably on CXR) → intubate as soon as recognized (BVM will inflate the stomach) and decompress the stomach with an 10F NG tube set to continuous suction
- Right main stem ETT → adjust tube, remember approximate depth of 3x the tube size
Is there a failure to begin spontaneous breathing?
- Hypoglycemia → test and treat. Generally use 2.2mmol/L as cut off and treat with D10W bolus of 2 ml/kg then D10W continuous at 4ml/kg/hr
- Maternal exposure to opioids → naloxone 0.1mg/kg IV (or IM if IV access not available)
Is this primarily a cardiac problem?
Especially consider is ongoing cyanosis or bradycardia despite good ventilations.
- Start PGE at 0.1mcg/kg/min IV
Could this be hemorrhagic shock?
If there was a history of placental abruption, resuscitate with O neg blood instead of NS as soon as available.
Could this be sepsis?
If you have made it passed the basic portion of the NRP algorithm, send cultures and start antibiotics
The AHA NRP algorithm:
The ERC NRP algorithm:
NRP traditionally suggested assessing the HR by umbilical palpation or auscultation for 6 seconds (and, hopefully obviously, multiplying by 10 for the rate). Now, they recommend that using ECG monitoring will provide a more rapid and accurate assessment of the heart rate.
When providing positive pressure, there is theoretical advantage to using PEEP for fluid filled lungs. There is inadequate science to make strong recommendations. The 2015 AHA guideline say: “We suggest using PEEP ventilation for premature newborns during delivery room resuscitation (weak recommendation, low-quality evidence). We cannot make any recommendation for term infants because of insufficient data.” I would consider adding a PEEP valve at a low setting until more information is available.
If there is any difficulty with bag valve mask ventilation, an LMA is an excellent option. I am very partial to using LMAs early in newborn resuscitation. I discussed 2 papers on this in the Articles of the Month May 2015. The guidelines say “the laryngeal mask may be used as an alternative to tracheal intubation during resuscitation of the late-preterm and term newborn (more than 34 weeks) if ventilation via the face mask is unsuccessful.”
Oxygen saturation is supposed to be low in the newborn period. It doesn’t make sense to me to memorize the numbers. I make the resuscitation decisions based on the classic algorithm of heart rate, respiratory effort, color, and tone. Then, when things start to settle down a little bit, I will pull out my phone to look at the table (in the algorithm above).Remember to put the oxygen sat probe in a pre-ductal location.
I am also not big on memorizing equipment sizes. I start at the smallest (3kg) end of the Broselow tape (or electronic version) and adjust from there. But a few for reference:
- ETT = 4.0 uncuffed for term babies, progressively smaller from there
- ETT depth = 3x tube size, or weight in kg + 6cm
- LMA = size 1 up to 5kg
- Laryngoscope = size 1 for term, 0 for PREEM (there is a 00 for extreme PREEM)
Other FOAMed Resources
Perlman JM, Wyllie J, Kattwinkel J. Part 7: Neonatal Resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 132(16 Suppl 1):S204-41. 2015. PMID: 26472855 [free full text]
Wyllie J, Perlman JM, Kattwinkel J. Part 7: Neonatal resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation. 95:e169-201. 2015. PMID: 26477424 [free full text]
Kattwinkel et al. Neonatal Resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics: 126 (5); pp. e1400-e1413.
Collin MF. Chapter 14. Resuscitation of Neonates. In: Tintinalli JE et al. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e. New York: McGraw-Hill; 2011. http://accessmedicine.mhmedical.com/content.aspx?bookid=348&Sectionid=40381474
Cantor RM and Rothrock SG. Neonatal Resuscitation. In: Baren JM et al. eds. Pediatric Emergency Medicine. Philadelphia: Elsevier; 2008.
Morgenstern, J. Neonatal (Newborn) Resuscitation 2015 update, First10EM, November 2, 2015. Available at: