II. Protocol

  1. Measure Heart Rate with palpation of Umbilicus or on chest auscultation
  2. Heart Rate over 100/min
    1. Proceed to Neonatal Perfusion Assessment
  3. Heart Rate under 100/min
    1. Positive Pressure Ventilation
      1. See Neonatal Breathing Assessment
      2. Continue Positive Pressure Ventilation until Heart Rate >100/min and adequate spontaneous respirations
      3. Re-evaluate Heart Rate every 30 seconds
    2. Heart Rate under 60/min after 30 seconds of PPV
      1. Positive Pressure Ventilation with 100% Oxygen
      2. Perform Chest Compressions
        1. Depress chest one third of AP chest diameter
      3. CPR Sequence
        1. Count: One and Two and Three and Breath
        2. Compression to breath ratio of 3:1 (unless cardiac etiology is suspected and then change to 15:2 compressions to breaths)
          1. Compress at rate of >90 beats per minute
          2. Breath at rate of 30 breaths per minute
      4. Available staff should work toward Intravenous Access
        1. Umbilical Vein Catheter or
        2. Peripheral IV
      5. Reassess 45-60 seconds after starting compressions
        1. Epinephrine for persistent Heart Rate <60/min after 60 seconds of compressions (and 90 seconds of PPV)
      6. Additional measures for prolonged Resuscitation beyond 2-3 minutes
        1. Consider Orogastric Tube to decompress Stomach
        2. Consider Endotracheal Intubation
    3. Heart Rate under 100/min after 30 seconds of PPV
      1. Continue Positive Pressure Ventilation until Heart Rate >100/min and adequate spontaneous respirations
    4. Heart Rate over 100/min
      1. Go back to Neonatal Breathing Assessment

III. Management: Epinephrine

  1. Indication
    1. Persistent Heart Rate <60/min after 60 seconds of compressions (and 90 seconds of PPV)
  2. Dosing (use of 1:10,000 Epinephrine)
    1. May repeat every 3-5 minutes for Heart Rate <60/min
    2. IV or Umbilical Venous Catheter (UVC) - preferred routes
      1. Dose: 0.01 to 0.03 mg/kg (0.1 to 0.3 ml/kg) of 1:10,000 Epinephrine
      2. Consider intrasseous line if unable to obtain UVC or IV Line
    3. Endotracheal Tube
      1. Dose: 0.10 mg/kg (1 ml/kg) of 1:10,000 Epinephrine

IV. Management: Pediatric Fluid Resuscitation

  1. Indication
    1. Suspected blood loss
  2. Crystalloid (NS or LR) 10 ml/kg over 5-10 minutes
    1. Umbilical Vein Catheter is most common site for delivery
    2. May repeat for a second dose
  3. Other fluids for Resuscitation
    1. Packed Red Blood Cells
    2. Colloid Solution

V. References

  1. Bhalla (2014) Crit Dec Emerg Med 28(1): 2-11
  2. Kattwinkel (2000) Neonatal Resuscitation, AAP-AHA
  3. Kattwinkel (2010) Neonatal Resuscitation, AAP-AHA
  4. Raghuveer (2011) Am Fam Physician 83(8): 911-8 [PubMed]

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