What is the recommended protocol for cardiopulmonary resuscitation (CPR) in a newborn, including assessment, ventilation, chest compressions, epinephrine administration, and defibrillation?

CPR in Newborn

Follow the 2025 AHA/AAP neonatal resuscitation algorithm with emphasis on effective ventilation as the single most critical intervention, using a 3:1 compression-to-ventilation ratio, and administer epinephrine at 0.01-0.03 mg/kg IV/IO every 3-5 minutes if heart rate remains below 60 bpm despite adequate ventilation and compressions. 1

Initial Assessment and Stabilization

Verify scene safety first. Simultaneously assess for breathing (or only gasping) and check pulse within 10 seconds. 2

Temperature Management

• Maintain normothermia immediately—this is critical for survival
• For preterm infants: cover with food-grade plastic wrap to prevent heat loss
• Avoid hyperthermia, which worsens outcomes 3

Airway and Ventilation Protocol

If no breathing or only gasping with heart rate <100 bpm:

1. Open airway using head tilt-chin lift (unless cervical spine injury suspected) 2

2. Begin positive pressure ventilation (PPV):

   • Initial inflation pressure: 20 cm H₂O (may require 30-40 cm H₂O in some term infants without spontaneous ventilation) 3
   • Rate: 40-60 breaths per minute 3
   • Start with room air (21% oxygen) for term infants 3
   • For preterm infants: start with low oxygen concentration, then titrate using pulse oximetry 3
   • Use bag-mask ventilation, T-piece resuscitator, or flow-inflating bag 3

3. Confirm effective ventilation by observing chest rise and increasing heart rate—this is your primary indicator of success 3

Chest Compressions

Initiate compressions ONLY if heart rate remains <60 bpm after 30 seconds of adequate ventilation with supplementary oxygen. 4

Compression Technique

• Location: Lower third of sternum
• Depth: Approximately one-third of anterior-posterior chest diameter 3, 4
• Method: Two-thumb encircling hands technique (preferred)—generates higher coronary perfusion pressure than two-finger technique 3, 4
• Rate: 90 compressions + 30 breaths = 120 events per minute 3, 4
• Ratio: 3:1 compression-to-ventilation (neonatal-specific due to respiratory etiology of arrest) 3, 4

Critical Compression Details

• Allow complete chest recoil between compressions
• Thumbs should not leave the chest during relaxation 4
• Coordinate compressions and ventilations to avoid simultaneous delivery 4
• Increase oxygen to 100% when chest compressions are initiated 3
• Wean oxygen concentration once heart rate recovers to reduce hyperoxia complications 3

Advanced Airway Management

If bag-mask ventilation is ineffective:

1. Endotracheal intubation (preferred if provider is experienced)

   • Perform laryngoscopy during ongoing compressions
   • Interrupt compressions for maximum 10 seconds only to pass tube through vocal cords 2
   • Confirm placement with exhaled CO₂ detection—most reliable method 3
   • Use waveform capnography or capnometry to monitor tube position 2

2. Laryngeal mask airway (alternative for ≥34 weeks gestation, ≥2000g)

   • Acceptable when bag-mask fails or intubation unsuccessful 3, 5
   • Achieves similar ventilation efficacy as endotracheal tube 5
   • Faster placement time than intubation 5

With advanced airway in place:

• Provide continuous compressions at 100-120/min
• Give 1 breath every 2-3 seconds (no longer cycling) 2

Epinephrine Administration

Administer if heart rate remains <60 bpm after minimum 30 seconds of adequate ventilation AND chest compressions. 3, 1

Dosing (Critical—Different Routes Have Different Doses)

Intravenous or Intraosseous (PREFERRED):

• Dose: 0.01-0.03 mg/kg (0.1-0.3 mL/kg of 1:10,000 concentration)
• Maximum single dose: 1 mg
• Repeat every 3-5 minutes 3, 1

Endotracheal (Only While Establishing Vascular Access):

• Dose: 0.05-0.1 mg/kg (0.1 mL/kg of 1:1,000 concentration)—higher dose required for adequate plasma levels 1
• Peak plasma concentrations delayed until 5 minutes (versus 1 minute for IV) 1
• Most infants require subsequent IV doses for ROSC 1

Vascular Access Priority

1. Umbilical venous catheter (first choice)
2. Intraosseous (effective alternative, achieves similar plasma levels) 1
3. Endotracheal (temporary bridge only)

Volume Resuscitation

Consider when blood loss is known/suspected (pale skin, weak pulses, persistent bradycardia) AND infant responds poorly to standard resuscitation. 3, 1

• Fluid of choice: Normal saline (0.9% NaCl) 1
• Dose: 10 mL/kg IV/IO (may need to repeat) 3
• For substantial blood loss: O-negative uncrossmatched blood preferred 1
• Caution in preterm infants: Avoid rapid large-volume infusions—associated with intraventricular hemorrhage 3

Defibrillation (Rare in Neonates)

If shockable rhythm (VF/pulseless VT) identified:

• Give 1 shock: 4 J/kg (monophasic or biphasic) 6
• Resume CPR immediately for 2 minutes before rhythm check 2
• If refractory VF/pulseless VT after 3 shocks:
  • Amiodarone: 5 mg/kg IV/IO bolus (may repeat up to 3 total doses) 2
  • Alternative: Lidocaine 1 mg/kg IV/IO 2

Reassessment and Monitoring

• Check heart rate response every 2 minutes during rescue breathing 2
• If heart rate <60 bpm with signs of poor perfusion despite rescue breathing: start CPR 2
• Continue coordinated compressions and ventilations until spontaneous heart rate ≥60 bpm 3
• Change compressor every 2 minutes or sooner if fatigued 2

Common Pitfalls to Avoid

1. Starting compressions before ensuring adequate ventilation—ventilation is THE key intervention in neonatal arrest 4
2. Using wrong epinephrine dose/concentration for route—endotracheal requires 10x higher dose than IV 1
3. Interrupting compressions excessively—minimize interruptions, maximum 10 seconds for intubation 2
4. Forgetting to increase oxygen to 100% when starting compressions 3
5. Rapid volume infusion in preterm infants—increases IVH risk 3
6. Inadequate compression depth—must be one-third of chest diameter 3
7. Using incorrect compression-to-ventilation ratio—neonates require 3:1, not 15:2 or 30:2 3, 4

Post-Resuscitation Care

Once ROSC achieved:

• Wean supplementary oxygen to avoid hyperoxia 3
• Assess for hypoxic-ischemic encephalopathy
• Consider therapeutic hypothermia (32-34°C for 12-24 hours) for term infants ≥36 weeks with evolving moderate-to-severe encephalopathy 3
• Maintain normothermia otherwise
• Monitor for complications: pneumothorax, ongoing shock

When to Consider Discontinuing Resuscitation

After 10 minutes of continuous, adequate resuscitative efforts with no signs of life (no heartbeat, no respiratory effort), discontinuation may be justified—associated with high mortality or severe neurodevelopmental disability 3, 7