Immediate CPR Without Delay
In the absence of a completed DNR discussion and formal DNR order, you must initiate CPR immediately for this neonate in cardiac arrest. 1, 2, 3
Clinical Reasoning
The 2020 American Heart Association guidelines are unequivocal: when a pediatric patient (including neonates) presents with cardiac arrest—indicated by "coded blue" (no breathing or only gasping, and no pulse)—CPR must be started immediately without delay. 1 The algorithm does not include a step to pause for discussion of resuscitation preferences during an active arrest. 2, 3
Key Principles
The incomplete DNR discussion has no legal or clinical standing. 4, 5
- A DNR order must be formally documented to be valid—discussions alone do not constitute an order. 4, 6
- Without a completed DNR order in place, the default is full resuscitation. 6
- The standard of care assumes CPR will be attempted unless there is explicit documentation otherwise. 6
Time-critical nature of neonatal cardiac arrest:
- The American Heart Association emphasizes minimizing any interruptions or delays in starting chest compressions, as continuous compressions are essential for survival. 2, 7
- Delaying CPR for any reason when a pediatric patient is in cardiac arrest worsens outcomes. 3
- The pediatric BLS algorithm requires immediate action: verify scene safety, check responsiveness, and if no breathing/pulse, start CPR immediately. 1
Proper Execution
Immediate CPR technique for neonates:
- Begin chest compressions at a depth of at least one-third of the anterior-posterior diameter of the chest at 100-120 compressions per minute. 1, 3
- Use a compression-to-ventilation ratio of 30:2 for single rescuer, or 15:2 when a second rescuer arrives. 1, 3
- Allow complete chest recoil between compressions. 1, 2
- Activate the emergency response system and retrieve emergency equipment/AED. 1
Concurrent actions during resuscitation:
- The DNR discussion can be completed with parents while CPR is ongoing or after stabilization. 8, 9
- If parents ultimately decide on DNR after discussion, the order can be written at that time and resuscitation efforts can be stopped. 8, 9
Critical Pitfalls to Avoid
- Never delay CPR to obtain consent or complete advance directive discussions during an active arrest. 2, 6 The emergency nature of cardiac arrest overrides the usual informed consent process. 6
- Do not assume an incomplete discussion equals a DNR order. 4, 5 Only formal, documented DNR orders are valid. 6
- Avoid inadequate compression depth or rate—compressions must be hard and fast to be effective. 2, 7
The correct answer is D) Do CPR immediately, as this aligns with standard resuscitation protocols and the legal requirement for a formal DNR order before withholding life-saving interventions. 1, 2, 3