What are the steps in neonatal resuscitation, including troubleshooting for each step, in a newborn with potential respiratory distress and bradycardia (heart rate less than 60 beats per minute)?

Neonatal Resuscitation: Step-by-Step Protocol with Troubleshooting

Initial Assessment (First 10-15 Seconds)

Immediately assess three critical characteristics: term gestation, good muscle tone, and breathing or crying—if all three are present, the infant stays with mother for routine care; if any are absent, begin resuscitation under a radiant warmer. 1

The "Golden Minute" Initial Steps

• Provide warmth by placing infant under radiant heat source (preterm infants <32 weeks require plastic wrapping up to neck level and room temperature >25°C to maintain 36.5-37.5°C) 2, 3
• Position the head in "sniffing" position to open airway 2, 3
• Clear secretions only if copious and obstructing airway—avoid routine nasopharyngeal suctioning as it causes bradycardia 4, 3
• Dry thoroughly and remove wet linen 2
• Stimulate breathing through drying and gentle tactile stimulation 2

Troubleshooting Initial Steps:

• If infant remains apneic or gasping after stimulation, immediately proceed to PPV—do not waste time with repeated stimulation 1
• If meconium-stained fluid is present, do NOT perform routine endotracheal suctioning even in non-vigorous infants; proceed directly to initial steps and PPV if needed 4, 1

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Step 1: Assess Heart Rate and Respirations (at 30 seconds)

Heart rate is the primary vital sign determining need for intervention—use auscultation of precordium or 3-lead ECG for rapid assessment, not umbilical pulse palpation which underestimates rate. 4, 1

Decision Points:

• HR >100 bpm AND breathing well: Continue observation with pulse oximetry monitoring 4
• HR <100 bpm OR gasping OR apnea: Immediately initiate PPV 4, 1
• Labored breathing or persistent cyanosis: Consider CPAP 4

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Step 2: Positive Pressure Ventilation (PPV)

Begin PPV immediately with room air (21% oxygen) for term infants using 40-60 breaths/minute at initial pressure of 20 cm H₂O—the primary indicator of effective ventilation is rising heart rate, not chest rise. 4, 1

PPV Technique:

• Use face mask with flow-inflating bag, self-inflating bag, or T-piece resuscitator 1
• Apply 5 cm H₂O PEEP 1
• Initial pressure 20 cm H₂O (may need 30-40 cm H₂O in some term infants) 4
• Attach pulse oximetry to right hand/wrist (preductal) with targets: 60-65% at 1 minute, 85-95% by 10 minutes 1

Troubleshooting PPV—The MR SOPA Algorithm:

If heart rate does not improve after 30 seconds of PPV, systematically apply corrective steps before escalating to chest compressions: 1

• Mask adjustment: Reapply mask to ensure good seal 1
• Reposition airway: Return to sniffing position 1
• Suction mouth and nose if secretions present 1
• Open mouth: Use jaw thrust 1
• Pressure increase: Gradually increase to 30-40 cm H₂O while monitoring chest rise 4, 1
• Alternative airway: Consider endotracheal intubation or laryngeal mask (≥34 weeks or ≥2000g) if MR SOPA fails 1

Critical Pitfall: Do not start chest compressions until you have achieved 30 seconds of effective ventilation with visible chest rise—the vast majority of bradycardic newborns respond to effective ventilation alone 1

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Step 3: Reassess After 30 Seconds of Adequate Ventilation

Decision Points:

• HR >100 bpm: Continue PPV until spontaneous respirations established 1
• HR 60-100 bpm: Continue effective PPV, ensure 100% oxygen, reassess every 30 seconds 1
• HR <60 bpm despite adequate ventilation: Proceed to chest compressions 4

Troubleshooting Persistent Bradycardia:

• Verify chest rise with each breath—if absent, return to MR SOPA algorithm 1
• Ensure 100% oxygen is being delivered 4
• Consider endotracheal intubation for more effective ventilation 4
• Use exhaled CO₂ detection to confirm endotracheal tube placement 1

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Step 4: Chest Compressions (if HR <60 after 30 seconds adequate ventilation)

Use the two-thumb encircling hands technique with compressions on lower third of sternum to depth of one-third anterior-posterior diameter, coordinated with ventilation at 3:1 ratio (90 compressions:30 breaths = 120 events/minute). 4

Chest Compression Technique:

• Two-thumb encircling hands method is superior to two-finger technique (generates higher coronary perfusion pressure) 4
• Compress lower third of sternum 4
• Depth: approximately one-third of anterior-posterior chest diameter 4
• Allow full chest recoil but thumbs remain on chest 4
• 3:1 compression:ventilation ratio with exhalation during first compression after each breath 4
• Each event takes approximately ½ second 4

Troubleshooting Chest Compressions:

• If umbilical access needed, two-finger technique may be used OR rescuer can stand at head for two-thumb technique in intubated infants 4
• Ensure ventilation is adequate BEFORE starting compressions—ineffective ventilation is the most common reason for failed resuscitation 4
• Consider 15:2 ratio only if arrest is of primary cardiac origin (extremely rare in neonates) 4

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Step 5: Reassess After 60 Seconds of Compressions + Ventilation

Decision Points:

• HR >60 bpm: Discontinue compressions, continue PPV until HR >100 and spontaneous breathing 1
• HR <60 bpm: Administer epinephrine while continuing compressions and 100% oxygen ventilation 4

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Step 6: Medications (Rarely Needed)

Administer epinephrine 0.01-0.03 mg/kg IV (preferred route) if heart rate remains <60 bpm despite adequate ventilation with 100% oxygen and chest compressions—endotracheal route is less effective and requires higher doses (0.05-0.1 mg/kg). 4

Epinephrine Administration:

• IV route (umbilical venous catheter): 0.01-0.03 mg/kg of 1:10,000 solution 4
• Endotracheal route (while establishing IV access): 0.05-0.1 mg/kg of 1:10,000 solution (less effective, higher dose needed) 4
• Do NOT use doses >0.1 mg/kg IV due to risk of hypertension, decreased myocardial function, and worse neurological outcomes 4

Troubleshooting Medication Administration:

• Establish umbilical venous access as soon as decision is made to give epinephrine—do not delay with repeated endotracheal doses 4
• If no response after epinephrine, consider volume expansion with 10 mL/kg isotonic crystalloid for suspected hypovolemia 5
• Reassess every 30 seconds after medication administration 4

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Critical Pitfalls to Avoid Throughout Resuscitation

• Never delay ventilation to establish IV access or prepare for intubation 1
• Never start with 100% oxygen in term infants—begin with room air and titrate based on pulse oximetry 4, 1
• Never perform routine endotracheal suctioning for meconium-stained fluid 4, 1
• Never start chest compressions before achieving 30 seconds of effective ventilation with chest rise 1
• Avoid hypothermia (maintain 36.5-37.5°C) and hyperthermia (>38°C) 1, 3
• Never use bicarbonate in the delivery room—it is not recommended during acute resuscitation 4

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When to Consider Discontinuing Resuscitation

It is appropriate to consider discontinuing resuscitation if there has been no detectable heart rate for 10 minutes, though many factors contribute to decisions beyond 10 minutes. 4