What to do for a newborn with hypoxemia, bradycardia, and chest indrawing?

Immediate Neonatal Resuscitation for Hypoxemia and Bradycardia

This newborn requires immediate positive-pressure ventilation (PPV) as the first and most critical intervention—bradycardia in newborns is nearly always caused by inadequate lung inflation and hypoxemia, not primary cardiac pathology, and effective ventilation is the single most important step in neonatal resuscitation. 1, 2

Initial Stabilization Steps

Before initiating PPV, rapidly complete these essential steps:

• Position the infant under a radiant warmer in the "sniffing" position to open the airway 2
• Dry and stimulate the infant through drying and gentle tactile stimulation 2
• Clear visible secretions only if the airway appears obstructed—avoid routine suctioning as it worsens bradycardia 2, 3
• Apply pulse oximetry to the right hand (preductal) immediately for accurate oxygen monitoring 2
• Assess heart rate by auscultating the precordium or using 3-lead ECG, as heart rate is the primary vital sign guiding all resuscitation decisions 2

Positive-Pressure Ventilation Protocol

Begin PPV immediately with the following parameters:

• Start with room air (21% oxygen) for term infants or 21-30% oxygen for preterm infants (<35 weeks) 2
• Rate: 40-60 breaths per minute 2
• Initial pressure: 20 cm H₂O (may require 30-40 cm H₂O in some term infants) 2
• Apply PEEP of approximately 5 cm H₂O using appropriate equipment 2
• The primary indicator of effectiveness is rising heart rate, not chest rise 2
• Reassess heart rate after 30 seconds of adequate ventilation 2

Oxygen Titration Strategy

• Target preductal oxygen saturations: 60-65% at 1 minute, 70-80% at 5 minutes, 85-95% by 10 minutes 2
• Increase oxygen concentration only if heart rate fails to improve despite effective ventilation or saturations remain below target 2
• Never start with 100% oxygen—this increases mortality and provides no advantage 2

If Heart Rate Remains <60 bpm After 30 Seconds of Adequate Ventilation

Escalate to chest compressions only after confirming effective ventilation with visible chest rise and increasing oxygen to 100%—do not start compressions until ventilation is established 1, 2

Chest Compression Technique

• Use two-thumb, hands-encircling-the-chest method as the preferred technique 1
• Compression-to-ventilation ratio: 3:1 (90 compressions and 30 breaths to achieve approximately 120 events per minute) 1, 2
• Compress one-third of the anterior-posterior diameter of the chest 2
• Coordinate compressions with ventilation—exhalation occurs during the first compression after each ventilation 1
• Reassess heart rate every 60 seconds 2

Medication Administration (Rarely Needed)

Epinephrine is indicated only if heart rate remains <60 bpm despite adequate ventilation with 100% oxygen and chest compressions 1, 2

• Preferred route: Intravenous (umbilical venous catheter) 1, 2
• IV dose: 0.01-0.03 mg/kg per dose 1, 2
• Preparation: 1:10,000 concentration (0.1 mg/mL) 1
• Do not use higher IV doses (0.1 mg/kg)—these cause exaggerated hypertension, decreased myocardial function, and worse neurological outcomes 1
• Endotracheal epinephrine is not recommended as initial therapy—it is ineffective at currently recommended doses 1, 2

Critical Clinical Context

Understanding the Chest Indrawing

The chest indrawing in this newborn indicates increased work of breathing due to poor lung compliance, which is causing the hypoxemia and subsequent bradycardia 1, 4. In newborns, chest indrawing is highly associated with hypoxemia (sensitivity 83.6%) and represents significant respiratory distress requiring immediate intervention 4, 5.

Why This Heart Rate is Critical

A heart rate of 67 bpm in a newborn is below the critical threshold of <60 bpm with poor perfusion that defines impending cardiac arrest 2, 6. While technically above 60 bpm, combined with saturation of 80% and chest indrawing, this represents severe cardiorespiratory compromise requiring immediate PPV 1, 2.

Common Pitfalls to Avoid

• Do not delay ventilation to obtain vascular access or administer medications—effective ventilation corrects bradycardia in the vast majority of cases 1, 2
• Do not start with 100% oxygen—begin with room air or 21-30% oxygen and titrate based on response 2
• Do not begin chest compressions before establishing effective ventilation—this is ineffective and delays the most important intervention 1, 2
• Do not use endotracheal epinephrine as first-line—it is ineffective at recommended doses and delays IV access 1, 2

Post-Resuscitation Monitoring

Once heart rate normalizes:

• Transfer to an environment with close monitoring as infants requiring resuscitation are at risk for deterioration 2
• Initiate IV glucose infusion as soon as practical to avoid hypoglycemia 2
• Monitor for complications: persistent pulmonary hypertension, pneumothorax, congenital heart disease, sepsis 2, 7
• Assess therapeutic endpoints: capillary refill ≤2 seconds, warm extremities, normal pulses, urine output >1 mL/kg/hour 2