Although most neonates will not require resuscitation, emergency clinicians must be prepared to manage neonates who require respiratory assistance. This issue reviews current expert recommendations and consensus updates of the best practices in resuscitation of neonates. An overview of neonatal physiology provides a framework for understanding how neonatal resuscitation differs from that of children and adults. A step-wise, systematic approach is provided for identifying and managing newborns who require resuscitation. The treatment, management, and over-arching goals for neonatal resuscitation and newborn care are also reviewed.
A 30-year-old healthy pregnant woman at 40 weeks' gestation presents to your community ED in labor. An infant is visibly crowning, and there is no obstetrician on site. As a medical team prepares to assist this precipitous delivery, what equipment should be prepared for the care of the neonate? What criteria would determine whether the infant can receive routine care?
Paramedics bring in an 18-year-old woman. She is complaining of abdominal pain for 1 day and fluid leaking from her vagina. She states that she is pregnant. She thinks her due date is in 2 weeks but says her prenatal care has been poor. The team delivers a baby girl stained with meconium fluid. The infant is limp and not crying. What are the priorities in assisting this baby? What equipment should be prepared if the mother's estimate is wrong and the baby is premature?
EMS is bringing in a woman who is at 37 weeks' gestation. She was in a motor vehicle crash and sustained significant blunt abdominal trauma and blood loss. While resuscitating her in the ED, her vital signs become unstable, and the obstetrician performs a perimortem caesarean delivery. What equipment should be available for the baby in anticipation of trauma and blood loss? The baby has a low heart rate and poor oxygenation despite initial steps for newborn care. What are the next resuscitation steps?
Neonatal resuscitation is an infrequent—though high-risk—event in the emergency department (ED) that may be required when a precipitous delivery occurs during prehospital transport or in the ED.1–3 A 2009 joint policy statement by the American Academy of Pediatrics, American College of Emergency Physicians, and Emergency Nurses Association recommended that all hospital EDs should be prepared to care for children of all ages, including neonates.4
Only 10% of full-term infants will require assistance with breathing after birth, and 0.1% will require extensive resuscitation.5,6 A 2000 survey by the Society for Academic Emergency Medicine (SAEM) suggested that ED physicians need more exposure to neonatal resuscitation.7 Unfortunately, knowledge and skill retention tend to decline over time.
This issue of Pediatric Emergency Medicine Practice reviews the recent changes in neonatal resuscitation and management in the ED.
A literature search was performed in PubMed using the search terms neonatal resuscitation program, neonatal resuscitation in the emergency department, and precipitous delivery in the emergency department. A total of 50 articles were reviewed from 1989 to the present. The Textbook of Neonatal Resuscitation, 7th edition is a nationally recognized textbook and was used as a reference.5 The 2019 Neonatal Life Support Task Force of the International Liaison Committee on Resuscitation (ILCOR) Draft Consensus on Initial Oxygen Concentration for Term Neonatal Resuscitation was also reviewed.8 The American Heart Association based its updated 2019 recommendations on expert consensus and national guidelines for neonatal resuscitation; these recommendations were graded and based on multiple robust randomized controlled and systematic studies, in addition to expert review.9
2. “The preterm baby was born with respiratory distress, so I initiated oxygen at 100%.”
Avoid initiating high FiO2 > 65% while initially resuscitating preterm infants. Newborns, especially those who are preterm, are at risk for oxidative damage from oxygen, including intraven-tricular hemorrhage, retinopathy of prematurity, and necrotizing enterocolitis. Resuscitation of the preterm (and full-term) infant should always start at 21% to 30% FiO2, increasing only if the newborn is not responsive to the initial FiO2. The FiO2 should be weaned down whenever possible.
4. “I started CPAP on the full-term baby because his saturation was at 65% when he was just born.”
A newborn will not be saturating > 95% until at least 10 minutes of life. At 1 minute of life, a newborn will be expected to saturate between only 60% and 65%.
8. “I was really having a hard time intubating the newborn with some facial anomalies, and her saturations were dropping.”
Do not forget alternative rescue airways (eg, laryngeal mask, bag-valve mask) if endotracheal intubation is difficult. Until a definitive airway is established, alternative rescue airways can be an effective method for ventilation.
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. The most informative references cited in this paper, as determined by the authors, are highlighted.
Andrea T. Vo, MD; Christine S. Cho, MD, MPH, MEd, FAAP
Lizveth Fierro, MD; Deborah A. Levine, MD
December 2, 2020
January 2, 2024
4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits.
Date of Original Release: December 1, 2020. Date of most recent review: November 15, 2020. Termination date: December 1, 2023.
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Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents.
Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most critical ED presentations; and (3) describe the most common medicolegal pitfalls for each topic covered.
Discussion of Investigational Information: As part of the journal, faculty may be presenting investigational information about pharmaceutical products that is outside Food and Drug Administration approved labeling. Information presented as part of this activity is intended solely as continuing medical education and is not intended to promote off-label use of any pharmaceutical product.
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