Neonatal Resuscitation in the Emergency Department

Neonatal Resuscitation in the Emergency Department

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Table of Contents
About This Issue

Neonatal resuscitation is a high-risk event that may be required when a precipitous delivery occurs during prehospital transport or in the emergency department. Although neonatal resuscitation is not frequently needed, 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. It also provides a step-wise, systematic approach to identify and manage newborns who require resuscitation. You will learn:

Physiologic changes that occur during the transition from uterine to extrauterine life

How normal neonatal oxygen saturation levels increase over the first 10 minutes of life

Abnormalities that may cause neonates to need resuscitation

Goals for prehospital care and transport of newborns

Options for vascular access (including intraosseous access and umbilical venous catheter) when peripheral intravenous access cannot be obtained

Recommendations for equipment that should be prepared in anticipation of a precipitous delivery and neonatal resuscitation

How to perform a rapid assessment to determine when the newborn can stay with the mother and receive standard care and when further interventions are needed

Initial interventions for neonates who do not pass the rapid assessment

Recommendations for providing supplemental oxygen, as well as techniques for ventilation correction

How to determine when chest compressions are indicated, as well as recommendations for the proper techniques for performing chest compressions on a neonate

When epinephrine should be administered and various routes for administration

When volume expanders are indicated

Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Etiology and Pathophysiology
  6. Differential Diagnosis
  7. Prehospital Care
  8. Emergency Department Management
    1. Rapid Assessment
    2. Initial Interventions
    3. Supplementary Oxygen
    4. Ventilation
    5. Chest Compressions
    6. Vascular Access
    7. Epinephrine Administration
    8. Volume Expansion
    9. Glucose Administration
    10. Postresuscitation Care and Debriefing
  9. Diagnostic Studies
  10. Special Considerations
  11. Controversies and Cutting Edge
    1. Intubation for Meconium Suctioning
    2. Endotracheal Administration of Epinephrine
    3. Time of Cord Clamping
    4. Supplemental Oxygen
  12. Disposition
  13. Summary
  14. Key Points
  15. Time- and Cost-Effective Strategies
  16. Risk Management Pitfalls in Neonatal Resuscitation in the Emergency Depart
  17. Case Conclusions
  18. Clinical Pathway for Neonatal Resuscitation in the Emergency Department
  19. Tables and Figures
    1. Table 1. Abnormalities and Management Considerations in Neonatal Resuscitation
    2. Table 2. Neonatal Resuscitation Equipment
    3. Figure 1. Fetal Circulation Path and Transitional Circulation Path
    4. Figure 2. Intraosseous Access Via the Tibia
    5. Figure 3. Umbilical Vein Catheterization
    6. Figure 4. Use of a Plastic Bag to Reduce Heat Loss
  20. References


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.

Case Presentations

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.

Critical Appraisal of the Literature

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

Risk Management Pitfalls in Neonatal Resuscitation in the Emergency Department

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.

Tables and Figures

Table 1. Abnormalities and Management Considerations in Neonatal Resuscitation


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.

  1. Del Portal DA, Horn AE, Vilke GM, et al. Emergency department management of shoulder dystocia. J Emerg Med. 2014;46(3):378-382. (Review article)
  2. Brunette DD, Sterner SP. Prehospital and emergency department delivery: a review of eight years experience. Ann Emerg Med. 1989;18(10):1116-1118. (Single-center retrospective review; 80 patients)
  3. Mercado J, Brea I, Mendez B, et al. Critical obstetric and gynecologic procedures in the emergency department. Emerg Med Clin North Am. 2013;31(1):207-236. (Review article)
  4. Joint policy statement--guidelines for care of children in the emergency department. Pediatrics. 2009;124(4):1233-1243. (Joint policy statement) DOI: 10.1542/peds.2009-1807
  5. American Academy of Pediatrics, American Heart Association. Textbook of Neonatal Resuscitation. 7th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2016. (Textbook) 
  6. Wyckoff MH, Aziz K, Escobedo MB, et al. Part 13: Neonatal resuscitation: 2015 American Heart Association Guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132(18 Suppl 2):S543-S560. (Guideline) DOI: 10.1161/cir.0000000000000267
  7. Tamariz VP, Fuchs S, Baren JM, et al. Pediatric emergency medicine education in emergency medicine training programs. SAEM Pediatric Education Training Task Force. Society for Academic Emergency Medicine. Acad Emerg Med. 2000;7(7):774-778. (Prospective multicenter survey; 111 participants)
  8. International Liaison Committee on Resuscitation. Initial oxygen concentration for term neonatal resuscitation. 2019; Accessed November 15, 2020. (Consensus statement)
  9. Escobedo MB, Aziz K, Kapadia VS, et al. 2019 American Heart Association focused update on neonatal resuscitation: an update to the American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2019;140(4):e922-e930. (Guideline) DOI: 10.1161/CIR.0000000000000729
  10. Collin MF. Resuscitation of neonates. In: Tintinalli JE, ed. Tintanalli’s Emergency Medicine. 8th ed: McGraw-Hill Education; 2016:689–695. (Book chapter)
  11. Quinones C, Bubolz B. Congenital heart disease. In: Shaw KN, Bachur R, ed. Fleisher and Ludwig’s Textbook of Pediatric Emergency Medicine. 7th ed: Wolters Kluwer; 2016:628-638. (Book chapter)
  12. Stephenson CD, Lockwood CL, MacKensie AP. Gastroschisis. UptoDate. 2019. Accessed November 15, 2020. (Review article)
  13. Stephenson CD, Lockwood CL, MacKensie AP. Omphalocele. UptoDate. 2018. Accessed November 15, 2020. (Review article)
  14. Thompson-Branch A, Havranek T. Neonatal hypoglycemia. Pediatr Rev. 2017;38(4):147-157. (Review article)
  15. Vohra S, Frent G, Campbell V, et al. Effect of polyethylene occlusive skin wrapping on heat loss in very low birth weight infants at delivery: a randomized trial. J Pediatr. 1999;134(5):547-551. (Prospective randomized single-center clinical trial; 62 patients)
  16. Wagner M, Olischar M, O'Reilly M, et al. Review of routes to administer medication during prolonged neonatal resuscitation. Pediatr Crit Care Med. 2018;19(4):332-338. (Review article)
  17. Kc A, Rana N, Malqvist M, et al. Effects of delayed umbilical cord clamping vs early clamping on anemia in infants at 8 and 12 months: a randomized clinical trial. JAMA Pediatr. 2017;171(3):264-270. (Randomized clinical trial; 540 late preterm and full-term infants)
  18. Kapadia VS, Chalak LF, Sparks JE, et al. Resuscitation of preterm neonates with limited versus high oxygen strategy. Pediatrics. 2013;132(6):e1488-e1496. (Prospective randomized single-center clinical trial; 88 patients) DOI: 10.1542/peds.2013-0978
  19. Vento M, Moro M, Escrig R, et al. Preterm resuscitation with low oxygen causes less oxidative stress, inflammation, and chronic lung disease. Pediatrics. 2009;124(3):e439-e449. (Prospective randomized single-center clinical trial; 540 patients) DOI: 10.1542/peds.2009-0434
  20. Kapadia VS, Lal CV, Kakkilaya V, et al. Impact of the neonatal resuscitation program-recommended low oxygen strategy on outcomes of infants born preterm. J Pediatr. 2017;191:35-41. (Retrospective single-center observational studies; 189 patients) DOI: 10.1016/j.jpeds.2017.08.074
  21. Flynn JT, Bancalari E, Snyder ES, et al. A cohort study of transcutaneous oxygen tension and the incidence and severity of retinopathy of prematurity. N Engl J Med. 1992;326(16):1050-1054. (Prospective cohort single-center study; 101 patients)
  22. Vento M, Asensi M, Sastre J, et al. Oxidative stress in asphyxiated term infants resuscitated with 100% oxygen. J Pediatr. 2003;142(3):240-246. (Prospective randomized multicenter clinical trial; 78 patients)
  23. O'Donovan DJ, Fernandes CJ. Free radicals and diseases in premature infants. Antioxid Redox Signal. 2004;6(1):169-176. (Review article)
Publication Information

Andrea T. Vo, MD; Christine S. Cho, MD, MPH, MEd, FAAP

Peer Reviewed By

Lizveth Fierro, MD; Deborah A. Levine, MD

Publication Date

December 1, 2020

CME Expiration Date

December 1, 2023    CME Information

CME Credits

4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits.

Pub Med ID: 33211444

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