Neonatal Resuscitation in the Emergency Department

Points & Pearls Excerpt

• Once the neonate is born, perform a rapid assessment (30 seconds or less) of the newborn for these 3 criteria: (1) whether the baby appears to be at full term; (2) has good tone; and (3) is breathing/crying. If all 3 of these criteria have been met, the baby can stay with the mother for routine care (eg, drying, warming, nasal suctioning as needed).
• By the first minute of life, the normal neonate’s oxygen saturation (SpO₂) is 60% to 65%, and it will increase steadily, by 10% approximately every 2 minutes. For example, by 3 minutes of life, a normal SpO₂ is 70% to 75%; by 5 minutes, 80% to 85%. Only after approximately 10 minutes of life will the full-term, healthy neonate exhibit an SpO₂ of 85% to 100%.
• If initiating positive pressure ventilation, ideal positive end-expiratory pressure is 5 cm H₂O and peak inspiratory pressure is 20 to 25 cm H₂O.
• When obtaining intraosseous access, placement should be 1 cm inferior to the patella and 1 cm medial to the tibial tuberosity (as opposed to 2 cm for older children and adults)
• When placing an umbilical venous catheter for resuscitation, it should be only deep enough for blood return.

Most Important References

• 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
• American Academy of Pediatrics, American Heart Association. Textbook of Neonatal Resuscitation. 7th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2016. (Textbook) 
• 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
• International Liaison Committee on Resuscitation. Initial oxygen concentration for term neonatal resuscitation. 2019; Accessed November 15, 2020. (Consensus statement)
• Collin MF. Resuscitation of neonates. In: Tintinalli JE, ed. Tintanalli’s Emergency Medicine. 8th ed: McGraw-Hill Education; 2016:689–695. (Book chapter)
• 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
• 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