Summary
Highlights
Inaccurate heart rate assessment can lead to unnecessary cardiac compressions; hence, a cardiac monitor is the preferred method for assessing heart rate when available. Chest compressions should be initiated if the infant's heart rate remains below 60 beats per minute after 30 seconds of effective positive pressure ventilation and corrective steps. Ensure adequate chest movement with ventilation before starting compressions. Upon initiation, increase supplemental oxygen to 100% and establish intravenous access via umbilical vein catheterization.
Two people are required to administer chest compressions: one for compressions and one for ventilation. These actions must be coordinated, with one ventilation interposed between every three compressions, aiming for 30 breaths and 90 compressions per minute. The two-thumb technique is preferred over the two-finger technique for delivering chest compressions, positioning the thumbs below the nipple line but above the xiphoid in the lower third of the sternum. Ensure compressions are delivered in the center of the sternum and depress the sternum by one-third of its anteroposterior diameter.
When chest compressions begin, increase the FiO2 to 100% to maximize oxygen uptake. After approximately 60 seconds of coordinated compressions and ventilation, pause for 6 seconds to reassess the heart rate. If the heart rate is above 60 beats per minute, discontinue chest compressions but continue positive pressure ventilation. If above 100 bpm and the newborn breathes spontaneously, slowly withdraw both.
If the heart rate remains below 60 beats per minute after 60 seconds of effective ventilation and chest compressions, administer epinephrine and establish emergency vascular access. Epinephrine is a cardiac and vascular stimulant indicated only when the heart rate remains below 60 bpm after adequate ventilation and at least 60 seconds of coordinated compressions. The intravenous route is preferred for epinephrine administration, with a recommended dose of 0.2 ml per kg of the 1:10,000 solution, followed by a 3 ml saline flush.
To insert an emergency umbilical venous catheter, flush the catheter with normal saline and wear sterile gloves. Wipe the cord base with antiseptic, place an umbilical tie, and incise the cord with a scalpel blade. Identify the large, thin-walled umbilical vein (usually at 11 or 12 o'clock) and insert the catheter 2-4 cm until blood can be aspirated. Secure the catheter to ensure emergent access for medication administration.
After epinephrine, the heart rate should increase to over 60 bpm within 30 seconds. If not, repeat the dose every 3-5 minutes intravenously. If poor response persists, recheck the effectiveness of ventilation, compressions, intubation, and epinephrine delivery. Consider hypovolemia if there's a history of blood loss and the newborn shows signs of shock despite other interventions. An isotonic crystalloid solution (10 ml per kg via umbilical vein catheter) is recommended for hypovolemia, to be infused over 5-10 minutes.
If effective ventilation, chest compressions, and medications are provided but there's no response, consider mechanical causes like airway malformation or pneumothorax. If there's no heart rate after 20 minutes of complete and adequate resuscitation efforts and no other causes for compromise, discontinuing resuscitation may be appropriate. The decision to stop must be individualized and involve the family, considering the baby's best interests.