Following 30 seconds of ventilations and chest compressions, reassess the heart rate. If it is now greater than 60, discontinue compressions and continue with ventilations, reassessing pulse every 30 seconds thereafter and continuing with post-resuscitation care as required and described above. If the newborn's heart rate remains under 60 beats per minute, endotracheal (ET) intubation, vascular access, epinephrine and volume replacement must be considered.
ET intubation is an infrequently performed intervention by EMS providers on a newborn; however, the rare possibility of ET intubation being required in the prehospital environment still exists. Three indicators for intubation are: initial suctioning of the meconium-stained newborn if it is non-vigorous; if bag-valve mask ventilation is ineffective or prolonged; and when chest compressions are performed. ET intubation also allows a route for administration of epinephrine when vascular access is unavailable or being attempted.7 Tube size is best selected by referring to neonatal resuscitation reference cards, but typically, preterm newborns will require smaller ET tubes than full-term. Having a selection of ET tubes sized down to 2.5 mm will address all possible resuscitation scenarios. An emerging alternative to ET intubation is the laryngeal mask airway (LMA) and other supraglottic airways, which EMS services are beginning to use as a secondary and, in some cases, a primary airway for adult patients,8 and it is being explored for the pediatric population.9 It has been demonstrated to be effective in ventilating newborns when caregivers are unable to intubate them,10 but its use during chest compressions and for administration of medications has not been researched.2
Medications and fluid administration are rarely needed in newborn resuscitations outside of the delivery room. Umbilical vein catherization (UVC) is commonly used in initial resuscitation in the hospital setting, but is seldom used in the prehospital environment. EMS providers are more familiar with intraosseous (IO) insertion, commonly used on both adult and pediatric patients, and are able to achieve it more rapidly than a UVC line, making it the route of choice for vascular access in the newborn requiring resuscitation in the prehospital environment.11-13
Typically, epinephrine is not needed in resuscitation of the newborn, since most bradycardia and cardiac arrests are due to hypoxia and not a cardiac cause.6 If epinephrine is required, IV or IO is the route of choice, with the recommended IV/IO dose of 0.01 to 0.03 mg/kg 1:10,000. Higher doses have been shown to negatively impact cardiac function when administered IV/IO. If there is a delay or vascular access is not obtainable, epinephrine may be administered through an ET tube, with suggested doses in the range of 0.05 to 0.1 mg/kg 1:10,000, but its safety and effectiveness at those doses has not been evaluated.2,14
Volume expanders should be considered when blood loss is evident or there are signs of hypovolemia or suspected hypovolemia, which include weak pulses greater than 100, persistent paleness despite adequate oxygenation, or the newborn responding poorly or not at all to resuscitative efforts.2,4 The prehospital solution of choice is an isotonic solution like normal saline (NS) or lactated Ringer's (LR), with an initial dose of 10 ml/kg over 5 to 10 minutes, repeated if needed. If administering fluids through an IO line, the line should be manually held or firmly secured so it does not inadvertently become dislodged. Remember, these fluids are being administered under pressure into a small marrow cavity. Unlike an adult IO, only a small portion of the needle may be in the bone and marrow cavity.
Meconium-Stained Amniotic Fluid