# Chest Compressions and Medications in Neonatal Resuscitation -- AHA/AAP 2020

## Chest Compressions

### Indications

Chest compressions should be initiated when the heart rate remains < 60 bpm after at least 30 seconds of effective PPV that produces visible chest rise (COR 1, LOE C-EO). Before starting compressions, confirm that ventilation is being delivered effectively (adequate chest rise, correct rate, appropriate pressures).

### Technique

- **Two-thumb encircling hands technique** is the preferred method (COR 2a, LOE C-LD). Place both thumbs side by side or overlapping on the lower third of the sternum, just below the inter-nipple line and above the xiphoid process. Encircle the torso with both hands to support the back.
- **Two-finger technique** (index and middle finger on the sternum with the other hand supporting the back) is an acceptable alternative when access to the umbilicus is needed for catheter insertion.

### Compression Parameters

| Parameter | Value |
|-----------|-------|
| **Compression depth** | Approximately one third of the anterior-posterior diameter of the chest |
| **Location** | Lower third of the sternum, above the xiphoid |
| **Compression-to-ventilation ratio** | 3:1 (3 compressions followed by 1 ventilation breath) |
| **Total events per minute** | 120 (90 compressions + 30 ventilations) |
| **Full chest recoil** | Allow complete chest recoil between compressions; do not lean on the chest |

### Coordination with Ventilation

- Deliver 3 compressions followed by 1 ventilation in a coordinated rhythm: "One-and-Two-and-Three-and-Breathe-and."
- Pause compressions briefly during the ventilation breath to allow effective lung inflation.
- The 3:1 ratio is preferred because neonatal cardiac arrest is almost always caused by respiratory failure (asphyxia), making effective ventilation the priority (COR 2b, LOE C-LD).

### FiO2 During Chest Compressions

When chest compressions are initiated, increase supplemental oxygen to 100% FiO2 (COR 2a, LOE C-EO). Once the heart rate recovers above 60 bpm and compressions are discontinued, wean FiO2 guided by pulse oximetry to targeted preductal SpO2 ranges.

### Reassessment

- Reassess the heart rate after 60 seconds of coordinated compressions and ventilation.
- **Heart rate >= 60 bpm:** Discontinue compressions. Continue PPV. Assess for spontaneous respirations.
- **Heart rate < 60 bpm:** Continue compressions and ventilation. Ensure adequate ventilation (consider intubation if not already done). Proceed to epinephrine administration.

## Vascular Access

### Umbilical Venous Catheter (UVC) -- Preferred

The umbilical vein is the preferred route for emergency vascular access during neonatal resuscitation (COR 2a, LOE C-LD).

- **Technique:** Insert a single-lumen catheter (3.5 Fr for preterm, 5 Fr for term) into the umbilical vein. Advance only 2-4 cm past the skin (until blood is freely aspirated) to avoid placement in the liver.
- **Confirmation:** Free aspiration of blood.

### Intraosseous (IO) Access -- Alternative

If umbilical venous access cannot be established rapidly, intraosseous access (proximal tibia) is a reasonable alternative (COR 2b, LOE C-LD). IO needles appropriate for neonatal use should be available.

## Epinephrine

### Indications

Epinephrine is indicated when the heart rate remains < 60 bpm despite at least 60 seconds of coordinated chest compressions with effective PPV (COR 2a, LOE C-LD).

### Dosing

| Route | Dose | Concentration | Volume |
|-------|------|---------------|--------|
| **IV (umbilical vein) -- Preferred** | 0.01-0.03 mg/kg | 1:10,000 (0.1 mg/mL) | 0.1-0.3 mL/kg |
| **Endotracheal (ET) -- If IV not available** | 0.05-0.1 mg/kg | 1:10,000 (0.1 mg/mL) | 0.5-1.0 mL/kg |

### Administration Protocol

1. **Preferred route is IV (umbilical vein).** IV epinephrine produces faster and more reliable increases in plasma epinephrine levels compared with endotracheal administration.
2. **If IV access is not yet available:** An endotracheal dose may be given while vascular access is being established. The ET dose is higher (0.05-0.1 mg/kg) because pulmonary absorption is less reliable.
3. **Flush:** Follow IV epinephrine with a normal saline flush of 0.5-1.0 mL to ensure delivery.
4. **Reassess:** Continue compressions and ventilation after epinephrine administration. Reassess heart rate after 1 minute.
5. **Repeat dosing:** If heart rate remains < 60 bpm, epinephrine may be repeated every 3-5 minutes. If the initial dose was given via ET, subsequent doses should be given IV once access is established.

### Important Notes

- Fewer than 1% of newborns requiring resuscitation will need epinephrine.
- Early umbilical venous catheterization should be considered when the need for epinephrine is anticipated, to avoid delays.
- Higher IV doses (> 0.03 mg/kg) are NOT recommended and may cause hypertension, tachycardia, and myocardial damage.

## Volume Expansion

### Indications

Volume expansion is indicated when blood loss is known or suspected (e.g., placental abruption, placenta previa, vasa previa, umbilical cord avulsion, feto-maternal hemorrhage) AND the newborn is not responding to resuscitation (COR 2b, LOE C-LD).

### Dosing

| Parameter | Value |
|-----------|-------|
| **Solution** | Normal saline (0.9% NaCl) or O-negative Rh-negative packed red blood cells (if blood loss is documented/suspected) |
| **Dose** | 10 mL/kg |
| **Route** | IV (umbilical vein) |
| **Rate** | Infuse over 5-10 minutes |
| **Repeat** | A second 10 mL/kg bolus may be given if there is inadequate response |

### Precautions

- Do not administer volume expansion routinely to all poorly responsive neonates -- limit to cases with evidence of hypovolemia.
- In preterm infants, rapid volume infusion (< 5 minutes) may contribute to intraventricular hemorrhage (IVH). Infuse slowly.
- Lactated Ringer solution is an acceptable alternative crystalloid.

## Naloxone

Naloxone is NOT recommended as part of initial resuscitation in the delivery room for newborns with respiratory depression. PPV should be the primary intervention for neonatal respiratory depression regardless of maternal opioid exposure.

## Sodium Bicarbonate

Routine use of sodium bicarbonate during neonatal resuscitation is NOT recommended due to lack of evidence of benefit and potential for harm (hyperosmolality, intracranial hemorrhage). Its use may be considered only for prolonged resuscitation unresponsive to other therapies, with adequate ventilation established.

## Limitations

- Evidence for epinephrine dosing in neonates is largely derived from animal models and observational human data; no randomized controlled trials exist for neonatal epinephrine use during delivery room resuscitation.
- The optimal dose, timing, and route of epinephrine remain areas of active research.
- Volume expansion thresholds have not been validated in randomized trials for neonatal resuscitation.
- The 3:1 compression-to-ventilation ratio is based on expert consensus; some settings (e.g., presumed cardiac etiology) may benefit from higher compression ratios, but evidence is insufficient to recommend a change.
