ERC Guidelines for resuscitation 2010

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Journal: Resuscitation

European Resuscitation Council Guidelines for Resuscitation 2010: Section 7. Resuscitation of babies at birth

Sam Richmond, Jonathan Wyllie.

Published online 19 October 2010, pages 1389 - 1399


Newborn life support

Commence newborn life support if assessment shows that the baby has failed to establish adequate regular normal breathing, or has a heart rate of less than 100 min−1. Opening the airway and aerating the lungs is usually all that is necessary. Furthermore, more complex interventions will be futile unless these two first steps have been successfully completed.

Airway

Place the baby on his or her back with the head in a neutral position ( Fig. 7.2 ). A 2 cm thickness of the blanket or towel placed under the baby's shoulder may be helpful in maintaining proper head position. In floppy babies application of jaw thrust or the use of an appropriately sized oropharyngeal airway may be helpful in opening the airway.

Fig. 7.2 Newborn with head in neutral position.

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References in context

  • Place the baby on his or her back with the head in a neutral position (Fig. 7.2).
    Go to context

Suction is needed only if the airway is obstructed. Obstruction may be caused by particulate meconium but can also be caused by blood clots, thick tenacious mucus or vernix even in deliveries where meconium staining is not present. However, aggressive pharyngeal suction can delay the onset of spontaneous breathing and cause laryngeal spasm and vagal bradycardia. 15 x L. Cordero Jr, E.H. Hon. Neonatal bradycardia following nasopharyngeal stimulation. J Pediatr 78 (1971) (441 - 447) The presence of thick meconium in a non-vigorous baby is the only indication for considering immediate suction of the oropharynx. If suction is attempted this is best done under direct vision. Connect a 12–14 FG suction catheter, or a Yankauer sucker, to a suction source not exceeding minus 100 mm Hg.

Breathing

After initial steps at birth, if breathing efforts are absent or inadequate, lung aeration is the priority ( Fig. 7.3 ). In term babies, begin resuscitation with air. The primary measure of adequate initial lung inflation is a prompt improvement in heart rate; assess chest wall movement if heart rate does not improve.

Fig. 7.3 Mask ventilation of newborn.

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References in context

  • After initial steps at birth, if breathing efforts are absent or inadequate, lung aeration is the priority (Fig. 7.3).
    Go to context

For the first five inflation breaths maintain the initial inflation pressure for 2–3 s. This will help lung expansion. Most babies needing resuscitation at birth will respond with a rapid increase in heart rate within 30 s of lung inflation. If the heart rate increases but the baby is not breathing adequately, ventilate at a rate of about 30 breaths min−1 allowing approximately 1 s for each inflation, until there is adequate spontaneous breathing.

Adequate passive ventilation is usually indicated by either a rapidly increasing heart rate or a heart rate that is maintained faster than 100 min−1. If the baby does not respond in this way the most likely cause is inadequate airway control or inadequate ventilation. Look for passive chest movement in time with inflation efforts; if these are present then lung aeration has been achieved. If these are absent then airway control and lung aeration has not been confirmed. Without adequate lung aeration, chest compressions will be ineffective; therefore, confirm lung aeration before progressing to circulatory support.

Some practitioners will ensure airway control by tracheal intubation, but this requires training and experience. If this skill is not available and the heart rate is decreasing, re-evaluate the airway position and deliver inflation breaths while summoning a colleague with intubation skills.

Continue ventilatory support until the baby has established normal regular breathing.

Circulatory support

Circulatory support with chest compressions is effective only if the lungs have first been successfully inflated. Give chest compressions if the heart rate is less than 60 min−1 despite adequate ventilation.

The most effective technique for providing chest compressions is to place the two thumbs side by side over the lower third of the sternum just below an imaginary line joining the nipples, with the fingers encircling the torso and supporting the back ( Fig. 7.4 ).16, 17, 18, and 19 x P.K. Houri, L.R. Frank, J.J. Menegazzi, R. Taylor. A randomized, controlled trial of two-thumb vs two-finger chest compression in a swine infant model of cardiac arrest [see comment]. Prehosp Emerg Care 1 (1997) (65 - 67) Crossref. x R. David. Closed chest cardiac massage in the newborn infant. Pediatrics 81 (1988) (552 - 554) x J.J. Menegazzi, T.E. Auble, K.A. Nicklas, G.M. Hosack, L. Rack, J.S. Goode. Two-thumb versus two-finger chest compression during CRP in a swine infant model of cardiac arrest. Ann Emerg Med 22 (1993) (240 - 243) Crossref. x M.M. Thaler, G.H. Stobie. An improved technique of external caridac compression in infants and young children. N Engl J Med 269 (1963) (606 - 610) An alternative way to find the correct position of the thumbs is to identify the xiphisternum and then to place the thumbs on the sternum one finger's breadth above this point. The sternum is compressed to a depth of approximately one-third of the anterior–posterior diameter of the chest allowing the chest wall to return to its relaxed position between compressions. 20 x A. Meyer, V. Nadkarni, A. Pollock, et al.. Evaluation of the Neonatal Resuscitation Program's recommended chest compression depth using computerized tomography imaging. Resuscitation 81 (2010) (544 - 548)

Fig. 7.4 Ventilation and chest compression of newborn.

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References in context

  • The most effective technique for providing chest compressions is to place the two thumbs side by side over the lower third of the sternum just below an imaginary line joining the nipples, with the fingers encircling the torso and supporting the back (Fig. 7.4).16–19 An alternative way to find the correct position of the thumbs is to identify the xiphisternum and then to place the thumbs on the sternum one finger's breadth above this point.
    Go to context

Use a ratio of three compressions to one ventilation, aiming to achieve approximately 120 events per minute, i.e. approximately 90 compressions and 30 ventilations. There are theoretical advantages to allowing a relaxation phase that is very slightly longer than the compression phase. 21 x J.M. Dean, R.C. Koehler, C.L. Schleien, et al.. Improved blood flow during prolonged cardiopulmonary resuscitation with 30% duty cycle in infant pigs. Circulation 84 (1991) (896 - 904) However, the quality of the compressions and breaths are probably more important than the rate.

Check the heart rate after about 30 s and every 30 s thereafter. Discontinue chest compressions when the spontaneous heart rate is faster than 60 min−1.

Drugs

Drugs are rarely indicated in resuscitation of the newly born infant. Bradycardia in the newborn infant is usually caused by inadequate lung inflation or profound hypoxia, and establishing adequate ventilation is the most important step to correct it. However, if the heart rate remains less than 60 min−1 despite adequate ventilation and chest compressions, it is reasonable to consider the use of drugs. These are best given via an umbilical venous catheter ( Fig. 7.5 ).

Fig. 7.5 Newborn umbilical cord showing the arteries and veins.

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References in context

  • These are best given via an umbilical venous catheter (Fig. 7.5).
    Go to context

Adrenaline

Despite the lack of human data it is reasonable to use adrenaline when adequate ventilation and chest compressions have failed to increase the heart rate above 60 min−1. If adrenaline is used, a dose of 10–30 μg kg−1 should be administered intravenously as soon as possible.

The tracheal route is not recommended (see below) but if it is used, it is highly likely that doses of 50–100 μg kg−1 will be required. Neither the safety nor the efficacy of these higher tracheal doses has been studied. Do not give these high doses intravenously.

Bicarbonate

If effective spontaneous cardiac output is not restored despite adequate ventilation and adequate chest compressions, reversing intracardiac acidosis may improve myocardial function and achieve a spontaneous circulation. There are insufficient data to recommend routine use of bicarbonate in resuscitation of the newly born. The hyperosmolarity and carbon dioxide-generating properties of sodium bicarbonate may impair myocardial and cerebral function. Use of sodium bicarbonate is discouraged during brief CPR. If it is used during prolonged arrests unresponsive to other therapy, it should be given only after adequate ventilation and circulation is established with CPR. A dose of 1–2 mmol kg−1 may be given by slow intravenous injection after adequate ventilation and perfusion have been established.

Fluids

If there has been suspected blood loss or the infant appears to be in shock (pale, poor perfusion, weak pulse) and has not responded adequately to other resuscitative measures then consider giving fluid. 22 x M.H. Wyckoff, J.M. Perlman, A.R. Laptook. Use of volume expansion during delivery room resuscitation in near-term and term infants. Pediatrics 115 (2005) (950 - 955) Crossref. This is a rare event. In the absence of suitable blood (i.e. irradiated and leucocyte-depleted group O Rh-negative blood), isotonic crystalloid rather than albumin is the solution of choice for restoring intravascular volume. Give a bolus of 10 ml kg−1 initially. If successful it may need to be repeated to maintain an improvement.

Stopping resuscitation

Local and national committees will determine the indications for stopping resuscitation. If the heart rate of a newly born baby is not detectable and remains undetectable for 10 min, it is then appropriate to consider stopping resuscitation. The decision to continue resuscitation efforts when the heart rate has been undetectable for longer than 10 min is often complex and may be influenced by issues such as the presumed aetiology, the gestation of the baby, the potential reversibility of the situation, and the parents’ previous expressed feelings about acceptable risk of morbidity.

In cases where the heart rate is less than 60 min−1 at birth and does not improve after 10 or 15 min of continuous and apparently adequate resuscitative efforts, the choice is much less clear. In this situation there is insufficient evidence about outcome to enable firm guidance on whether to withhold or to continue resuscitation.

Communication with the parents

It is important that the team caring for the newborn baby informs the parents of the baby's progress. At delivery, adhere to the routine local plan and, if possible, hand the baby to the mother at the earliest opportunity. If resuscitation is required inform the parents of the procedures undertaken and why they were required.

Decisions to discontinue resuscitation should ideally involve senior paediatric staff. Whenever possible, the decision to attempt resuscitation of an extremely preterm baby should be taken in close consultation with the parents and senior paediatric and obstetric staff. Where a difficulty has been foreseen, for example in the case of severe congenital malformation, discuss the options and prognosis with the parents, midwives, obstetricians and birth attendants before delivery. 23 x Nuffield Council on Bioethics. Critical care decisions in fetal and neonatal medicine: ethical issues. ISBN 1 904384 14 2006. Record carefully all discussions and decisions in the mother's notes prior to delivery and in the baby's records after birth.

 
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Fig. 7.2 Newborn with head in neutral position.

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References in context

  • Place the baby on his or her back with the head in a neutral position (Fig. 7.2).
    Go to context

Fig. 7.3 Mask ventilation of newborn.

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References in context

  • After initial steps at birth, if breathing efforts are absent or inadequate, lung aeration is the priority (Fig. 7.3).
    Go to context

Fig. 7.4 Ventilation and chest compression of newborn.

gr4

References in context

  • The most effective technique for providing chest compressions is to place the two thumbs side by side over the lower third of the sternum just below an imaginary line joining the nipples, with the fingers encircling the torso and supporting the back (Fig. 7.4).16–19 An alternative way to find the correct position of the thumbs is to identify the xiphisternum and then to place the thumbs on the sternum one finger's breadth above this point.
    Go to context

Fig. 7.5 Newborn umbilical cord showing the arteries and veins.

gr5

References in context

  • These are best given via an umbilical venous catheter (Fig. 7.5).
    Go to context

References

Label Authors Title Source Year
15

References in context

  • However, aggressive pharyngeal suction can delay the onset of spontaneous breathing and cause laryngeal spasm and vagal bradycardia.15 The presence of thick meconium in a non-vigorous baby is the only indication for considering immediate suction of the oropharynx.
    Go to context

L. Cordero Jr, E.H. Hon. Neonatal bradycardia following nasopharyngeal stimulation. J Pediatr 78 (1971) (441 - 447) 1971
20

References in context

  • The most effective technique for providing chest compressions is to place the two thumbs side by side over the lower third of the sternum just below an imaginary line joining the nipples, with the fingers encircling the torso and supporting the back (Fig. 7.4).16–19 An alternative way to find the correct position of the thumbs is to identify the xiphisternum and then to place the thumbs on the sternum one finger's breadth above this point.
    Go to context

A. Meyer, V. Nadkarni, A. Pollock, et al.. Evaluation of the Neonatal Resuscitation Program's recommended chest compression depth using computerized tomography imaging. Resuscitation 81 (2010) (544 - 548) 2010
21

References in context

  • There are theoretical advantages to allowing a relaxation phase that is very slightly longer than the compression phase.21 However, the quality of the compressions and breaths are probably more important than the rate.
    Go to context

J.M. Dean, R.C. Koehler, C.L. Schleien, et al.. Improved blood flow during prolonged cardiopulmonary resuscitation with 30% duty cycle in infant pigs. Circulation 84 (1991) (896 - 904) 1991
22

References in context

  • If there has been suspected blood loss or the infant appears to be in shock (pale, poor perfusion, weak pulse) and has not responded adequately to other resuscitative measures then consider giving fluid.22 This is a rare event.
    Go to context

M.H. Wyckoff, J.M. Perlman, A.R. Laptook. Use of volume expansion during delivery room resuscitation in near-term and term infants. Crossref. Pediatrics 115 (2005) (950 - 955) 2005
23

References in context

  • Where a difficulty has been foreseen, for example in the case of severe congenital malformation, discuss the options and prognosis with the parents, midwives, obstetricians and birth attendants before delivery.23 Record carefully all discussions and decisions in the mother's notes prior to delivery and in the baby's records after birth.
    Go to context

  • A consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents is an important goal.23 Withholding resuscitation and discontinuation of life-sustaining treatment during or following resuscitation are considered by many to be ethically equivalent and clinicians should not be hesitant to withdraw support when the possibility of functional survival is highly unlikely.
    Go to context

Nuffield Council on Bioethics. Critical care decisions in fetal and neonatal medicine: ethical issues. ISBN 1 904384 14 2006.

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