8.3 Neonatal Resuscitation Program (NRP) Standards
Key Takeaways
- The single most important step in neonatal resuscitation is establishing effective ventilation within the 'Golden Minute' of life.
- Initial Positive Pressure Ventilation (PPV) is indicated for apnea, gasping, or HR < 100 bpm. Start with 21% O2 for infants >= 35 weeks, and 21-30% O2 for infants < 35 weeks, titrating to pre-ductal SpO2 targets.
- Troubleshoot ineffective ventilation with the MR. SOPA corrective steps (Mask, Reposition, Suction, Open mouth, Pressure increase, Alternative airway) before starting compressions.
- Initiate chest compressions at a 3:1 ratio (90 compressions and 30 breaths per minute) if HR remains < 60 bpm after 30 seconds of effective, chest-expanding PPV; increase FiO2 to 100% simultaneously.
- Administer Epinephrine at 0.01-0.03 mg/kg IV/IO (preferred) or 0.05-0.1 mg/kg ET if HR remains < 60 bpm after 60 seconds of compressions and ventilation.
Neonatal Resuscitation Program (NRP) Standards
Resuscitating a newborn is a high-acuity, low-frequency event in critical care transport. The transition from intrauterine to extrauterine life requires rapid physiological changes, primarily the clearance of lung fluid and expansion of alveoli. The flight paramedic must master the Neonatal Resuscitation Program (NRP) algorithm, focusing on effective ventilation as the single most important step in neonatal resuscitation.
Initial Assessment and the First 30 Seconds
Immediately following birth, the flight paramedic must answer three rapid screening questions:
- Is the baby term gestation?
- Does the baby have good muscle tone?
- Is the baby breathing or crying?
If the answer to any of these questions is no, the infant must be moved to the radiant warmer (or incubator/warmed transport environment) for the initial steps of resuscitation:
- Warm: Prevent hypothermia (target axillary temperature of 36.5°C to 37.5°C). Use pre-warmed blankets, thermal mattresses, or plastic wraps for premature infants <32 weeks.
- Position Airway: Place the infant in the "sniffing position" (slightly extending the neck). Avoid hyperextension or hyperflexion, which can collapse the compliant neonatal airway.
- Suction: Suction only if the airway is obstructed by secretions or if the infant is breathing poorly with meconium-stained fluid. Use a bulb syringe or suction catheter. Suction the mouth first, then the nose ("M before N") to prevent the infant from aspirating nasal secretions when gasping.
- Dry and Stimulate: Dry the infant with warm towels to prevent evaporative heat loss (change wet towels immediately). Rub the back, trunk, or flick the soles of the feet to stimulate spontaneous respiration.
The Golden Minute: Positive Pressure Ventilation (PPV)
The first 60 seconds of life-the "Golden Minute"-is the target window to complete the initial steps, re-evaluate, and initiate positive pressure ventilation (PPV) if indicated.
Indications for PPV
- Apnea or gasping respirations.
- Heart rate <100 beats per minute (bpm).
PPV Technique and Parameters
- Rate: 40 to 60 breaths per minute (count aloud: "breathe, two, three; breathe, two, three...").
- Inspiratory Pressure (PIP): Start with an initial peak inspiratory pressure of 20 to 25 cmH2O. Term infants may require up to 30 to 40 cmH2O for the first few breaths to clear fetal lung fluid.
- Positive End-Expiratory Pressure (PEEP): Maintain a PEEP of 5 cmH2O to prevent alveolar collapse.
- Oxygen Concentration (FiO2):
- >= 35 weeks gestation: Start PPV with 21% oxygen (room air).
- <35 weeks gestation: Start PPV with 21% to 30% oxygen.
- Never use 100% oxygen initially, as hyperoxia causes oxidative stress and reperfusion injury, particularly in premature brains. Titrate FiO2 based on pre-ductal pulse oximetry.
Target Pre-Ductal SpO2 Limits (Right Wrist)
Place the pulse oximeter probe on the right hand or wrist (pre-ductal circulation) to measure blood oxygenation before it mixes with deoxygenated blood crossing the ductus arteriosus.
| Time After Birth | Target Pre-Ductal SpO2 Range |
|---|---|
| 1 Minute | 60% - 65% |
| 2 Minutes | 65% - 70% |
| 3 Minutes | 70% - 75% |
| 4 Minutes | 75% - 80% |
| 5 Minutes | 80% - 85% |
| 10 Minutes | 85% - 90% |
MR. SOPA: Ventilation Corrective Steps
If the infant's heart rate does not increase or chest rise is inadequate after 15 seconds of PPV, the clinician must troubleshoot using the MR. SOPA mnemonic:
- M - Mask adjustment: Reapply the mask to ensure an airtight seal.
- R - Reposition airway: Re-establish the sniffing position.
- Perform PPV and check for chest movement.
- S - Suction mouth and nose: Clear the airway of secretions.
- O - Open mouth: Open the mouth and lift the jaw forward.
- Perform PPV and check for chest movement.
- P - Pressure increase: Incrementally increase PIP by 5 cmH2O (maximum 40 cmH2O for term, 30 cmH2O for preterm).
- Perform PPV and check for chest movement.
- A - Alternative airway: Place an endotracheal tube (ETT) or a laryngeal mask airway (LMA).
Chest Compressions
Chest compressions are indicated only when the heart rate remains <60 bpm despite at least 30 seconds of effective PPV (defined as chest rise and bilateral breath sounds, typically via an endotracheal tube or LMA).
- Technique: Use the two-thumb wrap-around method. Place both thumbs on the lower third of the sternum (just below the intermammary line) and wrap your fingers around the thorax to support the back.
- Compression Depth: Depress the sternum approximately one-third of the anterior-posterior diameter of the chest.
- Ratio: 3:1 (3 compressions to 1 breath). This delivers 90 compressions and 30 breaths per minute (total of 120 events per minute).
- Oxygen Concentration: Increase FiO2 immediately to 100% as soon as chest compressions are initiated.
- Re-evaluation: Check the heart rate after 60 seconds of continuous compressions (preferably via ECG or umbilical cord palpation).
Pharmacological Resuscitation
If the heart rate remains <60 bpm after 60 seconds of high-quality chest compressions and 100% oxygen ventilation, pharmacotherapy is indicated.
Epinephrine
- Concentration: Use only the 1:10,000 (0.1 mg/mL) concentration.
- IV/IO Route (Preferred): Dose is 0.01 to 0.03 mg/kg (equivalent to 0.1 to 0.3 mL/kg). Administer via an umbilical venous catheter (UVC) or intraosseous (IO) line, followed by a 0.5 to 1 mL normal saline flush.
- Endotracheal (ET) Route: Dose is 0.05 to 0.1 mg/kg (equivalent to 0.5 to 1.0 mL/kg). Administer directly into the ETT while IV/IO access is being established. Note that the ET dose is much higher and absorption is less predictable.
- Frequency: Repeat every 3 to 5 minutes if the heart rate remains <60 bpm.
Volume Expansion
Indicated if there is a history of acute blood loss (e.g., placental abruption, placenta previa, cord tear) or if the infant signs of hypovolemic shock (pallor, poor perfusion, weak pulses) and fails to respond to resuscitation.
- Fluids: Normal Saline (0.9% NaCl) or emergency release O-negative blood.
- Dose: 10 mL/kg IV/IO administered slowly over 5 to 10 minutes.
You are resuscitating a newborn at 39 weeks gestation. The baby is gasping, and the heart rate is 50 bpm. You initiate PPV, but after 15 seconds, the baby's heart rate remains 50 bpm and there is no chest rise. What is the most appropriate next step in management?
Which of the following describes the correct drug dose, concentration, and administration route during neonatal resuscitation when the heart rate remains below 60 bpm despite effective ventilation and chest compressions?