6.2 NRP Corrective Steps, Compressions & Medications

6.2 NRP Corrective Steps, Compressions & Medications

Ineffective Ventilation: Correct Before Compressing

If heart rate does not rise, verify visible chest movement and perform ventilation corrective steps: improve mask seal and head position, suction only if obstructed, open the mouth, increase inflation pressure as needed, and place an alternative airway. A two-handed mask hold may improve seal. An endotracheal tube provides a definitive airway; video laryngoscopy can be useful. A laryngeal mask is an effective alternative in appropriately sized newborns, and during compressions may be reasonable at 34 weeks or later if intubation is unsuccessful. Evidence remains limited for smaller or more premature infants.

Do not begin compressions for a heart rate below 60 until the infant has received at least 30 seconds of ventilation that actually inflates the lungs, preferably through an alternative airway. Correcting leak or obstruction is more important than rushing down the algorithm.

Chest Compressions

When heart rate remains below 60/min after effective ventilation, begin compressions with the two-thumb encircling-hands technique on the lower third of the sternum to approximately one-third of the anterior-posterior chest depth. Coordinate a 3:1 ratio: 90 compressions and 30 inflations each minute. Use ECG for heart-rate assessment when compressions are underway. It may be reasonable to increase oxygen to 100% during compressions; promptly titrate down after the heart rate recovers.

After 60 seconds of coordinated compressions and effective ventilation, reassess. If heart rate remains below 60/min, give epinephrine and continue coordinated support while considering hypovolemia and pneumothorax.

Vascular Access, Epinephrine & Volume

The preferred emergency intravascular route is a low-lying umbilical venous catheter. Intraosseous access may be considered if venous access is not feasible. Use epinephrine concentration 0.1 mg/mL. The preferred intravascular dose is 0.01 to 0.03 mg/kg, followed by a 3 mL normal-saline flush regardless of birth weight. Endotracheal epinephrine 0.05 to 0.1 mg/kg may be considered while vascular access is being obtained, but give intravascular epinephrine promptly if the response is inadequate. Additional doses may be repeated every 3 to 5 minutes while heart rate remains below 60/min.

Give 0.9% saline or blood at 10 to 20 mL/kg when blood loss is known or suspected and bradycardia persists despite ventilation, compressions, and epinephrine. Volume is not routine treatment for asphyxial bradycardia. Evaluate for pneumothorax when ventilation suddenly becomes ineffective with asymmetric breath sounds or transillumination findings.

Postresuscitation Care & Team Performance

Infants receiving prolonged ventilation or advanced resuscitation require temperature, glucose, respiratory, cardiovascular, and neurologic monitoring. Identify candidates for therapeutic hypothermia under the regional protocol. Conduct a team debrief that separates system issues from individual blame and document timing, response, oxygen titration, access, and medication doses.

Exam Decision Sequence

1. Is the infant breathing effectively and is heart rate at least 100/min?
2. If not, provide effective ventilation within the first minute.
3. If heart rate fails to rise, correct ventilation and use an alternative airway.
4. If heart rate remains below 60 after 30 seconds of chest-moving ventilation, start 3:1 compressions.
5. If heart rate remains below 60 after 60 seconds of compressions plus ventilation, give intravascular epinephrine.
6. Consider blood loss and pneumothorax while continuing the algorithm.

Dose and Response Cross-Check

For a 3 kg newborn, the intravascular epinephrine range is 0.03-0.09 mg. With 0.1 mg/mL solution, that is 0.3-0.9 mL, followed by the 3 mL saline flush. State concentration, dose in mg/kg, calculated milligrams, volume, route, and flush in closed-loop communication. A tenfold concentration error is a major resuscitation hazard.

After each intervention, return to physiology. A rising heart rate confirms improving oxygen delivery. Persistent bradycardia requires verification of chest movement, airway position, compression depth and cadence, oxygen source, vascular route, and delivered drug. When blood loss is suspected, examine pallor, pulses, placental history, cord disruption, and response to volume. Sudden loss of ventilation with asymmetric air entry raises pneumothorax. Document sequence and debrief equipment, communication, and timing after stabilization.

Advanced-support checkpoint

Compressions compete with ventilation, so secure an alternative airway when feasible before starting them and confirm that the chest still moves. Use ECG to improve heart-rate assessment, but correlate the tracing with examination because electrical activity alone does not establish effective output. When the heart rate rises above 60/min, stop compressions and continue assisted ventilation until the rate is above 100/min with adequate spontaneous breathing. Titrate oxygen from preductal saturation and transition to postresuscitation monitoring.