This document summarizes the NALS algorithm for neonatal resuscitation presented by Dr. Kiran Dyavanagoudar. The algorithm is divided into 5 blocks beginning with birth and initial assessment. It describes the steps of positive pressure ventilation, indications for endotracheal intubation and chest compressions, and medications used in neonatal resuscitation such as epinephrine. Anticipation and preparation by the resuscitation team is important. Ventilation of the newborn's lungs is the most important step, and an increase in heart rate indicates effective resuscitation.

1. NALS- ALGORITHM
Presentor- Dr. Kiran Dyavanagoudar
Moderator- Dr. Srinivas (Pediatrician)
Dr. Pooja Shah.

3. OBJECTIVE
• To describe the steps of Positive Pressure Ventilation.
• To describe the indications for Endotracheal Intubation and Chest
Compressions.
• To discuss about the Medications used in NRP.

4. 4 key questions before birth:
( 1) What is the expected gestational age?
(2) Is the amniotic fluid clear?
(3) Are there any additional risk factors?
(4) What is our umbilical cord management plan?

5. INTRODUCTION
• Approximately 85% of term newborns will begin breathing-
spontaneously
• 10% will begin breathing - drying and stimulation.

6. INTRODUCTION
• 5% of term newborns - receive positive-pressure ventilation (PPV).
• 2% of term newborns -intubated.
• 1 to 3 babies per 1,000 births will receive chest compressions or
emergency medications.

7. INTRODUCTION
Ventilation of the newborn's lungs is the single most important and
effective step in neonatal resuscitation.

8. NRP ALGORITHM
• It is divided into 5 blocks beginning with birth and the initial
assessment.
• Throughout the Algorithm, hexagons indicate assessments and
rectangles show actions that may be required.

9. NRP ALGORITHM

10. RESUSCITATION TEAM
• Every birth should be attended by at least 1 qualified individual
• If risk factors are present, at least 2 qualified individuals should be
present.

11. EQUIPMENT CHECKLIST

12. ⦁ Anticipation
⦁ A radiant heat source ready for use
⦁ All resuscitation equipments immediately
available & in working order
⦁ At least 1 person skilled in neonatal
resuscitation

13. Neonatal Resuscitation Supplies & Equipments
-Suction Equipment
Mechanical suction
Suction catheters 10,12, or 14 F
Meconium aspirator
-Bag and Mask Equipment
Neonatal resuscitation bags ( self limiting)
Face-masks ( for both term & preterm babies)
Oxygen with flow meter and tubing
-Intubation Equipment
Laryngoscope with straight blades no.0 (preterm)& no.1 (term)
Extra bulbs & batteries ( for laryngoscope)
Endotracheal tubes ( int diameter 2.5, 3, 3.5 & 4)

14. Medications
Epinephrine
Normal saline or Ringer Lactate
Naloxone hydrochloride
Miscellaneous
Linen, shoulder roll, gauze
Radiant warmer
Stethoscope
Syringes 1,2,5,10,20,50 ml
Feeding tube 6 F
Umbilical catheters 3.5, 5 F
Three way stopcocks
Gloves

15. RAPID EVALUATION
High risk newborn: preterm,
poor tone, not crying
Low risk newborn:
Term,
good tone,
crying

16. INITIAL STEPS
• Provide warmth
• Dry
• Stimulate
• Positioning the head and neck
( to maintain patency of airway)
• Clearing the airway of secretions if needed
Vigorous term newborn – Skin to skin with
mother while initial steps are performed

17. INITIAL STEPS
• Gentle suctioning
• Mouth before Nose (M before N)
• Suction catheter – Negative pressure
80 – 100mmHg

18. Evaluation of initial steps
• Initial steps should be completed within 30 seconds

19. INITIAL STEPS -EVALUATION
• Auscultation
Measure for 6 seconds and
multiply by 10.
If heart rate not determined by
physical examination -
Pulse oximeter or cardiac monitor

20. APNEA/GASPING ? - NO
HR < 100bpm? - NO

21. PERSISTENT CYANOSIS
Acral cyanosis
• Supplemental oxygen needed only if oxygen saturation below
target.
Free flow oxygen

22. TARGET OXYGEN SATURATION
• Supplemental oxygen
1.Start with Fio2 – 30%
2.Flow – 10L/min

23. LABORED BREATHING? - YES
• Laboured breathing or oxygen saturation cannot be maintained within
target range despite oxygen.
• Trial of CPAP via Flow- inflating bag or T- piece.

24. T- piece
• PEEP – 5cm H2O
• Peak pressure
20 – 25mmHg
• Flow – 10L/min

25. POST RESUSCITATION
• POST RESUSCITATION CARE
• TEAM DEBRIEFING

27. POSITIVE PRESSURE VENTILATION
• Baby APNEA/GASPING or HR <100bpm
• Rate 40-60 breaths/ minute
• Rhythm – “Breathe, two, three”

28. POSITIVE PRESSURE VENTILATION
• Assess for increasing HR within 30 seconds of PPV, observe for chest movement.

30. MR SOPA
• 5 rescue breaths with each step to assess chest movement with PPV.
• Mask readjustment
+
Reposition the head and neck
• Suction the mouth and nose
+
Open the mouth
• Pressure increase
• Alternate airway

32. ENDOTRACHEAL INTUBATION
Assess after 30 seconds of PPV
• HR < 60cpm
• Intubate if not already done.
• Start chest compressions

34. CHEST COMPRESSION
• Ratio of PPV to CC = 1:3 in 2 sec ( 1 and 2 and 3 and breathe)
• 100% Oxygen

35. MEDICATIONS
• If HR < 60bpm
1. Continue co- ordinated PPV and CC
2. Access Umbilical venous line
3. Injection Adrenaline 1:10000 dilutions of 0.2ml/kg (0.1 – 0.3) followed by
saline flush of 3ml. Every 3-5 minutes.
4. ET adrenaline may be administered at a dose of 1.0ml/kg till umbilical
venous access is established

36. MEDICATIONS
• Consider hypovolemia
• Consider Pneumothorax

37. • No response to adrenaline
1. Consider discontinuing resuscitation, if HR = 0 after 20 minutes of
life.
2. Post – resuscitation debriefing and family counselling.

38. TAKE HOME MESSAGES
• Newborn resuscitation requires anticipation and preparation by
providers who train individually and as teams.
• Ventilation of the newborn's lungs is the single most important
and effective step in neonatal resuscitation.
• A rise in heart rate is most important indicator of effective ventilation
and response to resuscitative interventions.

39. REFERENCES
• Zaichkin J, Kamath-Rayne BD, Weiner G. Neonatal Resuscitation, 8th
edition (2021), Jaypee Publication

40. THANK YOU