This document outlines a neonatal resuscitation algorithm. It describes assembling a resuscitation team that includes at least one qualified individual for routine births and two for high-risk births. The algorithm then details assessing the newborn at birth and providing positive pressure ventilation if needed. It provides corrective steps if ventilation is inadequate and describes assessing the heart rate after 15-30 seconds. For persistent bradycardia, the steps are chest compressions, epinephrine, and volume expanders. Intubation is indicated if ventilation with a mask is ineffective. The document provides details on techniques and dosages for interventions.

1. Mahmoud Ismail
MD, Fellowship of Egyptian board
Neonatal Resuscitation Algorithm

2. Neonatal Resuscitation Algorithm

3. Neonatal Resuscitation Algorithm

4. Neonatal Resuscitation Algorithm
Resuscitation team:
The number of personnel depends on anticipated risks:
 If no risk factors:
o Qualified individual skilled in initial steps of
neonatal At least 1 care and PPV.
 If there is (are) risk factor (s):
o At least 2 least 1 qualified individuals.

5. Antenatal counseling
(4 questions)
 Expected GA?
 Is amniotic fluid is clear?
 No of babies?
 Other risk factors?
Team briefing
 Review risk factors.
 Discuss possible scenarios.
 Identify team leader.
o Any well trained person.
o Must understand the algorithm
o Not necessary most senior.
o Must have situational awareness
 Assign roles and responsibilities.

8.  Apnea
 Gasping
 HR < 100/MIN
 PPV:
o Rate: 40-60/ min (breath two three)
o Pressure: 20-25 cm H2O (max 30-40).
o Peep: 5 cm H2O.
o Duration: 15 second then do primary assessment
 Connect Spo2 monitor.
 Connect ECG leads.

10. Corrective steps
Mask adjustment ( E technique, 2 hand technique)
M
Repositioning of air way (sniffing position)
R
Suction (M then N)
S
Open mouth
O
Pressure increase (5 – 10 cm H2O max 20 – 30 cm H2O)
P
Alternative air way (ETT, laryngeal mask)
A

11. First assessment of heart rate after 15 seconds of PPV
Not increasing
chest is not moving
Not increasing
chest is moving
Increasing
 Announce.
 Corrective steps until chest
movement with PPV.
 Announce.
 ETT or laryngeal mask.
 Second assessment after 30
seconds of PPV.
 Announce.
 Continue PPV
 Second assessment after
15 seconds of PPV.
 Announce.
 Continue PPV
 Second assessment
after 15 seconds of
PPV.
Second assessment of heart rate after 30 seconds of PPV that moves the chest
< 60 /min
60 – 99 min
≥ 100 min
 Reassess ventilation.
 Corrective steps if
necessary.
 Insert alternative airway.
 If not improved:
o 100% oxygen.
o Start chest compression.
 Reassess ventilation.
 Corrective steps if
necessary.
 Continue PPV until
spontaneous effort

12. Intubation
Indicated if:
o If PPV with face mask does not lead to clinical
improvement.
o If PPV lasts for more than few minutes.
 Strongly recommended in:
o If chest compressions are necessary.
o Suspected diaphragmatic hernia.
o Surfactant administration.
o Direct tracheal suction if airway is obstructed
by thick secretions.

13. Indication:
 Persistent bradycardia < 60/min
after at least 30 seconds of
ventilation that inflates the lung
Chest
compression

14. Technique:
 Increases fio2 to 100%.
 Site:
o On the sternum.
o Just below the line connecting to nipples.
o Thumbs are put over lower third of sternum,
hands encircling the chest.
 Depth: 1/3 of AP diameter of chest.
 Rate:
o 3 compressions and 1 ventilation every 2
seconds (1 and 2 and 3 and breath an d).
o Synchronize compression and ventilation.
 Assessment of heart rate:
o After 1 min of chest compression.
o Methods:
 Stet: need long time.
 Pulse oximeter: need good perfusion.
 ECG monitor: show electrical activity
only.

15. Epinephrine
 Indications:
If heart rate remains < 60 bpm after:
o At least 30 secs of PPV that inflates the lungs.
o Another 60 secs of chest compressions.
 Concentration:
o Only the 1:10,000 preparation (0.1 mg/mL) should be used
for neonatal resuscitation
o IV or IO: 1-mL syringe labeled “Epinephrine-IV”.
o Endotracheal: 3- 5-mL syringe labeled “Epinephrine-ET only”
 Dose:
o IV/IO: 0.1 to 0.3 mL/kg (= 0.01 to 0.03 mg/kg).
Flush with 0.5 to 1 mL normal saline
o Endotracheal: 0.5 to 1 mL/kg (= 0.05 to 0.1 mg/kg).
DO NOT give this higher dose via IV or IO.
 Frequency:
o Repeat every 3-5 min if HR remains < 60 bpm.
 Assessment of HR:
o After 1 minute of epinephrine administration.
o Repeat every 3-5 min.
o If persistent HR <60 / min assess for hypovolemia and
tention pneumothorax

16. Volume Expanders
 Type:
o Crystalloid: Normal Saline.
o Packed RBCs (if anemia): O-negative packed red blood cells.
 Dose: 10 ml/kg, may be repeated if the baby does not improve after the first dose.
 Route: IV/IO.
 Administration: Over 5 to 10 minutes.
 Preparation: 30- to 60-mL syringe (labeled).

17. Pneumothorax
 Causes:
o Spontaneous.
o Secondary: PPV, MV, meconium ….
 C/P:
o Asymptomatic
o Symptomatic: RD, Tension pneumothorax.
 Diagnosis: transillumination, x-ray,
 Treatment:
o Oxygen and FU: if asymptomatic
o Evacuation and chest tube: tension or on MV