Resuscitation of the newly born infant differs significantly from CPR for older infants and children. Newborns are transitioning from intrauterine to extrauterine physiology, and their resuscitation priorities reflect this unique physiology. For young infants who are not newly born but present in cardiac arrest, either NRP or PALS algorithms may be appropriate. Institutions should establish policies based on local expertise to ensure high-quality CPR regardless of the algorithm used.
Although neonatal resuscitation in the ED is uncommon, the team must be prepared. Approximately 90% of newborns require only routine care, 10% need some assistance, and 1% require extensive resuscitation. Resuscitation needs vary by gestational age and birth weight. Because high-risk births in the ED are often unanticipated, readiness is essential.
Effective ED readiness requires staff education, a standardized newborn resuscitation kit, clear mobilization procedures, and a radiant warmer with a dosing chart. Regular simulation helps maintain familiarity with neonatal skills. High-risk factors such as prematurity, multiple gestation, meconium-stained fluid, maternal drug use, or trauma-induced labor help anticipate the need for advanced interventions.
Essential Equipment:
Medications: Epinephrine 1:10,000, Dextrose 10%, isotonic crystalloids, and a weight-based dosing chart.
Fetal circulation relies on right-to-left shunts through the foramen ovale and ductus arteriosus. At birth, cord clamping and spontaneous respirations initiate a transition to neonatal circulation, increasing PaO₂ and reducing pulmonary vascular resistance. Initial breaths clear lung fluid and stimulate surfactant release. Surfactant production and alveolar development are incomplete before 34 weeks, making resuscitation before 23–24 weeks rarely successful outside a NICU.
Newborns who are term, have good tone, and are breathing or crying do not require resuscitation and may remain with the mother for routine care. Those who do not meet these criteria should be placed under a radiant warmer and undergo the initial steps of the Neonatal Resuscitation Algorithm. The “Golden Minute” refers to the first 60 seconds after birth, during which initial steps should be completed, the infant reassessed, and ventilation begun if needed.
Ventilation is the most important step in neonatal resuscitation. If a newborn does not respond to warming, airway positioning, drying, and stimulation, positive pressure ventilation (PPV) should be initiated promptly. Progression through the Neonatal Resuscitation Algorithm is guided by assessment of respirations and heart rate. A heart rate below 100/min indicates the need for PPV. Once PPV or supplemental oxygen is started, response is assessed by heart rate, respiratory effort, and oxygen saturation. Heart rate is the most sensitive indicator of effective ventilation.
Newborns are highly susceptible to heat loss due to their large surface area-to-weight ratio, minimal fat stores, and thin skin. Hypothermia increases the risk of intraventricular hemorrhage, respiratory compromise, hypoglycemia, and late-onset sepsis. The recommended axillary temperature is 36.5–37.5°C. Strategies to prevent hypothermia include radiant warmers, hats, plastic wrap for infants under 32 weeks, warmed blankets, skin-to-skin contact, and warmed humidified gases. Temperature should be monitored continuously, avoiding both hypothermia and hyperthermia.
Most newborns begin effective respirations with simple stimulation during drying and suctioning. Safe techniques include rubbing the back or flicking the soles. Vigorous stimulation is unnecessary and may be harmful.
Position the infant in the “sniffing” position with slight neck extension to open the airway. A towel under the shoulders may help. Avoid flexion or hyperextension, which can worsen obstruction.
Suction only if the airway appears obstructed or if PPV is required. Excessive suctioning may cause bradycardia, apnea, or atelectasis. Use a bulb syringe or suction catheter as needed.
Approximately 2–5% of infants born through meconium-stained fluid develop aspiration syndrome. Vigorous infants with good tone and respiratory effort may receive routine care with gentle clearing of the mouth and nose. Non-vigorous infants should be moved to a radiant warmer for initial resuscitation steps and PPV if needed. Routine intubation for tracheal suctioning is no longer recommended; intubation and suctioning should be performed only if the airway is obstructed.
Use a 3-lead ECG for rapid and accurate heart rate assessment. Auscultation and pulse oximetry alone are less reliable. Pulse oximetry should be used primarily to assess oxygenation.
Pulse oximetry should be used during resuscitation, during PPV, when supplemental oxygen is administered, or when central cyanosis persists beyond 5–10 minutes of life. Oxygen saturation should be interpreted using NRP-recommended minute-by-minute target ranges.
Delayed cord clamping (DCC) provides benefits for newborns who do not require immediate resuscitation, including reduced intraventricular hemorrhage, higher blood volume, improved blood pressure, decreased need for transfusion, and lower rates of necrotizing enterocolitis. Although DCC is associated with slightly higher bilirubin levels, no mortality benefit has been demonstrated. Current recommendations support DCC for up to 30 seconds in both term and preterm infants who do not require resuscitation. Evidence is insufficient to guide cord clamping practices in infants requiring immediate resuscitation.
Evidence for cord milking is limited, and it should be avoided in infants born at less than 29 weeks gestation due to increased risk of intraventricular hemorrhage.
Newborns resuscitated with room air (21% oxygen) have improved survival compared with those resuscitated with 100% oxygen. Supplemental oxygen should be titrated to achieve preductal oxygen saturation targets appropriate for minute of life. Initiating resuscitation of preterm infants with high oxygen concentrations (>65%) is not recommended. Warm, humidified oxygen should be used when possible.
PPV is indicated for apnea, gasping, or heart rate below 100 bpm after initial steps. Either a flow-inflating or self-inflating bag may be used. Although PEEP does not improve heart rate recovery or reduce intubation, it decreases supplemental oxygen needs; therefore, 5 cm H₂O PEEP is suggested for preterm infants receiving PPV. Effective ventilation is indicated by visible chest rise, breath sounds, and an increasing heart rate. Ventilation should be delivered at 40–60 breaths per minute.
If BVM ventilation continues for several minutes, an orogastric tube should be placed to decompress the stomach. If respirations improve and heart rate exceeds 100 bpm, PPV may be discontinued. If inadequate respirations or heart rate below 100 bpm persist, continue PPV and consider advanced airway placement.
CPAP may be used for spontaneously breathing preterm infants with respiratory distress in centers with neonatal respiratory expertise. CPAP reduces the need for intubation, shortens mechanical ventilation duration, decreases bronchopulmonary dysplasia, and reduces mortality. Self-inflating bags cannot deliver CPAP and may not reliably provide PEEP.
Intubation is indicated for prolonged or ineffective PPV, when chest compressions are required, or in cases of congenital diaphragmatic hernia. Exhaled CO₂ detection is the most reliable method of confirming tube placement, supported by chest rise, breath sounds, and condensation in the tube. Rising heart rate is the best indicator of effective ventilation through the tube.
ET tube size may be estimated by dividing gestational age in weeks by 10. Insertion depth (cm at the gumline) is approximately 6 plus the infant’s weight in kilograms.
LMAs may be used for full- or near-term infants (>34 weeks, >2,000 g) when BVM ventilation is ineffective or intubation fails. Evidence is insufficient to recommend routine use in preterm infants. LMAs should not be used during chest compressions or for administering emergency medications.
Chest compressions are required in less than 0.1% of births. Neonatal bradycardia and asystole are almost always secondary to respiratory failure, hypoxemia, and acidosis, and therefore respond best to effective ventilation. Compressions are indicated when the heart rate remains below 60 bpm despite adequate PPV with 100% oxygen.
The preferred technique is the two-thumb encircling method, which provides superior perfusion and reduces rescuer fatigue. Compress the lower third of the sternum to a depth of one-third the anterior–posterior chest diameter, allowing full recoil. Coordinate compressions and ventilations at a 3:1 ratio (90 compressions and 30 breaths per minute, 120 events per minute). A 15:2 ratio may be used only in the rare case of a primary cardiac etiology. Increase oxygen to 100% during compressions and titrate down once the heart rate recovers.
The umbilical vein is the preferred route for vascular access during neonatal resuscitation. Catheter insertion of 2–4 cm is typically sufficient. Peripheral IVs, scalp veins, and IO access are alternatives. ET administration of epinephrine may be used temporarily until IV/IO access is obtained, but IV dosing should be used as soon as possible.
Epinephrine is indicated when the heart rate remains below 60 bpm despite effective ventilation with 100% oxygen and coordinated chest compressions. It may be administered via umbilical venous catheter, peripheral IV, IO line, or ET tube and repeated every 3–5 minutes. IV doses should be followed by a 1 mL saline flush. High-dose epinephrine is not recommended.
Volume expansion is indicated when the heart rate does not respond to ventilation, oxygenation, compressions, and epinephrine, or when blood loss is suspected. Administer isotonic crystalloid or packed RBCs in 10 mL/kg aliquots. Avoid rapid infusion in premature infants due to risk of intraventricular hemorrhage. Albumin-containing solutions are not recommended.
Hypoglycemia increases the risk of brain injury, especially after hypoxic-ischemic events. IV glucose infusion should be initiated as soon as practical after stabilization, with the goal of maintaining euglycemia.
Stabilization should focus on ventilation, oxygenation, compressions, and epinephrine. Other medications are rarely needed in the ED phase of care.
Not recommended routinely. May worsen intracellular acidosis. Consider only in prolonged resuscitation with documented metabolic acidosis or hyperkalemia, after adequate ventilation is established. Use 4.2% solution to reduce hypertonicity.
Not recommended during initial resuscitation. Ventilation remains the priority. Naloxone may precipitate withdrawal and seizures in infants of opioid-dependent mothers.
Not recommended for neonatal resuscitation. Neonatal bradycardia is typically hypoxia-mediated, and the vagal response is a useful physiologic indicator.
Indicated for respiratory distress due to surfactant deficiency, most commonly in infants under 35 weeks gestation. Administer via ET tube in consultation with a neonatologist.
For suspected chorioamnionitis, empiric therapy with ampicillin and gentamicin is appropriate.
After stabilization of ventilation and circulation, the infant should be continuously monitored and transported to a neonatal unit. These infants remain at high risk for deterioration. Transport should be performed by personnel trained in neonatal care with appropriate equipment and medications.
There is no validated prognostic score to guide decisions about initiating resuscitation in infants born at less than 25 weeks gestation. Decisions should be informed by regional guidelines, available resources, and shared decision-making with the mother and family. These choices must be individualized and ethically grounded.
An Apgar score of 0 at 10 minutes strongly predicts mortality and severe morbidity in late preterm and term infants. If the heart rate remains undetectable after 10 minutes of well-performed resuscitation, continuation of assisted ventilation is generally considered futile. Decisions should be individualized and inclusive of the family.
Therapeutic hypothermia initiated within 6 hours of birth reduces death or neurologic disability in infants ≥36 weeks gestation with moderate or severe hypoxic-ischemic encephalopathy. It is not recommended for infants under 36 weeks. Hypothermia should be performed in facilities capable of comprehensive neonatal care, following standardized protocols for 72 hours. Early consultation and transfer are essential when local resources are limited.
Pneumothorax can rapidly progress to tension pneumothorax and is more common in premature infants, those with surfactant deficiency, or those receiving PPV. If suspected, perform needle decompression using a 20-gauge needle or catheter with a three-way stopcock at the fourth intercostal space in the anterior axillary line or the second interspace in the midclavicular line. Follow with placement of an 8F chest tube.
CDH is a neonatal emergency confirmed by chest radiograph showing bowel gas in the thorax. Management requires immediate endotracheal intubation, avoidance of bag-mask ventilation, rapid placement of a nasogastric tube for decompression, stabilization of ventilation, and urgent pediatric surgical consultation.
Effective resuscitation requires strong leadership, clear role assignment, and closed-loop communication. Postresuscitation debriefing, simulation training, and review of resuscitation recordings help improve team performance. ED providers must maintain procedural and leadership competencies despite infrequent exposure to neonatal resuscitation.
The American Academy of Pediatrics recommends routine parental presence during pediatric resuscitation when feasible. EDs should have written policies and trained staff to support families, ensuring that all parents are offered this opportunity.
If well-executed resuscitative measures fail to achieve return of spontaneous circulation (ROSC), efforts should be discontinued unless the child is an appropriate candidate for extracorporeal CPR (E-CPR). Evidence shows that meaningful survival is extremely unlikely in children with unwitnessed arrest who remain unresponsive to airway intervention, high-quality chest compressions, and two doses of epinephrine. A brief, well-executed resuscitation is appropriate for children arriving to the ED in cardiopulmonary arrest, during which the team leader can review the history and complete the primary and secondary surveys.
Prolonged resuscitation beyond 20 minutes without ROSC is generally futile unless a reversible cause exists, such as hypothermia, drug overdose, or ventricular tachycardia/ventricular fibrillation. Longer resuscitation may be appropriate for witnessed collapse with rapid initiation of effective BLS/ACLS, particularly when a cardiac etiology is suspected. Ultimately, the decision to discontinue resuscitative efforts is made by the team leader in collaboration with the resuscitation team.
A decision not to begin resuscitation is rarely made in the ED unless a written do-not-resuscitate (DNR) order is provided by the child’s parent or guardian.
A well-prepared ED should have protocols addressing advanced directives, palliative care, bereavement support, postmortem care, survivor follow-up, and requests for autopsy or organ donation. Proper documentation is essential, as is notification of medicolegal authorities, donor programs, and referring physicians or consultants.
Cerebral injury is the leading cause of long-term morbidity in survivors of pediatric cardiac arrest. The extent of brain injury is influenced by arrest time (no-flow state), CPR duration (low-flow state), and temperature. Oxygen stores are depleted within 20 seconds of arrest, and glucose and adenosine within 5 minutes. During no-flow states, complex biochemical derangements contribute to neuronal death, and after ROSC, cerebral blood flow remains impaired. Most therapeutic interventions aimed at preventing postanoxic brain injury have been disappointing, with the exception of preventing fever.
Mild hypothermia after out-of-hospital VF arrest in adults has been associated with improved neurologic outcomes. Current AHA recommendations support targeted temperature management between 32°C and 36°C for all comatose adults after cardiac arrest, regardless of presenting rhythm or arrest location.
Large randomized trials show that therapeutic hypothermia initiated within 6 hours of birth reduces death or neurologic disability in infants ≥36 weeks gestation with moderate or severe hypoxic-ischemic encephalopathy. AHA guidelines recommend offering therapeutic hypothermia to all such infants. Hypothermia is not recommended for infants <36 weeks until further evidence is available.
Evidence for hypothermia in older infants and children is less clear. Recent randomized trials found no difference in neurologic outcomes between hypothermia (32–34°C) and normothermia (36–37.5°C). Current AHA guidelines state that either normothermia for 5 days or hypothermia for 2 days followed by 3 days of normothermia may be considered for comatose children after ROSC. Fever worsens ischemic brain injury and should be aggressively prevented; temperatures ≥38°C should be avoided.
The ED is a high-risk environment due to clinical uncertainty, frequent interruptions, time pressure, and the complexity of weight-based pediatric care. Resuscitation is especially vulnerable to error because it is team-dependent, information-intensive, and fast-paced. Ongoing surveillance of resuscitation events is essential to support the team, minimize distractions, and maximize protocol adherence.
Video review programs—where all resuscitations are recorded and a subset reviewed by a multidisciplinary committee—provide opportunities to improve care. Reviews focus on time to critical interventions, adherence to protocols, teamwork and communication, role clarity, and identification of barriers and facilitators to care. High-risk or uncommon events are often selected for review.
System-level improvements may include optimizing equipment layout, adjusting staffing models, or assigning additional senior physicians during CPR. Simulation training, especially multidisciplinary simulations in the actual resuscitation environment, helps identify latent system issues. Video review enhances cognitive decision-making, and group education sessions reinforce best practices. EDs must maintain ongoing quality improvement processes to ensure optimal care in this high-stakes environment.
Pediatric resuscitation raises complex ethical questions, including when resuscitation is futile, the physician’s obligations when families insist on continued care, the influence of religious beliefs, the role of parental presence, the appropriateness of procedures on the recently deceased, and whether resuscitation research can occur without informed consent. While professional organizations provide guidance, each ED must address these issues locally.
Postresuscitation debriefing is essential. Taking a few minutes for structured reflection improves teamwork, communication, and future performance.