Guideline 1.3 — Stabilization & Resuscitation Outside the Delivery Room

Bedside Priority

Outside the delivery room, do not assume every neonatal arrest is only a transition problem — airway and ventilation remain first, but circulatory, metabolic, equipment, surgical, and medication causes are more common than at birth.
Use the unit's neonatal code standard consistently. In most NICU settings, NRP-style ventilation-first resuscitation is appropriate during the birth hospitalization, with selected PALS concepts applied when the physiology is primarily cardiac, arrhythmic, or metabolic.
A rising heart rate is the best immediate sign that ventilation and perfusion are improving.

1. Overview & Why This Topic Matters

This chapter provides a practical NICU approach to stabilization and resuscitation of neonates who deteriorate after initial delivery room transition, including infants in the NICU, newborn nursery, radiology, procedure areas, transport preparation, or any location outside the delivery room. The goal is to rapidly restore effective ventilation, circulation, temperature control, glucose delivery, and cause-specific treatment while avoiding chaotic code management.

Why It Matters
NICU decompensation is often preventable or reversible if airway, breathing, circulation, temperature, glucose, and equipment problems are identified quickly.
Compared with delivery room resuscitation, NICU codes have a broader differential diagnosis: ETT obstruction or displacement, pneumothorax, sepsis, shock, pulmonary hypertension, duct-dependent cardiac disease, electrolyte disturbance, hypoglycemia, tamponade, and postoperative complications.
Delay in effective ventilation, chest compressions, epinephrine, or treatment of the underlying cause increases risk of death, brain injury, severe acidosis, IVH, and multiorgan injury.
A rehearsed neonatal code structure improves team communication, role clarity, timekeeping, documentation, and post-event learning.

Practical Definitions

Term	Practical Definition	Immediate Concern
Neonatal deterioration	Acute change in color, tone, respiratory effort, oxygenation, perfusion, blood pressure, or heart rate requiring urgent intervention.	May precede arrest; treat early.
Respiratory arrest	Absent or ineffective breathing with inadequate gas exchange, with or without bradycardia.	Ventilation is the key lifesaving intervention.
Severe bradycardia	Heart rate persistently <60/min despite initial corrective actions or rapidly falling with poor perfusion.	Requires effective ventilation first, then compressions if not improving.
Cardiorespiratory arrest	Absent or severely inadequate cardiac output with severe bradycardia, asystole, or pulseless rhythm.	Start full neonatal code sequence.
Pulseless electrical activity (PEA)	Organized electrical activity on ECG without effective mechanical output: no pulse, no heart sounds, absent arterial waveform, and poor perfusion.	Treat as arrest and search aggressively for reversible causes.

2. Risk Factors & Reversible Causes

Risk Factor / Cause	Why It Matters	Immediate Clinical Action
ETT displacement	A small movement can place the ETT in the pharynx, right mainstem, or outside the airway.	Check chest rise, breath sounds, depth, CO2 color change/waveform, and securement. Reintubate if uncertain.
ETT obstruction / mucus plug	Can cause sudden desaturation, bradycardia, absent chest movement, or high ventilator pressures.	Pass suction catheter. If unable to pass or no CO2/chest rise, remove/replace ETT.
Pneumothorax	May present as sudden hypoxemia, bradycardia, asymmetric chest movement, or shock.	Transilluminate/POCUS if available without delaying treatment. Needle decompress if tension physiology suspected.
Ventilator/circuit failure	Disconnected tubing, empty gas source, occluded filter, wrong settings, or failed blender can mimic infant collapse.	Disconnect from ventilator and provide manual ventilation with known functioning T-piece/bag and oxygen source.
Sepsis or septic shock	Can cause apnea, hypoperfusion, acidosis, hypotension, PEA, or arrest.	Cultures, antibiotics, fluids/inotropes as indicated after initial stabilization.
Hypovolemia / blood loss	Placental/fetal hemorrhage, postoperative bleeding, NEC, line-related bleeding, or trauma may cause shock.	Assess bleeding, Hct, lactate; give isotonic fluid or emergency PRBC when blood loss suspected.
Duct-dependent cardiac lesion	Ductal closure can cause cyanosis, shock, acidosis, or cardiovascular collapse.	Start prostaglandin urgently when suspected; consult cardiology/transport.
Pulmonary hypertension crisis	Hypoxia, acidosis, handling, and hypothermia can increase pulmonary vascular resistance.	Optimize oxygenation, ventilation, pH, sedation, systemic BP; consider iNO per unit policy.
Electrolyte/metabolic emergency	Hypoglycemia, hyperkalemia, hypocalcemia, or severe acidosis may cause bradycardia, arrhythmia, or arrest.	Check bedside glucose and urgent gas/electrolytes; treat cause immediately.
Postoperative/procedural complication	Airway edema, bleeding, tamponade, pneumothorax, anesthetic effect, or line complication may occur.	Call surgical/anesthesia team early; evaluate procedure-specific complications.

3. Clinical Presentation

Severity	Typical Findings	Clinical Concern
Early deterioration	Increasing oxygen requirement, apnea/bradycardia episodes, poor color, new retractions, reduced chest movement, abnormal ventilator alarms, temperature instability, poor perfusion.	Potentially reversible; intervene before arrest.
Impending arrest	HR trending down, severe desaturation, poor or absent respiratory effort, poor pulses, hypotension, rising CO2, worsening acidosis, mottling, low urine output.	Immediate team response; prepare advanced airway/access.
Arrest / code	HR <60/min with poor perfusion despite ventilation, asystole, PEA, no palpable pulse/heart sounds, absent arterial waveform, severe cyanosis/pallor.	Full neonatal code, compressions, epinephrine, and cause-specific treatment.

4. Diagnosis During Resuscitation — Think in Parallel

Red Flags Requiring Immediate Senior Help

No heart rate response after 30 seconds of effective ventilation.
No CO2 detection or absent chest movement in an intubated infant.
Sudden collapse in an infant with central line, chest drain, postoperative status, pulmonary hypertension, or duct-dependent cardiac disease.
Organized ECG rhythm with no pulse, no heart sounds, or absent arterial waveform: suspect PEA.
Rapidly rising lactate, severe metabolic acidosis, or persistent hypotension despite apparently adequate ventilation.

Assessment Domain	What to Check Quickly	Interpretation / Next Step
Airway	Position, secretions, ETT depth, tube patency, CO2 detector/waveform, breath sounds, chest rise.	Use DOPE: Displacement, Obstruction, Pneumothorax, Equipment failure. If uncertain, re-establish airway.
Breathing	Chest movement, oxygen source, FiO2, pressures, PEEP, lung compliance, transcutaneous CO2 if available.	Inadequate chest movement means ventilation is not effective even if the ventilator is cycling.
Circulation	HR by ECG and auscultation, pulses, perfusion, BP/arterial waveform, lactate trend.	Treat severe bradycardia after effective ventilation; suspect PEA if ECG activity exists without output.
Bedside metabolic	Glucose immediately; blood gas with pH, CO2, lactate, sodium, potassium, ionized calcium.	Treat hypoglycemia/electrolyte emergency without waiting for full lab confirmation if clinically obvious.
Imaging / POCUS	CXR, transillumination, lung ultrasound, focused cardiac ultrasound when skilled operator available.	Use only if it will not interrupt effective ventilation/compressions or urgent decompression.
History/context	Recent intubation, surfactant, suction, line placement, feeds, procedure, sedation, surgery, infection, blood loss.	The most recent event often points to the cause.

5. Management — Step-by-Step NICU Code Pathway

What to Do in the First 60 Seconds

Call for neonatal code help and start a visible timer.
Assign roles: airway, compressor, medication/access, recorder, team leader, runner, family communicator.
Move the infant to a safe resuscitation position, maintain warmth, and attach ECG/pulse oximetry if not already present.
Start effective ventilation immediately if apnea, gasping, severe bradycardia, or poor chest movement is present.
If intubated, verify tube position and patency; if in doubt, remove/replace the tube rather than ventilating through a nonfunctional airway.

5.1 Airway and Breathing

Open and position the airway; suction only if secretions or obstruction are suspected.
Provide PPV with enough pressure to generate visible chest movement and a rising heart rate; avoid excessive pressure, especially in ELBW infants, air leak, CDH, pulmonary hypoplasia, or postoperative lungs.
Use ECG heart rate, pulse oximetry, auscultation, CO2 detection, and chest movement together — no single monitor is perfect during a code.
When compressions are needed, an endotracheal tube is preferred if skilled personnel are available; a laryngeal mask can be a rescue airway when mask ventilation is ineffective and intubation is unsuccessful or delayed.
For ventilated infants, disconnect from the ventilator and manually ventilate with a functioning device if equipment failure or circuit obstruction is possible.

5.2 Chest Compressions

Begin compressions when HR remains <60/min after effective ventilation and ventilation corrective steps.
Use the two-thumb encircling technique whenever possible; compress the lower third of the sternum to approximately one-third of the anterior-posterior chest diameter and allow full recoil.
Use 3 compressions to 1 ventilation for most neonatal arrests because respiratory failure is the common pathway.
Use 100% oxygen during compressions, then wean once heart rate and oxygenation recover.
Minimize interruptions — pause briefly only when needed to assess heart rate/rhythm accurately or deliver critical interventions.

5.3 When to Consider a 15:2 Ratio

Compression Ratio Decision

A 3:1 ratio remains the default for most neonatal deterioration and NICU codes.
A 15:2 synchronized ratio can be considered when the arrest is believed to be primarily cardiac, arrhythmic, or due to severe electrolyte disturbance — especially in older/larger infants during prolonged hospitalization.
Do not switch algorithms in a way that confuses the team. The best algorithm is the one the team can execute correctly and consistently.

5.4 Vascular Access and Medications

Obtain UVC, existing central line access, PIV, or IO access quickly; do not delay ventilation/compressions for access attempts.
Give epinephrine if HR remains <60/min after effective ventilation and 60 seconds of coordinated compressions.
Treat volume loss only when suspected or when shock is present; routine volume during arrest can worsen myocardial performance and may increase risk in extremely preterm infants.
Correct hypoglycemia immediately and treat severe electrolyte abnormalities according to neonatal formulary/local policy.

Medication / Intervention	Typical Neonatal Dose	When to Use	Monitoring / Cautions
Epinephrine IV/IO 1:10,000 (0.1 mg/mL)	0.01–0.03 mg/kg = 0.1–0.3 mL/kg; repeat every 3–5 min if HR remains <60/min.	After effective ventilation and 60 sec of compressions if HR remains <60/min.	Preferred route is intravascular. Flush per local policy. Confirm concentration carefully.
Epinephrine via ETT	0.05–0.1 mg/kg = 0.5–1 mL/kg of 1:10,000 while vascular access is being obtained.	Temporary route only if no IV/IO access yet.	Absorption is unreliable; do not delay vascular access.
Normal saline 0.9%	10 mL/kg IV/IO; reassess before repeating.	Shock, suspected hypovolemia, blood loss, poor perfusion with acidosis.	Avoid routine or rapid repeated boluses in ELBW/preterm infants unless clearly indicated.
Emergency PRBC	10–15 mL/kg; use emergency O-negative/uncrossmatched per hospital policy if life-threatening hemorrhage.	Suspected major blood loss or severe anemia causing shock/arrest.	Monitor perfusion, lactate, Hct, calcium/potassium if massive transfusion.
Dextrose 10%	2–2.5 mL/kg IV; then adjust GIR/continuous infusion.	Hypoglycemia or suspected low glucose during decompensation.	Recheck glucose within 15–30 min and avoid rebound hyperglycemia.
Sodium bicarbonate 4.2%	1–2 mmol/kg IV slowly; only after adequate ventilation is established and under senior direction.	Selected cases of severe metabolic acidosis or prolonged resuscitation after correcting ventilation/perfusion.	Not routine initial resuscitation; rapid/hypertonic administration may be harmful, especially in preterm infants.
Cause-specific therapy	Per neonatal formulary: calcium for severe hypocalcemia/hyperkalemia with ECG changes; insulin/glucose for hyperkalemia; antibiotics for sepsis; prostaglandin for duct-dependent lesion.	When the code is driven by a defined reversible cause.	Use pharmacy support and double-check concentrations.

Baylor Ch 1.3 — NRP or PALS in the NICU?

Which algorithm

NICU codes are not delivery-room codes. In the delivery room almost every arrest is a ventilation problem; in the NICU only 75–80% are — the rest are circulatory and need compressions.
No evidence favours switching to PALS at any particular age or corrected age. Baylor uses NRP as the standard throughout the NICU, on the principle that an algorithm the team practises is safer than one it rarely uses — while borrowing specific PALS concepts where they help.
Ventilation still comes first. If the airway is not secure, place a tube or laryngeal mask — a tube is preferred when compressions are needed.

Element	Baylor guidance
Compression technique	Depth at least one-third of the chest's front-to-back diameter — about 1.5 inches in an infant. Full recoil between compressions, and as few interruptions as possible. Two thumbs, hands encircling the chest, up to a year of age. If your hands cannot encircle the chest, use the heel of one hand with a backboard so the depth is real.
Compression-to-ventilation ratio	3:1 (NRP) — it shortens the time to return of circulation in newborns. PALS uses 15:2 without an advanced airway, and 20–30 breaths/min with one. Baylor does not use continuous asynchronous compressions in neonates, because they interfere with adequate ventilation. Switch to 15:2 when the arrest is from a suspected primary arrhythmia or electrolyte disturbance rather than a respiratory cause.
Defibrillation	Place pads early if a primary arrhythmia or electrolyte disturbance is suspected (see 3.5)
Reversible causes	Work through the H's and T's — see the dedicated section on this page

Pulseless electrical activity — under-recognized in neonates

What it is: organized electrical activity on the monitor with no detectable cardiac output. The rate may be fast, normal or slow, and the complexes normal or wide, with varying T waves or AV dissociation. It is pre-terminal and usually progresses to asystole.
Suspect it when there is a rhythm on the ECG but no palpable brachial or femoral pulse and no audible heart sounds, and no waveform on the pulse oximeter or arterial line.
Careful with waveforms during CPR — what you see may be flow generated by the compressions, not the heart.
Point-of-care ultrasound for myocardial activity helps make the diagnosis.
Treat it exactly as asystole: CPR with epinephrine every 3–5 minutes, while hunting the reversible cause.

Source check: Baylor prints a compression rate of “100–200 per min”. NRP delivers 90 compressions with 30 breaths per minute in the 3:1 pattern, and PALS uses 100–120/min — use those; the printed upper figure has no basis in either standard.

Baylor medication chart (Table 19-5)	Dose	How / cautions
Epinephrine 0.1 mg/mL	IV 0.01–0.03 mg/kg (0.1–0.3 mL/kg); ET 0.05–0.1 mg/kg (0.5–1 mL/kg)	Every 3–5 min for pulseless arrest, PEA, asystole or bradycardia; maximum 0.1 mg per dose; 5 manual breaths after ET dosing
Adenosine	0.1 mg/kg, then 0.2 mg/kg if no effect in 2 min	Rapid push over 1–2 s with saline flush before and after, via central line or a site close to the trunk
Synchronized cardioversion	0.5–1 J/kg, then 2 J/kg	Sedate if possible but do not delay
Calcium chloride 10%	20 mg/kg	Over 3–5 min; hyperkalaemia or arrest with hypocalcaemia; not with phosphate-containing fluids
Calcium gluconate	100 mg/kg	Slow push over 5–10 min; not with phosphate
Dextrose 10%	Hypoglycaemia 2 mL/kg; hyperkalaemia 4 mL/kg with regular insulin 0.1 units/kg	At 1 mL/min
Albumin 5%	10–20 mL/kg over 2–4 h	Volume only (use 25% for albumin replacement)
Lidocaine	IV 1 mg/kg; ET 2 mg/kg	Pulseless VT/VF — not SVT
Naloxone	IV/IM 0.1 mg/kg every 2–3 min if needed; ET 0.2 mg/kg	Reverses all analgesia; may precipitate withdrawal. NRP does not include naloxone in delivery-room resuscitation — support ventilation first.
Sodium bicarbonate 4.2%	2 mEq/kg over 2 min	Use in codes discouraged — may cause IVH and worsen intracellular acidosis
Intubation drugs	Atropine 0.02 mg/kg (no minimum dose); fentanyl IV 1–2 mcg/kg over 5 min (intranasal 1.5–2 mcg/kg, half in each nostril, 50 mcg/mL); vecuronium 0.08–0.1 mg/kg	Same doses as the premedication table in 5.3
Infusions	Alprostadil 0.0125–0.1 mcg/kg/min; dopamine 2.5–20; epinephrine 0.01–1; norepinephrine 0.02–1; phenylephrine 0.1–0.5 mcg/kg/min; vasopressin 0.01–0.04 units/kg/h (watch sodium); milrinone 0.25–0.75 mcg/kg/min (loading doses cause hypotension; caution in renal dysfunction and severe outflow obstruction)	Titrate to effect
Antihypertensive infusions	Nitroprusside 0.5–10 mcg/kg/min (thiosulfate above 4; <3 in renal dysfunction; de-escalate if no response 10 min at maximum); nicardipine 0.5–2 mcg/kg/min; esmolol 25–500 mcg/kg/min	Nicardipine maximum 2 mcg/kg/min, on ECMO too (6.3)
Sedation	Fentanyl 1–2 mcg/kg bolus, infusion 0.5–1 mcg/kg/h (titrate 0.5–1); morphine 0.05–0.1 mg/kg every 4–8 h or bolus then 0.01 mg/kg/h (titrate 0.01–0.03); midazolam 0.05–0.15 mg/kg every 2–4 h, infusion 0.03 (≤32 wk PMA) or 0.06 mg/kg/h (>32 wk); lorazepam 0.05 (0.02–0.1) mg/kg every 4–8 h, status epilepticus 0.1 mg/kg repeatable once	Fentanyl preferred in renal dysfunction, bolus over ≥5 min (chest-wall rigidity); avoid morphine in renal dysfunction. Avoid benzodiazepines for sedation below 44 weeks PMA, except CDH sedation (11.7).
Other	Ibuprofen lysine 10 mg/kg then 5 mg/kg every 24 h × 2 (birth weight); indomethacin IVH prophylaxis 0.1 mg/kg every 24 h × 3, started within 12 h, for ≤26 6/7 weeks or <800 g; vecuronium 0.1 mg/kg every 1–2 h as needed or 0.06–0.09 mg/kg/h infusion	Ibuprofen preferred for PDA (less nephrotoxicity); vecuronium lasts longer in hepatic or renal dysfunction

6. Monitoring During and After Resuscitation

Parameter	Frequency	Target / Concern	Action if Abnormal
Heart rate	Continuous ECG plus auscultation during checks	Rising HR is best sign of effective ventilation; HR <60/min triggers compressions after effective ventilation.	Confirm chest movement/CO2; start or continue compressions and epinephrine pathway.
Chest movement and CO2	Continuous visual assessment; CO2 with every airway change	Visible movement and exhaled CO2 support effective ventilation and airway placement.	Use MR SOPA/DOPE; reintubate if uncertain.
SpO2	Continuous when signal reliable	Use preductal sensor when relevant; interpret cautiously during poor perfusion.	Titrate FiO2 after stabilization; use 100% during compressions.
Blood pressure / arterial waveform	Continuous if arterial line present; frequent cuff if not	Hypotension, absent waveform, or PEA physiology.	Assess perfusion, volume loss, inotropes, tamponade, pneumothorax.
Blood gas and lactate	At stabilization and repeated based on severity	Severe acidosis, hypercarbia, rising lactate, electrolyte abnormality.	Optimize ventilation/perfusion; treat metabolic cause.
Glucose	Immediately during unexplained deterioration; repeat after treatment	Hypoglycemia can mimic or worsen arrest.	D10 bolus and GIR adjustment.
Temperature	During code and after return of circulation	Avoid hypothermia and hyperthermia.	Use incubator/radiant heat, plastic wrap/hat in ELBW, warmed gases/fluids when appropriate.
Urine output	Hourly after event	Low output suggests shock, renal injury, or poor perfusion.	Review fluids, BP, lactate, renal function.

7. Complications

Complication	Timing	Prevention / Management
Hypoxic-ischemic injury	During arrest and recovery	Rapid effective ventilation/perfusion; avoid recurrent events; consider neurology evaluation when indicated.
Severe acidosis and myocardial dysfunction	During prolonged shock/arrest	Restore ventilation and circulation; treat cause; serial lactate/gas.
Pneumothorax or air leak	During PPV, high pressures, or lung disease	Use the lowest effective pressure; diagnose and decompress quickly if tension physiology.
IVH risk in ELBW/preterm infants	During rapid hemodynamic shifts	Avoid unnecessary rapid fluid boluses, hyperosmolar therapy, excessive ventilation pressure, and rough handling.
Medication error	During code urgency	Use closed-loop communication, weight-based code sheet, pharmacy double-check, concentration labels.
Post-resuscitation instability	Minutes to hours after return of circulation	Close monitoring for recurrent apnea, shock, glucose disturbance, seizures, electrolyte changes, and organ injury.

8. Special Situations

Situation	Key Bedside Issue	Practical Approach
Intubated infant suddenly deteriorates	DOPE until proven otherwise.	Check displacement, obstruction, pneumothorax, equipment. If no CO2/chest rise or suction catheter cannot pass, remove/replace ETT.
HFOV/HFJV patient	Ventilator alarms may hide airway or lung emergency.	Assess chest wiggle/vibration, ETT patency, circuit, gas source, pneumothorax. Manually ventilate if equipment failure suspected.
ELGAN / ELBW infant	High risk of hypothermia, skin injury, IVH, pneumothorax, and rapid glucose instability.	Gentle handling, thermal bundle, careful pressure/volume, avoid rapid unnecessary boluses, use experienced airway operator.
Duct-dependent CHD	Excess oxygen and hyperventilation may worsen systemic-pulmonary balance in selected lesions.	If suspected, consult cardiology/transport and start prostaglandin per policy; target oxygen based on lesion physiology.
Pulmonary hypertension crisis	Hypoxia/acidosis/hypothermia/agitation increase pulmonary vascular resistance.	Optimize oxygenation, ventilation, pH, temperature, sedation, and systemic BP; consider iNO and echo.
Postoperative neonate	Bleeding, airway edema, pain, anesthetic effect, tamponade, pneumothorax, or line complication.	Call surgery/anesthesia early; inspect drains/lines, hemoglobin, gas/lactate, CXR/POCUS as indicated.
PEA	ECG rhythm does not equal perfusion.	Check pulses, heart sounds, arterial waveform, POCUS if skilled; start CPR/epinephrine and treat Hs and Ts.

9. NICU Code Algorithm — Outside the Delivery Room

Recognize deterioration — call neonatal code, start timer, assign roles.

Do not wait for full arrest if the infant is rapidly worsening.

Warm, position, attach ECG/pulse oximetry — assess airway/breathing/circulation simultaneously.

Avoid hypothermia and delay in ventilation.

If apnea, gasping, HR falling, or poor chest movement: begin effective PPV immediately.

Look for chest rise and rising HR.

If HR not rising after 15–30 sec: perform ventilation corrective steps (MR SOPA) and evaluate DOPE if intubated.

If no effective ventilation, place or replace advanced airway.

If HR remains <60/min after effective ventilation: increase FiO2 to 100%, begin 3:1 compressions, confirm airway.

Use ETT if skilled team available; minimize interruptions.

Obtain UVC/PIV/IO or use existing reliable central access.

Do not interrupt compressions/ventilation for prolonged access attempts.

If HR remains <60/min after 60 sec of compressions: give IV/IO epinephrine; repeat every 3–5 min as needed.

ETT epinephrine only as temporary bridge while vascular access is obtained.

Treat reversible causes: Hs and Ts, glucose, electrolytes, blood loss, pneumothorax, sepsis, duct closure, tamponade, equipment failure.

Assign a clinician to lead diagnostic thinking while the code continues.

After return of circulation: stabilize ventilation, perfusion, temperature, glucose, and acid-base status.

Prepare post-code monitoring, imaging, labs, consults, and family update.

Debrief, document exact timeline, and identify preventable system issues.

Complete event review/QI process.

10. Hs and Ts for Neonatal Arrest

H Causes

Hypoxia

Ensure effective ventilation and airway; check ETT/circuit.

Hypovolemia

Assess blood loss/shock; isotonic fluid or PRBC as indicated.

Hydrogen ion / acidosis

Improve ventilation and perfusion; consider senior-directed bicarbonate only after effective ventilation.

Hypoglycemia

Check bedside glucose; give D10 and adjust GIR.

Hypo-/hyperkalemia

Check gas/electrolytes; treat per emergency electrolyte protocol.

Hypothermia

Warm actively; avoid cold exposure during code.

T Causes

Tension pneumothorax

Transilluminate/POCUS if no delay; needle decompress if suspected.

Tamponade

Suspect with central line/cardiac disease/procedure; urgent echo/consult.

Toxins / medication

Review recent opioids, sedatives, paralytics, infusions; stop error and treat accordingly.

Thrombosis, coronary

Rare; consider CHD, catheter-related event; urgent cardiology.

Thrombosis, pulmonary

Consider line-associated or postoperative collapse; urgent specialist input.

Equipment failure

Not classic H/T but common in NICU: switch device/source and manually ventilate.

11. Areas Where Practice May Differ

Clinical Question	Approach A	Approach B	Practical Interpretation
NRP or PALS outside the delivery room?	Use NRP-style neonatal algorithm throughout the birth hospitalization.	Use selected PALS concepts for older infants or primary cardiac/electrolyte physiology.	Choose a unit standard and train consistently; modify by physiology, not by habit.
3:1 or 15:2 compression ratio?	3:1 for most neonatal arrests where respiratory failure is primary.	15:2 may be considered for primary cardiac, arrhythmia, or electrolyte arrest.	3:1 remains the default NICU neonatal code ratio unless the team leader deliberately chooses otherwise.
LMA or ETT?	LMA can rescue failed mask ventilation or failed intubation.	ETT is preferred for prolonged ventilation and compressions when skilled intubator is present.	Do not let repeated failed intubation delay effective ventilation.
Sodium bicarbonate?	Not part of routine initial resuscitation.	May be used selectively after adequate ventilation/perfusion for severe metabolic acidosis under senior direction.	Correct ventilation and perfusion first; avoid rapid hypertonic boluses in preterm infants.
Routine volume bolus?	Avoid routine volume in arrest without evidence of shock/blood loss.	Use volume or blood when hypovolemia is suspected or perfusion is poor.	Volume is a treatment for a cause, not a substitute for ventilation and compressions.

12. Common Mistakes

Common Mistake	Why It Is Harmful	Better Approach
Continuing ventilator breaths through an obstructed or displaced ETT	No effective ventilation occurs while bradycardia worsens.	Check CO2/chest rise; suction; remove/replace ETT if uncertain.
Starting compressions before effective ventilation	Most neonatal arrests are ventilation-related; compressions without ventilation do not fix the cause.	Prioritize airway opening, chest movement, and rising HR before compressions unless obvious primary cardiac event.
Trusting ECG alone	ECG can show organized rhythm without mechanical output (PEA).	Confirm heart sounds, pulses, perfusion, and arterial waveform; suspect PEA when discordant.
Repeated intubation attempts by multiple operators	Delays oxygenation and causes trauma/hypoxia.	Limit attempts, use most skilled airway operator, switch to LMA or mask ventilation when needed.
Not checking glucose/electrolytes	Metabolic causes may drive recurrent bradycardia or PEA.	Point-of-care glucose and urgent gas/electrolytes early in unexplained collapse.
No team leader or recorder	Timeline, medications, and decisions become unreliable.	Assign roles immediately; use closed-loop communication.
No post-code debrief	Preventable system issues are repeated.	Complete hot debrief, documentation, family update, and QI review.

13. Teaching Points

High-Yield Teaching Points

Ventilation is still the first lifesaving treatment in most neonatal codes, but NICU collapse is not always a delivery-room transition problem.
In an intubated infant, sudden desaturation/bradycardia is DOPE until proven otherwise.
A rising heart rate tells you more than almost any other single sign during early resuscitation.
PEA is easy to miss in neonates — organized ECG activity is not enough if there is no pulse, heart sound, perfusion, or arterial waveform.
The code team must run two processes in parallel: high-quality resuscitation and active search for the reversible cause.
Closed-loop communication prevents duplicated epinephrine, missed glucose checks, delayed compression starts, and unclear airway decisions.

14. Family Communication

Suggested Language for Parents

"Your baby had a sudden serious change in breathing and circulation. The team immediately supported breathing, heart rate, blood pressure, and oxygen levels while looking for the cause. We will explain what happened, what treatments were needed, what we think caused it, and what we are monitoring now. We will keep you updated and answer your questions as clearly as possible."

Documentation and Debrief

Document objective facts: time deterioration recognized, initial findings, airway status, HR, oxygen saturation, interventions, medication dose/route/time, response, suspected cause, consultants called, and family communication.
Record the post-code plan: respiratory settings, target saturations, hemodynamic goals, labs/imaging, antimicrobials, prostaglandin/iNO/inotropes if used, neurologic monitoring, and follow-up discussions.
Perform a short hot debrief before the team disperses: what went well, what was delayed, equipment/medication issues, communication gaps, and immediate safety fixes.

15. High-Yield Summary

Key Takeaways

Call help early; assign roles and start a timer.
Fix ventilation first — airway position, ETT patency, ETT position, chest movement, and CO2 detection.
Start compressions when HR remains <60/min after effective ventilation and corrective steps.
Use epinephrine IV/IO after effective ventilation plus 60 seconds of compressions if HR remains <60/min.
Search for reversible causes using DOPE and Hs/Ts — pneumothorax, equipment failure, hypoglycemia, hyperkalemia, sepsis, blood loss, PEA, duct closure, and pulmonary hypertension.
After return of circulation: stabilize, monitor, document, update the family, and debrief.

16. References

1. Lee HC, Strand ML, Finan E, et al. Part 5: Neonatal Resuscitation: 2025 American Heart Association and American Academy of Pediatrics Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics. 2026;157(1):e2025074352.
2. American Heart Association. Part 5: Neonatal Resuscitation: 2025 AHA/AAP Guidelines for CPR and ECC.
3. Weiner GM, Lee HC, Cooper CM, eds. Textbook of Neonatal Resuscitation, 9th edition. American Academy of Pediatrics; 2025.
4. Baylor College of Medicine, Division of Neonatology. Guidelines for Acute Care of the Neonate, Edition 33, 2025–2026: Section 1.3 Stabilization and Resuscitation Outside of the Delivery Room.
5. Bedside Clinical Guidelines Partnership and West Midlands Perinatal Network. Neonatal Guidelines 2025–28: Resuscitation guideline.
6. Ministry of Health Belize. Neonatal Clinical Practice Guidelines 2018–2021: Neonatal Resuscitation.

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