NRP practice cases with decision points and answers

Start positive-pressure ventilation. Assisted ventilation is indicated for apnea, gasping or a heart rate below 100 bpm by 1 minute, and it should begin within the first minute.

At 37 weeks, start with 21% oxygen at 30 to 60 breaths per minute and an initial PIP of 25 cm H₂O. Place the pulse oximeter on the right hand or wrist, and consider a cardiac monitor.

Start the ventilation corrective steps and check for chest movement after each one.

Adjust the mask, reposition the head and neck, suction the mouth and nose, open the mouth, increase the pressure, and move to an alternative airway if the chest still doesn't move (MR SOPA).

Keep ventilating while the baby starts to breathe, and adjust FiO₂ to the minute-specific SpO₂ targets. Lower the rate and pressure as breathing effort improves.

If mask ventilation goes on for more than several minutes, insert an orogastric tube. Afterward, move to post-resuscitation care, talk with the family and hold a team debriefing.

The heart rate is below 60 bpm despite at least 30 seconds of ventilation that moves the chest, so raise FiO₂ to 100% and start chest compressions.

Move to the head of the bed now that the airway is secure. Put your thumbs on the sternum just below the nipple line, press about one third of the front-to-back diameter of the chest, and coordinate 3 compressions to 1 breath (90 and 30 per minute). Ask for help and get vascular access ready (UVC or IO).

Give epinephrine. Use only the dilute 0.1 mg/mL concentration, IV or IO. The suggested dose is 0.02 mg/kg (acceptable range 0.01 to 0.03), and you can repeat it every 3 to 5 minutes.

An endotracheal dose (0.1 mg/kg) may be considered only while vascular access is being established. You can work out the volume with the epinephrine dose calculator.

Hypovolemia and pneumothorax. Give a 10 mL/kg volume expander if there are signs of shock or a history of acute blood loss. A pneumothorax may show up as decreased breath sounds and increased transillumination on the affected side.

A room at 23 to 25 °C (74 to 77 °F). Because the baby is under 32 weeks, a polyethylene plastic bag or wrap and a thermal mattress. A ventilation device that can give PEEP and CPAP, an oxygen blender and a pulse oximeter. Skilled personnel and surfactant available.

Wrap the baby in the plastic bag or wrap without drying, and place the baby on the preheated radiant warmer. Keep the room warm.

Use the pulse oximeter, give oxygen if needed and consider CPAP rather than intubating. CPAP is an option when a baby is breathing spontaneously with a heart rate of at least 100 bpm but has labored respirations or low oxygen saturation.

Avoid high CPAP pressures.

To lower the risk of neurologic injury, handle the baby gently, avoid positioning the legs higher than the head, avoid high ventilation or CPAP pressures, use the pulse oximeter and blood gases to adjust ventilation and oxygen, and avoid rapid IV fluid infusions.