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

4. 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 /min60 – 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