C0009 NRP® Current Issues Seminar: Monumental Changes on the Horizon
Chest Compressions in Neonatal
Cardiopulmonary Resuscitation
Vishal Kapadia, MD, MSCS, FAAP
University of Texas Southwestern Medical Center at Dallas
Faculty Disclosure Information
In the past 12 months, I have no relevant financial
relationships with the manufacturer(s) of any commercial
product(s) and/or provider(s) of commercial services
discussed in this CME activity.
I do not intend to discuss an unapproved/investigative
use of a commercial product/device in my presentation.
Session Objectives
 Describe indications of chest compressions
during neonatal CPR
 Understand goal of cardiac compression during
neonatal CPR
 Understand correct technique of neonatal chest
compressions
 Discuss evidence behind current guidelines for
neonatal CPR
Anticipate Neonatal CPR
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You get a page for stat C/S
20 yo G1P0 mom, No prenatal care
Clinical diagnosis of Chorioamnionitis
Fetal bradycardia with loss of baseline
variability
 Bedside sono suggest 39 wks
How to Prepare for Neonatal CPR
 Assessment of perinatal risk
 Mobilization of the team
 Identification of team leader and pre-resuscitation
briefing: Anticipating interventions and assigning roles.
 A standardized checklist to ensure that all necessary
supplies and equipment are present and functioning
 Decide on an estimated weight
 May prepare umbilical catheter and may draw up
intravenous epinephrine doses and label
Going Back to Our Baby
 Baby is delivered, cord clamped and given to
neonatal team
 Found to be not breathing and limp
 Airway positioned, secretions cleared, dried and
stimulation provided
 Remains apneic and HR around 20
 Positive pressure ventilation is initiated. Pulse
oximeter is attached.
 Heart rate remains 20 bpm.
What is the next step?
If after initiation of PPV, HR remains < 60
You should
A. Start chest compressions
B. Stimulate the neonate
C. Auscultate for full 1 minute for accurate HR
assessment
D. Attempt ventilation corrective steps:
MRSOPA
Indication of Cardiac Compression during
Neonatal CPR
 If heart rate remains below 60 bpm despite
adequate ventilation via advanced airway if
possible.
 Ensure that assisted ventilation is being delivered
optimally before starting chest compressions
 Ventilation is the most effective action in neonatal
resuscitation.
 Chest compressions are likely to compete with
effective ventilation
Ventilation Corrective Steps
Goal of Compressions
 Goal is to deliver sufficient oxygenated blood to the
myocardium ( coronary) and to vital organs,
especially brain.
 Coronary perfusion is a determinant of return of
spontaneous circulation (ROSC). As oxygenated
blood reaches the heart providing the energy (ATP),
it may start beating again.
 Cerebral perfusion is a determinant of neurologic
outcome
Coronary Perfusion Pressure
Coronary Perfusion Pressure=Aortic DBP – Right Atrial DBP
Compressions with
 Diastolic BP
Compressions with
Minimal Diastolic BP
Coronary
Arteries
ATPATP
ATP
Heart
Heart
Aorta
α-adrenergic effects
of epinephrine or
uninterrupted
compressions
lead to 
Aorta
Aortic DBP
Adequate Diastolic Blood Pressure is Critical
to the Success of CPR
Coronary Perfusion
Pressure = Aortic
DBP – Right Atrial
DBP
C
P
P
Compression Ventilation
Robert A. Berg et al. Circulation. 2001;104:2465-2470
Optimal Neonatal Cardiac Compressions
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Location
Compression depth
Two thumbs versus Two finger Method
Compression to ventilation ratio
Synchronization
Location: Lower 1/3 of Sternum
 You et al. Resuscitation 2009: Retrospective review of
CT scan images. ( n= 75, mean age 4 ± 3 months) Left
ventricle (Max AP diameter of heart ) located under
lower third of sternum.
 Clements 2000 and Saini 2012 : Anatomic relationship
between the nipples and lower sternum to determine
finger position is not reliable.
 Running one’s fingers along the lower edge of the rib
cage to locate the xiphoid, then placing the thumbs
centrally and immediately above the xiphoid, avoiding
direct pressure on the xiphoid.
Compression Depth
 Chest compressions should be
administered to a depth of approximately
one-third of the AP diameter of the chest
to produce a palpable pulse.
 The chest should be allowed to fully recoil
before the next compression to allow the
heart to refill with blood.
Administer Compressions at a Depth of
1/3 the AP Diameter of the Chest
– Retrospective observational
study in neonates (n=54)
– Mathematical modeling based
upon neonatal chest CT scan
dimensions
– 1/3 AP chest depth should be
more effective than 1/4
compression depth, and safer
than 1/2 AP compression depth
Meyer et al. Resuscitation 2010
What method of compressions should be
used?
 Two thumb technique: Hands encircling
the chest and thumbs depressing the
sternum
 Two finger technique: Index and middle
fingers to depress the sternum with the
other hand behind the back providing a
firm base
Which technique is recommended for providing
chest compressions?
A. Two thumbs method
B. Two fingers method
C. Two thumbs method except when
attempting line placement or managing
airway
D. The one you are most familiar with
Use Two-Thumb Method Rather than
Two-Finger Method for Neonatal Cardiac
Compressions
Use Two-Thumb Method Rather than
Two-Finger Method for Neonatal Cardiac
Compressions
Use Two-Thumb (TT) Method Rather
than Two-Finger (TF) Method
 11 manikin RCTs including those using newborn manikin
show with TT method:
•
•
•
•
•
Higher BP
Appropriate compression depth
Consistent correct placement on chest
Less variance in compression quality
Less fatigue over time
 Multiple human and neonatal observational studies and
animal studies agree with superiority of two thumbs method.
Two Finger Method Should Not
be Used
 Disadvantages of two thumb method from the
side of the bed.
1. No easy access to the umbilicus for line and
medication. Many providers switch to TF
method during line placement.
2. Must reach across the patient and body is
not aligned to use large muscle groups for
effective chest compressions.
Head of Bed Compressions Allows
Continuous Two-thumb Technique
 Once an airway is secured, move the
compressor to head of bed
 Potential Advantages: Arms are in a more natural
position, Umbilical access is more readily available
while continuing Two-thumb technique, More space
for person giving meds at the patient’s side
 Less compressor fatigue (Unpublished data, Sparks et
al)
 Two finger method should no longer be
used.
What Ratio of Compression to Ventilation to
Use (C:V ratio)
 In Adult V-fib model: problem with flow, not the content of
the blood
• Forward flow from left ventricle ceases
• Blood has near normal carbon dioxide, oxygen and pH.
• Emphasis on chest compression over ventilation
 In Neonatal asphyxial arrest, left ventricular blood has much
lower oxygen tension, higher carbon dioxide and lower pH.
• Neonatal CPR needs adequate airway and ventilation to
oxygenate the blood and good quality chest compression to
move that blood forward.
In Asphyxia Animal Model, Chest Compression with
Ventilation is Superior to Ventilation or Compression
Alone
CC + V
(n=10)
CCC
(n=10)
V
(n=10)
7.42 ± 0.01
7.42 ± 0.02
7.40 ± 0.01
43 ± 1
42 ± 1
45 ± 2
7.20 ± 0.03
7.17 ± 0.04
7.23 ± 0.04
68 ± 5
77 ± 11
51 ± 3
10 (100%)
4 (40%)
6 ( 60%)
Baseline (before asphyxia)
Arterial pH
Arterial pCO2 (mmHg)
After 1 min of CPR
Arterial pH
Arterial pCO2 (mmHg)
ROSC obtained in < 2 min, n
(%)*
*p  0.01
Berg RA et al. Circulation 2000
What Ratio of Compression to
Ventilation to Use
Study
Year
Design
Total Pts
Population
Solevag
2010
RCT
32
Pigs (12-36 hrs)
Solevag
2011
RCT
22
Pigs (12-36 hrs)
Solevag
2012
RCT
2 (x 5 runs) Neo Resus Providers
Dannevig
2012
RCT
31
Pigs (12-36 hrs)
Dannevig
2013
RCT
54
Pigs ( 14-34 hrs)
Hemway
2013
RCT
32
Neo Resus Providers
Schmolzer
2014
RCT
16
Pigs (1-4 days)
Compression to Ventilation Ratio 15:2 is Not
Superior to 3:1 in Neonatal Asphyxia Model
3:1
(n=9)
15:2
(n=9)
P
Value
58 ± 7
75 ± 5
<0.001
4.8 ± 2.6
7.1 ± 2.8
0.004
2
2
NS
150 (140-180)
195 (145-358)
NS
pH following ROSC
6.6 ± 0.1
6.6 ± 0.1
NS
pCO2 ( kPa)
11.2 ± 4.3
9.6 ± 2.7
NS
Cardiac Compression/min
Increase in DBP during compression cycles
(mmHg)
Number of animals with no ROSC
Time to ROSC (sec)*
DBP=Diastolic Blood Pressure, ROSC=return of spontaneous circulation
Solevåg et al. ADC 2011
Continue Use of 3:1 Compression to
Ventilation Ratio
 Animal studies: No advantage to higher C:V ratio for tissue
injury, gas exchange during CPR, time to return of
spontaneous circulation.
 Manikin studies ( Hemway 2013, Solevag 2012): disadvantage
of higher ratio regarding compressor fatigue and minute
ventilation.
 A 3:1 C:V ratio is recommended, with 90 compressions and 30
breaths to achieve approximately 120 events per minute to
maximize ventilation at an achievable rate.
 Rescuers may consider using higher ratios (eg, 15:2) if the
arrest is believed to be of cardiac origin
Should we continue to coordinate the
compressions and ventilations?
 Compressions and ventilations should be
coordinated to avoid simultaneous
delivery.
Asynchronous CPR Appears Equivalent
to 3:1 CPR in Asphyxiated Neonatal Pigs
 Term newborn piglets,
8/group
 After ROSC CCaV group had
higher pCO2, lower pH and
higher lactate.
 No difference in
◦ 3:1
◦ 3:1
• Asynchronous − ROSC
• Asynchronous
− Survival
− Hemodynamic parameters
− Minute ventilation
Schmölzer et al Resuscitation 2014
What is the recommended method to
estimate heart rate during neonatal CPR?
A.
B.
C.
D.
E.
Auscultation
Palpation of umbilical cord
ECG monitor
Pulse oximetry
Palpation of radial pulse
Continue Good Practice and Change in
Practice
 Anticipate need for resuscitation
 Optimal assisted ventilation via advanced airway before
starting chest compressions
 Use ECG monitor during CPR
 Always two thumb compressions. Move to head of the bed
during emergent umbilical line placement.
 Continue 3:1 C:V ratio. Compress lower third of sternum.
 Avoid unnecessary interruption of chest compression as CPP
drops when interrupted.
 Be aware of compressor fatigue and switch
Evidence Based Resuscitation
Guideline documents:
 Perlman JM, Wyllie J, Kattwinkel J, Wyckoff M, Aziz K,
Guinsburg R, Kim HK, Liley H, Mildenhall L, Simon WM, Szyld E,
Tamura M, Velaphi S. Part 7: Neonatal resuscitation: 2015
International consensus on cardiopulmonary resuscitation and
emergency cardiovascular care science with treatment
recommendations. Circulation 2015; In press.
 Wyckoff MH, Aziz K, Escobedo M, Kapadia V, Kattwinkel J,
Perlman JM, Simon W, Weiner GM, Zaichkin J. Part 13:Neonatal
resuscitation: 2015 American Heart Association Guidelines for
cardiopulmonary resuscitation and emergency cardiovascular
care. Circulation. 2015; In press.
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