Drugs are rarely indicated in resuscitation of the newly born infant. Bradycardia in the newborn infant is usually the result of inadequate lung inflation or profound hypoxemia, and establishing adequate ventilation is the most important step toward correcting it. If the heart rate remains <60 per minute despite adequate ventilation (usually with endotracheal intubation) with 100% oxygen and chest compressions, administration of epinephrine or volume expansion, or both, may be indicated. Rarely, buffers, a narcotic antagonist, or vasopressors may be useful after resuscitation, but these are not recommended in the delivery room. Epinephrine is recommended to be administered intravenously (Class IIb, LOE C). Past guidelines recommended that initial doses of epinephrine be given through an endotracheal tube because the dose can be administered more quickly than when an intravenous route must be established. However, animal studies that showed a positive effect of endotracheal epinephrine used considerably higher doses than are currently recommended, and the one animal study that used currently recommended doses via endotracheal tube showed no effect. Given the lack of supportive data for endotracheal epinephrine, the IV route should be used as soon as venous access is established (Class IIb, LOE C). The recommended IV dose of epinephrine is 0.01 to 0.03 mg/kg per dose. Higher IV doses are not recommended because animal and pediatric studies show exaggerated hypertension, decreased myocardial function, and worse neurological function after administration of IV doses in the range of 0.1 mg/kg. If the endotracheal route is used, doses of 0.01 or 0.03 mg/kg will likely be ineffective. While access is being obtained, administration of a higher dose (0.05 to 0.1 mg/kg) through the endotracheal tube may be considered, but the safety and efficacy of this practice have not been evaluated (Class IIb, LOE C). The concentration of epinephrine for either route should be 1:10,000 (0.1 mg/mL). Volume expansion should be considered when blood loss is known or suspected (pale skin, poor perfusion, weak pulse) and the baby’s heart rate has not responded adequately to other resuscitative measures (Class IIb, LOE C). An isotonic crystalloid solution or blood is recommended for volume expansion in the delivery room (Class IIb, LOE C). The recommended dose is 10 mL/kg, which may need to be repeated. When resuscitating premature infants, care should be taken to avoid giving volume expanders rapidly, because rapid infusions of large volumes have been associated with intraventricular hemorrhage (Class IIb, LOE C).
Kattwinkel, et al. Neonatal resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics: 2010, 126(5);e1400-13