P3C335: A Shock at a Newborn Delivery: When NRP Should Turn to PALS

Introduction: The Neonatal Resuscitation Program (NRP) is an evidence-based program intended to be used by providers providing care to infants requiring cardiopulmonary resuscitation immediately after birth. These set of guidelines have an algorithmic process describing interventions that will optimize ventilation in the majority, but not all, neonates.

Case Description: A 2.93 kg 34 0/7 week appropriate for gestational age male infant delivered to a 41 y/o G1P0101 mother with prenatal history of gestational diabetes mellitus via emergent Cesarean section after non-reassuring fetal heart tones in the setting of a Category III fetal tracing were noted at a clinic visit. Pregnancy was otherwise uncomplicated. Upon delivery, infant was noted to be vigorous, crying, good tone, and cyanotic. Infant developed apnea at 2 minutes of life at which time heart rate was noted to be >200 via auscultation. Continuous three lead EKG monitoring revealed heart rate of 250 with narrow QRS complex tachycardia. At the time the infant was noted to have generalized pallor, severe hypoxia, diminished peripheral pulses, and prolonged capillary refill raising concerns for unstable supraventricular tachycardia. Patient patient underwent vagal maneuvers, rapid adenosine bolus administration, elective intubation, and ultimately synchronized cardioversion resulting in return to normal sinus rhythm (Figure 1). Patient was admitted to the neonatal intensive care unit where he was diagnosed with Wolff-Parkinson-White syndrome and discharged home on propranolol.

Discussion: NRP guidelines encapsulate resuscitation methods that address ineffective ventilation which is the primary etiology of cardiopulmonary arrest in most neonates. Pediatric Advanced Life Support (PALS) guidelines encompass variations in compression to ventilation ratio, arrhythmias, and broader cardiac medications and interventions. When NRP guidelines did not yield clinical stabilization in this patient, based on clinical presentation and data, it was necessary to apply PALS guidelines to address the underlying etiology of unstable SVT.

Conclusion: Currently there is no evidence to identify an age when infant resuscitation should follow PALS guidelines. Differences in physiology of the underlying etiology should dictate choices for NRP versus PALS algorithms. For patients in whom respiratory failure is not the primary cause of cardiopulmonary arrest, neonatology providers should maintain a broad differential to correctly identify the diagnosis and appropriate interventions. This case highlights a potential need for neonatal providers to maintain PALS certification in addition to NRP.