Cardiac arrest with pulseless electrical activity rhythm in newborn infants: a case series

Abstract

The 2015 neonatal resuscitation guidelines added ECG to assess an infant’s heart rate when determining the need for resuscitation at birth. However, a recent case report raised concerns about this technique in the delivery room. We report four cases of pulseless electrical activity during neonatal cardiopulmonary resuscitation in levels II–III neonatal intensive care units in Canada (Edmonton [n=3] and Winnipeg [n=1]).Healthcare providers should be aware that pulseless electrical activity can occur in newborn infants during cardiopulmonary resuscitation. We propose an adapted neonatal resuscitation algorithm to include pulseless electrical activity. Furthermore, in compromised newborns, heart rate should be assessed using a combination of methods/techniques to ensure accurate heart rate assessment. When ECG displays a heart rate but the infant is unresponsive, pulseless electrical activity should be suspected and chest compression should be started.

A Porcine Model of Neonatal Hypoxia-Asphyxia to Study Resuscitation Techniques in Newborn Infants

“…These studies indicate that cardiac arrest in the presence of a nonperfusing cardiac rhythm is common in asphyxiated neonatal piglets. Furthermore, this animal data is in agreeance with clinical observations of reduced CPR success in the presence of PEA in the delivery room in newborn infants [15,16].…”

“…It is possible that PEA may be common in asphyxiated newborns but has been undetected in the clinical setting prior to the recent use of ECG in the delivery room. Recent case reports have raised concerns over the reliability of ECG use during neonatal resuscitation, and the detection of PEA has been cited as a potential limitation of ECG use to guide delivery room resuscitation [15,16]. Data from studies in the pediatric population indicate decreased survival following resuscitation with PEA events [17,18], however this is inconsistent throughout the literature.…”

“…Data from studies in the pediatric population indicate decreased survival following resuscitation with PEA events [17,18], however this is inconsistent throughout the literature. Recent case studies in newborn infants presenting with cardiac arrest with PEA rhythm, as indicated on ECG [15,16], suggest dire outcomes. Further studies (animal and prospective clinical) are needed to determine the cause and actual incidence of PEA in order to improve the survival of newborns experiencing PEA in the delivery room.…”

Heart Rate Assessment during Neonatal Resuscitation

“…Two studies report that the ECG displayed a HR during PEA in 40-50% of asphyxiated newborn piglets [48,49]. There have been one case report and a case series totaling seven cases of PEA in the delivery room during neonatal resuscitation [50][51][52][53]. This is concerning, especially if healthcare professionals are relying exclusively on the ECG signal.…”

Improving newborn heart rate assessment using a simple visual timer

“…2 However, incorrect HR estimates occur in 28%-46% using this method; these could result in the incorrect management and delay of stabilisation potentially affecting outcome. 3 4 Technological approaches for HR measurement may not be available or initially inaccurate, [5][6][7] so healthcare professionals (HCPs) need to be able to accurately estimate HR using a stethoscope especially in the resource-poor setting or with the lone resuscitator. 7 The Neonatal Resuscitation Program suggests using the 6 s rule to estimate HR, but this is not universal; for example, it is not a taught component of the UK Newborn Life Support (NLS).…”