NRP Pocket Guide

For education only. Verify doses with your local protocol and a second person before giving any drug.

Weight-based calculator

NRP 9e p.67–68 (Table 4-2), p.102 (Table 5-1), p.113–114 (Table 5-3), p.148–154

Weight (kg)

0.3–6 kg

Gestational age (wk)

Completed weeks (20–45)

Enter a weight to see the results.

Rounding: mL to 2 decimals and mg to 3 decimals (half rounds up). Weight is used to the nearest gram. GA with decimals is read as completed weeks (e.g. 34.6 → 34).

The algorithm at a glance

Redrawn from NRP 9e Figure 1.3, p.7 (Neonatal Resuscitation Program Algorithm)

Weight for doseskg Same weight as the calculator. Boxes for PPV, airway, compressions and epinephrine then show numbers for this baby.

Heart rate: count for 6 s and multiply by 10. A rising HR is the most important sign that ventilation works. (p.40, p.69)

PPV settings and oxygen

NRP 9e Table 4-1 p.67, Table 4-2 p.68, Table 4-3 p.70; p.76–77, p.136, p.177

Setting	Start with
Rate	30–60 breaths/min (“Breathe, two, three”)
Inflation pressure	25 cm H₂O (≥ 32 wk 25–30; < 32 wk 20–25)
Face mask max	40 cm H₂O term; 30 cm H₂O preterm
PEEP	5 cm H₂O
Gas flow	10 L/min

Initial FiO₂

Gestational age	Initial FiO₂
≥ 35 weeks	21%
32–34 weeks	21–30%
< 32 weeks	≥ 30% may be considered
Chest compressions	100%

Adjust FiO₂ by 20–30% every 30 s to reach the target.

Target pre-ductal SpO₂ (right hand)

Time after birth	Target SpO₂
2 min	65–70%
3 min	70–75%
4 min	75–80%
5 min	80–85%
10 min	85–95%

< 32 weeks: reaching 80–85% by 5 min is important.

CPAP 5–6 cm H₂O (not more than 8) only if breathing and HR ≥ 100 but labored or SpO₂ below target. Not possible with a self-inflating bag.

Airway

NRP 9e Table 4-3 p.70; p.69–75, p.82–83, p.95, p.102–103 (Table 5-1), p.110–116 (Table 5-3), Table 5-4 p.119

MR SOPA: until the chest moves

M	Mask: reapply; consider the 2-hand hold
R	Reposition: head neutral or slightly extended
S	Suction mouth and nose
O	Open the mouth
P	Pressure: increase by 5 cm H₂O (mask max 40 term, 30 preterm)
A	Alternative airway: endotracheal tube or laryngeal mask

Try ventilation after each step. When the chest moves, say “The chest is moving NOW”, give 30 s of effective ventilation, then check the HR.

Endotracheal tube size (Table 5-1, p.102)

Weight	GA (wk)	ETT ID (mm)	Suction (F)
< 800 g	22–25	2.5*	5
800–1,200 g	26–28	2.5	5 or 6
1,201–2,200 g	29–34	3.0	6 or 8
> 2,200 g	> 34	3.5	8

* 2.0 mm may be considered for extremely preterm babies under about 750 g.

Blade (straight): No. 1 term; No. 0 preterm; some use No. 00 for extremely preterm. Suction 80–100 mm Hg.

Insertion depth (“tip-to-gum”, upper gum)

Estimate = NTL + 1 cm (NTL: nasal septum to ear tragus), or use Table 5-3.

Table 5-3: initial depth by GA / weight (p.114)

GA (wk)	Depth at gum	Weight
< 23	5.0–5.5 cm	< 500 g
23–24	5.5 cm	500–600 g
25–26	6.0 cm	700–800 g
27–29	6.5 cm	900–1,000 g
30–32	7.0 cm	1,100–1,400 g
33–34	7.5 cm	1,500–1,800 g
35–37	8.0 cm	1,900–2,400 g
38–40	8.5 cm	2,500–3,100 g
41–43	9.0 cm	3,200–4,200 g

Both methods are estimates: listen to both axillae. X-ray: tip in the mid-trachea, near T1–T2.

Confirm a tube or laryngeal mask

Primary: exhaled CO₂ within 8–10 breaths + rapidly rising HR
Equal breath sounds in both axillae, symmetric chest movement, little air over the stomach
Intubation: aim to finish in about 30 s; if the baby worsens, stop and ventilate

Laryngeal mask

First ventilation device or alternative to intubation; sizes 0–1
May be too large for extremely preterm babies; lower weight limit not established
Not studied for suctioning; insufficient evidence for intratracheal drugs

Sudden deterioration after intubation: DOPE

D	Displaced tube
O	Obstructed tube
P	Pneumothorax
E	Equipment failure

Compressions and medicines

NRP 9e p.129–137; p.145–163, Table 7-1; p.217

Chest compressions

Start: HR < 60 after at least 30 s of ventilation that moves the chest (ideally via tube or laryngeal mask)
Two thumbs, lower third of the sternum, just below the nipple line; depth 1/3 of chest diameter
3:1 every 2 s: 90 compressions + 30 breaths = 120 events/min (“One-and-Two-and-Three-and-Breathe”)
FiO₂ 100%; check HR after 60 s (ECG preferred)
Stop when HR ≥ 60; then ventilate 30–60/min

Epinephrine: only 0.1 mg/mL (1 mg/10 mL)

Route	Dose	Volume	Then
IV / IO (preferred)	0.02 mg/kg (0.01–0.03)	0.2 mL/kg (0.1–0.3)	Push fast; 3 mL NS flush
ET	0.1 mg/kg (0.05–0.1)	1 mL/kg (0.5–1)	No flush; give breaths

Indication: HR < 60 after 30 s effective ventilation + 60 s coordinated compressions with 100% O₂
Repeat every 3–5 min; check HR 1 min after a dose
ET dose only while getting vascular access; never give the ET dose IV

→ Calculate for a specific weight

Volume expansion

Only if not responding and signs of shock or acute blood loss. 10 mL/kg IV/IO over 5–10 min; may repeat 10 mL/kg. Normal saline; severe anemia: O Rh-negative packed red cells.

< 32 weeks: bolus on day 1, rapid bolus, or > 10 mL/kg are linked to intracranial hemorrhage.

Umbilical venous catheter (first choice)

3.5F or 5F single-lumen catheter, filled with normal saline
Cut the cord about 2 cm above the skin
Insert 3–4 cm beyond the abdominal wall until blood flows freely; less in extremely preterm babies
Do not go deeper: drugs into the liver can cause injury
Omphalocele: UVC cannot be used; use IO

Intraosseous needle (reasonable alternative)

Term: flat surface of the lower leg, about 2 cm below and 1–2 cm medial to the tibial tuberosity
Flush 3–5 mL normal saline
Risks: extravasation, infection, fracture, limb ischemia; success in very preterm babies unknown

Peripheral IV is not recommended for emergency drugs in cardiovascular collapse.

HR still < 60? Check (Table 7-1)

Chest moving with each breath?
Airway secured with a tube or laryngeal mask?
3 compressions + 1 breath every 2 s? Depth 1/3?
Device giving 100% oxygen?
Epinephrine dose and route correct (IV/IO)?
UVC or IO still in place?
Pneumothorax or pericardial effusion?

Also think: hypovolemia (pale, delayed capillary refill, weak pulses, acute blood loss).

Special situations

NRP 9e p.30–49; p.174–183; p.201–213; p.33, p.152–158

Meconium, not vigorousMeconium-stained fluid, baby not vigorous → initial steps, PPV if needed; no routine tracheal suction

Routine laryngoscopy ± tracheal suction is not suggested. Initial steps; PPV within 60 s if apneic or HR < 100. Intubate and suction only if PPV does not inflate the lungs and obstruction is suspected.

NRP 9e p.30, p.46–49

Preterm < 32 weeksBorn before 32 weeks → plastic wrap without drying, CPAP if breathing, PIP 20–25

Room 23–25 °C, thermal mattress, hat
Do not dry: plastic bag/wrap to the neck
CPAP 5–6 cm H₂O if breathing, HR ≥ 100
PIP 20–25; mask max 30
No cord milking < 28 wk
No head-down tilt; slow fluids

NRP 9e p.174–183

PneumothoraxSudden distress, decreased breath sounds on one side → needle aspiration

Sudden distress or no improvement; decreased breath sounds; increased transillumination.

Needle: 4th ICS anterior axillary line or 2nd ICS midclavicular line, 20- or 24-gauge catheter-over-needle, over the top of the rib.

Pleural effusion: 5th or 6th ICS, posterior axillary line. ICS = intercostal space. NRP 9e p.201–207

Congenital diaphragmatic hernia (CDH)CDH suspected → no face mask; intubate and decompress the stomach

No face-mask ventilation. Intubate promptly; 10F orogastric tube with suction. PIP limit 25 cm H₂O (consensus). Pre-ductal SpO₂ may not exceed 80–85% at first.

NRP 9e p.201, p.212–213

Robin sequenceAirway obstruction → prone; 2.5 mm tube through the nose, tip in the pharynx

Prone. 2.5 mm tube through the nose, tip in the pharynx (not the trachea). Still obstructed: laryngeal mask.

NRP 9e p.201, p.210–211

Bilateral choanal atresiaThin catheter will not pass the nose → tube in the mouth, tip in the posterior pharynx

Thin catheter will not pass the nose. Tube in the mouth, tip in the posterior pharynx.

NRP 9e p.201, p.211

Hypovolemic shockPale, delayed capillary refill, weak pulses after blood loss → NS 10 mL/kg over 5–10 min

Abruption, bleeding previa, cord avulsion: clamp the cord now. Emergency UVC; NS 10 mL/kg over 5–10 min, or O Rh-negative red cells.

NRP 9e p.33, p.152–158

After resuscitation

NRP 9e p.188–197

Temperature 36.5–37.5 °C; avoid overheating
Glucose: check soon after birth and at regular intervals until stable and normal; IV dextrose may be needed (use local thresholds)
Therapeutic hypothermia: ≥ 36 weeks with moderate to severe HIE; start within 6 h of birth; cooling for 3 days. No program: call the referral centre as soon as you suspect a candidate; avoid overheating and excessive cooling in transport.
No routine sodium bicarbonate; no routine volume without hypovolemia

Stopping and ethics

NRP 9e p.155, p.222–227

No heart rate after all appropriate steps: discuss with the team and family
Reasonable time frame: around 20 min after birth, individualized
Best interest of the baby; parents share decisions
Withholding and withdrawing are ethically equivalent
Compassionate comfort care for every baby not resuscitated
Written for the US and Canada; adapt to local context

2 min	65%–70%
3 min	70%–75%
4 min	75%–80%
5 min	80%–85%
10 min	85%–95%

Weight-based calculator

The algorithm at a glance

PPV settings and oxygen

Initial FiO2

Airway

MR SOPA: until the chest moves

Endotracheal tube size (Table 5-1, p.102)

Insertion depth (“tip-to-gum”, upper gum)

Confirm a tube or laryngeal mask

Laryngeal mask

Sudden deterioration after intubation: DOPE

Compressions and medicines

Chest compressions

Epinephrine: only 0.1 mg/mL (1 mg/10 mL)

Volume expansion

Umbilical venous catheter (first choice)

Intraosseous needle (reasonable alternative)

Special situations

After resuscitation

Stopping and ethics

Initial FiO₂