A term newborn delivered vaginally has an APGAR score of 3 at 1 minute (blue, limp, no response to stimulation, gasping respirations, no heart rate audible). After initial steps of resuscitation and 15 seconds of positive pressure ventilation, there is no improvement and the heart rate remains <60 bpm. What is the drug of choice for immediate administration?

## Neonatal Resuscitation: Epinephrine Indications **High-Yield:** In neonatal resuscitation, epinephrine is the first and primary drug used when the heart rate remains <60 bpm despite adequate ventilation and chest compressions for 15 seconds. ### Mechanism of Action Epinephrine acts as an α- and β-adrenergic agonist, increasing myocardial contractility and coronary perfusion pressure—both critical for restoring spontaneous circulation in severe bradycardia or asystole. ### Dosing and Route in Neonates - **Concentration:** 1:10,000 (0.1 mg/mL) for intravenous or intraosseous administration - **Dose:** 0.01–0.03 mg/kg IV/IO every 3–5 minutes - **Endotracheal route:** 0.1 mg/kg of 1:1,000 concentration (if IV/IO access unavailable) **Key Point:** Epinephrine is indicated when heart rate <60 bpm persists after 15 seconds of effective PPV and chest compressions. It is the only medication recommended as first-line in severe neonatal bradycardia/asystole. ### Clinical Pearl The 2015 Neonatal Resuscitation Program (NRP) guidelines emphasize that epinephrine should be given as soon as possible once the decision to administer medications is made—delayed administration is associated with worse outcomes. ### Why Not Other Agents? - **Atropine:** Not recommended in neonatal resuscitation; bradycardia in newborns is primarily due to hypoxia/ischemia, not vagal tone. - **Sodium bicarbonate:** Reserved for metabolic acidosis after return of spontaneous circulation; not a first-line resuscitation drug. - **Dopamine:** Not used in acute resuscitation; reserved for post-resuscitation hemodynamic support. [cite:NRP 8e Guidelines 2015]