ICU and You · Aphorism Series · Number 35
“The newborn generally does not have a cardiac arrest. It has a respiratory arrest with a cardiac ending.”
An aphorism is a compressed argument, not a rule. It earns its shape by leaving things out, which is exactly what makes it memorable and what makes it arguable. Every one in this series is contestable, and chosen because it is.
Each is a mantra, a paradigm, a truism or occasionally a plain myth — something repeated in our units often enough that nobody examines it any more. The piece sets out the case for it, the case against it, and the case for something in between, and then asks which you hold.
There is no right answer waiting at the bottom. The point is to find out what you actually believe and why, because the beliefs that run your practice at three in the morning are mostly ones you have never said out loud.
Everything you know about adult resuscitation arrives at the newborn's side slightly wrong. In the adult we assume the heart failed first, and the algorithm reflects it: compressions early, defibrillator, adrenaline, and ventilation somewhere behind. In the newborn the sequence is almost always inverted. The lungs are fluid-filled and have never been inflated, or have stopped being inflated. Hypoxia follows. Bradycardia follows that, because a newborn's cardiac output is rate-dependent and there is no stroke volume to recruit. Asystole is the end of the story, not the beginning.
Which makes the intervention that matters unglamorous. Not the drug, not the compressions — the inflation of the lungs. A rising heart rate after effective ventilation is the whole of the evidence that you are succeeding, and if it is not rising the answer is almost never more adrenaline. It is that the lungs are not being inflated, and MR SOPA exists because the reasons are enumerable.
The word generally is doing real work. Congenital heart disease, a duct that has closed, hyperkalaemia, a pneumothorax under tension — these are primary circulatory catastrophes, and they will not respond to a better mask seal.
When you last managed a deteriorating patient of any age, what did you reach for first — and was it the thing that was actually failing?
Send it back to me either way, with your Yes, No or Maybe. Themes, and the best of your responses, go into a coming newsletter.
The button opens a reply straight to me with the headings already in it. If your device blocks it, write to icuandyou@icloud.com instead.