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guidelines or infant (PALS) guidelines can be appropriate and there is currently no evidence for a specific age to transition from one to the other Hospital or agency policy should be established which leans on the expertise of the unit to ensure high-quality CPR is delivered regardless of algorithm followed Though rare, the ED team must be prepared for the resuscitation of the newly born infant Fortunately, 90% of neonates transition from intrauterine to extrauterine life without resuscitative needs beyond simple warming and stimulation However, the remaining 10% requires some assistance, and 1% will require extensive resuscitative measures, such as cardiac compressions and medications Resuscitative needs vary greatly by gestational age and birth weight Approximately 6% of term newborns will require resuscitation at birth, as will nearly 80% of infants who weigh less than 1,500 g Given that anticipation of a high-risk birth in the ED setting is not always feasible, successful newborn resuscitation for the ED team hinges on readiness of staff and equipment EMERGENCY DEPARTMENT READINESS Education of staff, necessary equipment, and specific policies and procedures are critical for ED readiness Early notification, when feasible, allows time to assemble key personnel Each institution should have a procedure in place for rapidly mobilizing a team with complete newborn resuscitation skills for any birth In addition to a standard obstetric tray, every ED should have a newborn resuscitation kit that is readily accessible, maintained, and rapidly restocked after use Necessary equipment and medications are listed in Table 9.8 A radiant warmer and medication dosing chart are critical A standardized checklist is recommended to ensure that all necessary equipment and supplies are present and functional Because neonatal resuscitations in the ED are uncommon, simulation scenarios at regular intervals allow staff to remain familiar with neonatal resuscitation skills and supplies Most births that occur outside of the delivery room have high-risk components such as trauma-induced labor and unexpected pregnancy Important historical factors include prematurity, multiple gestation, meconium-stained amniotic fluid, and maternal drug use The team can then anticipate the need for assisted ventilation, simultaneous resuscitations, tracheal suctioning, or pharmacologic interventions PATHOPHYSIOLOGY The fetal heart has two large right-to-left shunts: from the right atrium to the left atrium through the foramen ovale, and from the pulmonary artery to the aorta across the ductus arteriosus At birth, two major changes occur that eliminate these shunts: the umbilical cord is clamped, and spontaneous respirations are