Management of an extremely premature infant in the out-of-hospital environment

The rate of premature infant mortality has decreased over the last several decades, with an accompanying decrease in the gestational age of premature infants who survive to hospital discharge. Emergency medical services (EMS) providers are sometimes called to provide prehospital care for infants born at the edge of viability. Such extremely premature infants (EPIs) present medical and ethical challenges. In this case report, we describe an infant born at 24 weeks into a toilet by a mother who thought she had miscarried. The EMS providers evaluated the infant as nonviable and placed him in a plastic bag for transport to a local emergency department (ED). The ED staff found the infant to have a bradycardic rhythm, initiated resuscitation, and admitted him to the neonatal intensive care unit. The infant died seven days later. We review the literature for recommendations in resuscitation of EPIs and discuss the ethics regarding their management in the prehospital setting.