Simulation Scenario. I. Title: Newborn with Apnea and Cyanosis. Target Audience: Emergency physicians, and ED nurses. Learning Objectives:

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1 Simulation Scenario I. Title: Newborn with Apnea and Cyanosis II. III. Target Audience: Emergency physicians, and ED nurses. Learning Objectives: A. Primary Management of apnea in the newborn period and newborn resuscitation. Tips on management during resuscitations of common and rare conditions in the newborn period. B. Secondary Indications for providing positive pressure ventilation, indications for initiation and discontinuation of chest compression in newborn, endotracheal intubation, indications for medication use, and dosages C. Critical actions checklist This includes: 1. Newborn position, clear airway a) head in sniffing position b) mouth suction by a bulb suction 2. Stimulate newborn and reposition: a) rubbing newborn back b) flicking the soles of his feet 3. Initiate positive pressure ventilation (PPV) a) when the newborn is not resuming breathing and color is blue despite step 1 and 2 b) safety tip caveat: do not start PPV if you are concern about diaphragmatic hernia: proceed immediately to tracheal intubation 4. Chest compression: a) start chest compression if newborn hear rate is <60 beats per minute after 30 seconds of PPV. b) discontinue chest compression when heart rate is >60 5. Indications for endotracheal intubation a) if PPV results in normalization of the heart rate and color, but the newborn is not breathing due to brain injury, severe acidosis or sedation given to the mother, endotracheal intubation should be performed to maintain oxygenation and ventilation b) safety tip caveat: consider narcotic antagonist prior to intubation if there is a recent maternal narcotic administration and if the newborn remains apneic after PPV. The dose of naloxone is 0.1 mg/ Kg c) primary and secondary checks for endotracheal tube placement 1

2 6. Vascular access in newborn a) peripheral vein b) umbilical vessels c) intra-osseous needle into the tibia 7. Indication for epinephrine use, routes of administration and dosage 8. Common reasons for seizures in newborn period IV. Environment A. Lab Set Up ED, trauma bay, in lab or in real ED B. Manikin Set Up type of simulator, newborn (Sim NewB), cyanotic (blue colored lips) C. Props basic and advanced airway equipment, peripheral IVs, IOs, Umbilical Vein Catheter (UVC) kits, meds (epinephrine, Naloxone), fluids (normal saline and DW10) D. Distractors Parents crying V. Actors A. Roles physician, nurse, parents B. Who may play them improvise based on class structure C. Action Role Physician: Direct management, airway control, UVC or IO insertion if nurses are unable to obtain a peripheral venous line. Nurses: start chest compression if heart rate is <60 despite PPV. Give meds and fluids per the physician orders. Parent: distract team by crying. VI. Case Narrative A. Scenario Background Given to Participants: A 2 day old baby boy was found by his mother apneic, blue in the crib several hours after she attempted to breast feed him. The baby was born at home after uncomplicated pregnancy or labor. The mother was planning on taking the baby to his pediatrician that afternoon. The mother called rescue, which suctioned the baby s mouth with bulb suction and stimulated him with no response. 1. Chief complaint, triage note, and medic report- Attempts to intubate the baby by rescue were unsuccessful. PPV was performed during the transport to the ED with 100% oxygen. The rescue report indicated an apneic full term baby, pink in color with PPV with heart rate of 65 beats per minutes. 2. Past medical history. No complications during pregnancy except for gestational diabetes. Patient was 41 weeks of gestation and birth weight estimated at 4, 100 g. Patient was delivered at home per mother s choice without any excessive bleeding. Mother did not seek any medical attention, but was planning on taking the newborn to his pediatrician the next day. Mother stated that she was attempting to breast feed her newborn, but was not sure if he 2

3 was taking enough milk and she was concern that his sucking is weak. 3. Meds and allergies: none 4. Family/social history: mother denied any sexually transmitted diseases or drug abuse. B. Scenario conditions initially 1. History patient gives: none 2. Patients initial exam a. Apneic, unresponsive, good chest rise with PPV with 100% Oxygen. Pulse ox= 100%, Temperature: 37 C. b. Anterior fontanel is open and flat. No scalp hematoma or bruising c. Pupils equal, 5mm, minimally reactive to light. d. Heart rate in the ED is 50 beats per minutes e. Skin is clammy f. The nurses ask you if the twitching mouth rhythmic movements are normal 3. Patient s physiology: two day old, term newborn, with apnea, bradycardia, and possible seizure. Electrolytes imbalance such as hypoglycemia should be considered due to inadequate feeding and limited glycogen storage in the newborn period. In addition, hyponatremia should be considered as well particularly if there a history of giving the newborn water or diluted formula. Other electrolyte abnormalities such as hypocalcemia can cause seizure as well. 4. Actions: Continue PPV with oxygen to maintain O2 saturation of 100%. Start chest compression if the heart rate remains below 60 beats per minute. Obtain bed side glucose, if it <40mg/dL then start 2-4 ml/kg of dextrose 10%. In addition, consider intubation if patient remains apneic. If the patient has feeding difficulty secondary to neurologic insult during delivery, coordination of sucking, swallowing and breathing might take several days during which intravenous fluids and nutrition may be required. If the heart rate remains <60 beats per minutes, epinephrine should be given. The recommended intravenous dose is 0.1 to 0.3 ml/kg of a solution of 1:10, 000 (equal to 0.01 to 0.03 mg/kg). If the IV is not readily obtainable, epinephrine can be given via the endotracheal route while the UVC or the IO is placed. Check the patient s heart rate 30 seconds after epinephrine administration as the PPV and chest compression are in progress. If the heart rate is not above 60 beats per minute after that time interval, a repeat dose of epinephrine can be administered every 3-5 minutes. Of note, the repeat doses should be given intravenously if possible. 3

4 C. Scenario branch points 1. Failure to adequately ventilate the patient will results in persistent bradycardia and cyanosis. Safety tip caveat: if you suspect Robin syndrome due to small mouth and possible upper airway obstruction, consider placing a nasopharyngeal tube and position patient in the prone position (on their abdomen) that could help since intubation of these patients is typically difficult. 2. Monitor breaths sounds. If patient has unequal breath sounds consider pneumothorax or congenital diaphragmatic hernia. The later should be suspected if the abdomen is scaphoid (flatappearing). Both of these conditions can deteriorate with PPV. 3. Failure to check electrolytes abnormalities such as hypoglycemia and hyponatremia can lead to status epilepticus, apnea or even death if no actions were taken. Rapid correction of chronic hyponatremia (>2 meq/l/h) has been associated with central pontine myelinolysis. Rapid partial correction of symptomatic hyponatremia has not been associated with adverse effects. Therefore, if the patient is symptomatic (seizures), a more rapid partial correction is indicated. Hypertonic (3%) sodium chloride solution (0.5 meq/ml) may be used for rapid partial correction of symptomatic hyponatremia. A bolus dose of 4 ml/kg raises the serum sodium by 3-4 meq/l. 4. If the patient remains bradycardic and cyanotic despite good ventilation also think congenital heart disease (CHD). Confirmation with a chest radiograph, electrocardiogram, and/or an echocardiogram may be necessary. Of note, congenital hear block or even cyanotic CHD are rare conditions, while inadequate ventilation is a more common cause of persistent cyanosis and bradycardia. 5. The intubation in this case can be modified to become a difficult airway such as including choanal atresia, which could be rule out by passing a nasopharyngeal catheter through the nares or Robin syndrome with very small mouth and upper airway obstruction, which could be helped by placing a nasopharyngeal tube and placing patient in the prone position. Failure to control patient s airway will result in respiratory arrest and eventually cardiac arrest. 6. Vascular access could be modified to become a difficult access. Alternatives to peripheral veins include UVC and intraosseous needle insertion in the tibia. Failure to obtain vascular access will delay the administration of resuscitative fluids, medications and electrolytes. 4

5 VII. Instructors Notes A. Tips to keep scenario flowing in lab and via computer- this could be accomplished by following the critical actions specific to the learning objectives. Multifaceted scenario could be used for advanced learners. For an example, it probably will make no difference in this case if the learner boluses with IFV or maintains fluids, but it is crucial to check bedside electrolytes such as glucose. Failure to diagnose hypoglycemia in a patient/newborn, which is not being fed appropriately with limited glycogen storage to avoid missing potential life threats such as seizures and apnea. In addition, hyponatremia should also be considered in a seizing newborn. In advanced learners, other electrolytes abnormalities such as hypocalcemia, associated with DiGeorge syndrome (small thymus shadow on chest radiograph) should be considered. B. Tips to direct actors- use a confederate that understands the scenario and can help redirect the evaluation if nuance of the simulator or moulage confuse the learner. C. Scenario programming 1. Optimal management path: Sniffing position of the newborn s head, PPV with oxygen to maintain O2 saturation of 100%. Chest compression if the heart rate remains below 60 beats per minute. In addition, consider intubation if patient remains apneic. Obtain bed side glucose and give DW10 if patient is hypoglycemic. If the heart rate remains <60 beats per minutes despite intubation, chest compression and electrolytes correction, epinephrine should be given. The recommended intravenous dose is 0.1 to 0.3 ml/kg of a 1:10, 000 solution (equal to 0.01 to 0.03 mg/kg) via IV. Check the patient s heart rate 30 seconds after epinephrine administration as the PPV and chest compression are in progress. If the heart rate is not above 60 beats per minute after that time interval, a repeat dose of epinephrine can be administered every 3-5 minutes. Also consider sepsis by obtaining appropriate cultures (blood, urine and CSF if LP can be done safely) and administering antibiotics. 2. Potential airway complications. The intubation in this case can be modified to become a difficult airway such as including choanal atresia, which could be rule out by passing a nasopharyngeal catheter through each of the naris. If the catheter does not advance when it is correctly directed along the floors of the nasal passageway, choanal atresia may be present. Insert a plastic oral airway to allow air to pass through the mouth. Robin syndrome with very small mouth and upper airway obstruction could challenge airway control and can be helped by placing a nasopharyngeal tube and placing patient in the prone position. Use of adjunct airway or needle cricothyrotomy may be incorporated into the scenario given the congenital structural abnormalities. 5

6 VIII. Debriefing Plan Failure to control patient s airway will result in respiratory arrest and eventually cardiac arrest. 3. Additional potential complication path (s): failure to successfully obtain vascular access via peripheral vein can include placement of a UVC or placement of IO in proximal tibia. 4. Potential errors path(s): failure to ventilate patient appropriately due to inadequate seal between the mask and the patient s face and not using sufficient PPV. Place patient on a monitor to observe the heart rate response to ventilation. Not detecting bradycardia (< 60 beats per minute) will delay starting chest compression to avoid full cardiac arrest. Failure to check for electrolyte imbalences such hypoglycemia, hyponatremia and hypocalcemia will lead to seizures and if it is not treated correctly will lead to persistent seizures, apnea or even death. A. Method of debriefing individual, group, with/without video, knowledge support items B. Critical Actions: 1. Airway management: This is the first critical action in an apneic newborn who is not responding to any stimuli. a. Clear the airway, position the newborn s head in the sniffing position and ensure a tight seal between the patient s face and the mask and use PPV. b. Monitor the heart rate, color, and tone for improvement c. If the patient remains bradycardiac, there is a need to ensure that there is a perceptible chest movement with each PPV breath and good air flow on lung auscultation. d. Failure to see chest movement or hearing good air flow could be due to one of several problems such as: Mucus in the pharynx or trachea Pneumothorax Congenital pleural effusion Congenital diaphragmatic hernia Choanal atresia Pharyngeal airway malformation Pulmonary hypoplasia Congenital lobar emphysema or pneumonia 2. Circulation: If the patient s heart rate remains < 60 beats per minute despite PPV, chest compression should be started and coordinated with PPV. If the heart rate remains < 60, then a vascular access should be obtained and patient should be give epinephrine. The first dose can be given via the endotracheal tube, while the IV or UVC is obtained for needed subsequent doses of epinephrine. 6

7 3. Seizures/Apnea: The newborn in this scenario was large for gestational age, borne at home to a diabetic mother, with poor feeding and sucking. These symptoms could be the manifestations of metabolic abnormalities such as hypoglycemia or other electrolytes abnormalities such as hyponatremia and hypocalcemia. All of which can cause seizures and if not treated can have devastating neurological consequences and even death. Treatment include glucose and or/electrolytes via an intravenous line. In addition, apnea could be a reflection of hypoxic ischemic event (HIE) in the perinatal period, which could present initially with decrease muscle tone. Of note, seizure associated with HIE could require treatment with anticonvulsant therapy such as Phenobarbital. Other etiologies for seizures and apnea should include sepsis with the appropriate cultures (blood, urine and CSF) obtained and antibiotics given (Aminoglycoside with Gentamicin or cephalosporin). C. Questions to facilitate the debriefing: 1. Persistent bradycardia and cyanosis during resuscitation most likely are caused by heart diseases or inadequate ventilation? 2. When you do start chest compression in a newborn resuscitation? 3. What type of vascular access do you have during a newborn resuscitation? 7

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