Post on 11-Oct-2020
NeonatalResuscitationProgram(NRP)+MeconiumAspirationSyndrome(MAS)CaseIDNumber:VirtualResusRoom2Author:JamesLeungRevisingAuthors:QuangNgo,MeaganDoyle,SarahFooheyDateofModifiedCaseCreation:July16,2020(NB*ThiscaseisamodificationofCodeDelivery1).ThiscasehasbeenmodifiedtoworkwithVirtualResusRoomCasePedsNRP(James)DateofOriginalCaseCreation:August29,2017TargetAudience:
- ResidentMD(FRCPCPediatrics/CCFP-EM/CCFP/FRCPCEM)SimulationDifficultyLevel:Intermediate(FRCPClevel)Objectives:Overarchinggoalsofsimulation:NeonatalPatientObjectives:Bytheendofthesession,participantswill:Knowledge:
1. RecognizeandtreatmeconiumaspirationsyndromeinaccordancetorecentNRP2017guidelines.
2. UnderstandcomponentsoftheMRSOPAPPVcorrectivemnemonic.3. Recognizeindicationstosecureairwayinseveremeconiumaspiration.4. Considerindicationsfortrachealsuctioninachildwithmeconium
aspiration.Skills:
1. Demonstrateanorganized,systematicapproachtoprimaryandsecondarysurveyofnewbornrequiringresuscitation.
2. Correct:a. SetupofneonatalresuscitationequipmentinEDenvironmentb. Neonatalintubationandmeconium/trachealsuctioningc. SetupofneonatalventilatorinEDenvironment
3. Demonstratesafemedicationadministrationpractices,particularlydosinganddeliveryof:
a. NeonatalRSIManager/Collaborator:
1. Succinctlycollect,reviewandsummarizeinformationpresentedtoteamsduringhandover(EMS)
2. Effectiveclosedloopcommunicationtoteammembers3. Teamleaderdemonstrateinclusiveleadership4. Developmentofasharedmentalmodel5. Completedocumentationofevent6. Demonstrateskillwithcrisisresourcemanagementparticularlywith:
a. Roledelegationb. Prioritizationoforders/tests/medicationadministrationc. Situationalawareness
Materials:Location:VirtualResuscitationRoom–NRP(James)PhysicalProps/Equipment:
§ Umbilicalcordclamp§ Neonatalbedwarmer§ Oxygendeliverydevices
o lowflow(nasalprongs,NRBmask)o Bagmask
• Selfinflating• Flowinflating
§ StandardAirwayEquipmento OPA/NPAo Laryngoscopewithcurvedandstraightbladeso ETTsizes3-4o CO2detectiondeviceo Suctioncatheters(10-12Fr,8FrforETT)
§ StandardIVEquipmento IVcatheterso IVPumpo IVtubing
§ UVCInsertionkit§ Meconiumaspirationkit§ IVfluids:
o NSo D50.45NS
§ Oxygenblender(roomairand100%FiO2).§ Medications
o StandardNRPmedicationso RSIKit
• Succinylcholine• Rocuronium• Ketamine• Etomidate• Propofol• Fentanyl• Midazolam(avoidusingperCPSstatement)
o EpinephrineMulti-Media:
• Initiallabs–CBC/generalchemistry,criticalbloodgas• CXR–noPTX,TTNappearance
LABORATORY SERVICES COLLECTION SITE: NAME: BABY Boy PATIENT ID: PHYSICIAN: RESULT REFERENCE RANGE BLOOD GAS (CRITICAL VENOUS) BLOOD GAS VALUES pH 7.10 H 7.35-7.45 pCO2 50 mmHg H 35-45 pO2 30 mmHg L 35-45 cHCO3 20 mmol L 18-26 OXIMETRY VALUES ctHb 180 g/L H 125-180 FO2Hb 3 % 88-100 FCOHb 0 % 0-1.5 fMetHb 0 % 0-1.5 ELECTROLYTE VALUES cNa 140 mmol/L (138-148) cK 4.8 mmol/L (3.6-5.6) cCl 100 mmol/L (98-110) cCa 2 mmol/L (0-2) METABOLIC VALUES cGlu 5.0 mmol/L H (3.9-6.1) cLactate 2.3 mmol/L H (0-2)
NeonatalCXR
SCENARIO:(Duration30minutesimulation+30minutedebrief)Introduction(providedtoparticipants):Basedonatruestory…EMSisrushingintoyourPEDafterjustdeliveringaninfantintheparkingoutsideofthePED.ThemotherwasenroutetoL+Dbutunabletomakeitupstairs,andEMS(bystanders)deliveredtheinfantintheparkinglot.PerEMS,theinfantcameoutcoveredinamnioticfluidandmeconiumstainingandisflat.TheyhaveliterallytakentheinfantfromtheparkinglotandrushedhimbacktotheED.Themother(stable)isbeingtreatedintheEDforpost-deliverycarebytheL+Dteam.Sheisavailableforquestioning.NICUiscurrentlyattendingtoanotherdelivery.Additionalinformation:ObtainedfromOnfurtherquestioning28yearsold,healthy.SheisG1P0andthisisanplanned/expectedpregnancy.Routinepre-natalcarewassoughtwithnoconcernsonvisits.PrenatalserologywasunremarkableandGBSstatusisnegative.Duedatewas1weekago.Mother’swaterbrokeapproximately1houragowithsomemeconiumstainingatthetime.Regularcontractionsbeganenroutetohospital.CaseProgression:
ScenarioTransitions/Evolution EffectiveManagement IneffectiveManagement Notes1.PrimaryandsecondaryassessmentwithNRPresuscitationinitiatedInitialvitalsT:35.9Cskinprobe|HR30|BP:50/32|SpO268%RA|RR0(noeffort)Weight(~3kg).TermappearinginfantA-PatentB–Norespiratoryeffort.C–CoolperipheriesCRT4-5central.Pallorous/paleD–Poortone,NotvigorousE–Bloodstainsoninfant.Nomeconiumstaining
• Setupequipment,andturnonwarmer
• Monitorsapplied• Pre-postductalsaturations
obtained• IVaccess–successfulx1
tohand• Considerclamping
umbilicalcord(oncePIVaccessobtained)
• NRPresuscitationstarted
• Suctionmouth• Dry+stimulate
• IfnoPPVstartedby1minute,decreaseSpO2to40%,HRdecreaseto25
• GiventheverycheckliststyleofNRP,debriefersshouldkeeptrackofactionstaken
• SpO2targetat5minbirth=80-85%Moveontophase2withinitiationofPPVandinsertionofIV
• HRthenbreathingwithinoneminute
• DecisiontoinitiatePPV–startwithroomairFiO2
2.PPVwithfailureofMRSOPAanddecisiontointubateVitalswithPPVinitiatedT:36.5Cskin|HR50|BP:50/32|SpO268%RA|RR0(noeffort)A–UnchangedB-UnchangedC–UnchangedD–UnchangeE-Unchanged
• MRSOPAinitiated• PPVinitiatedwithPEEP
(Useflowinflatingbag)• Changefromroomairto
100%O2• Decisiontointubate
BEFOREchestcompressions
• Ifnodecisiontointubateafter1minutemakedesaturateto30%slowly.Childwillhavearrest(PEA)after5minutesifnodecisiontointubate
• Ifchestcompressionsstarted,therewillbenoimprovementinchilduntilintubationcompleted.
• Ifchildis
overaggressivelybagged,willdeveloptensionPTX
MRSOPA• Maskadjustment• Repositionairway(sniffing)• Suctionmouthandnose• Openmouthslightlyandforward• Increasepressure• Airwayalternative(ETTorLMA)NoRSIneededasemergency(perNICU)IfRSI:Atropinepremedication,thenFentanyl2-5mcg/kgIVpush(1minute)+Succinylcholine2mg/kg–1stchoiceforparalytic/Rocuronium1mg/kg(2ndchoiceduetoprolongedduration)+atropine(nomidazolam)Thereisnolongera‘minimum0.1mg’doseforatropineanymore.Dose0.02mg/kgbasedonweightMovetoPhase3withintubationdecision
3.IntubationBeforeintubationvitalsT:36.5Cskin|HR46|BP:50/32|SpO265%100FiO2|RR0Post-intubationafter1minuteT:36.5Cskin|HR52|BP50/32|SpO282%at100FiO2|RR0
• Intubationwithappropriateback-upplan
• Pre-intubationchecklist• Considerepinephrine
drawnuppre-intubation• Postintubationsedation
plan• Considermeconium
suctionaspirationkitforETT
• Iffailstointubatewithin30s,SpO2decreasesto45%.WillallowSpO2toriseto65%withrestartedBMV.
• Ifchestcompressionsnotinitiatedafter2minutesof
• Considerfentanylinfusionforsedation,postintubation.
MovetoPhase4afterintubation(chestcompressionstostart15-30safter)
Nochangeinprimaryassessment.Remainslimp
intubationthendecreaseHR(willPEAarrestifnotstartedafter5minutes)
4.ChestcompressionstorecoveryNochangeinvitalswithchestcompressionsT:36.5Cskin|HR52|BP50/32|SpO282%at100FiO2|RR0ATENDOFCASE,MAKEINFANTSTARTCRYINGT.36.5skin|HR100|BP50/32|SpO290%at100FiO2|RR12
• Chestcompressionsstartedwith3:1ratio15-30safterintubation
• RecheckHRafter60s–nochange
• Epinephrine(0.1mg/mLviaPIV)
• CallNICU• Considerpassiveneonatal
cooling(postresuscitationcare)
• NochangeifIfPALS/CPRCPRratiosused(15:2),childwillhavenochangeinHRandSpO2gradualdecreasesto75%
• Compressiontoventilationratioof
3:1VERYimportanttokeeptrackofinNRPversusPALS/CPRaskparticipantstoverbalize
• ENDCASEWITHEPINEPHRINEADMINISTRATION,OR2CYCLESOFCPR
KeyDebriefingPoints:1. NRP–considerallowingcasetorepeatiflearnersneedpractice.2. Provisionofpainmanagement3. LEAN–medicationthatcanbegivenbyETT4. Considerationofwhentoventilate/jetventilateaneonate.5. Meconiumaspirationkit–indicationstouse6. Postresuscitationcare
NeonatalResuscitationProgram(NRP)+MeconiumAspirationSyndrome(MAS)CaseIDNumber:VirtualResusRoom2Author:JamesLeungRevisingAuthors:QuangNgo,MeaganDoyle,SarahFooheyDateofModifiedCaseCreation:July16,2020(NB*ThiscaseisamodificationofCodeDelivery1).ThiscasehasbeenmodifiedtoworkwithVirtualResusRoomCasePedsNRP(James)DateofOriginalCaseCreation:August29,2017TargetAudience:
- ResidentMD(FRCPCPediatrics/CCFP-EM/CCFP/FRCPCEM)SimulationDifficultyLevel:Intermediate(FRCPClevel)Objectives:Overarchinggoalsofsimulation:NeonatalPatientObjectives:Bytheendofthesession,participantswill:Knowledge:
1. RecognizeandtreatmeconiumaspirationsyndromeinaccordancetorecentNRP2017guidelines.
2. UnderstandcomponentsoftheMRSOPAPPVcorrectivemnemonic.3. Recognizeindicationstosecureairwayinseveremeconiumaspiration.4. Considerindicationsfortrachealsuctioninachildwithmeconium
aspiration.Skills:
1. Demonstrateanorganized,systematicapproachtoprimaryandsecondarysurveyofnewbornrequiringresuscitation.
2. Correct:a. SetupofneonatalresuscitationequipmentinEDenvironmentb. Neonatalintubationandmeconium/trachealsuctioningc. SetupofneonatalventilatorinEDenvironment
3. Demonstratesafemedicationadministrationpractices,particularlydosinganddeliveryof:
a. NeonatalRSIManager/Collaborator:
1. Succinctlycollect,reviewandsummarizeinformationpresentedtoteamsduringhandover(EMS)
2. Effectiveclosedloopcommunicationtoteammembers3. Teamleaderdemonstrateinclusiveleadership4. Developmentofasharedmentalmodel5. Completedocumentationofevent6. Demonstrateskillwithcrisisresourcemanagementparticularlywith:
a. Roledelegationb. Prioritizationoforders/tests/medicationadministrationc. Situationalawareness
Materials:Location:VirtualResuscitationRoom–NRP(James)PhysicalProps/Equipment:
§ Umbilicalcordclamp§ Neonatalbedwarmer§ Oxygendeliverydevices
o lowflow(nasalprongs,NRBmask)o Bagmask
• Selfinflating• Flowinflating
§ StandardAirwayEquipmento OPA/NPAo Laryngoscopewithcurvedandstraightbladeso ETTsizes3-4o CO2detectiondeviceo Suctioncatheters(10-12Fr,8FrforETT)
§ StandardIVEquipmento IVcatheterso IVPumpo IVtubing
§ UVCInsertionkit§ Meconiumaspirationkit§ IVfluids:
o NSo D50.45NS
§ Oxygenblender(roomairand100%FiO2).§ Medications
o StandardNRPmedicationso RSIKit
• Succinylcholine• Rocuronium• Ketamine• Etomidate• Propofol• Fentanyl• Midazolam(avoidusingperCPSstatement)
o EpinephrineMulti-Media:
• Initiallabs–CBC/generalchemistry,criticalbloodgas• CXR–noPTX,TTNappearance
LABORATORY SERVICES COLLECTION SITE: NAME: BABY Boy PATIENT ID: PHYSICIAN: RESULT REFERENCE RANGE BLOOD GAS (CRITICAL VENOUS) BLOOD GAS VALUES pH 7.10 H 7.35-7.45 pCO2 50 mmHg H 35-45 pO2 30 mmHg L 35-45 cHCO3 20 mmol L 18-26 OXIMETRY VALUES ctHb 180 g/L H 125-180 FO2Hb 3 % 88-100 FCOHb 0 % 0-1.5 fMetHb 0 % 0-1.5 ELECTROLYTE VALUES cNa 140 mmol/L (138-148) cK 4.8 mmol/L (3.6-5.6) cCl 100 mmol/L (98-110) cCa 2 mmol/L (0-2) METABOLIC VALUES cGlu 5.0 mmol/L H (3.9-6.1) cLactate 2.3 mmol/L H (0-2)
NeonatalCXR
SCENARIO:(Duration30minutesimulation+30minutedebrief)Introduction(providedtoparticipants):Basedonatruestory…EMSisrushingintoyourPEDafterjustdeliveringaninfantintheparkingoutsideofthePED.ThemotherwasenroutetoL+Dbutunabletomakeitupstairs,andEMS(bystanders)deliveredtheinfantintheparkinglot.PerEMS,theinfantcameoutcoveredinamnioticfluidandmeconiumstainingandisflat.TheyhaveliterallytakentheinfantfromtheparkinglotandrushedhimbacktotheED.Themother(stable)isbeingtreatedintheEDforpost-deliverycarebytheL+Dteam.Sheisavailableforquestioning.NICUiscurrentlyattendingtoanotherdelivery.Additionalinformation:ObtainedfromOnfurtherquestioning28yearsold,healthy.SheisG1P0andthisisanplanned/expectedpregnancy.Routinepre-natalcarewassoughtwithnoconcernsonvisits.PrenatalserologywasunremarkableandGBSstatusisnegative.Duedatewas1weekago.Mother’swaterbrokeapproximately1houragowithsomemeconiumstainingatthetime.Regularcontractionsbeganenroutetohospital.CaseProgression:
ScenarioTransitions/Evolution EffectiveManagement IneffectiveManagement Notes1.PrimaryandsecondaryassessmentwithNRPresuscitationinitiatedInitialvitalsT:35.9Cskinprobe|HR30|BP:50/32|SpO268%RA|RR0(noeffort)Weight(~3kg).TermappearinginfantA-PatentB–Norespiratoryeffort.C–CoolperipheriesCRT4-5central.Pallorous/paleD–Poortone,NotvigorousE–Bloodstainsoninfant.Nomeconiumstaining
• Setupequipment,andturnonwarmer
• Monitorsapplied• Pre-postductalsaturations
obtained• IVaccess–successfulx1
tohand• Considerclamping
umbilicalcord(oncePIVaccessobtained)
• NRPresuscitationstarted
• Suctionmouth• Dry+stimulate
• IfnoPPVstartedby1minute,decreaseSpO2to40%,HRdecreaseto25
• GiventheverycheckliststyleofNRP,debriefersshouldkeeptrackofactionstaken
• SpO2targetat5minbirth=80-85%Moveontophase2withinitiationofPPVandinsertionofIV
• HRthenbreathingwithinoneminute
• DecisiontoinitiatePPV–startwithroomairFiO2
2.PPVwithfailureofMRSOPAanddecisiontointubateVitalswithPPVinitiatedT:36.5Cskin|HR50|BP:50/32|SpO268%RA|RR0(noeffort)A–UnchangedB-UnchangedC–UnchangedD–UnchangeE-Unchanged
• MRSOPAinitiated• PPVinitiatedwithPEEP
(Useflowinflatingbag)• Changefromroomairto
100%O2• Decisiontointubate
BEFOREchestcompressions
• Ifnodecisiontointubateafter1minutemakedesaturateto30%slowly.Childwillhavearrest(PEA)after5minutesifnodecisiontointubate
• Ifchestcompressionsstarted,therewillbenoimprovementinchilduntilintubationcompleted.
• Ifchildis
overaggressivelybagged,willdeveloptensionPTX
MRSOPA• Maskadjustment• Repositionairway(sniffing)• Suctionmouthandnose• Openmouthslightlyandforward• Increasepressure• Airwayalternative(ETTorLMA)NoRSIneededasemergency(perNICU)IfRSI:Atropinepremedication,thenFentanyl2-5mcg/kgIVpush(1minute)+Succinylcholine2mg/kg–1stchoiceforparalytic/Rocuronium1mg/kg(2ndchoiceduetoprolongedduration)+atropine(nomidazolam)Thereisnolongera‘minimum0.1mg’doseforatropineanymore.Dose0.02mg/kgbasedonweightMovetoPhase3withintubationdecision
3.IntubationBeforeintubationvitalsT:36.5Cskin|HR46|BP:50/32|SpO265%100FiO2|RR0Post-intubationafter1minuteT:36.5Cskin|HR52|BP50/32|SpO282%at100FiO2|RR0
• Intubationwithappropriateback-upplan
• Pre-intubationchecklist• Considerepinephrine
drawnuppre-intubation• Postintubationsedation
plan• Considermeconium
suctionaspirationkitforETT
• Iffailstointubatewithin30s,SpO2decreasesto45%.WillallowSpO2toriseto65%withrestartedBMV.
• Ifchestcompressionsnotinitiatedafter2minutesof
• Considerfentanylinfusionforsedation,postintubation.
MovetoPhase4afterintubation(chestcompressionstostart15-30safter)
Nochangeinprimaryassessment.Remainslimp
intubationthendecreaseHR(willPEAarrestifnotstartedafter5minutes)
4.ChestcompressionstorecoveryNochangeinvitalswithchestcompressionsT:36.5Cskin|HR52|BP50/32|SpO282%at100FiO2|RR0ATENDOFCASE,MAKEINFANTSTARTCRYINGT.36.5skin|HR100|BP50/32|SpO290%at100FiO2|RR12
• Chestcompressionsstartedwith3:1ratio15-30safterintubation
• RecheckHRafter60s–nochange
• Epinephrine(0.1mg/mLviaPIV)
• CallNICU• Considerpassiveneonatal
cooling(postresuscitationcare)
• NochangeifIfPALS/CPRCPRratiosused(15:2),childwillhavenochangeinHRandSpO2gradualdecreasesto75%
• Compressiontoventilationratioof
3:1VERYimportanttokeeptrackofinNRPversusPALS/CPRaskparticipantstoverbalize
• ENDCASEWITHEPINEPHRINEADMINISTRATION,OR2CYCLESOFCPR
KeyDebriefingPoints:1. NRP–considerallowingcasetorepeatiflearnersneedpractice.2. Provisionofpainmanagement3. LEAN–medicationthatcanbegivenbyETT4. Considerationofwhentoventilate/jetventilateaneonate.5. Meconiumaspirationkit–indicationstouse6. Postresuscitationcare
NeonatalResuscitationProgram(NRP)+MeconiumAspirationSyndrome(MAS)CaseIDNumber:VirtualResusRoom2Author:JamesLeungRevisingAuthors:QuangNgo,MeaganDoyle,SarahFooheyDateofModifiedCaseCreation:July16,2020(NB*ThiscaseisamodificationofCodeDelivery1).ThiscasehasbeenmodifiedtoworkwithVirtualResusRoomCasePedsNRP(James)DateofOriginalCaseCreation:August29,2017TargetAudience:
- ResidentMD(FRCPCPediatrics/CCFP-EM/CCFP/FRCPCEM)SimulationDifficultyLevel:Intermediate(FRCPClevel)Objectives:Overarchinggoalsofsimulation:NeonatalPatientObjectives:Bytheendofthesession,participantswill:Knowledge:
1. RecognizeandtreatmeconiumaspirationsyndromeinaccordancetorecentNRP2017guidelines.
2. UnderstandcomponentsoftheMRSOPAPPVcorrectivemnemonic.3. Recognizeindicationstosecureairwayinseveremeconiumaspiration.4. Considerindicationsfortrachealsuctioninachildwithmeconium
aspiration.Skills:
1. Demonstrateanorganized,systematicapproachtoprimaryandsecondarysurveyofnewbornrequiringresuscitation.
2. Correct:a. SetupofneonatalresuscitationequipmentinEDenvironmentb. Neonatalintubationandmeconium/trachealsuctioningc. SetupofneonatalventilatorinEDenvironment
3. Demonstratesafemedicationadministrationpractices,particularlydosinganddeliveryof:
a. NeonatalRSIManager/Collaborator:
1. Succinctlycollect,reviewandsummarizeinformationpresentedtoteamsduringhandover(EMS)
2. Effectiveclosedloopcommunicationtoteammembers3. Teamleaderdemonstrateinclusiveleadership4. Developmentofasharedmentalmodel5. Completedocumentationofevent6. Demonstrateskillwithcrisisresourcemanagementparticularlywith:
a. Roledelegationb. Prioritizationoforders/tests/medicationadministrationc. Situationalawareness
Materials:Location:VirtualResuscitationRoom–NRP(James)PhysicalProps/Equipment:
§ Umbilicalcordclamp§ Neonatalbedwarmer§ Oxygendeliverydevices
o lowflow(nasalprongs,NRBmask)o Bagmask
• Selfinflating• Flowinflating
§ StandardAirwayEquipmento OPA/NPAo Laryngoscopewithcurvedandstraightbladeso ETTsizes3-4o CO2detectiondeviceo Suctioncatheters(10-12Fr,8FrforETT)
§ StandardIVEquipmento IVcatheterso IVPumpo IVtubing
§ UVCInsertionkit§ Meconiumaspirationkit§ IVfluids:
o NSo D50.45NS
§ Oxygenblender(roomairand100%FiO2).§ Medications
o StandardNRPmedicationso RSIKit
• Succinylcholine• Rocuronium• Ketamine• Etomidate• Propofol• Fentanyl• Midazolam(avoidusingperCPSstatement)
o EpinephrineMulti-Media:
• Initiallabs–CBC/generalchemistry,criticalbloodgas• CXR–noPTX,TTNappearance
LABORATORY SERVICES COLLECTION SITE: NAME: BABY Boy PATIENT ID: PHYSICIAN: RESULT REFERENCE RANGE BLOOD GAS (CRITICAL VENOUS) BLOOD GAS VALUES pH 7.10 H 7.35-7.45 pCO2 50 mmHg H 35-45 pO2 30 mmHg L 35-45 cHCO3 20 mmol L 18-26 OXIMETRY VALUES ctHb 180 g/L H 125-180 FO2Hb 3 % 88-100 FCOHb 0 % 0-1.5 fMetHb 0 % 0-1.5 ELECTROLYTE VALUES cNa 140 mmol/L (138-148) cK 4.8 mmol/L (3.6-5.6) cCl 100 mmol/L (98-110) cCa 2 mmol/L (0-2) METABOLIC VALUES cGlu 5.0 mmol/L H (3.9-6.1) cLactate 2.3 mmol/L H (0-2)
NeonatalCXR
SCENARIO:(Duration30minutesimulation+30minutedebrief)Introduction(providedtoparticipants):Basedonatruestory…EMSisrushingintoyourPEDafterjustdeliveringaninfantintheparkingoutsideofthePED.ThemotherwasenroutetoL+Dbutunabletomakeitupstairs,andEMS(bystanders)deliveredtheinfantintheparkinglot.PerEMS,theinfantcameoutcoveredinamnioticfluidandmeconiumstainingandisflat.TheyhaveliterallytakentheinfantfromtheparkinglotandrushedhimbacktotheED.Themother(stable)isbeingtreatedintheEDforpost-deliverycarebytheL+Dteam.Sheisavailableforquestioning.NICUiscurrentlyattendingtoanotherdelivery.Additionalinformation:ObtainedfromOnfurtherquestioning28yearsold,healthy.SheisG1P0andthisisanplanned/expectedpregnancy.Routinepre-natalcarewassoughtwithnoconcernsonvisits.PrenatalserologywasunremarkableandGBSstatusisnegative.Duedatewas1weekago.Mother’swaterbrokeapproximately1houragowithsomemeconiumstainingatthetime.Regularcontractionsbeganenroutetohospital.CaseProgression:
ScenarioTransitions/Evolution EffectiveManagement IneffectiveManagement Notes1.PrimaryandsecondaryassessmentwithNRPresuscitationinitiatedInitialvitalsT:35.9Cskinprobe|HR30|BP:50/32|SpO268%RA|RR0(noeffort)Weight(~3kg).TermappearinginfantA-PatentB–Norespiratoryeffort.C–CoolperipheriesCRT4-5central.Pallorous/paleD–Poortone,NotvigorousE–Bloodstainsoninfant.Nomeconiumstaining
• Setupequipment,andturnonwarmer
• Monitorsapplied• Pre-postductalsaturations
obtained• IVaccess–successfulx1
tohand• Considerclamping
umbilicalcord(oncePIVaccessobtained)
• NRPresuscitationstarted
• Suctionmouth• Dry+stimulate
• IfnoPPVstartedby1minute,decreaseSpO2to40%,HRdecreaseto25
• GiventheverycheckliststyleofNRP,debriefersshouldkeeptrackofactionstaken
• SpO2targetat5minbirth=80-85%Moveontophase2withinitiationofPPVandinsertionofIV
• HRthenbreathingwithinoneminute
• DecisiontoinitiatePPV–startwithroomairFiO2
2.PPVwithfailureofMRSOPAanddecisiontointubateVitalswithPPVinitiatedT:36.5Cskin|HR50|BP:50/32|SpO268%RA|RR0(noeffort)A–UnchangedB-UnchangedC–UnchangedD–UnchangeE-Unchanged
• MRSOPAinitiated• PPVinitiatedwithPEEP
(Useflowinflatingbag)• Changefromroomairto
100%O2• Decisiontointubate
BEFOREchestcompressions
• Ifnodecisiontointubateafter1minutemakedesaturateto30%slowly.Childwillhavearrest(PEA)after5minutesifnodecisiontointubate
• Ifchestcompressionsstarted,therewillbenoimprovementinchilduntilintubationcompleted.
• Ifchildis
overaggressivelybagged,willdeveloptensionPTX
MRSOPA• Maskadjustment• Repositionairway(sniffing)• Suctionmouthandnose• Openmouthslightlyandforward• Increasepressure• Airwayalternative(ETTorLMA)NoRSIneededasemergency(perNICU)IfRSI:Atropinepremedication,thenFentanyl2-5mcg/kgIVpush(1minute)+Succinylcholine2mg/kg–1stchoiceforparalytic/Rocuronium1mg/kg(2ndchoiceduetoprolongedduration)+atropine(nomidazolam)Thereisnolongera‘minimum0.1mg’doseforatropineanymore.Dose0.02mg/kgbasedonweightMovetoPhase3withintubationdecision
3.IntubationBeforeintubationvitalsT:36.5Cskin|HR46|BP:50/32|SpO265%100FiO2|RR0Post-intubationafter1minuteT:36.5Cskin|HR52|BP50/32|SpO282%at100FiO2|RR0
• Intubationwithappropriateback-upplan
• Pre-intubationchecklist• Considerepinephrine
drawnuppre-intubation• Postintubationsedation
plan• Considermeconium
suctionaspirationkitforETT
• Iffailstointubatewithin30s,SpO2decreasesto45%.WillallowSpO2toriseto65%withrestartedBMV.
• Ifchestcompressionsnotinitiatedafter2minutesof
• Considerfentanylinfusionforsedation,postintubation.
MovetoPhase4afterintubation(chestcompressionstostart15-30safter)
Nochangeinprimaryassessment.Remainslimp
intubationthendecreaseHR(willPEAarrestifnotstartedafter5minutes)
4.ChestcompressionstorecoveryNochangeinvitalswithchestcompressionsT:36.5Cskin|HR52|BP50/32|SpO282%at100FiO2|RR0ATENDOFCASE,MAKEINFANTSTARTCRYINGT.36.5skin|HR100|BP50/32|SpO290%at100FiO2|RR12
• Chestcompressionsstartedwith3:1ratio15-30safterintubation
• RecheckHRafter60s–nochange
• Epinephrine(0.1mg/mLviaPIV)
• CallNICU• Considerpassiveneonatal
cooling(postresuscitationcare)
• NochangeifIfPALS/CPRCPRratiosused(15:2),childwillhavenochangeinHRandSpO2gradualdecreasesto75%
• Compressiontoventilationratioof
3:1VERYimportanttokeeptrackofinNRPversusPALS/CPRaskparticipantstoverbalize
• ENDCASEWITHEPINEPHRINEADMINISTRATION,OR2CYCLESOFCPR
KeyDebriefingPoints:1. NRP–considerallowingcasetorepeatiflearnersneedpractice.2. Provisionofpainmanagement3. LEAN–medicationthatcanbegivenbyETT4. Considerationofwhentoventilate/jetventilateaneonate.5. Meconiumaspirationkit–indicationstouse6. Postresuscitationcare
NeonatalResuscitationProgram(NRP)+MeconiumAspirationSyndrome(MAS)CaseIDNumber:VirtualResusRoom2Author:JamesLeungRevisingAuthors:QuangNgo,MeaganDoyle,SarahFooheyDateofModifiedCaseCreation:July16,2020(NB*ThiscaseisamodificationofCodeDelivery1).ThiscasehasbeenmodifiedtoworkwithVirtualResusRoomCasePedsNRP(James)DateofOriginalCaseCreation:August29,2017TargetAudience:
- ResidentMD(FRCPCPediatrics/CCFP-EM/CCFP/FRCPCEM)SimulationDifficultyLevel:Intermediate(FRCPClevel)Objectives:Overarchinggoalsofsimulation:NeonatalPatientObjectives:Bytheendofthesession,participantswill:Knowledge:
1. RecognizeandtreatmeconiumaspirationsyndromeinaccordancetorecentNRP2017guidelines.
2. UnderstandcomponentsoftheMRSOPAPPVcorrectivemnemonic.3. Recognizeindicationstosecureairwayinseveremeconiumaspiration.4. Considerindicationsfortrachealsuctioninachildwithmeconium
aspiration.Skills:
1. Demonstrateanorganized,systematicapproachtoprimaryandsecondarysurveyofnewbornrequiringresuscitation.
2. Correct:a. SetupofneonatalresuscitationequipmentinEDenvironmentb. Neonatalintubationandmeconium/trachealsuctioningc. SetupofneonatalventilatorinEDenvironment
3. Demonstratesafemedicationadministrationpractices,particularlydosinganddeliveryof:
a. NeonatalRSIManager/Collaborator:
1. Succinctlycollect,reviewandsummarizeinformationpresentedtoteamsduringhandover(EMS)
2. Effectiveclosedloopcommunicationtoteammembers3. Teamleaderdemonstrateinclusiveleadership4. Developmentofasharedmentalmodel5. Completedocumentationofevent6. Demonstrateskillwithcrisisresourcemanagementparticularlywith:
a. Roledelegationb. Prioritizationoforders/tests/medicationadministrationc. Situationalawareness
Materials:Location:VirtualResuscitationRoom–NRP(James)PhysicalProps/Equipment:
§ Umbilicalcordclamp§ Neonatalbedwarmer§ Oxygendeliverydevices
o lowflow(nasalprongs,NRBmask)o Bagmask
• Selfinflating• Flowinflating
§ StandardAirwayEquipmento OPA/NPAo Laryngoscopewithcurvedandstraightbladeso ETTsizes3-4o CO2detectiondeviceo Suctioncatheters(10-12Fr,8FrforETT)
§ StandardIVEquipmento IVcatheterso IVPumpo IVtubing
§ UVCInsertionkit§ Meconiumaspirationkit§ IVfluids:
o NSo D50.45NS
§ Oxygenblender(roomairand100%FiO2).§ Medications
o StandardNRPmedicationso RSIKit
• Succinylcholine• Rocuronium• Ketamine• Etomidate• Propofol• Fentanyl• Midazolam(avoidusingperCPSstatement)
o EpinephrineMulti-Media:
• Initiallabs–CBC/generalchemistry,criticalbloodgas• CXR–noPTX,TTNappearance
LABORATORY SERVICES COLLECTION SITE: NAME: BABY Boy PATIENT ID: PHYSICIAN: RESULT REFERENCE RANGE BLOOD GAS (CRITICAL VENOUS) BLOOD GAS VALUES pH 7.10 H 7.35-7.45 pCO2 50 mmHg H 35-45 pO2 30 mmHg L 35-45 cHCO3 20 mmol L 18-26 OXIMETRY VALUES ctHb 180 g/L H 125-180 FO2Hb 3 % 88-100 FCOHb 0 % 0-1.5 fMetHb 0 % 0-1.5 ELECTROLYTE VALUES cNa 140 mmol/L (138-148) cK 4.8 mmol/L (3.6-5.6) cCl 100 mmol/L (98-110) cCa 2 mmol/L (0-2) METABOLIC VALUES cGlu 5.0 mmol/L H (3.9-6.1) cLactate 2.3 mmol/L H (0-2)
NeonatalCXR
SCENARIO:(Duration30minutesimulation+30minutedebrief)Introduction(providedtoparticipants):Basedonatruestory…EMSisrushingintoyourPEDafterjustdeliveringaninfantintheparkingoutsideofthePED.ThemotherwasenroutetoL+Dbutunabletomakeitupstairs,andEMS(bystanders)deliveredtheinfantintheparkinglot.PerEMS,theinfantcameoutcoveredinamnioticfluidandmeconiumstainingandisflat.TheyhaveliterallytakentheinfantfromtheparkinglotandrushedhimbacktotheED.Themother(stable)isbeingtreatedintheEDforpost-deliverycarebytheL+Dteam.Sheisavailableforquestioning.NICUiscurrentlyattendingtoanotherdelivery.Additionalinformation:ObtainedfromOnfurtherquestioning28yearsold,healthy.SheisG1P0andthisisanplanned/expectedpregnancy.Routinepre-natalcarewassoughtwithnoconcernsonvisits.PrenatalserologywasunremarkableandGBSstatusisnegative.Duedatewas1weekago.Mother’swaterbrokeapproximately1houragowithsomemeconiumstainingatthetime.Regularcontractionsbeganenroutetohospital.CaseProgression:
ScenarioTransitions/Evolution EffectiveManagement IneffectiveManagement Notes1.PrimaryandsecondaryassessmentwithNRPresuscitationinitiatedInitialvitalsT:35.9Cskinprobe|HR30|BP:50/32|SpO268%RA|RR0(noeffort)Weight(~3kg).TermappearinginfantA-PatentB–Norespiratoryeffort.C–CoolperipheriesCRT4-5central.Pallorous/paleD–Poortone,NotvigorousE–Bloodstainsoninfant.Nomeconiumstaining
• Setupequipment,andturnonwarmer
• Monitorsapplied• Pre-postductalsaturations
obtained• IVaccess–successfulx1
tohand• Considerclamping
umbilicalcord(oncePIVaccessobtained)
• NRPresuscitationstarted
• Suctionmouth• Dry+stimulate
• IfnoPPVstartedby1minute,decreaseSpO2to40%,HRdecreaseto25
• GiventheverycheckliststyleofNRP,debriefersshouldkeeptrackofactionstaken
• SpO2targetat5minbirth=80-85%Moveontophase2withinitiationofPPVandinsertionofIV
• HRthenbreathingwithinoneminute
• DecisiontoinitiatePPV–startwithroomairFiO2
2.PPVwithfailureofMRSOPAanddecisiontointubateVitalswithPPVinitiatedT:36.5Cskin|HR50|BP:50/32|SpO268%RA|RR0(noeffort)A–UnchangedB-UnchangedC–UnchangedD–UnchangeE-Unchanged
• MRSOPAinitiated• PPVinitiatedwithPEEP
(Useflowinflatingbag)• Changefromroomairto
100%O2• Decisiontointubate
BEFOREchestcompressions
• Ifnodecisiontointubateafter1minutemakedesaturateto30%slowly.Childwillhavearrest(PEA)after5minutesifnodecisiontointubate
• Ifchestcompressionsstarted,therewillbenoimprovementinchilduntilintubationcompleted.
• Ifchildis
overaggressivelybagged,willdeveloptensionPTX
MRSOPA• Maskadjustment• Repositionairway(sniffing)• Suctionmouthandnose• Openmouthslightlyandforward• Increasepressure• Airwayalternative(ETTorLMA)NoRSIneededasemergency(perNICU)IfRSI:Atropinepremedication,thenFentanyl2-5mcg/kgIVpush(1minute)+Succinylcholine2mg/kg–1stchoiceforparalytic/Rocuronium1mg/kg(2ndchoiceduetoprolongedduration)+atropine(nomidazolam)Thereisnolongera‘minimum0.1mg’doseforatropineanymore.Dose0.02mg/kgbasedonweightMovetoPhase3withintubationdecision
3.IntubationBeforeintubationvitalsT:36.5Cskin|HR46|BP:50/32|SpO265%100FiO2|RR0Post-intubationafter1minuteT:36.5Cskin|HR52|BP50/32|SpO282%at100FiO2|RR0
• Intubationwithappropriateback-upplan
• Pre-intubationchecklist• Considerepinephrine
drawnuppre-intubation• Postintubationsedation
plan• Considermeconium
suctionaspirationkitforETT
• Iffailstointubatewithin30s,SpO2decreasesto45%.WillallowSpO2toriseto65%withrestartedBMV.
• Ifchestcompressionsnotinitiatedafter2minutesof
• Considerfentanylinfusionforsedation,postintubation.
MovetoPhase4afterintubation(chestcompressionstostart15-30safter)
Nochangeinprimaryassessment.Remainslimp
intubationthendecreaseHR(willPEAarrestifnotstartedafter5minutes)
4.ChestcompressionstorecoveryNochangeinvitalswithchestcompressionsT:36.5Cskin|HR52|BP50/32|SpO282%at100FiO2|RR0ATENDOFCASE,MAKEINFANTSTARTCRYINGT.36.5skin|HR100|BP50/32|SpO290%at100FiO2|RR12
• Chestcompressionsstartedwith3:1ratio15-30safterintubation
• RecheckHRafter60s–nochange
• Epinephrine(0.1mg/mLviaPIV)
• CallNICU• Considerpassiveneonatal
cooling(postresuscitationcare)
• NochangeifIfPALS/CPRCPRratiosused(15:2),childwillhavenochangeinHRandSpO2gradualdecreasesto75%
• Compressiontoventilationratioof
3:1VERYimportanttokeeptrackofinNRPversusPALS/CPRaskparticipantstoverbalize
• ENDCASEWITHEPINEPHRINEADMINISTRATION,OR2CYCLESOFCPR
KeyDebriefingPoints:1. NRP–considerallowingcasetorepeatiflearnersneedpractice.2. Provisionofpainmanagement3. LEAN–medicationthatcanbegivenbyETT4. Considerationofwhentoventilate/jetventilateaneonate.5. Meconiumaspirationkit–indicationstouse6. Postresuscitationcare
NeonatalResuscitationProgram(NRP)+MeconiumAspirationSyndrome(MAS)CaseIDNumber:VirtualResusRoom2Author:JamesLeungRevisingAuthors:QuangNgo,MeaganDoyle,SarahFooheyDateofModifiedCaseCreation:July16,2020(NB*ThiscaseisamodificationofCodeDelivery1).ThiscasehasbeenmodifiedtoworkwithVirtualResusRoomCasePedsNRP(James)DateofOriginalCaseCreation:August29,2017TargetAudience:
- ResidentMD(FRCPCPediatrics/CCFP-EM/CCFP/FRCPCEM)SimulationDifficultyLevel:Intermediate(FRCPClevel)Objectives:Overarchinggoalsofsimulation:NeonatalPatientObjectives:Bytheendofthesession,participantswill:Knowledge:
1. RecognizeandtreatmeconiumaspirationsyndromeinaccordancetorecentNRP2017guidelines.
2. UnderstandcomponentsoftheMRSOPAPPVcorrectivemnemonic.3. Recognizeindicationstosecureairwayinseveremeconiumaspiration.4. Considerindicationsfortrachealsuctioninachildwithmeconium
aspiration.Skills:
1. Demonstrateanorganized,systematicapproachtoprimaryandsecondarysurveyofnewbornrequiringresuscitation.
2. Correct:a. SetupofneonatalresuscitationequipmentinEDenvironmentb. Neonatalintubationandmeconium/trachealsuctioningc. SetupofneonatalventilatorinEDenvironment
3. Demonstratesafemedicationadministrationpractices,particularlydosinganddeliveryof:
a. NeonatalRSIManager/Collaborator:
1. Succinctlycollect,reviewandsummarizeinformationpresentedtoteamsduringhandover(EMS)
2. Effectiveclosedloopcommunicationtoteammembers3. Teamleaderdemonstrateinclusiveleadership4. Developmentofasharedmentalmodel5. Completedocumentationofevent6. Demonstrateskillwithcrisisresourcemanagementparticularlywith:
a. Roledelegationb. Prioritizationoforders/tests/medicationadministrationc. Situationalawareness
Materials:Location:VirtualResuscitationRoom–NRP(James)PhysicalProps/Equipment:
§ Umbilicalcordclamp§ Neonatalbedwarmer§ Oxygendeliverydevices
o lowflow(nasalprongs,NRBmask)o Bagmask
• Selfinflating• Flowinflating
§ StandardAirwayEquipmento OPA/NPAo Laryngoscopewithcurvedandstraightbladeso ETTsizes3-4o CO2detectiondeviceo Suctioncatheters(10-12Fr,8FrforETT)
§ StandardIVEquipmento IVcatheterso IVPumpo IVtubing
§ UVCInsertionkit§ Meconiumaspirationkit§ IVfluids:
o NSo D50.45NS
§ Oxygenblender(roomairand100%FiO2).§ Medications
o StandardNRPmedicationso RSIKit
• Succinylcholine• Rocuronium• Ketamine• Etomidate• Propofol• Fentanyl• Midazolam(avoidusingperCPSstatement)
o EpinephrineMulti-Media:
• Initiallabs–CBC/generalchemistry,criticalbloodgas• CXR–noPTX,TTNappearance
LABORATORY SERVICES COLLECTION SITE: NAME: BABY Boy PATIENT ID: PHYSICIAN: RESULT REFERENCE RANGE BLOOD GAS (CRITICAL VENOUS) BLOOD GAS VALUES pH 7.10 H 7.35-7.45 pCO2 50 mmHg H 35-45 pO2 30 mmHg L 35-45 cHCO3 20 mmol L 18-26 OXIMETRY VALUES ctHb 180 g/L H 125-180 FO2Hb 3 % 88-100 FCOHb 0 % 0-1.5 fMetHb 0 % 0-1.5 ELECTROLYTE VALUES cNa 140 mmol/L (138-148) cK 4.8 mmol/L (3.6-5.6) cCl 100 mmol/L (98-110) cCa 2 mmol/L (0-2) METABOLIC VALUES cGlu 5.0 mmol/L H (3.9-6.1) cLactate 2.3 mmol/L H (0-2)
NeonatalCXR
SCENARIO:(Duration30minutesimulation+30minutedebrief)Introduction(providedtoparticipants):Basedonatruestory…EMSisrushingintoyourPEDafterjustdeliveringaninfantintheparkingoutsideofthePED.ThemotherwasenroutetoL+Dbutunabletomakeitupstairs,andEMS(bystanders)deliveredtheinfantintheparkinglot.PerEMS,theinfantcameoutcoveredinamnioticfluidandmeconiumstainingandisflat.TheyhaveliterallytakentheinfantfromtheparkinglotandrushedhimbacktotheED.Themother(stable)isbeingtreatedintheEDforpost-deliverycarebytheL+Dteam.Sheisavailableforquestioning.NICUiscurrentlyattendingtoanotherdelivery.Additionalinformation:ObtainedfromOnfurtherquestioning28yearsold,healthy.SheisG1P0andthisisanplanned/expectedpregnancy.Routinepre-natalcarewassoughtwithnoconcernsonvisits.PrenatalserologywasunremarkableandGBSstatusisnegative.Duedatewas1weekago.Mother’swaterbrokeapproximately1houragowithsomemeconiumstainingatthetime.Regularcontractionsbeganenroutetohospital.CaseProgression:
ScenarioTransitions/Evolution EffectiveManagement IneffectiveManagement Notes1.PrimaryandsecondaryassessmentwithNRPresuscitationinitiatedInitialvitalsT:35.9Cskinprobe|HR30|BP:50/32|SpO268%RA|RR0(noeffort)Weight(~3kg).TermappearinginfantA-PatentB–Norespiratoryeffort.C–CoolperipheriesCRT4-5central.Pallorous/paleD–Poortone,NotvigorousE–Bloodstainsoninfant.Nomeconiumstaining
• Setupequipment,andturnonwarmer
• Monitorsapplied• Pre-postductalsaturations
obtained• IVaccess–successfulx1
tohand• Considerclamping
umbilicalcord(oncePIVaccessobtained)
• NRPresuscitationstarted
• Suctionmouth• Dry+stimulate
• IfnoPPVstartedby1minute,decreaseSpO2to40%,HRdecreaseto25
• GiventheverycheckliststyleofNRP,debriefersshouldkeeptrackofactionstaken
• SpO2targetat5minbirth=80-85%Moveontophase2withinitiationofPPVandinsertionofIV
• HRthenbreathingwithinoneminute
• DecisiontoinitiatePPV–startwithroomairFiO2
2.PPVwithfailureofMRSOPAanddecisiontointubateVitalswithPPVinitiatedT:36.5Cskin|HR50|BP:50/32|SpO268%RA|RR0(noeffort)A–UnchangedB-UnchangedC–UnchangedD–UnchangeE-Unchanged
• MRSOPAinitiated• PPVinitiatedwithPEEP
(Useflowinflatingbag)• Changefromroomairto
100%O2• Decisiontointubate
BEFOREchestcompressions
• Ifnodecisiontointubateafter1minutemakedesaturateto30%slowly.Childwillhavearrest(PEA)after5minutesifnodecisiontointubate
• Ifchestcompressionsstarted,therewillbenoimprovementinchilduntilintubationcompleted.
• Ifchildis
overaggressivelybagged,willdeveloptensionPTX
MRSOPA• Maskadjustment• Repositionairway(sniffing)• Suctionmouthandnose• Openmouthslightlyandforward• Increasepressure• Airwayalternative(ETTorLMA)NoRSIneededasemergency(perNICU)IfRSI:Atropinepremedication,thenFentanyl2-5mcg/kgIVpush(1minute)+Succinylcholine2mg/kg–1stchoiceforparalytic/Rocuronium1mg/kg(2ndchoiceduetoprolongedduration)+atropine(nomidazolam)Thereisnolongera‘minimum0.1mg’doseforatropineanymore.Dose0.02mg/kgbasedonweightMovetoPhase3withintubationdecision
3.IntubationBeforeintubationvitalsT:36.5Cskin|HR46|BP:50/32|SpO265%100FiO2|RR0Post-intubationafter1minuteT:36.5Cskin|HR52|BP50/32|SpO282%at100FiO2|RR0
• Intubationwithappropriateback-upplan
• Pre-intubationchecklist• Considerepinephrine
drawnuppre-intubation• Postintubationsedation
plan• Considermeconium
suctionaspirationkitforETT
• Iffailstointubatewithin30s,SpO2decreasesto45%.WillallowSpO2toriseto65%withrestartedBMV.
• Ifchestcompressionsnotinitiatedafter2minutesof
• Considerfentanylinfusionforsedation,postintubation.
MovetoPhase4afterintubation(chestcompressionstostart15-30safter)
Nochangeinprimaryassessment.Remainslimp
intubationthendecreaseHR(willPEAarrestifnotstartedafter5minutes)
4.ChestcompressionstorecoveryNochangeinvitalswithchestcompressionsT:36.5Cskin|HR52|BP50/32|SpO282%at100FiO2|RR0ATENDOFCASE,MAKEINFANTSTARTCRYINGT.36.5skin|HR100|BP50/32|SpO290%at100FiO2|RR12
• Chestcompressionsstartedwith3:1ratio15-30safterintubation
• RecheckHRafter60s–nochange
• Epinephrine(0.1mg/mLviaPIV)
• CallNICU• Considerpassiveneonatal
cooling(postresuscitationcare)
• NochangeifIfPALS/CPRCPRratiosused(15:2),childwillhavenochangeinHRandSpO2gradualdecreasesto75%
• Compressiontoventilationratioof
3:1VERYimportanttokeeptrackofinNRPversusPALS/CPRaskparticipantstoverbalize
• ENDCASEWITHEPINEPHRINEADMINISTRATION,OR2CYCLESOFCPR
KeyDebriefingPoints:1. NRP–considerallowingcasetorepeatiflearnersneedpractice.2. Provisionofpainmanagement3. LEAN–medicationthatcanbegivenbyETT4. Considerationofwhentoventilate/jetventilateaneonate.5. Meconiumaspirationkit–indicationstouse6. Postresuscitationcare