Case ID Number: Virtual Resus Room 2 · 1. Recognize and treat meconium aspiration syndrome in...
40
Neonatal Resuscitation Program (NRP) + Meconium Aspiration Syndrome (MAS) Case ID Number: Virtual Resus Room 2 Author: James Leung Revising Authors: Quang Ngo, Meagan Doyle, Sarah Foohey Date of Modified Case Creation: July 16, 2020 (NB* This case is a modification of Code Delivery 1). This case has been modified to work with Virtual Resus Room Case Peds NRP (James) Date of Original Case Creation: August 29, 2017 Target Audience: - Resident MD (FRCPC Pediatrics/CCFP-EM/CCFP/FRCPC EM) Simulation Difficulty Level: Intermediate (FRCPC level) Objectives: Overarching goals of simulation: Neonatal Patient Objectives: By the end of the session, participants will: Knowledge: 1. Recognize and treat meconium aspiration syndrome in accordance to recent NRP 2017 guidelines. 2. Understand components of the MRSOPA PPV corrective mnemonic. 3. Recognize indications to secure airway in severe meconium aspiration. 4. Consider indications for tracheal suction in a child with meconium aspiration. Skills: 1. Demonstrate an organized, systematic approach to primary and secondary survey of newborn requiring resuscitation. 2. Correct : a. Set up of neonatal resuscitation equipment in ED environment b. Neonatal intubation and meconium/tracheal suctioning c. Set up of neonatal ventilator in ED environment 3. Demonstrate safe medication administration practices, particularly dosing and delivery of: a. Neonatal RSI Manager/Collaborator:
Transcript of Case ID Number: Virtual Resus Room 2 · 1. Recognize and treat meconium aspiration syndrome in...
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
