www.emergencypedia.com KhanhNguyen Scenario3SIMULATIONOSCE(FACEM)–DOUBLESTATION

Youaretheconsultantinapaediatrictertiaryemergencydepartment.Amotherhasbroughtinher7-dayoldbabyboyJoshuaduetodifficultybreathingandcomplaintsofpoorfeeding.

Themothertellsyouthatthepregnancywasuncomplicatedwithnormalvaginaldeliveryofatermbabyweighing3.2kg.

Herchildwasfeedingwellondischargebutoverthelast2dayshasnotbeenabletofeedforlongerthan5minsandappearstobestrugglingtobreathe.Hehasonlyhad2wetnappiestoday.

• Thechildhasbeenbroughtdirectlyintotheresuscitationbayasthenursingstaffwereconcernedthathelookedcyanotic.

Youareto:

1) Teamleadtheresuscitationandmanagethechildaccordingly2) Handovertoinpatientadmittingteam

Therewillbearegistrarand2nursesintheroomwhoarecompetentwithclearinstructions.

Domains:

Leadershipandprioritisation

Communication

Medicalexpertise

www.emergencypedia.com KhanhNguyen Scenario3DUCTDEPENDANTCONGENTIALCARDIACDISEASE

PROGRESSOFTHESCENARIO

W:3kg

E:12J

T:size3.5/4ETT

F:60mLNS

M:0.5mgmidazolam

A:0.3mL1:10,000Adrenaline

G:6mL10%dextrose

0-2min:Assignroles

Briefdiscussionwithmother

PPE

Monitoring:RR50,sats75%RA(postductal),sats95%(preductal),HR160,SBP70,alert,36

deg

AchieveIV/IOaccess

2-7min:A-Eassessment

A:patent,notprotected.Nostridororsignsofobstruction.Positionshouldbeneutral

B:labouredbreathing,tachypneic,accessorymuscleuse,cyanotic

Applyhighflowoxygentherapyandplanforintubationbutacknowledginghighrisk

IfCXRperformed(attached)–lungfieldsareclear,cardiomegaly

C:tachycardic,borderlinehypotensive,caprefill6s,cooltotouch,peripherallyshutdown

Cardiacmurmurpresent

IVaccessandbloodscollected.VBG(attached)

IVFboluswithnilimprovementofhaemodynamics

IfongoingIVFbolusgiven,patientwillgetincreasinglybreathless/APO

ECGshowssinustachycardiaandRBBB(attached)

D:alertbutappearstired,PEARL3mm,BSL6

E:afebrile,nilevidenceofrash

www.emergencypedia.com KhanhNguyen Scenario3Recap:Unwellbabywithundifferentiatedshock–considerationforsepsis,cardiogenic,

metaboliccauses.

IVantibiotics–cefotaxime50mg/kg+ampicillin50mg/kg+gentamycin7mg/kg

7-12min:Ifnilconsiderationforprostaglandininfusionchildwillcontinuetodeteriorate

PGE1infusion:0.05mcg/kg/min.Maintenancedosemaybeaslowas0.01mcg/kg/min

Limitoxygentherapy

CautioususeofIVFascanworsecardiacfailure

Promptfromfacultyifnilconsiderationforcongenitalcardiacdisease

CancallNICUforadvice

Considerationofadrenalinsufficiency(highK,lowNa,lowBSL)andempiricalsteroids

12-15min:Ifprogressingwellthen:

Childcontinuestodeterioratedespiteaboveifinitiated–willneedtopreparetointubate

Highrisk–callforanaestheticssupportwhoarenotavailable

Atropinepremedication

PlanA,B,C

Size1blade,size4ETT,insert12cm

15-17min:Handovertocardiology/NICU

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www.emergencypedia.com KhanhNguyen Scenario3DUCTDEPENDENTLESIONS

- TetralogyofFallot

- Tricuspidatresia

- Pulmonaryatresiaorstenosis

HYPEROXIATEST

IfthecauseofcyanosisisnoncardiacthearterialPaO2willincreaseto>100mmHgonexposureto100%oxygen.Ifthereisacardiaccauseforcyanosis,thePaO2willremainbelow100mmHg

www.emergencypedia.com KhanhNguyen Scenario3DUCTINDEPENDENTLESIONS

- Truncusarteriosus

- Transpositionofthegreatarteries

- Totalanomalouspulmonaryvenousreturn

- Hypoplasticleftheartsyndrome