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NRP Scenario Complicated Newborn ED Delivery

NRP Scenario Complicated Newborn ED Delivery
NRP Scenario Complicated Newborn ED Delivery
Item# ISBN-13: 9781581104981

NRP Scenario Complicated Newborn ED Delivery Author Sharon Griswold, MD, John Erbayri, BS, NREMT-P

Reviewer: John Vozenilek, MD

Target Audience: Medical Students, Residents, Nursing Staff

Primary Learning Objectives:

1. Manages the newborn patient optimizing the NRP resuscitation algorithm

2. Assessment of mothers’ past medical history from maternal resuscitation team or pupil assessment of newborn to identify pinpoint pupils

3. Delineates a differential diagnosis for a delivery of a newborn from a mother with substance abuse issues and no prenatal care

4. Arranges disposition to a facility or nursing unit appropriate for a critical newborn patient



Secondary Learning Objectives: optional objectives of the scenario

1. Identification and management of a nuchal cord prior to delivery of the infant

2. Treatment of newborn opiate dependence

3. Identification and treatment of newborn hypoglycemia

4. Consultation of appropriate services, OB, NICU, Social Services

Critical actions checklist – a list to ensure the educational / assessment goals are met.

1. Identification and reduction of nuchal cord in the car

2. Dries, warms, stimulates.

3. Ventilates by BVM

4. Intubates and ventilates

5. Initiates chest compressions

6. Treats with epinephrine, 0.01 mg/kg IV/IO

7. Treats with naloxone, 0.1mg/kg IV/IO

8. Identifies and treats hypoglycemia with glucose 5cc of D10 or (250 to 500 mg/kg = 2.5 to 5.0 cc/kg of D10% newborn)



Environment (if using as a simulation case) 1. Room Set Up – Simulation Lab presented as an ED Trauma Bay Environment

a. Equipment - Laerdal Sim NewB, Broselow Tape Patient Care Monitor/Defibrillator OB Kit, Umbilical Access Equipment, Airway Equipment, IO/IV Access Equipment, NSS, D10%, Epinephrine, Naloxone (All of this can be found pediatric/broselow code cart)

Actors

1. Roles – ER Staff (2 RN’s, 1 Paramedic), Consultant, disheveled father of baby

2. Who may play them – other residents, other students, actors

3. Action Role – ER staff can assist or perform procedures within scope of practice. ER staff can also alert to clinical cues to progress scenario. Consultant to receive patient report and facilitate smooth transfer of patient



For Examiner Only

Author: Sharon Griswold, MD, John Erbayri, BS, NREMT-P Reviewer:

Case Title: Complicated ED Delivery

CASE SUMMARY

CORE CONTENT AREA Pediatrics, Neonatal Resuscitation, PALS

This case is complex with multiple critical actions required to resuscitate a precipitous delivery born to a drug addicted mother. In addition to the need to follow neonatal resuscitation guidelines, the newborn may have one or more of the following complications requiring intervention:

1. Nuchal cord

2. Opiate dependence

3. Hypoglycemia



SYNOPSIS OF CASE

This case involves a precipitous term delivery born to a mother with substance abuse issues and no prenatal care. The candidate must resuscitate the newborn and demonstrate knowledge of glucose and naloxone dosing in the newborn.

SYNOPSIS OF HISTORY/ Scenario Background

Learner is alerted by a disheveled man to stumbles into the ER yelling that his wife is giving birth in their car in the ambulance bay. You find a woman in the passenger’s seat, with a baby crowning. She does not know when her water broke and appears to have altered mental status. Her duration of labor and other past medical history are unknown at presentation. Another team should be assigned the resuscitation of the mother and the learner’s responsibility is to manage the resuscitation of the baby.

If asked, this is a term singleton gestation, her fourth pregnancy. Another team of physicians is brought in to resuscitate mom. The cord must be clamped and cut to begin the resuscitation.

SYNOPSIS OF PHYSICAL

On assessment, the baby is cyanotic, floppy, wet, and apneic. Pulse is 50. No injury is apparent.

For Examiner Only

CRITICAL ACTIONS SCENARIO BRANCH POINTS/ PLAY OF CASE GUIDELINES

1. Identification of nuchal cord X1 and appropriate reduction prior to delivery of the body, suctioning of nares and mouth.

1a. Dries, Warms, Stimulates This critical action is met by the candidate drying, warming, and stimulating the infant.

Cueing Guideline: If the candidate misses this step, the nurse remarks that the baby is wet and slimy.



2. Ventilates by bag/valve/mask (should be superseded by intubation)

This critical action is met by the candidate ventilating by BVM

Cueing Guideline: If the candidate is slow to ventilate, the nurse reports that the pulse is still 50 and the patient is apneic.

3. Intubates and ventilates

This critical action is met by the candidate intubating with an appropriate sized ETT.

Cueing Guideline: Nurse reports that the pulse is still 50, the patient is cyanotic, and that there doesn’t seem to be good chest rise with BVM ventilation.

4. Performs chest compressions

This critical action is met by the candidate performing chest compressions.

Cueing Guideline: Nurse reports that the pulse is still 50 and patient is cyanotic

5. Starts epinephrine in appropriate dose by ETT, IO, or umbilical line

This critical action is met by the candidate starting epinephrine at an acceptable dose as outlined above.

Cueing Guideline: Nurse reports that the pulse is still 50, and patient is cyanotic

SCORING GUIDELINES

(Critical Action No.)

1. Identification of nuchal cord prior to delivery of head

2. Intubation before BVM ventilation is acceptable

3. ETT size should be 3.5 to 4.0.

4. Epinephrine doses may be modified by a factor of two in either direction. The candidate should provide the weight-based dose to the nurse. Score down if the dose is not known.

5. The candidate should ensure rapid IV access. Score down if more than two peripheral IV attempts are made without attempt at alternative access such as umbilical vein catheterization or interosseous.

6. Must identify opiate toxicity and treat with appropriate dose

7. Must identify hypoglycemia and treat with appropriate dose

For Examiner Only

HISTORY

Onset of Symptoms:

Precipitous ED Delivery (Newborn is cyanotic, floppy, wet and apenic)

Background Info:

Mother has a substance abuse problem and didn’t have any prenatal care

Chief Complaint: “I think I just had a baby.”

Past Medical Hx: G5 P3, Substance Abuse.

Past Surgical Hx: None.

Family Medical Hx: Unknown (mother was adopted)

Social Hx: Marital Status: Single Children: 3 children, all have been taken away by social services.

Education: Grade 11 then dropped out of high school

Employment: None

ETOH: Occasionally

Drugs: Crack, Heroine, Amphetamines and patient states anything she can get her hands on



For Examiner Only

PHYSICAL EXAM

Patient: Baby Boy Smith Age and Sex: Male, Newborn 36 week gestation

General Appearance: Term, cyanotic, apneic, floppy, wet.

Vital Signs: BP: 40/p P: 50 R: 0 T: 97ºF

Head: moderate coning, no lesions.

Eyes: closed, pupils sluggish, pinpoint 1mm

Ears: Full of fluid

Mouth: normal

Neck: Normal, supple

Skin: Wet, covered in vernix. No meconium visible

Chest: Normal, but apneic

Heart: Normal S1, S2; no murmur, but bradycardic

Abdomen: Soft, normal. Umbilical cord clamped.

Extremities: Normal

Rectal: Hopefully not done.

Pelvic: n/a

Neurological: Floppy, not responsive until epinephrine begun, then responds, becoming normally vigorous over 2 minutes.

Mental Status: Floppy, unresponsive, apneic until as above.



For Examiner Only

STIMULUS INVENTORY

#1 Emergency Admitting Form – There is an admitting form attached to this document. However as the learner needs to deliver the baby precipitously, an admitting form would not ordinarily be available.

#2 CX



Learner Stimulus #1

ABEM General Hospital Emergency Admitting Form

Name: Baby Boy Smith

Age: Unborn on presentation; 36 weeks gestation

Sex: Male

Method of Transportation: Private car

Person giving information: A disheveled man to stumbles into the ER yelling that his wife is giving birth in their car in the ambulance bay.

Presenting complaint: Needs to be successful delivered then resuscitated

Background: This case presents as an emergent delivery. No chart or vital signs will initially be available. You find a woman in the passenger’s seat, with a baby crowning. She does not know when her water broke and appears to have altered mental status. Her duration of labor and other past medical history are unknown at presentation. Another team should be assigned the resuscitation of the mother and the learner’s responsibility is to manage the resuscitation of the baby.

Triage or Initial Vital Signs BP: 40/p P: 50 R: 0 T : 97OF





Learner Stimulus #2

Image taken from



Feedback/ Assessment Form

Complicated Newborn ED Delivery



Candidate ________________________ Examiner _________________________



Critical Actions:

Identification and reduction of nuchal cord

Dries, Warms, Stimulates

Clears the airway as necessary including direct visualization of the cords with aggressive suctioning in the presence of meconium

Ventilates by bag/valve/mask (should be preceded by intubation)

Intubates and ventilates

Appropriate and timely performance of chest compressions

Starts epinephrine in appropriate dose by IV/IO, or umbilical line

Initiates appropriate treatment of opiate toxicity

Initiates appropriate treatment for hypoglycemia

Appropriate consultation of services such as OB, NICU and/or social services

Dangerous Actions: (Performance of one dangerous action results in failure of the case)

A successful candidate should identify the nuchal cord prior to delivery of the body

Inappropriate glucose dosing in a newborn. A successful candidate should NOT give D50 or D25 to a newborn infant.

A successful candidate should attempt warming/drying and stimulating as an initial resuscitation step for the newborn (non-meconium stained amniotic fluid)

Overall Score:

Pass Fail



Date: Examiner: Examinee(s):

Scoring: In accordance with the Standardized Direct Observational Tool (SDOT)

The learner should be scored (based on level of training) for each item above with one of the following: NI = Needs Improvement ME = Meets Expectations AE = Above Expectations NA= Not Assessed

Critical Actions NI ME AE NA Category Identification and reduction of nuchal cord in the car

Dries, warms, stimulates

Clears the airway as necessary including direct visualization of the cords with aggressive suctioning in the presence of meconium

Ventilates with BVM

Intubates and ventilates

Initiates chest compressions

Treats with epinephrine 0.01mg/kg IV/IO or umbilical line (0.1cc/kg of 1:10,000 epinephrine [concentration 1mg in 10cc])

Assessment of mothers past medical history from maternal resuscitation team or pupil assessment of newborn to identify pinpoint pupils

Treats with naloxone 0.1mg/kg IV/IO

Identifies and treats hypoglycemia with glucose D10% (2.5 to 5.0cc/kg)

Appropriate consultation of services such as OB, NICU and/or social services

The score sheet may be used for a variety of learners. For example, in using the case for 4th year medical students, the key teaching points of the case may be the recognition of shock and treatment with appropriate fluid resuscitation. Other items may be marked N/A= not assessed.





Category: One or more of the ACGME Core Competencies as defined in the SDOT

PC= Patient Care Compassionate, appropriate, and effective for the treatment of health problems and the promotion of health

MK= Medical Knowledge Residents are expected to formulate an appropriate differential diagnosis with special attention to life-threatening conditions, demonstrate the ability to utilize available medical resources effectively, and apply this knowledge to clinical decision making

PBL= Practice Based Learning & Improvement Involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care

ICS= Interpersonal Communication Skills Results in effective information exchange and teaming with patients, their families, and other health professionals

P= Professionalism Manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population

SBP= Systems Based Practice Manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value

Keywords for future searching functions Newborn resuscitation, newborn opiate dependence, poor Apgar scores

Has this work been previously published? no

References 1. Normal findings on chest x-ray of Neonates. Review Article. Radiologia Brasileira, Vol 39, No 6, Nov/Dec 2006.

2. Newborn Resuscitation. American Heart Association Circulation Journal: http://circ.ahajournals.org/cgi/content/full/112/24_suppl/IV-188. Retrieved November 21, 2010.

3. Treatment of Hypoglycemia. http://emedicine.medscape.com/article/802334-overview. Retrieved November 21, 2010.

4. Neonatal hypoglycemia. McGowan, et al. Pediatrics in Review. 1999;20:6-15.





Complicated Newborn ED Delivery Debriefing Materials

This case is complex with multiple critical actions required to resuscitate a precipitous delivery born to a drug addicted mother. In addition to the need to follow neonatal resuscitation guidelines, the newborn may have one or more of the following complications requiring intervention:

1. Nuchal cord 2. Opiate dependence 3. Hypoglycemia

Neonatal Resuscitation Algorithm

The neonatal resuscitation algorithm is a unique algorithm to support the conversion from the maternal to independent newborn circulation. Approximately 10% of newborns require some assistance to begin breathing at birth. About 1% require extensive resuscitative measures. Although the vast majority of newly born infants do not require intervention to make the transition from intrauterine to extrauterine life, because of the large number of births, a sizable number will require some degree of resuscitation.

The neonatal resuscitation algorithm suggests that each patient receive the routine care of providing warmth, drying, stimulating, clearing the airway and the assessment of a brief maternal history within the first 30 seconds of life.

Neonatal Resuscitation Triangle

The heart rate, color and quality of respirations should be assessed within the next 30 seconds while the provider continues to provide warmth, dries, stimulates and continues to clear the airway as needed.

If there is persistent cyanosis, apnea or a HR <100, then positive pressure ventilation should be initiated and CPR initiated at 60 seconds for a HR <100 beats per minute.

If the HR is <60 beats per minute at 60 seconds, the provider should consider volume resuscitation and epinephrine and discuss the differential diagnosis of lack of response to care.

Pediatric Epinephrine Dosing Although appropriate pediatric dosing approximations can be found on the colormetric weight based tapes, we offer a simplistic method to recall appropriate dosing. The appropriate dose is 0.01mg/kg via an IV/IO or umbilical line. (When concentration is standardized: 1mg of epinephrine in 10cc.)

This translates to 0.1cc/kg of 1:10,000 epinephrine ***The usual preparation of 1mg in 10cc must be used Endotracheal Tube Placement

Endotracheal intubation may be indicated at several points during neonatal resuscitation:

• When tracheal suctioning for meconium is required

• If bag-mask ventilation is ineffective or prolonged

• When chest compressions are performed

• When endotracheal administration of medications is desired • For special resuscitation circumstances, such as congenital diaphragmatic hernia or extremely low birth weight (<1000 g)

Apgar Score The physical assessment should include a determination of weeks of gestation, length of labor, the color of the amniotic fluid, muscle tone. Apgars should be scored at 1 and 5 minutes after birth.

Scored at 1 and 5 minutes

Sign

0 Score

1

2 Activity (muscle tone) Flaccid Some tone Active Pulse (heart rate) 0 <100 >100 Grimace (response to simulation) None Grimace Cry or cough Appearance (color) White Blue Pink centrally Respirations (respiratory effort) Absent Gasping or irregular Regular or crying



Treatment of Hypoglycemia In the US, the overall incidence of symptomatic hypoglycemia in newborns varies from 1.3-3 per 1000 live births. Incidence varies with the definition, population, method and timing of feeding, and the type of glucose assay. Serum glucose levels are higher than whole blood values. The incidence of hypoglycemia is greater in high-risk neonatal groups. Screening for hypoglycemia should occur in any infant with an APGAR score less than or equal to 5. Cerebral edema will occur if undiluted D50 is given to the newborn as the hyperosmolar D50 will draw free water through the underdeveloped neonatal blood brain barrier. If D10 is not readily available, D50 can be diluted 1:4 with sterile water 1part D50 in 4 parts sterile water.

Table 1. Etiologies of Neonatal Hypoglycemia ETIOLOGY DURATION OF HYPOGLYCEMIA Prematurity, intrauterine growth retardation Transient* Asphyxia, hypothermia Transient Sepsis Transient Infant of diabetic mother Transient Erythroblastosis fetalis Transient Exposure to beta-agonist tocolytics Transient Familial hyperinsulinism Prolonged Inborn errors of metabolism Prolonged *Generally <7 days of life

The appropriate dosages of hypoglycemia differ by age. The appropriate treatment of a newborn with hypoglycemia is with glucose 5cc/kg of D10 or

250 to 500 mg/kg = 2.5 to 5.0 cc/kg of D10% newborn 250 to 500 mg/kg = 1.0 to 2.0 cc/kg of D25% child 250 to 500 mg/kg = 0.5 to 1.0 cc/kg of D50% adult







Treatment of Opiate Dependence

Naloxone is not recommended as part of the primary resuscitation effort for newborns with respiratory depression. Attempts to improve heart rate, color and respiratory efforts should first be attempted by supporting ventilation.

The usual dose is 0.1mg/kg.

Naloxone may have a shorter half-life than the original maternal opioid; therefore the neonate should be monitored closely for recurrent apnea or hypoventilation, and subsequent doses of naloxone or naloxon

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