EM ReSCu Peds 3 | Congenital Adrenal Hyperplasia & Adrenal Insufficiency Shock

Brief Narrative Description of Case

Patient is brought in by parents for vomiting. He is lethargic, ill- appearing, and severely dehydrated. Learners will need to establish that he is in hypotensive shock with poor perfusion. Intravenous access will be unable to be obtained, requiring intraosseous access. He is hypoglycemic and will require a glucose bolus. He is later found to be hyponatremic and hyperkalemic to alert providers of adrenal crisis.

Primary Learning Objectives

At the end of this simulation, participants should be able to:

  1. Describe signs/symptoms of shock in a neonate (comprehension)
  2. Construct a differential for shock in a neonate (synthesis)
  3. Identify neonatal hypoglycemia (comprehension)
  4. Construct and implement an initial management plan for a neonate in shock (application)
  5. Interpret signs/symptoms of adrenal hyperplasia and adrenal crisis (evaluation)
  6. Demonstrate intraosseous placement (application)
  7. Demonstrate focused history taking from a caregiver (application)
  8. Explain diagnosis and management to caregivers (synthesis)
  9. Demonstrate teamwork and closed loop communication (application)
  10. Optional: Identify signs/symptoms and treat hyperkalemia (knowledge & application)
  11. Optional: Identify and treat ventricular tachycardia with pulses (knowledge & application)

Critical Actions

  • Assign/assume team roles
  • Obtain brief history from parent
  • Establish basic airway maneuvers
  • Place patient on continuous cardiac monitor
  • Obtain a point of care glucose
  • Administer glucose bolus
  • Establish vascular access
  • Recognize adrenal crisis and administer hydrocortisone
  • Obtain a venous blood gas to establish electrolytes
  • Obtain ECG for hyperkalemia on labs (advanced optional stage)
  • Administer medications appropriate for hyperkalemia, such as calcium gluconate, albuterol, insulin/glucose, sodium polystrene (advanced optional stage)
  • Perform synchronized cardioversion for ventricular tachycardia with pulses (advanced optional stage)
  • Perform focused physical exam
  • Recognize signs for adrenal crisis
  • Explain diagnosis to parent and how it relates to the patient presentation

Case Creators

Authors

  • Andrea Vo, MD
  • Todd P Chang, MD, MAcM

Editors

  • Ilana Bank, MDCM, FRCPC, FAAP
  • Rebekah Burns, MD
  • Jason Lowe, DO
  • Hillary Moss, MD
  • Marc Auerbach, MD

Updated August 18, 2020

Setup

Chief complaint: Vomiting
Patient age: 3 weeks old
Weight: 3 kg

Recommended Supplies

  • Manikin: Male neonate with male genitalia can be programmed to have the sunken fontanelle on exam
  • Moulage (optional): Darkening of scrotum, cool extremities (take a paper towels wet them and place in the refrigerator then wrapping the arms/legs in those)
  • Resources: PALS card and/or length-based tape (e.g., Broselow Tape)
  • Manikin set up: Arms and legs placed in ice before simulation
  • Equipment:
    • Intraosseous equipment including E-Z IO, needle, stabilizer, and connectors, saline flushes
    • Pediatric airway equipment of various sizes/airway cart
      • Simple facemask
      • Non-rebreather mask
      • Nasal cannula
      • Oxygen tubing
      • Suction
      • 3.5 uncuffed endotracheal tube, stylet, laryngoscope size 1 Miller/Mac
      • End-tidal monitoring device
  • Medications (pre-calculated/pre-drawn):
    • D10W
    • Normal saline bags
    • Normal saline flush
    • Hydrocortisone
    • Ampicillin
    • Cefotaxime (or preferred antibiotics for presumed neonatal sepsis)
    • Calcium gluconate (advanced)
    • Sodium polystyrene (advanced)
    • Insulin (advanced)
    • Albuterol (advanced)

Supporting Files

  • Point-of-care labs
  • Electrocardiogram

Participants/Roles

  • Participants/Learners:
    • Team Leader
    • Airway Manager
    • Survey Physician
    • Medication Giver
    • Family Liaison
  • Faculty or other embedded participants can play a nurse, respiratory therapist, or tech, if there are not enough learners to perform the above roles.
  • Standardized patient (actor or faculty) to play patient’s parent

Team roles may need to be adjusted in order to suit local practices and norms

Prerequisite Knowledge

  • Faculty
    • PALS protocols
    • General knowledge of emergency medicine
    • Simulation implementation and debriefing experience
  • Emergency medicine residents
    • Any stage of training (preferably PGY-2 year; PGY-3 or 4 for advanced options)
    • Completed PALS certification

Case Alternatives

  • If residents fail to recognize and treat adrenal crisis within 10 minutes of the case (e.g., residents continue to give normal saline boluses, administer antibiotics, consider pressors), stop the scenario.
  • For advanced learners, the potassium (K) is extremely elevated to 10 mEq/L on VBG. Learners must obtain an ECG and administer appropriate medications to lower K, including Ca gluconate, albuterol, insulin/glucose, and/or sodium polystyrene (with Ca gluconate being required medication). If Ca gluconate is given within 5 minutes (i.e., very quickly, indicating proficiency in hyperkalemia management), then the patient can go into ventricular tachycardia with pulses. The team must cardiovert patient back into sinus rhythm.

Milestones

PC1. Emergency Stabilization
PC2. Performance of Focused History & Physical Exam
PC3. Diagnostic Studies
PC4. Differential Diagnoses and Management
PC5. Pharmacotherapy
PC9. General Approach to Procedures
PC10. Airway Management
PC14. Vascular Access
PC15. Medical Knowledge
ICS1. Patient Centered Communication
ICS2. Team Management

Resources

  1. Agus MSD, Dorney K. Endocrine Emergencies. In R. Bachur & K. Shaw (Eds.), Fleisher and Ludwig’s Textbook of Pediatric Emergency Medicine. 2015; 7th ed., pp. 701-704.
  2. Speiser PW, Azziz R, Baskin LS, et al. Congenital adrenal hyperplasia due to steroid 21-hydroxylase deficiency: An Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2010;95:4133. PMID: 20823466
ITEMFINDING
Overall Appearance3-week-old male lethargic, ill-appearing, shallow breathing
HPIThe patient arrives by private vehicle accompanied by a parent. “He has been acting very tired for the past week.” If the learners ask for specifics:

  • He has been feeding poorly in the past few days, which is difficult to quantify since he’s breastfed.
  • His diapers have been decreased, only 1 minimally wet diaper today.
  • His pediatrician called and left a message yesterday about an abnormal newborn screen.
  • ROS: Fatigues and tires at the breast easily. Tactile fever, but no cough, emesis, diarrhea, or rashes.
Past Medical/Surgical HistoryBorn at 40-weeks gestation, unremarkable gestation/ delivery
MedicationsNone
AllergiesNone
Family HistoryNon-contributory
Social HistoryNo pet, no smokers, taken care of by mom at home

Hypoglycemia

Start of case through treatment of hypoglycemia

Critical Actions

  • Team leader assigns tasks
  • Obtain brief history from parent
  • Perform focused physical exam (ABCs)
  • Perform basic airway maneuvers based on pediatric anatomy
  • Place patient on continuous cardiac monitor
  • Verbalize recognition of shock
  • Obtain point-of-care glucose
  • Obtain vascular access
  • Verbalize recognition of hypoglycemia
  • Administer D10W bolus at 5 mL/kg or D25 at 2 mL/kg
  • Administer normal saline bolus at 10-20 mL/kg
  • Administer antibiotics (e.g., ampicillin 100 mg/kg/dose IV, cefotaxime 50 mg/kg/dose IV)
  • Discuss progress and plan of care with the parent

* Unbolded items may be excluded depending on local practices and norms

Physical Exam

ITEMFINDING
Vital SignsT: 37.5oC, HR: 190, BP: 50/28, RR: 35, SpO2: 92% (tracing not consistently good)
GeneralIll-appearing, lethargic, cries weakly
HEENTSunken fontanelle, pupils equal round and reactive, full extraocular movements
NeckNormal
LungsClear to auscultation bilaterally
CardiovascularTachycardic, no abnormal heart sounds, weak pulses, capillary refill >3 seconds
AbdomenNormal, soft, non-distended, non-tender
NeurologicalCries weakly to painful stimuli, moves all extremities
SkinCold, no rashes or bruises
GenitourinaryNormal male genitalia, slightly increase pigmentation of scrotum

Instructor Notes: Changes and Case Branch Points

INTERVENTION / TIME POINTCHANGE IN CASEADDITIONAL INFORMATION
Team performs basic airway maneuvers (e.g., patient placed in sniffing position, shoulder roll, placed on oxygen)SpO2 improves to 100%
Team attempts intravenous lineFaculty/nurse verbalizes that attempt is unsuccessful
Team sends blood drawn for labs (including bedside electrolytes)Labs other than bedside glucose will be pending until Stage 2.
Team places IOIO is functional if placed in the appropriate location.
IO placement initiated without discussing with parentParent asks, “What are you doing to my child?” Parent will be satisfied with a direct/accurate explanation.
Participant requests finger stick blood glucoseGlucose level is 28 mg/dL
Team gives 5 mL/kg of D10 IV (or 2 mL/kg of D25)Patient cries more vigorously. Proceed to Stage 2.
Team requests isotonic fluid boluses and empiric antibiotics.Blood pressure decreases to 45/30
Team requests vasopressors for hypotensionBlood pressure improves to 62/44
IntubationNo change other than paralysis, O2 sats will be 100% with oxygenTeam may elect to intubate the patient
Atropine is given prior to intubationHeart rate increases by 10 for all stages

Adrenal Crisis

10 minutes from the start of the case or after dextrose given for hypoglycemia through administration of steroids

Critical Actions

  • Verbalize recognition of adrenal crisis
  • Administer hydrocortisone 2 mg/kg IV bolus

Physical Exam

ITEMFINDING
Vital SignsT: 37.5oC, HR: 180, BP: 55/30, RR: 40, SpO2: 100% RA
Exam ChangesPatient slightly more active (more vigorous cry), but still hypotensive with poor capillary refill

Instructor Notes: Changes and Case Branch Points

INTERVENTION / TIME POINTCHANGE IN CASEADDITIONAL INFORMATION
Point-of-care venous blood gas shows hyperkalemia, hyponatremia, metabolic acidosisVBG/CBG:

  • pH 7.21
  • pCO2 35 mmHg
  • pO2 60 mmHg
  • HCO3 10 mEq/L
  • Lactate 25 mg/dL
  • Na 120 mEq/L
  • K 7.2 mEq/L
Team administers IV hydrocortisoneBP improves to 80/60, and tachycardia improves to 130. Proceed to Stage 3.For advanced learners go to optional Stage 4.
Team continues to give isotonic fluid boluses and/or starts pressorsPatient becomes increasingly more hypotensive and tachycardic, but never loses pulses. Within 10 minutes of the case, stop the case.The patient will remain in distress, lethargic appearing until IV hydrocortisone is given.

Case Conclusion

Administration of steroids through signout to admitting team/facility

Critical Actions

  • Explain diagnosis to parent and how it relates to the patient presentation
  • Notify admission team

Physical Exam

ITEMFINDING
Vital SignsT: 37.5oC, HR: 150, BP: 70/48, RR: 45, SpO2: 100% RA
Exam ChangesPatient now vigorous and actively crying with improved color and capillary refill 2 seconds

Instructor Notes: Changes and Case Branch Points

INTERVENTION / TIME POINTCHANGE IN CASEADDITIONAL INFORMATION
Point-of-care venous blood gas repeat shows improvementVBG/CBG:

  • pH 7.30
  • pCO2 37 mmHg
  • O2 100mmHg
  • HCO3 17 mEq/L
  • Lactate 16 mg/dL
  • Na 128 mEq/L
  • K 7.0 mEq/L
Team provides signout to admitting service, Pediatric ICU, and/or admitting facilityCase ends

Hyperkalemia (optional)

After 2nd stage, repeat VBG shows K of 9.5 through administration of calcium gluconate or 10 minutes

Critical Actions

  • Obtain electrocardiogram
  • Administer calcium gluconate
  • Perform cardioversion: If Ca gluconate is not administered within the first 5 min of this stage, patient will go into ventricular tachycardia with pulses. If Ca gluconate is not given within 10 minutes of the case, the case will be stopped.

Physical Exam

ITEMFINDING
Vital SignsT: 37.5oC, HR: 180, BP: 48/25, RR: 30, SpO2: 100%
Exam ChangesIncreasing pallor/mottled appearance

Instructor Notes: Changes and Case Branch Points

INTERVENTION / TIME POINTCHANGE IN CASEADDITIONAL INFORMATION
Peaked T waves on cardiac monitorPatient more agitated and cries more
Team obtains ECGECG shows sinus tachycardia, peaked T waves.
Team fails to obtain ECG or notice peaked T wavesWithin 5 minutes, case will be stopped.
Team administers albuterol, sodium bicarbonate, insulin/glucose, or furosemidePatient’s peaked T waves resolve, and patient becomes responsive.
Team administers calcium gluconate within <5 minutesPatient remains stable. Case ends.The assumption is that with such quick Ca gluconate administration, the team has proficiency in hyperkalemia management.

Or for advanced learners: Patient goes into ventricular tachycardia with pulses.

Team administers calcium gluconate at 5–10 minute time pointPatient remains stable. Case ends.The assumption is that the 5–10 minute time frame of Ca gluconate administration means that hyperkalemia management is not at proficient level, but still with some partial credit.
Team provides signout to admitting service, Pediatric ICU, and/or admitting facilityCase ends.No Ca gluconate within 10 minutes means the team is unlikely to implement hyperkalemia management.

Describe signs and symptoms and manage shock in a neonate (comprehension)

  • Brief: Initial assessment to determine the neonate is ill, short discussion about potential differentials of shock in a neonate and initial resuscitation measures
  • Pediatric assessment triangle
  • PALS algorithm
  • Learners should approach a critically ill patient in a standardized fashion. Always check for responsiveness. If unresponsive, check for a pulse. If no pulse, start CPR and proceed to airway, breathing, and circulation. Interventions such as airway repositioning/adjuncts/ intubation should be considered if poor air movement or difficulty with BMV. After A, B, and C have been addressed, the patient should be evaluated for disability and exposed for a thorough head to toe exam. In Pediatrics, people often say that D also stands for “don’t forget the dextrose” as a blood glucose level should be checked in any child with altered mental status.
  • Learners should recognize abnormal vitals. The appropriate PALS algorithm for fluid-refractory hypotensive shock should include intravenous fluids and escalate to pressors and steroids.

Demonstrate early evaluation of a critically ill patient (application)

  • Learners should approach a critically ill patient in a standardized fashion. Airway, breathing, and circulation should be assessed immediately. Interventions such as airway repositioning/ adjuncts, bag valve mask ventilation, and CPR should be started concurrently, if required. After A, B, C have been addressed, the patient should be evaluated for disability and exposed for a thorough head to toe exam. In pediatrics, D also stands for “don’t forget the dextrose” as a blood glucose level should be checked in any child with altered mental status.
  • In this patient with obvious respiratory distress, airway and breathing are paramount. A quick evaluation including placement on continuous monitoring is important and early planning to begin addressing problems with airway and breathing must be started as quickly as they are identified.
  • Alertness and airway are important early indicators of the severity of anaphylaxis.
  • Understanding normal vitals in a child is important. For example, the systolic blood pressure (SBP) is generally above 70 + 2 times the age (5th percentile) and the mean is closer to 90 + 2 times the age in years. A shorter way to remember is 60-80-100 with the SBP being:
    • 60 mmHg for an infant
    • 80 mmHg for a child
    • 100 mmHg for an adolescent

Construct a differential for shock in a neonate (synthesis)

Discuss how the case could be changed to demonstrate one of these other diagnoses instead.

  • For sepsis, the child may present with tachycardia, fevers, and hypotension. The correct management would be aggressive fluid resuscitation and early administration of empiric antibiotics. Blood cultures should be obtained prior to antibiotics administration.
  • Cardiogenic shock may manifest as clinical worsening (increased tachycardia, hypotension) with the administration of fluids. Lung crackles and hepatomegaly may be appreciated on exam. Learners should recognize cardiogenic shock and stop fluids, and administer pressors immediately. Prostaglandin should be considered if there are concerns of congenital cardiac defects (e.g., coarctation of the aorta).
  • Adrenal crisis would manifest as fluid refractory hypotensive shock. Learners may administer fluids, antibiotics, and pressors without effect. Labs obtained would show hypoglycemia, hyponatremia, and hyperkalemia. This should prompt learners to administer steroids immediately. Physical exam features may indicate hyperandrogenism in the infant (enlarged clitoris in the female infant or hyperpigmented scrotum in the male infant).
  • Dehydration or electrolyte abnormalities can manifest as tachycardia, hypotension, and poor perfusion. Aggressive fluid hydration and electrolyte correction should be administered.
  • Hypoglycemia should be recognized early with a glucose check in an ill-appearing infant, and is defined as <47 mg/ dL. Administration of glucose is indicated to correct.
  • Trauma should be suspected, especially nonaccidental trauma. Concerning physical exam signs may include bruising, bogginess on the scalp, or fractures. Management steps should follow the standardized ABCs.

Identify neonatal hypoglycemia (comprehension)

  • Importance of a finger stick glucose test in any altered patient
  • Hypoglycemia is the great mimicker.
  • Neonates and other pediatric patients have minimal glucose stores and will become hypoglycemic with minimal insult.
  • Short-term management of hypoglycemia consists of a bolus of dextrose-containing fluids. The mnemonic “Rule of 50” states that the product of the dextrose concentration and dose in mL/kg equals 50 (e.g., D10 at 5 mL/kg, D25 at 2 mL/kg). A critical sample of blood should be drawn before glucose administration. An infusion of dextrose-containing fluids should follow the bolus, and frequent glucose checks should be obtained to ensure appropriate resuscitation.

Construct and implement an initial management plan for a neonate in shock (application)

  • Early administration of intravenous fluids is needed for shock (20 mL/kg boluses of isotonic crystalloid, to be repeated as necessary).
  • Hypoglycemia or hypocalcemia should be corrected if found.
  • If sepsis is a concern, blood cultures should be obtained prior to early administration of empiric antibiotics.
  • Frequent reassessments should be done to monitor for improvement or worsening of shock. Consideration may be given to escalate to pressors if hypotension persists.
  • Stress dose hydrocortisone for refractory shock (e.g., for adrenal crisis) may also be considered.

Interpret signs/symptoms of adrenal hyperplasia and adrenal crisis (evaluation)

  • On physical exam, learners may appreciate hyperandrogenism in female infants (enlarged clitoris) and in males (hyperpigmented scrotum). Initial labs would show hypoglycemia, hyponatremia, and hyperkalemia. Administration of fluids, antibiotics, and pressors would not improve symptoms, so learners would need to recognize that hydrocortisone is indicated for adrenal crisis.

Demonstrate intraosseous placement (application)

  • Intraosseous lines should be placed in critically ill children when IV access cannot be obtained quickly.
  • Learners should be able to voice or show during the case the different sites that intraosseous lines can be placed. For children <6 years of age, placement in the proximal/distal tibia and distal femur are preferred over the humerus.
    • Proximal tibia
    • Distal tibia
    • Distal femur
    • Proximal humerus

Advanced Option: Identify signs/symptoms and treat hyperkalemia (knowledge & application)

  • Learners should recognize hyperkalemia can cause arrhythmias.
  • Identify peaked T waves on cardiac monitor.
  • Management: Discussion with the team about next steps including the need for an ECG. ECG confirmation of peaked T waves indicates symptomatic hyperkalemia. Learners should discuss what medications would be indicated. The most urgent of these is calcium gluconate for cardiac protection. Other medications to lower K include furosemide, insulin and glucose combination, and albuterol. Kayexalate can be considered but is a slower acting agent.

Optional: Identify and treat ventricular tachycardia (VT) with pulses (knowledge & application)

  • As per the PALS algorithm, learners should immediately recognize wide-complex tachycardia.
  • If the patient is in ventricular tachycardia with pulses but is unstable, synchronized cardioversion should be done, starting at 0.5-1 J/kg, titrated up to 2 J/kg as needed. If the patient is stable, and the rhythm is regular with monomorphic QRS complexes, a trial of adenosine can be considered or consultation with an expert recommended (e.g., cardiology) prior to the initiation of anti-arrhythmic medications such as procainamide or amiodarone.

Demonstrate focused history taking from a caregiver (application)

  • Components of history taking: past medical history, surgical history, family history, medications, allergies, social history, vaccination history. For a neonate, it is especially important to ask about birth history, complications and medical care during pregnancy, results of the newborn screen, and family history related to genetic disorders.
  • The differential for a neonate presenting with shock is broad (see above) so a comprehensive review of systems is important. It is important to note that neonates may not demonstrate fever when septic so the absence of infectious symptoms does not exclude septic shock.

Explain diagnosis and management to caregivers (synthesis)

  • If personnel are available, one member of the team may stay with the family to gather history and explain interventions. Information should be relayed to the family using layperson’s terms. The rationale for interventions such as IO placement should be explained preceding or at the time of occurrence, when possible.

Demonstrate teamwork and closed loop communication (application)

Teams may use different frameworks to improve team dynamics and communication. Below are a few definitions that may be helpful to discuss, adapted from the AHRQ TeamSTEPPS Pocket Guide.

  • Brief: Short session prior to start of encounter to share the plan, discuss team formation, assign roles and responsibilities, establish expectations and climate, anticipate outcomes and likely contingencies
  • Huddle: Ad hoc team discussion to re-establish Situation Awareness; designed to reinforce plans already in place and assess the need to adjust the plan
  • Callout: A strategy used to communicate critical information during an emergent event. Helps the team prepare for vital next steps in patient care. (Example: Leader- “Airway status?”; Surveying provider- “Airway clear”; Leader- “Breath sounds?”; Surveying provider- “Breath sounds decreased on right”)
  • Check-back: A closed-loop communication strategy that requires a verification of information ensuring that information conveyed by the sender is understood by the receiver as intended. The sender initiates the message; the receiver accepts it and restates the message. In return, the sender verifies that the re-statement of the original message is correct or amends if not. (Example: Leader- “Give diphenhydramine 25 mg IV push”; Med Prep- “Diphenhydramine 25 mg IV push”; Leader- “That’s correct”)
  • SBAR: A framework for team members to structure information when communicating to one another.
    • S = Situation (What is going on with the patient?)
    • B = Background (What is the clinical background or context?)
    • A = Assessment (What do I think the problem is?)
    • R = Recommendation (What would I do to correct it?)
  • Situation monitoring: The process of continually scanning and assessing a situation to gain and maintain an understanding of what is going on around you.
  • Situation awareness: The state of “knowing what’s going on around you.”
  • Shared mental model: Result of each team member maintaining situation awareness and ensures that all team members are “on the same page.” An organizing knowledge structure of relevant facts and relationships about a task or situation that are commonly held by team members.
  • STEP: A tool for monitoring situations during complex situations. A systematic method to review Status of patient, Team members’ performance and status, Environment, and Progress towards goal.
  • Cross-monitoring: A harm error reduction strategy that involves 1. Monitoring actions of other team members 2. Providing a safety net within the team. 3. Ensuring that mistakes or oversights are caught quickly and easily. 4. “Watching each other’s back.”
  • CUS: Signal phrases that denote “I am Concerned,” “I am Uncomfortable,” and “This is a Safety Issue.” When spoken, all team members should understand clearly not only the issue but also the magnitude of the issue.

ECG 1

ECG 2

Download Case 3 supporting Files

Notes:

  1. ECG 1 Interpretation: Normal sinus rhythm. Image from Dr. Andrea Vo.
  2. ECG 2 Interpretation: Normal sinus rhythm with widened QRS complex and peaked T waves. Image from Dr. Andrea Vo.

For the embedded participant (patient’s parent)

Case Background Information

Your son has congenital adrenal hyperplasia (CAH) and is going to be in adrenal crisis by the time he presents to the Emergency Department. This is a genetic condition that makes him unable to make certain types of hormones that are critical for his immune system, blood pressure, and metabolism. Typically this disorder is diagnosed through a screening process that all newborns receive. If not treated promptly, CAH can become life-threatening. You are bringing him to the Emergency Department because you are worried that he hasn’t been eating and just being listless and tired, with no wet diapers in the past 12 hours.

Who are the Learners?

Emergency Medicine residents

This case is specifically aimed at interns who are in their first year of specialty training and may have experience in gathering information from patients and families, and standard medical treatments and procedures. They may be less familiar with escalating medical therapies when first measures are not successful.

Standardized Patient Information

Your son has been increasingly more tired in the past few weeks. Since he was born a few weeks ago, he has never been that vigorous but recently he’s been more lethargic. He never regained his birth weight and you have been taking him to the pediatrician for weight checks with the last one about a week ago. Today, he was just exceedingly tired and listless. You just remembered that the pediatrician tried calling you yesterday for something about an abnormal test he had done when he was born, and you tried calling back the pediatrician. However it is of course Sunday so the office was closed.

Your demeanor is frazzled and worried. You do not want to obstruct care but you also have no idea what has been going on and why he is suddenly so tired. You sporadically interrupt them if they are thinking out loud or discussing care with one another to ask questions about his care and what is happening.

Patient Information

(Please remember not to offer any of this information, but when asked please respond while remaining in character.)

  • CHIEF COMPLAINT: “He is so tired and has been sleeping so much today.”
  • AGE: 3 weeks old
  • ADDITIONAL HISTORY: You noticed that today your son has been sleeping almost all day. He woke up at 9 AM with a weak cry and was able to nurse for only 3 minutes before falling asleep again. Since he came home with you, you notice that he has been increasingly more tired and sleeping frequently. You have been bringing him into the pediatrician’s office in the past 2 weeks because he’s never fully regained his birth weight. You have been trying to alternate between breast and formula but he never seems to feed for more than 1 oz at a time. You also note that he has not had a wet diaper since last night (over 12 hours). He seems pale and mottled, and feels cool to you. No medications were given at home. There have been no recent coughs, congestion, vomiting, or diarrhea.
  • PAST MEDICAL HISTORY: Born at 40-weeks’ gestation. Spent 2 days in the hospital.
  • SOCIAL HISTORY: Lives with both parents, no siblings. No pets. No smoke exposure. No travel.
  • FAMILY HISTORY: Unremarkable
  • PAST SURGICAL HISTORY: None
  • MEDICATIONS: None
  • ALLERGIES: No known drug allergies
  • IMMUNIZATIONS: Received Hepatitis B vaccine and Vitamin K at birth
  • FEEDINGS: Since birth, he has always been a poor feeder and takes less than 1 oz every 2 to 3 hours or stays only 5 min at the breast every 2-3 hours. Since last night, he has been feeding even less, about 1 oz every 4-5 hours or <5 min at the breast every 4-5 hours.
  • WET DIAPERS: Only one wet diaper in past 12 hours
  • BIRTH HISTORY: Born by spontaneous vaginal delivery at 37 weeks to a 30 yo G1P1 woman. Normal prenatal care, no complications during pregnancy or delivery. Discharged home from hospital on day 2 of life with mom.

Potential Dialogue

IMPORTANT: Do not offer unsolicited information. Please allow the learners to ask questions. Do not offer information unless they ask you.

Things you could say without being asked:

  • “I don’t know what I’ve been doing wrong. He’s never been the greatest eater but today he’s just been sleeping all day. I tried waking him up but he would just go back to sleep.”
  • “We’ve been taking him to the pediatrician to check his weight but he’s just not feeding. We’ve been trying all different types of formula and breastfeeding.”
  • “I did receive a phone call from my pediatrician yesterday about an abnormal newborn screen he had done.”

Things you might say triggered by events in the scenario:

EVENTYOUR POTENTIAL RESPONSE
If they start drilling an intraosseous line without explanation“What are you doing? Why does this have to be done?”
If they decide to intubate“Why are you doing that?”
If they give glucose bolus or start pressors“Did that work?”
If they diagnose him with adrenal crisis“What’s that?”
If they give hydrocortisone“Why do you need to do that? Is that a steroid?”
If they express concern about peaked T waves and obtain an ECG“What’s going on? Is he going to die??”

The learners enter the room to find a thin, pale appearing patient who is lethargic but breathing. They immediately perform basic airway maneuvers (e.g., patient placed in sniffing position, placed on nasal cannula oxygen, shoulder roll placed), and patient’s oxygen saturation improves to 100%. The team notices that the patient is hypotensive and tachycardic. Attempts to place IV access are unsuccessful, and the team must place an IO line and draw off a VBG. During stage 1, the team obtains a point-of-care glucose test and note that the patient is hypoglycemic. The team administers isotonic fluid boluses and glucose bolus which minimally improve the patient’s hypotension and neurological status. During stage 2, the VBG then comes back and reveals hyponatremia, hyperkalemia, and metabolic acidosis. The team recognizes adrenal crisis and administers hydrocortisone. The patient regains normotension and tachycardia improves.

For advanced learners, the patient develops peaked T waves from hyperkalemia, confirmed on ECG. The providers administer hyperkalemia drugs, most critically calcium gluconate. Finally, if calcium gluconate is given very quickly, there is an option to move into ventricular tachycardia with pulses to add further challenge. Upon resolution, the providers arrange for patient admission to the floors/medical ICU.

Anticipated Management Mistakes

  1. Failure to obtain blood glucose: Some learners may not immediately recognize the patient is hypoglycemic. The patient will continue to be lethargic despite isotonic fluid boluses. We may have the mother prompt the learners by saying the patient had not eaten for 6 hours.
  2. Failure to recognize adrenal crisis: Some learners may think that the patient is in septic shock and continue giving fluids and adding pressors. Mom prompts at 5 min of stage 2 for learners saying that she had been unable to keep the patient’s PMD appointment last week when the pediatrician had called saying that there was some abnormality with his newborn screening.
  3. Failure to give the correct steroid (e.g., methylprednisolone): If the learner requests for a different steroid but still recognizes adrenal crisis, they will be prompted by the nurse saying there is no methylprednisolone in the rescue cart and suggest hydrocortisone. This should then be appropriately debriefed.

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