Setup

Chief complaint: Tachypnea, poor feeding
Patient age: 7 days old
Weight: 3.5 kg

Recommended Supplies

• Manikin/Simulated actor:
  • Neonate manikin that can be bag-mask ventilated and tolerate chest compressions
  • Simulated patient actor to play laboring mother
• Moulage: None
• Resources:
  • PALS algorithm, length based tape (e.g., Broselow) or other weight-based equipment, sizing and medication dosing reference
• Manikin set up:
  • Grey, lethargic, diaphoretic infant in respiratory distress
• Equipment:
  • Infant warmer bed with scale
  • Warm blankets, hat
  • Diaper
  • Monitors: Pulse oximetry, cardiac, temperature, blood pressure cuff
  • Rectal thermometer
  • Heel stick sampling kit, including alcohol wipe, lancet, portable blood sugar level reader
  • Bag valve mask, cardiorespiratory (CR) monitoring including ETCO2, intubation supplies, code cart
  • Suction: Bulb and wall suction (set at 80-100 mmHg)
  • Oxygen source
  • IV/IO access equipment
• Medications:
  • Normal saline, epinephrine 1:10,000, prostaglandin (PGE1), atropine, fentanyl, rocuronium or vecuronium, ampicillin, gentamicin, acyclovir

Supporting Files

• Point-of-care labs
• Chest x-ray
• Echocardiogram clips

Participants/Roles

• Participants/learners:
  • Team leader
  • Airway manager
  • Survey physician
  • Medication preparer
  • Medication giver
  • Family liaison/history taker
• Embedded participant roles:
  • Bedside nurse: Gets patient on monitor
  • Mom: Provides history
  • EMS: States uneventful transport. Thought heard wheezing, but did not give albuterol because of age. Gave blow-by oxygen for comfort.

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

Prerequisite Knowledge

• Faculty
  • NRP and PALS protocols
  • General knowledge of emergency medicine
  • Simulation implementation and debriefing experience

• Emergency medicine residents
  • Any stage of training
  • Completed a required pediatric rotation in medical school

Case Alternatives

• If the participants do not resuscitate the infant (oxygen, fluids) and give PGE1, the patient decompensates into cardiorespiratory failure and requires cardiopulmonary resuscitation.

Virtual Resus Room

This simulation case can be run virtually using Google Slides and Zoom from the Virtual Resus Room (Congenital Heart Disease) page.

Milestones

PC1. Emergency Stabilization
PC2. Performance of Focused History & Physical Exam
PC3. Diagnostic Studies
PC4. Differential Diagnoses and Management
PC5. Pharmacotherapy
PC6. Observation and Reassessment
PC7. Disposition
PC10. Airway Management
PC15. Medical Knowledge
ICS1. Patient Centered Communication
ICS2. Team Management

Resources

1. Textbook of Neonatal Resuscitation, 8th Ed. American Academy of Pediatrics and American Heart Association; 2021.
2. Wing R. The neonate in shock: When to think CARDIAC. Brown Emergency Medicine (blog). 2015.
3. Rüegger C, Bucher HU, Mieth RA. Pulse oximetry in the newborn: is the left hand pre- or post-ductal? BMC Pediatr. 2010 May 21;10:35. PMID 20492689

Initial Assessment

Start through assessment of pediatric triangle (color, respiratory effort and tone), followed by A, B, C, Ds

Critical Actions

• Assess ABCs
• Obtain vital signs
• Obtain IV access
• Place on oxygen
• Ask for POC glucose, labs

Physical Exam

Instructor Notes: Changes and Case Branch Points

Initial Interventions

Completion of primary assessment through evaluation of chest x-ray

Critical Actions

• Attach ECG monitors
• Interpret POC labs
• Order NS bolus
• Order antibiotics
• Order chest x-ray

Physical Exam

Instructor Notes: Changes and Case Branch Points

Initiation of PGE1

Review of CXR through initiation of PGE1 AND intubation

Critical Actions

• Order prostaglandin (PGE1)
• Request a stat cardiology consult
• Repeat NS IV bolus

Physical Exam

Instructor Notes: Changes and Case Branch Points

Case Conclusion

After fluid resuscitation and PGE1 administration and calling for NICU/CICU/Pediatrics help

Critical Actions

• Discussion of patient with NICU and appropriate disposition stated

Physical Exam

Instructor Notes: Changes and Case Branch Points

Demonstrate early evaluation of a critically ill patient (application)

Learners should approach a sick infant in a standardized fashion. The pediatric triangle and airway, breathing, and circulation should be assessed immediately. Interventions such as airway repositioning/ adjuncts, BMV, 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, and a blood sugar level should be obtained. Labs/imaging should be ordered and antibiotics and fluids administered in a timely fashion.

Describe signs and symptoms concerning for a ductal dependent cardiac lesion (comprehension)

Learners should recognize the symptoms of poor feeding and poor perfusion in a neonate as evidence of shock and to keep cardiogenic shock from a closing ductus arteriosus at the top of their differential.

Learners should recognize that different blood pressure values obtained pre-ductus arteriosus (right upper extremity and usually left upper extremity) and post-ductus arteriosus (reliably the lower extremities) is suggestive of a coarctation.

Implement a plan to care for an ill infant with likely ductal dependent lesion (application)

The learners should promptly assess ABCDEs: Keep airway patent, supplement as appropriate with oxygen, ventilate the patient if necessary, support circulation by administering prostaglandin (PGE1) to reopen a closing ductus arteriosus and administer small fluid boluses with frequent reassessments between interventions, assess for disability, and maintain euglycemia and euthermia.

The learners should also identify appropriate consultants to discuss the case with and determine appropriate disposition based on their local resources.

The learners should also learn to anticipate adverse effects from the medications or interventions that are necessary for the care of an ill infant with a likely ductal-dependent lesion. They should consider interventions to mitigate these effects.

Demonstrate focused history taking from a caregiver (application)

The parental history should be focused during the initial evaluation on possible newborn etiologies of cardio-respiratory failure. Assign a participant to get a thorough history from the mother in a sensitive manner.

Explain diagnosis and management to caregivers (synthesis)

If personnel are available, assign one member of the team to stay with the mother to gather history and explain interventions. Update the mother on the baby’s status, interventions that have been done, and what next steps are (admission to the NICU/CICU). Avoid using medical jargon.

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.

Develop a plan to transfer an infant to a higher level of care where needed resources are available (synthesis)

Give an organized and thorough patient sign-out to the transferring team (NICU/CICU/Peds/transport team). Be specific about the presenting scenario, initial evaluation, labs/imaging obtained, and what interventions were done with an update on how the patient has responded to said interventions.

Chest X-Ray

Chest X-ray

• Chest x-ray interpretation: Post intubation film showing orogastric tube, leads, temperature probe, and high-riding ET tube. There are also some patchy opacities in the lung fields and possible cardiomegaly. Image from Dr. Leah Carr.

Echocardiogram Clips

Apical 4-chamber view of pediatric ultrasound, showing left ventricular dysfunction with flattened septum. Image from Dr. Amy Romer, used with permission.

Parasternal short view showing left ventricular dysfunction with flattened septum. Image from Dr. Amy Romer, used with permission.

Subcostal view showing left ventricular dysfunction with flattened septum. Image from Dr. Amy Romer, used with permission.

Apical 4-chamber view showing moderate mitral regurgitation.

Download Case 4 supporting files

For the embedded participant playing the mother of her newborn baby, who is coming in with poor feeding and fast breathing

Case Background Information

The case is a 10-day-old male who is brought in by EMS for concerns of fast breathing and poor feeding for the past 1-2 days. The medical team entertains a broad differential including the diagnosis of a congenital heart lesion (i.e., closing of duct with dependent lesion), metabolic, sepsis, and pulmonary etiologies.

Who are the Learners?

Emergency Medicine interns and residents: They have little prior experience resuscitating babies, but do have significant experience in gathering information from patients and family members.

Standardized Patient Information

Over the past few days your 10-day-old son has been breathing faster and does not want to eat (breast milk or bottle). He last ate for <5 minutes just prior to the ambulance arrival. He seems tired. He has not stopped breathing or turned blue, but his color seems “off” to you. No vomiting, normal stooling, fewer wet diapers (3 per day instead of 6), no fevers. Given his fast breathing and poor color, you called an ambulance because you did not have a ride to the ED.

Meanwhile, the infant is being attended to by the medical team. The baby is grey and mottled with tachypnea. The patient is supported with airway and breathing maneuvers (including supplemental oxygen, positive pressure ventilation, and intubation), fluids, antibiotics, and a medication, PGE1, to treat the cardiac lesion before being signed out to the NICU team.

Patient Information

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

• CHIEF COMPLAINT (your response to open-ended questions such as “what’s going on?” or “what can we do for you? Or “what happened?”): Fast breathing and difficulty with eating
• AGE: 10 days old
• ADDITIONAL HISTORY: Prenatal care limited to first trimester. You moved and did not find a new OB to get care with. Baby is estimated to be at or near term.
• PAST MEDICAL HISTORY: Ex-full term, precipitous vaginal delivery, normal prenatal/ perinatal care, delivery at 38 6/7 weeks, GBS negative, birth weight 7 pounds
• SOCIAL HISTORY: Lives with 2 parents, first baby
• FAMILY HISTORY: Does not know
• PAST SURGICAL HISTORY: None
• MEDICATIONS: None
• ALLERGIES: No known drug allergies
• IMMUNIZATIONS: Up-to-date

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:

• “How is my baby? I want to hold my baby. Can someone tell me what’s going on?”

Things you might say triggered by events in the scenario:

The patient will be brought back to the room. The nurse quickly asks for the physician to evaluate the patient because he doesn’t look “well.” The patient is noted to be tachypneic and tachycardic, and his color/perfusion is poor. He is awake, but not vigorous. The medical team should initially recognize an ill neonate and have on their differential diagnoses: sepsis, respiratory failure, cardiac disease, and metabolic disorder. On physical examination, they will note a murmur, decreased LE pulses, and hepatosplenomegaly. They should ask for IV access, general labs, a normal saline bolus, and a chest x-ray.

When considering congenital heart disease, the team should ask for an ECG, 4-extremity blood pressure measurements, chest x-ray, and pre- and post-ductal saturations. The team should recognize the potential for a ductal-dependent lesion and call for more assistance, either Cardiology/Neonatology/or Pediatrics, whichever is more likely. Either independently, or after consultation with experts, they should order prostaglandin E (PGE1; alprostadil). Their expert consultation should warn them that apnea is a PGE1 side effect and be ready to support breathing with BMV and intubation if necessary. If the team does not recognize apnea, the patient should go into cardiopulmonary arrest.

Disposition should be to the nearest NICU or CCU/CICU, depending on the discussion with the consultants.

Dosing for PGE1: Start at low dose initially (0.01 mcg/kg/min), can increase up to 0.05 mcg/kg/min in consultation with NICU/CICU up to max dose of 0.1 mcg/kg/min. Note that the team should start PGE1 empirically if there is a strong clinical suspicion for ductal-dependent congenital heart disease based on the initial evaluation. They should anticipate the side effect of apnea and learn that the risk increases with increasing doses of PGE1 infusion. The team should discuss intubation and mechanical ventilation early when ordering and administering PGE1.

Anticipated Management Mistakes

1. Failure to consider a broad differential, including cardiac etiology: The patient will decompensate quickly if treated with aggressive fluid resuscitation (>30 mL/kg) and/or do not support airway, breathing, and circulation with PGE1. The differential in a persistently hypoxic newborn is broad and includes: sepsis, persistent pulmonary hypertension, and congenital anomalies (e.g., congenital diaphragmatic hernia, congenital cystic adenomatoid malformation, tracheoesophageal fistula, and congenital cardiovascular anomalies).
2. Failure to obtain access with IV: The participants must obtain access to administer PGE1 and resuscitation. If unable to obtain a peripheral IV, must obtain IO access.
3. Failure to initiate PGE1 or only at the lower dosing range: Patient will continue to deteriorate.
4. Initiating PGE1 at higher doses: This increases the risk of apnea. Team should discuss this and be prepared to intubate.
5. Fluid resuscitation at 20mL/kg or above will increase preload: This will result in further cardiac failure and increase pulmonary edema and venous backup into liver, causing further enlargement of liver.