Setup

Chief complaint: Neonatal delivery
Patient age: Neonate of unknown gestational age
Weight: 2.5 kg

Recommended Supplies

• Manikin/Simulated actor:
  • Neonate manikin that can be ventilated
  • Simulated patient actor to play laboring mother
• Moulage: None
• Resources: NRP algorithm, Broselow tape or other weight-based equipment-sizing and medication dosing reference
• Manikin set up: Cyanotic, bradycardic, and limp infant with minimal respiratory effort delivers in ED
• Equipment:
  • Newborn warmer bed with scale and timer (if not available, bring accessory timer and scale next to bed)
  • Warm blankets
  • Newborn hat
  • Diaper
  • Monitors: Pulse oximetry, cardiac, temperature
  • Rectal thermometer
  • Heel stick sampling kit, including alcohol wipe, lancet, portable BSL reader
  • ED delivery kit: sterile gloves, sterile towels and drapes, surgical scissors, hemostats, syringes (10 ml), needles (25 G), gauze sponge (4 x 4), rubber suction bulb, neonatal airways, cord clamps, towels (infant), placenta basin.
  • ED UVC Tray and UVC lines: Sterile drapes and gauze, scalpel (No. 11-blade), 3-0 silk suture on a curved needle, small clamps, forceps, scissors, and needle holder, curved iris forceps without teeth, umbilical tie, infusion solution (usually NS or D10W), 3-way stopcock, tegaderm and tape. UVC sizing: 5.0 Fr for term babies
  • T-piece resuscitator (e.g. Neopuff® group) or flow-inflating bag with neonatal mask
  • Suction: Bulb and wall suction (set at 80-100 mmHg)
  • Oxygen source
• Medications:
  • Dextrose 10% (0.1 g/mL). Dose: 2 mL/kg of D10W bolus, continuous infusion of 60 mL/kg/24hrs
  • Ampicillin dose: 100 mg/kg/dose, gentamicin dose: 4 mg/ kg/dose
  • All other meds “being drawn up”:
    • Naloxone: If drawn up and given, will have no effect on clinical status
    • Epinephrine: If drawn up and given, HR and BP will increase but no change in oxygen saturation

Supporting Files

• Neonatal Resuscitation Program (NRP) algorithm
• Point-of-care labs
• X-ray after UVC placement

Participants/Roles

• Participations/learners:
  • Team leader
  • Airway manager
  • Survey physician
  • Medication preparer
  • Medication giver
  • Family liaison/history taker
• Other:
  • 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
  • NRP protocols
  • General knowledge of emergency medicine
  • Simulation implementation and debriefing experience

• Emergency medicine residents
  • Any stage of training
  • Completed a required obstetric and pediatric rotation in medical school
  • UVC insertion (for procedural list)
  • Neonatal intubation

Case Alternatives

• If the participants do not follow NRP initially, the patient becomes progressively more hypoxemic and bradycardic, such that the neonate decompensates into cardiorespiratory failure requiring resuscitation.

Virtual Resus Room

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

Milestones

PC1. Emergency Stabilization
PC2. Performance of Focused History & Physical Exam
PC3. Diagnostic Studies
PC4. Differential Diagnoses and Management
PC5. Pharmacotherapy
PC7. Disposition
PC9. General Approach to Procedures
PC10. Airway Management
PC14. Other Diagnostic and Therapeutic Procedures
MK. 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. Emergent umbilical venous catheter (UVC) placement. Brown Emergency Medicine. 2015.

Initial Assessment of Neonate

Start of case through start of Positive Pressure Ventilation (PPV)

Critical Actions

• Call for OB/Peds/NICU help
• Elicit help to gather supplies (see above recommended supplies)
• Elicit a team to help with tasks, specifically: Team lead, monitors and survey, airway, access, labs/medication administration, runner for help
• Acknowledge and start following NRP algorithm
• By 60 seconds of life, start PPV

Physical Exam

Instructor Notes: Changes and Case Branch Points

Neonatal Resuscitation

Start of PPV through 120 seconds of PPV

Critical Actions

• Continue down NRP algorithm
• Continue PPV, and perform MR SOPA airway maneuvers
• Note hypothermia, and provide warming maneuvers
• Reassess respiratory effort after HR and SpO₂ improve with PPV
• Recognize the need for some ventilatory support, though no longer needs PPV
• Initiate CPAP and request neonatal CPAP set up

Physical Exam

Instructor Notes: Changes and Case Branch Points

Recognition and Treatment of Life Threatening Issues

>2 minutes of life AND 120 sec of PPV through correction of hypoglycemia

Critical Actions

• Continue CPAP, wean FiO₂
• Place emergency UVC after 2 failed PIV attempts
• Obtain ancillary studies: POC labs, x-ray
• Note the patient is hypoglycemic at 30 mg/dL (<40 mg/dL)
  • Administer D10W bolus at 2 mL/kg through UVC.
  • The estimated vs baby warmer scale weight is 2.5 kg, so give 5 mL bolus.
  • Following bolus, give D10W at 60 mL/kg/24hrs = ~6.25 mL/hr.
• Consider broad differential for respiratory failure in newborn, including sepsis, respiratory distress syndrome, upper airway anatomic abnormalities (e.g., choanal atresia), intrathoracic lesions (e.g., congenital diaphragmatic hernia, congenital pulmonary airway malformation), congenital heart disease, intrauterine stroke
• Order antibiotics: Ampicillin 100 mg/kg/dose and gentamicin 4 mg/kg/ dose
• Call NICU for consultation and discuss the case
• Discusses with team and pharmacy medical doses for neonatal code

Physical Exam

Instructor Notes: Changes and Case Branch Points

Case Conclusion

Correction of hypoglycemia through NICU signout

Critical Actions

• Discussion of patient with NICU and appropriate disposition stated

Physical Exam

Instructor Notes: Changes and Case Branch Points

Demonstrate post-delivery resuscitation of a neonate following NRP guidelines (application)

Learners should approach a newborn delivery in a standardized fashion, using the NRP algorithm. The emphasis is on the airway and breathing in NRP resuscitation. If the neonate continues to have decreased oxygen saturation, consider problem the following interventions:

“MR SOPA”

• M – Adjust Mask
• R – Reposition head to open airway
• S – Suction mouth then nose
• O – Open mouth, lift jaw forward
• P – Gradually increase Pressure until visible chest rise is noted
• A – Use artificial Airway (ETT or LMA)

Persistent desaturations could also be indicative of a mixing heart lesion or inadequate oxygen transfer in the lungs.

Demonstrate early evaluation of a critically ill patient (application)

Learners should approach a sick neonate in a standardized fashion. Airway, breathing, and circulation should be assessed immediately. Interventions such as airway repositioning/adjuncts and starting PPV or CPAP should happen promptly. 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.

Demonstrate umbilical line placement (application)

See Wing’s “Emergent umbilical venous catheter (UVC) placement” blog post with Brown Emergency Medicine (2015).

Demonstrate focused history taking from a caregiver (application)

The maternal history should be focused during the initial evaluation on possible prenatal etiologies of neonatal 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). 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 dextrose with D10W: 3 mL bolus via the UVC”;
  Med Prep – “D10W 3 mL bolus giving via UVC”; 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.

Organize transfer to a higher level of care where needed resources are available (analysis)

Give an organized and thorough patient sign-out to the transferring team (NICU/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 responded to said interventions.

X-ray

Download Case 9 supporting files

Notes:

• X-Ray Interpretation: Some patchy opacities in the lung fields. Support devices seen include ECG leads, temperature probe, orogastric tube, and low-lying UVC. Image from Dr. Leah Carr.

For the embedded participant playing the patient’s mother, who just delivered her baby precipitously in the ambulance bay of your Emergency Department

Case Background Information

The case is a precipitous delivery of a newborn in the ambulance bay of a busy ED. You had limited prenatal care early in the pregnancy, but lost your job and insurance so has not been to the OB since early in the 2nd trimester. You believe the baby is close to her due date but can’t remember. Your newborn is immediately taken away to be medically resuscitated.

Who are the Learners?

The targeted learners are Emergency Medicine interns and residents. They have little prior experience delivering and resuscitating babies but do have significant experience in gathering information from patients and family members.

Standardized Patient Information

You are emotional about not being able to hold your baby upon delivery, are insistent on knowing how the baby is, and are frightened by the austere and unfamiliar ED environment. You should make it known that you are very upset and want to be with your baby, but you are calmed if someone talks to you and explains what is happening, as to not distract the residents from the neonatal resuscitation.

Meanwhile, the infant is being attended to by the medical team. The medical team resuscitates the baby by following the Neonatal Resuscitation Program (NRP) algorithm and by doing the following: breathing for and supplementing oxygen to the newborn who is having persistently low blood oxygen levels with PPV and then CPAP, obtaining IV access through the umbilical cord, giving dextrose- containing fluids to correct low blood sugar, warming the baby, and eliciting prompt specialty help from the Neonatal Intensive Care Unit (NICU).

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?”): Precipitous newborn delivery with limited prenatal care
• AGE: 25 years old
• ADDITIONAL HISTORY: Prenatal care limited to first trimester. Baby is estimated to be at or near term.
• PAST MEDICAL HISTORY: None
• SOCIAL HISTORY: Lives alone and denies substance use.
• 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.”
• “Why don’t I hear crying?”
• “Can someone tell me what’s going on?”

Things you might say triggered by events in the scenario:

Learners enter the room to find a precipitous newborn delivery. The neonate is cool, cyanotic, not crying, and floppy. They immediately warm the baby with blankets while simultaneously setting up a warmer bed. The heart rate and tone improve following the NRP algorithm and providing effective PPV. The neonate’s tone and color improve, the heart rate rises to a goal of >100, and the pulse oximetry improves. Without PPV, the infant’s work of breathing still increases, so CPAP should be initiated, with resultant improvement in work of breathing and continued vital signs at NRP goals. They also must recognize and treat hypothermia and hypoglycemia. They place an emergency UVC after 2 failed PIV attempts, while no IO kit can be found. They consider sepsis and order labs and antibiotics. The learners may prepare intubation equipment and accessory airways but never have to use them as the newborn is appropriately supported with non-invasive positive pressure ventilation via CPAP. The scenario concludes when the team makes an appropriate disposition decision for the infant (NICU) and updates the mother on the plan. If the participants do not follow NRP, the patient’s condition deteriorates into cardiorespiratory failure.

Anticipated Management Mistakes

1. Failure to follow NRP: If the learners fail to follow the NRP protocol, the neonate will collapse into cardiopulmonary failure. The facilitator might guide the learners by providing the NRP algorithm and/or embed a respiratory therapist to provide effective PPV which maintains the heart rate at goal.
2. Failure to consider hypothermia: A cold neonate will decompensate quickly. If participants do not recognize that the baby is cold, have the SP playing the mom say: “it’s cold in here and my baby looks freezing!”
3. Failure to consider hypoglycemia: In neonatal and pediatric resuscitation, the “D” in ABCD also stands for Dextrose, and the “S” in the STABLE neonatal resuscitation course stands for Sugar. If participants do not check the baby’s glucose level and treat hypoglycemia, the patient will decompensate. As the facilitator, consider having the Mom SP say “my baby needs to eat something- I want to nurse my baby! How do you know she isn’t hungry?”
4. Failure to obtain access with UVC: The participants fail twice while trying to obtain a peripheral IV. Getting parenteral access on this patient is of utmost importance. If they do not recall the option of getting neonatal access through the umbilical vein, consider embedding a nurse participant to grab the UVC tray and placing it next to the patient. If they are unsuccessful placing the UVC, during the debrief consider watching a video on how to place a UVC.