CSC Standardized Curriculum
Specialty: Pediatrics
Simulation: Neonatal resuscitation(NRP) megacode
Submitted by: MAJ Taylor Sawyer
Target Audience:Pediatric, Family Medicine, Obstetric/Gynecology residents and Pediatric, FamilyMedicine, Obstetric/Gynecology Medicine staff
ACGME Competencies Addressed:
Patient Care
Medical Knowledge
Practice-Based Learning & Improvement
Professionalism
RRC Requirements Addressed:
Basic and advanced life support
Endotracheal intubation
Umbilical artery and vein catheterization
Case Scenarios
Primary:
The participants are called to attend the spontaneous vaginal delivery of a 42 week infant with an estimated fetal weight of 4500gms. The mother is a G1PO 35 yo with a history of poorly controlled A2GDM. Prenatal history and labs are otherwise unremarkable. Mother has been in labor for 10 hours and within the last 10 minutes the fetal heart rate tracing has become concerning for late decelerations. Amniotic fluid was clear at SROM. The infant requires forceps assist at delivery and is placed on warmer limp, cyanotic and apneic.
Alternate scenario
The participants are called to attend a crash C-section of a 39 week infant with a estimated fetal weight of 3500 gms. The mother was seen in labor and delivery triage due to report of decreased fetal movement and fetal heart rate on doppler was 50. Amniotic fluid was clear at AROM. At delivered the infant is noted to have tight nucal cord x 2 requiring surgical reduction. The infant is delivered to the warmer limp, cyanotic and apneic
Basic Instructions for participants
Please read the scenario and then enter the room when instructed by your staff.
You may ask questions if you have them, and please remember to:
- Treat the situation as realistically as possible.
- Think out loud, vocalize abnormal/critical findings, state the doses of drugs, and declare differential diagnoses you are considering. Only with this behavior can we evaluate you and make sure you succeed.
- If you have questions about the simulation or manikin ask the supervisor
- If you need further patient information, ask; do not make assumptions; do not declare the answers/results to physical finding/labs without asking
- Assume that you can request any resource you would have available in the hospital in which you are training.
Simulation Setup
Simulators to be used:Gaumard PEDI® Blue Neonatal Simulator
Simulation Location: Labor and delivery room for primary scenario. Operating room for alternate scenario.
Room Setup: The labor and delivery room or OR should be set up in the standard fashion with mother’s bed and infant warmer. The Gaumard NOELLE™ Maternal Simulator can be placed in the bed and confederates acting as obstetricians can be dressed gowns and gloves simulating the delivery. The infant simulator should be delivered to the warmer by obstetrician as in a real delivery. The room should be stocked with the usual instruments (bag-valve mask, laryngoscope, ET tubes, buld suction, De lee suction, etc.) and medications (epinephrine 1:10,000, 4.2% sodium bicarbonate, Normal saline, etc.) used in a delivery/resuscitation.
Additional Equipment needed:
-Birthing simulator: GaumardNOELLE™ Maternal Simulator
-Infant warmer
-Standard Neonatal resuscitation equipment including:
Bulb suction
Bag-valve mask
Laryngoscope
ET tubes (2.5-4.0)
Stylet
De-lee suction catheter and tubing
Umbilical line kit
Umbilical catheter
Syringes
Medications: epinephrine, bicarbonate, normal saline
Optional Equipment:
- Fetal Monitoring: Gaumard NOELLE™ Maternal Simulator includes a fetal monitor that may be used in the primary scenario to produce fetal bradycardia.
Personnel needed:
- Gaumard PEDI® Blue technician to operate controls and umbilical pulse
- Confederates to act as obstetricians and OR personnel : 2-3
- Bedside nurse: 1
- Scenario supervisor: 1
- Scenario grader: 1
Basic Scenario Tips:
Participants should be paged STAT on the regular delivery pagers to the DR or OR you are using for simulation. Upon arrival the residents should be given a brief history by one of the confederate obstetrician. Give the participants 60 seconds to set up the warmer and equipment prior to ‘delivering’ the baby. When the infant is delivered it should be walked by the confederate obstetrician and placed on the warmer.
Once on the warmer the PEDI® Blue technician will need to operate the controls for HR, and cyanosis. Umbilical pulse will need to be simulated using the hand pump for this manikin.
Case Flow/Algorithm with branch point and completion criteria:
Initial state:(both scenarios)
Apperance= central cyanosis(Blue lights on both face and hand with PEDI® Blue)
Pulse = 30 (selected on PEDI® Blue control and simulated with hand pump)
Grimace= none
Activity/tone = limp
Respirations = absent
In both scenarios the infant is born basically lifeless, except a slow pulse. Participants must proceed through the complete NRP resuscitation algorithm(see ‘Brief Didactic’ for review) including the placement of an emergency umbilical vein catheter (or IO line for the very intrepid) and administration of IV epinephrine before clinical status improves (HR increases to 150, central cyanosis resolves). Endotracheal epi administration does not change scenario.
Case Flow/Algorithm:
+ -
+ -
+ -
+ -
+ -
+ -
if given
+ -
if given
+ -
Critical Actions
- Must warm, dry and stimulate infant
- Must re-position airway
- Must provide at least 30 seconds EFFECTIVE positive pressure ventilation before moving to chest compressions, intubation, line placement, drugs, etc. (40-60 breaths/min)
- Must use 100% FIO2 during the resuscitation
- Must provide positive pressure via BVM with good hand position and seal of mask on face*
- Must check for HR and communicate rate to code leader
- Must give compressions once HR is < 60 BPM and positive pressure ventilation has not been successfully delivered x 30 seconds
- Must use proper chest compression technique (two finger or hand around chest)
Check depth with compression gauge on PEDI® Blue
- Must use proper ratio of chest compressions/ventilations
3:1, 90 compressions:30 ventilations per minute
- Must place emergency umbilical vein catheter using sterile technique
- Must pre-flush UVC with fluid to avoid air embolus
- Must give proper dose/concentration of epinephrine via umbilical catheterfollowed by 2-3ml of flush before HR will rise back above 30bpm
- Must use correct IV epinephrine dose: 0.1-0.3 ml/kg (0.01-0.03 mg/kg) of 1:10,000
Please note 2005 NRP dosing for endotracheal epinephrine = 0.3-1ml/kg
* Intubation not required if team thinks they are providing adequate ventilation with BVM, but should be considered when infant does not improve with BVM alone.
Common pitfalls to monitor for:
Not position airwaycorrectly- ‘sniffing position’
Not providing at least 30 seconds EFFECTIVE positive pressure ventilation before moving to chest compressions, and meds
Improper hand position and/or poor seal of mask on face
Not communicating HR rate to code leader
Not using NRP ratio of chest compressions/ventilations
Not using sterile technique during emergency umbilical vein catheter placement
Not pre-flushing UVC prior to placement in order to avoid air embolus
Not using proper dose/concentration of epinephrine
Not continuing chest compressions and ventilation for at least 30 seconds after epinephrine dose
Physician # / Name ______Date ______
Training Site ______Grader ______
Training Level: (Circle One) PGY-1 PGY-2 PGY-3Fellow Staff
CompletedNot Completed Indeterminate
History/Preperation (4 points)
Obtains relevant history (2 point)
Prepares infant warmer prior to delivery
(2 point)
Physical Exam(6 points)
Recognizes cyanosis (1 points)
Recognizes apnea (2 point)
Recognizes bradycardia (3 points)
Diagnostic evaluation (3 points)
Recognizes secondary apnea (3 points)
Management (11 points)
Warms, dries and stimulates infant to breath (1 points)
Provides PPV via BVM (3 points)
Provides chest compression and ventilation in a 3:1 ratio (2 points)
Places emergency umbilical venous catheter (UVC) (3 points)
Gives correct dose of epinephrine via emergency UVC (2 points)
Completed Not completed Indeterminate
Time goals (6 points)
Starts PPV via BVM within 30 seconds of birth (3 points)
Gives IV epinephrine within 10 minutes of birth (3 points)
Incorrect
Incorrect Actions and Interventions
Starts chest compressions prior providing 30 seconds of PPV
(-2 points)
Does not intubate infant after PPV via BVM fails to improve the heart rate (-2 points)
Gives incorrect dose of epinephrine (-3 points)
Scenario score: Assign points for all items checked as ‘Completed’ or ‘Incorrect”.
No points are given for “Not completed” and ‘Indeterminate’ actions.
(Maximum points possible for this scenario = 30)
Correct action points = _____
Incorrect action points = _____
Total scenario points = _____
Percent scenario score (Total scenario points /30) = _____
Overall scenario performance rating:
1 (poor) 2 (fair) 3 (good) 4 (Very good) 5 (Excellent)
Please answer the following questions about this provider’s performance:
1. Provider performed airway evaluation in timely fashion
Strongly DisagreeNeither agreeStrongly Agree
Or disagree
0 1 2345678910
2. Respiratory status exam was accurate and complete
Strongly DisagreeNeither agreeStrongly Agree
Or disagree
0 1 2345678910
3. Providerinitiated appropriate diagnostic evaluation in a timely fashion
Strongly DisagreeNeither agreeStrongly Agree
Or disagree
0 1 2345678910
4. Providermade appropriate therapeutic decision
Extremely Poor Average Outstanding
0 1 2345678910
4. How prepared do you feel the provider was to manage this scenario?
Not prepared at allReasonably preparedVery prepared
012345678910
Perceived competency:
Not competent tohandle a similar scenario on a patient even with supervision*
Competent to handle a similar scenario on a patient with supervision
Competent to handle a similar scenario on a patient independently
Competent to teach others about this scenario
* If student not competent to perform procedure please refer for remedial simulation training
Key Teaching Points/Critical Actions to discuss in debriefing:
-Discuss primary and secondary apnea
Primary: resolves with stimulation
Secondary: does not resolve with stimulation- Needs PPV!
-Discuss/review the NRP algorithm and any deviations
-
-Emphasize importance of EFFECTIVEpositive pressure ventilation as the corner stone of NRP
-Demonstrate proper performance of chest compressions and proper ratio of compressions/ventilations - 3:1 coordinated
-Review epinephrine dosage, concentration and routes of administration. According to the 2005 NRP Textbook intravenous dosing is the preferred route.
-Emphasize importance of crisis resource management skills
Suggested time length for modules:
Total time: up to 30 minutes.
10 min simulation
20 min feedback session
Brief Didactic:
NRP flow:
Ventilation rate: 40-60 breaths/min
Compression rate: 120 events/min (90 compressions interspersed with 30 ventilations).
Compression-ventilation rate: 3:1 coordinated (pause compressions for ventilation).
Medications (epinephrine, volume): Indicated if heart rate remains <60 bpm despite adequate ventilation with 100% oxygen and chest compressions.
30 second intervals between each step
NRP Algorithm:
(Taken from Neonatal Resuscitation Textbook, 5th Ed. 2005)
ET Tube Size and Depth of Insertion:
Weight (g) / Gestational Age (wk) / Blade / ET Size (mm) / Insertion Depth (cm)Below 1000 / < 25 / 00 / 2.5 / 6-7
1000-2000 / 30- 35 / 0 / 3.0 / 7-8
2000-4000 / 35-40 / 0-1 / 3.5 / 8- 9
4000 / 40 / 1 / 4.0 / 9-10
ETsize: equal to gest age: 25wks=2.5 tube, 30 wks= 3.0 tube, 35wk-3.5 tube, etc.
ET Depth: 6cm + weight in Kg: 1kg= 7 cm at lip, 2 kg= 8cm at lip, 3kg= 9cm at lip, etc.
NRP Medications:
Medications / Dose/Route / Concentration / Wt (kg) / IV Volume (ml) / PrecautionsEpinephrine / IV (UVC preferred)
IV: 0.1-0.3ml/kg
Higher IV doses not recommended
ET: 0.3-1ml/kg / 1:10,000 / 1
2
3
4 / 0.1-0.3
0.2-0.6
0.3-0.9
0.4-1.2 / Give rapidly followed by NS flush
Repeat q3-5 min
Higher dose for ET route
Volume expanders / 10 ml/kg IV / 1
2
3
4 / 10
20
30
40 / Indicated for hypovolemic shock (cord accident, abruption, etc.)
Give over 5-10 minutes
Reassess after bolus
Sodium Bicarb / 1-2 meq/kg IV / 0.5 meq/ml
(4.2% solution) / 1
2
3
4 / 2-4
4-8
6-12
8-16 / Establish adequate ventilation first
Only for prolonged NRP
Slow push over 2 min
Naloxone / 0.1mg/kg
IV or IM preferred route
ET route not recommended / Neonatal vial: 0.4 mg/ml
Adult vial: 1 mg/ml / 1
2
3
4
1
2
3
4 / 0.25
0.50
0.75
1
0.1
0.2
0.3
0.4 / Address ventilation first with routine measures: PPV
Repeat q2-3min
Caution in opioid addiction- can cause seizure
Dextrose (10% solution) / 2ml/kg, D10W IV / 0.1g/ml / 1
2
3
4 / 2
4
6
8 / Check bedside glucose.
Positive pressureVentilation:
Indications:
Positive pressure ventilation with the Bag-valve mask is THE most critical skill to learn in NRP. PPV should be provided to all infants who do not establish good respiratory effort after 30 seconds of warming and stimulation. The provision of effective PPV via BVM will resolve secondary apnea and result in improvement in HR and respiratory effort in the vast majority of depressed neonates.
Review with participants the correct mask fit and positioning:
(Taken from Neonatal Resuscitation Textbook, 5th Ed. 2005)
Chest Compressions:
Indications:
Heart rate is less than 60 beats per minuteafter 30 seconds of EFFECTIVE positive pressure ventilation. If BVM not effective then intubate and give PPV x 30 seconds before going to compressions.
Heart rate is evaluated by either auscultation or palpation at the umbilicus or brachial artery.
Compression Technique:
Chest compressions should be performed over the lower half of the sternum.
(Taken from Neonatal Resuscitation Textbook, 5th Ed. 2005)
Compression on the xiphoid process can cause trauma to the liver, spleen, or stomach, and must be avoided. The effectiveness of compressions can be maximized by attention to the following:
The chest should be depressed by one-third to one-half of its anterior-posterior diameter with each compression.
The optimum rate of compressions is 90 per minute. Each compression and decompression phase should be of equal duration.
Chest compressions may be performed with either two fingers or with the two thumb-encircling hands technique.
Two fingers technique is recommended when there is a single rescuer. Compressions are performed with two middle fingers, placed on the sternum just below the nipples.
Two handsencirclingchest technique recommended when there are two rescuers. The thorax is encircled with both hands and cardiac compressions are performed with the thumbs of both hands. The thumbs compress over the lower half of the sternum, avoiding the xiphoid process, while the fingers squeeze the thorax.
Supporting Literature and Suggested Readings:
Neonatal Resuscitation Textbook, 5th Ed. 2005
1
Version 1, 4/11/2008