Simulation 3: Post-term Baby in Labor and Delivery Opening Scenario (Links to Section 1) You are an evening-shift respiratory therapist in a large hospital with a level III neonatal unit. You are paged to the delivery room to help in the delivery of a post-term baby. Section # 1 Type: IG Links from: Opening scenario Links to Section #(s): 2 Perfect Score: 9 Minimum Pass Score: 7 As you enter the delivery room the baby is being delivered and pea soup-like amniotic fluid is observed covering the neonate. After performing tracheobronchial suctioning, which of the following would you evaluate immediately? (SELECT AS MANY as you consider indicated) Requested Information Data Response Score Gestational age 43 weeks +1 Heart rate 90/min +2 Apgar score The nurse informs you that it will be done later -1 Muscle tone Some flexion +1 Color Pale, blue throughout +2 Respiratory pattern Rapid with some nasal flaring noted +2 Glucose level Pending 0 Lanugo Minimal -1 Weight 3900 g +1 Pulmonary compliance Not performed
Section # 2 Type: DM Links from Section #: 1 Links to Section #(s): 3 Perfect Score: 2 Minimum Pass Score: 1 Based on the information obtained, you would recommend which of the following? (CHOOSE ONLY ONE unless you are directed to Make another. ) Intubating the baby and initiating Physician disagrees, make another mechanical ventilation selection on this section Obtaining a STAT chest X-ray Physician disagrees, make another selection on this section Providing positive pressure ventilation Physician agrees. PPV via mask is +2 3 with O2 by bag-mask provided for 30 sec. Administering O2 by simple mask at 4 Physician disagrees, make another -1 L/min selection on this section. Inserting an umbilical artery line Physician disagrees, make another selection on this section Section # 3 Type: IG Links from Section #: 2 Links to Section #(s): 4 Perfect Score: 7 Minimum Pass Score: 5 A minute later, you are providing the baby with manual positive pressure ventilation via bag-mask. You would now evaluate which of the following? (SELECT AS MANY as you consider indicated) Requested Information Data Response Score Chest movement Chest rising bilaterally with each breath +2 Bilirubin level Pending -1 Moro reflex Not done -1 Arterial blood gas Not done Color Baby remains pale +2 1-minute Apgar score 5 +1 Respirations Remains rapid but with less nasal flaring +2 Scarf sign Not assessed -1 Lactate level Not done Hering-Breuer reflex Not assessed -1 2
Section # 4 Type: DM Links from Section #: 3 Links to Section #(s): 7 Perfect Score: 3 Minimum Pass Score: 2 After 30 seconds of manual positive pressure ventilation with O2, what would you do next? (CHOOSE ONLY ONE unless you are directed to Make another. ) Continue manual positive pressure Physician disagrees 7 ventilation Initiate SpO2 monitoring SpO2 70% - make another selection in +1 this section Provide nasal CPAP at 5 cm H2O Physician disagrees -3 7 Reassess the baby's heart rate Physician agrees +2 7 Place the baby in an oxyhood with 50% O2 Physician disagrees -3 7 Section # 7 Type: DM Links from Section #: 4 Links to Section #(s): 8 Perfect Score: 2 Minimum Pass Score: 2 After an additional 30 seconds of manual ventilation, the baby's heart rate is 57/min and dropping, with an SpO2 of 60%. You would now recommend which of the following? (CHOOSE ONLY ONE unless you are directed to Make another. ) Intubating the baby and initiating mechanical ventilation Initiating chest compressions at 90/min interspersed with 30 breaths/min Administering IV epinephrine 0.01 to 0.03 mg/kg Initiating 5 cm H2O nasal CPAP with 50% O2 Administering a 10 ml/kg fluid bolus -3 Done. +2 8 0-3 -3 3
Section # 8 Type: IG Links from Section #: 7 Links to Section #(s): 9 Perfect Score: 8 Minimum Pass Score: 7 Chest compressions are started and the baby is intubated with a 3.0 mm ET tube and bagged. Immediately after intubation you note decreased chest movement on the left and ventilation becomes difficult. Which of the following would you evaluate at this time? Requested Information (SELECT AS MANY as you consider indicated) Chest X-ray Not done Respiratory pattern No effort noted during manual ventilation 0 Expired CO2 (colorimetric detector) >5% CO2 +2 Breath sounds Decreased on the left and increased on the +2 right Epigastric sounds Negative +1 Color Baby remains pale +1 Peak airway pressure Not available -1 Heart sounds +1 heart murmur -1 Transillumination of the chest Data Uniform circles of reflected light observed on both the right and left chest +2 Response Score Section # 9 Type: DM Links from Section #: 8 Links to Section #(s): 10 Perfect Score: 3 Minimum Pass Score: 2 Based on the information you have obtained, you would now recommend which of the following? (CHOOSE ONLY ONE unless you are directed to Make another. ) Performing needle decompression of -3 the left chest Inserting a nasogastric tube Reintubating the baby with a 2.5 mm ET tube Performing endotracheal suctioning Physician agrees. Make another selection in this section +1 Repositioning the ET tube +2 10 4
Section # 10 Type: IG Links from Section #: 9 Links to Section #(s): End Perfect Score: 2 Minimum Pass Score: 1 The ET tube is repositioned and the left lung expanded. The baby is stabilized and transported with manual ventilation to the NICU. The Neonatology resident asks for your suggestions on managing the cardiopulmonary status of the baby. You would now recommend: (CHOOSE ONLY ONE unless you are directed to Make another. ) Extubating and applying 5 cm H2O -3 CPAP by nasal prongs with 50% O2 Initiating assist/control mode ventilation: rate = 50/min; PIP = 30 cm H2O; PEEP = 8 cm H2O; FIO2 = 0.50 Initiating SIMV mode ventilation: rate Physician agrees - End simulation +2 End = 30/min; PIP = 25 cm H2O; PEEP = 5 cm H2O; FIO2 = 0.50 Extubate and place on oxyhood with -3 an FIO2 of 0.40 Initiating SIMV mode ventilation: rate = 30/min; PIP = 20 cm H2O; FIO2 = 0.50 Physician agrees - End simulation +1 End Individual Response Scoring (Used for All RTBoardReview.com Simulations) Score Meaning +2 Essential/optimum to identifying or resolving problem +1 Likely helpful in identifying or resolving problem 0 Neither helpful nor harmful in identifying or resolving problem -1 Unnecessary or potentially harmful in identifying or resolving problem Wastes critical time in identifying problem or causes direct harm to patient -3 Results in life-threatening harm to patient Summary Scoring of Simulation 3 Section IG Max IG Min DM Max DM Min 1 9 7 2 2 1 3 7 5 4 3 2 7 2 2 8 8 7 9 3 2 10 2 1 TOTALS 24 19 12 8 5
RTBoardReview.com Simulation 3 Newborn Baby in Labor & Delivery Condition/Diagnosis: Possible Meconium Aspiration and Resuscitation Case Management Pointers for Possible Meconium Aspiration and Resuscitation A baby born at or near term who is crying or breathing and has good muscle tone does not need resuscitation; dry the baby, place skin-to-skin with mother, cover with dry linen to keep warm; continue to observe breathing, activity, and color If a meconium-stained baby has depressed respiratory effort, poor muscle tone, and/or a low heart rate (<100/min), intubate and suction the trachea immediately after delivery (5 secs max). If no meconium is retrieved, do not repeat. If meconium is retrieved and the heart rate exceeds 100/min, re-suction. If the heart rate is low, administer PPV and consider suctioning again later. If a meconium-stained baby has normal respiratory effort, muscle tone, and a heart rate >100/min do not intubate; instead clear secretions and meconium from the mouth and nose with a bulb syringe or a large-bore suction catheter. Since the most common causes of neonatal distress are respiratory in nature, the traditional ABC acronym (Airway, Breath, Circulate) applies to resuscitation. After clearing the airway, a newborn baby with apnea, gasping, or labored breathing and/or a heart rate less than 100/min should receive positive pressure ventilation (PPV) with oxygen If heart rate is below 60/min, start chest compressions + intubate (coordinate with PPV) During resuscitation assess heart rate, respirations and oxygenation, ideally via preductal (right upper extremity) SpO2 Preductal SpO2s immediately after birth typically range from 60-70%; it may take 5-10 minutes for the SpO2 to normalize, i.e., exceed 85% If O2 is needed, target the following SpO2 levels for newborns: Targeted Preductal SpO2 after birth 1 min 60-65% 2 min 65-70% 3 min 70-75% 4 min 75-80% 5 min 80-85% 10 min 85-95% Neonatal chest compressions should be delivered on the lower 1/3 rd of the sternum to a depth of about 1/3 rd the AP diameter of the chest The ratio of compressions to ventilations should be 3:1, with 90 compressions and 30 breaths per minute (1/2 sec per event, exhalation coordinated with 1 st of 3 compressions) Coordinated chest compressions and ventilations should continue until the heart rate is at least 60/min If the baby s heart remains below 60/min despite adequate ventilation with O2 and chest compressions, epinephrine should be considered Chest transillumination that produces a circular reflected halo pattern can quickly rule out a pneumothorax Exhaled CO2 detection is effective for confirmation of ET tube placement in infants 6
Follow-up Resources Standard Text Resources: Des Jardins, T., & Burton, G.G. (2011). Meconium aspiration syndrome (Chapter 32). In Clinical Manifestations and Assessment of Respiratory Disease, 6th Ed. Maryland Heights, MO: Mosby-Elsevier. Useful Web Links: Clark, M.B., & Clark, D.A. Meconium Aspiration Syndrome. E-Medicine/Medscape. http://emedicine.medscape.com/article/974110-overview Bissinger,, R.L., & Ohning, B.L. Neonatal Resuscitation. E-Medicine/Medscape. http://emedicine.medscape.com/article/977002-overview American Heart Association. (2010). 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 15: Neonatal Resuscitation. Circulation, 122(suppl 3), S909 S919. http://circ.ahajournals.org/content/122/18_suppl_3/s909.full.pdf 7