Emergency Medicine Simulation Workbook. Группа авторов

      Initial Scenario Conditions

      Parent is holding the neonate. Patient has a weak cry.

Vital signs:	T 102.4°F (39.1°C) rectal, HR 215, RR 60, BP 70/35, SpO2 97% on room air.
Weight:	2.7 kg.
Head:	Atraumatic, normocephalic, fontanelle soft.
Eyes:	Pupils 4 mm bilaterally and reactive to light.
Neck:	Supple, full range of motion, no meningismus.
Heart:	Tachycardic, regular, no murmurs/rubs/gallops.
Lungs:	Tachypnea, clear to auscultation bilaterally.
Abdomen:	Moderately distended with high‐pitched bowel sounds; patient screams when abdomen is palpated in all quadrants. No palpable masses. Dark black soft stool in diaper (hemoccult positive, if asked).
Extremities:	No gross deformities; warm extremities with capillary refill two to three seconds.
Skin:	Warm, no rashes, no mottling.
Neurologic:	Moves all extremities spontaneously; weak cry that increases with palpation of the abdomen.

      Physical exam findings that are not available on your mannequin may be offered verbally to learners if they ask (e.g., rectal exam and hemoccult testing can be reported if specifically requested by learners).

See flow diagram (Figure 1.5) for further scenario changes described.

      Case Narrative, Continued

      During the initial minutes of the scenario, learners of all levels should collect a thorough history from the patient's parent/s and perform a complete physical exam. Initial lab tests and imaging studies should be ordered after this assessment is complete. All learners should request a heelstick glucose (prompted by the nurse if the learner fails to request it).

      Over the next five minutes, the patient will deteriorate regardless of interventions, becoming less responsive with hypotension, increased respiratory rate, and hypoxia. Eventually, there will be episodes of bradycardia with short apneic episodes.

      For novice learners, not trained to perform intubation on infants, the use of bag–valve mask (BVM ) ventilation for supplemental oxygen will stabilize the patient until the NICU team arrives. They may consult anesthesiology as well.

      For more advanced learners, intubation will be required because of impending respiratory failure and worsening lethargy.

      If there is a delay in providing advanced airway interventions (BVM and/or intubation), the patient will progress into a pulseless electrical activity (PEA ) rhythm and require cardiopulmonary resuscitation (CPR ). After two minutes of appropriate pediatric CPR, the patient will regain pulses.

      Advanced learners will need to initiate vasopressors for persistent hypotension. If the learners do not order vasopressors, the nurse may prompt them by mentioning that the blood pressure remains abnormally low and the full IV fluid bolus has already been given.

      Once the airway and hypotension are addressed (or upon finishing CPR), the learners will receive any remaining results not yet reported. They should then communicate their concern for NEC with pediatric surgery as well as the NICU/PICU team for admission and intervention. The case will end upon appropriate consultation with these teams.

      Instructor Notes

      Epidemiology

       NEC is more common in premature neonates:Only around 10% occurs in full‐term neonates.Higher risk in lower birth weights.Timing of onset is the inverse of gestational age (e.g. born close to term presents earlier postnatally than if born more prematurely).

      Pathophysiology

       Etiology unclear:Possibly related to intestinal ischemia with an immature gut barrier that predisposes to infectious agents.Cytokines and growth factor implicated in pathogenesis.Bacteria in intestinal lumen ferment carbohydrates and produce hydrogen gas that leads to pneumatosis and portal venous gas.

      Clinical Features

       Variable presentation.

       Historical features:Increasing lethargy.Forceful/projectile vomiting.Presence of bloody or bilious vomit [1].

       May present similar to sepsis:Hypo/hyperthermia, lethargy, apneic episodes, bradycardia, hypotension, poor glucose regulation.

       Gastrointestinal signs/symptoms:Abdominal distension, bloody stools, vomiting, a palpable abdominal mass (intestinal loops) or abdominal wall redness or crepitus.Scrotal discoloration (males).

      Differential Diagnosis for Vomiting Neonate

       Gastrointestinal causes:Overfeeding.Gastroenteritis.Malrotation with midgut volvulus.NEC.Intussusception.Intestinal atresia.Gastroesophageal reflux.Pyloric stenosis.Hirschsprung disease.

       Non‐gastrointestinal causes:Central nervous system diseases.Metabolic/endocrine disorders.Trauma.

      Diagnosis

       Laboratory abnormalities may include:Thrombocytopenia.Hyponatremia.Metabolic acidosis with elevated lactate.Neutropenia or leukocytosis.

        Abdominal radiographs (anteroposterior and lateral) may show:Pneumatosis intestinalis.Portal venous gas.Non‐specific gas‐filled loops of bowel.

      Management [2–5]

       NPO.

       Gastric decompression with an orogastric tube

       Broad‐spectrum intravenous antibiotics.

       Intravenous fluids.

       Surgical intervention, if pneumatosis is present.

       Survival rates depend on disease severity:Those requiring surgical management have worse outcomes with mortality, around 35%.If treated medically, mortality is around 20%.

      Debriefing Plan

      Allow approximately 20–30 minutes for debriefing after this scenario.

      Potential Questions for Discussion

       What are pertinent history and physical exam findings in a vomiting neonate/infant?

       What