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, Family Medicine, 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
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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:
1. Treat the situation as realistically as possible.
2. 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.
3. If you have questions about the simulation or manikin ask the supervisor
4. If you need further patient information, ask; do not make assumptions; do not declare
the answers/results to physical finding/labs without asking
5. 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: Gaumard NOELLE™ 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
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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.
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Case Flow/Algorithm:
INITIAL STATE:
HR: 30
No respiratory effort
Limp
Cyanotic

+
No change


-
Dry and stimulate infant
No change


+
No change
No change

-
Bag/mask ventilation


+
No change
Chest compressions
No change

-


+
No change

-
Intubation
No change


+
No change
Endotracheal Epi

-
No change

HR to 150
Central cyanosis resolves

+
Epi given via umbilical vessel catheter

No change

+
 
-
No change
if given
NS bolus given via umbilical vessel catheter
 
No change
 if given
No change

+
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Bicarbonate via umbilical vessel catheter

-
No change
4
Critical Actions
1. Must warm, dry and stimulate infant
2. Must re-position airway
3. Must provide at least 30 seconds EFFECTIVE positive pressure ventilation before
moving to chest compressions, intubation, line placement, drugs, etc. (40-60
breaths/min)
4. Must use 100% FIO2 during the resuscitation
5. Must provide positive pressure via BVM with good hand position and seal of
mask on face*
6. Must check for HR and communicate rate to code leader
7. Must give compressions once HR is < 60 BPM and positive pressure ventilation
has not been successfully delivered x 30 seconds
8. Must use proper chest compression technique (two finger or hand around chest)
Check depth with compression gauge on PEDI® Blue
9. Must use proper ratio of chest compressions/ventilations
3:1, 90 compressions:30 ventilations per minute
10. Must place emergency umbilical vein catheter using sterile technique
11. Must pre-flush UVC with fluid to avoid air embolus
12. Must give proper dose/concentration of epinephrine via umbilical catheter
followed by 2-3ml of flush before HR will rise back above 30 bpm
13. 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.
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Common pitfalls to monitor for:
Not position airway correctly- ‘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
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Physician # / Name ____________________________
Date
_______________________
Training Site __________________________________
Grader
__________________
Training Level: (Circle One)
Fellow Staff
PGY-1
PGY-2
PGY-3
Completed
Not 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)
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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)
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 3 (good)
 4 (Very good)
 5 (Excellent)
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Please answer the following questions about this provider’s performance:
1. Provider performed airway evaluation in timely fashion
Strongly Disagree
0
1
2
Neither agree
Or disagree
3
4
5
6
Strongly Agree
7
8
9
10
2. Respiratory status exam was accurate and complete
Strongly Disagree
0
1
2
Neither agree
Or disagree
3
4
5
6
Strongly Agree
7
8
9
10
3. Provider initiated appropriate diagnostic evaluation in a timely fashion
Strongly Disagree
0
1
2
Neither agree
Or disagree
3
4
5
6
Strongly Agree
7
8
9
10
4. Provider made appropriate therapeutic decision
Extremely Poor
0
1
Average
2
3
4
5
6
Outstanding
7
8
9
10
4. How prepared do you feel the provider was to manage this scenario?
Not prepared at all
0
1
Reasonably prepared
2
3
4
5
6
Very prepared
7
8
9
10
Perceived competency:
 Not competent to handle 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
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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
-
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
Emphasize importance of EFFECTIVE positive pressure ventilation as the corner
stone of NRP
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).
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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)
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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
Epinephrine
IV (UVC
preferred)
Concentration
Wt
(kg)
1:10,000
1
IV
Volume
(ml)
0.1-0.3
2
0.2-0.6
Give rapidly
followed by NS
flush
3
0.3-0.9
Repeat q3-5 min
4
0.4-1.2
Higher dose for
ET route
1
10
2
20
3
30
Indicated for
hypovolemic
shock (cord
accident,
abruption, etc.)
4
40
IV: 0.10.3ml/kg
Higher IV
doses not
recommended
Precautions
ET: 0.3-1ml/kg
Volume
expanders
Sodium
Bicarb
10 ml/kg IV
1-2 meq/kg IV
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0.5 meq/ml
1
2-4
(4.2% solution)
2
4-8
Give over 5-10
minutes
Reassess after
bolus
Establish
adequate
ventilation first
12
Naloxone
0.1mg/kg
Neonatal vial:
0.4 mg/ml
IV or IM
preferred route
4
8-16
1
0.25
2
0.50
3
0.75
4
Adult vial:
1 mg/ml
2ml/kg, D10W
IV
6-12
Only for
prolonged NRP
Slow push over 2
min
Address
ventilation first
with routine
measures: PPV
Repeat q2-3min
ET route not
recommended
Dextrose
(10%
solution)
3
0.1g/ml
1
1
0.1
2
0.2
3
0.3
4
1
0.4
2
2
4
3
6
4
8
Caution in opioid
addiction- can
cause seizure
Check bedside
glucose.
Positive pressure Ventilation:
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:
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(Taken from Neonatal Resuscitation Textbook, 5th Ed. 2005)
Chest Compressions:
Indications:
Heart rate is less than 60 beats per minute after 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.
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(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 thumbencircling 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 hands encircling chest 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
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