CSC Standardized Curriculum
Specialty: Pediatrics
Simulation: Infant (newborn) Code Blue in MBU/ALTE in MBU
Submitted by: MAJ Taylor Sawyer
Target Audience: Pediatric and Family Medicine Residents, Pediatric and Family
Medicine Staff
ACGME Competencies Addressed:
Medical Knowledge
Patient Care
Communication
Professionalism
RRC Requirements Addressed:
Advanced life support
Endotracheal intubation
IO insertion
Version1, 4/11/2008
1
Case Scenarios
Primary:
Mother-Baby unit: Student called to a code in the MBU treatment room of a 1 day old
full term, previously healthy infant who was found ‘blue and not breathing’ in its crib in
the mother’s room. The mother called for the nurse who brought infant to treatment
room and began resuscitation. Infant was born via SVD approx 24 hours ago. Prenatal
course was unremarkable. Prenatal labs negative. Infant had previously doing well with
normal vital signs and good feeding attempts. On arrival infant is apneic, and cyanotic.
Monitors are not attached and nurse is rubbing baby’s back to stimulate respirations.
Alternate scenario:
Labor and delivery: Student called to labor and delivery room after infant ‘turned blue’
while breast feeding and stopped breathing. Nurse was called by mother and infant
moved to warmer. Infant was born via SVD approx 2 hours ago. Prenatal course was
unremarkable. Prenatal labs negative. Infant had previously doing well, Apgars 8/9. On
arrival infant is apneic, and cyanotic. Monitors are not attached and nurse is rubbing
baby’s back to stimulate respirations.
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.
Version1, 4/11/2008
2
Simulation Setup:
Simulators to be used: SimBaby
Room Setup:
 Primary: SimBaby on warmer in Mother Baby Unit treatment room.
 Have room set-up in normal fashion with BVM in usual place (if there is one).
 Peds crash cart (if available)
 Alternate: SimBaby on warmer in L&D room
 Routine delivery room resuscitation equipment.
Equipment needed:
 Pediatric code cart,
 Resuscitation meds (Epi),
 Bag-valve mask, ET tubes infant sizes: 3.0 - 4.0,
 laryngoscope, stylet, tape
 IV catheters (24 and 22 gauge),
 IV extension tubing, pediatric interosseus needle, tape,
 monitor leads,
 5cc syringe,
 3 cc syringe, 1 cc syringe,
 3 way stop cock
Optional Equipment:
 Sim Baby monitor screen for CRM,
 Pulse oximeter probe (display sats on SimBaby monitor if used)
Personnel needed:
 scenario instructor,
 scenario monitor,
 confederate nurse,
 Sim Baby technician
Basic Scenario Tips:
 Participants should be paged STAT on the either the delivery pagers or code
pager to the location used (MBU, L&D).
 Upon arrival the residents should be given a brief history by the confederate
nurse.
 Have monitor leads and pulse-ox available but not hooked up in MBU scenario.
 Monitor not available in L&D.
 But may use pulse-ox if these are routinely available in L&D.
Version1, 4/11/2008
3
Case Flow/Algorithm with branch point and completion criteria:
Primary scenario: Infant (newborn) code in MBU
1. Initial assessment:
General: limp cyanotic and apneic infant
Airway: Clear, without obstruction
Appropriate initial interventions include providing BVM with 100% oxygen.
Breathing: SimBaby initial RR = 0.
Appropriate intervention includes support of respirations with BVM or intubation.
Circulation: HR low at 30pbm. BP-not available.
Appropriate intervention include airway management and PPV (chest
compression should not be started until airway and breathing are addressed)
Improvement:
If adequate PPV given via BVM within 1 minute after start of scenario, Sats improve to
80%. HR stays at 30bpm. Apnea continues
If ETT placed successfully and PPV provided within 5 minute after start of scenario,
Sats improve to 100%. HR increases to 120. Spontaneous respirations start.
Deterioration:
If adequate PPV not given via BVM within 1 minute after start of scenario, Sats drop to
60%. HR drops to 10 bpm. Apnea continues
If ETT not placed successfully and PPV provided within 3 minute after start of scenario,
Sats drop to 40%. HR drops to 0. Apnea continues.
If ETT not placed successfully and PPV provided within 5 minute after start of scenario,
Sats drop 20%. HR stays at 0. Apnea continues and simulation ends.
2. Call for Diagnostic tools:
 If participant calls for CXR the supervisor should respond “they are on their way”
(but they never show up).
 If ABG or other labs are ordered the results will be ‘pending’ and not available
during the simulation.
Version1, 4/11/2008
4
Case Flow
ALTE in MBU or L&D
Initial state:
Cyanotic
Apneic
RR= 0
HR= 30
Improvement:
PPV given via BVM
Sats improve to 80%
HR stays at 30bpm.
Apnea continues
Improvement:
ETT placed successfully
and PPV provided
Sats improve to 100%
HR increases to 120
Spontaneous respirations start at
RR 40
Deterioration:
PPV NOT given via BVM
within 1 minute after start
of scenario
Sats drop to 60%.
HR drops to 10 bpm.
Apnea continues
Deterioration:
ETT NOT placed
successfully and PPV
provided within 3 minutes
after start of scenario
Improvement:
PPV given via BVM
Sats drop to 40%.
HR drops to 0.
Apnea continues
Improvement:
ETT placed successfully
and PPV provided
Only improvement in scenario
results from airway management
Deterioration:
ETT NOT placed
successfully and PPV
provided within 5 minutes
Sats drop to 20%
HR stays at 0
Apnea continues
Simulation ends
Chest compression or medications
result in no change
Version1, 4/11/2008
5
Alternate scenario: Newborn ALTE in L&D
Case Flow: Same as above
Common pitfalls to monitor for:
Not recognizing that need for intubation with sats of 80% with BVM
Starting chest compressions before establishing an airway
Giving epinephrine before establishing an airway
Version1, 4/11/2008
6
Physician # / Name ____________________________
Date
_______________________
Training Site __________________________________
Grader
__________________
Training Level: (Circle One)
Fellow Staff
PGY-1
PGY-2
PGY-3
Completed
Not Completed Indeterminate
History (3 points)
Obtains relevant history (2 point)
Requests vital signs (1 point)
Physical Exam (9 points)
Recognizes apnea (3 points)
Recognizes cyanosis (3 point)
Recognizes bradycardia (3 points)
Diagnostic evaluation (3 points)
Diagnoses respiratory arrest (3 points)
Management (9 points)
Applies oxygen (1 point)
Facemask 5-10 LPM
Nasal cannula 2LPM
Provides PPV via BVM (3 point)
Intubates infant (3 points)
Reassesses vitals after each intervention
(2 points)
Version1, 4/11/2008
7
Completed
Not completed Indeterminate
Time goals (6 points)
Provides PPV via BVM within one minute
after start of scenario (3 points)
Endotracheal intubation completed within
five minutes after start of scenario
(3 points)
Incorrect
Incorrect Actions and Interventions
Starting chest compressions before airway is secured
(-3 points)
Gives IV epinephrine before airway is secured
(- 2 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)
Version1, 4/11/2008
 3 (good)
 4 (Very good)
 5 (Excellent)
8
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 an infant code in the MBU?
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
Version1, 4/11/2008
9
Key Teaching Points/Critical Actions to discuss in debriefing:
In neonatal codes establishment of airway is the primary concern. The airway must be
secured and adequate ventilation ensured prior to proceeding to chest compressions or
medications. Without an adequate airway and adequate ventilation chest compressions
and medications are unlikely to be improve the infant’s status.
Suggested time length for modules: Total time: 20-30 minutes.
1-2 minutes for history
5 – 7 minutes scenario
15 minutes feedback session on performance
Brief Didactic:
Exposure to hypoxia in both term and preterm infants results in initial hyperpnea
followed quickly by ventilatory depression and possible apnea. This hypoxemic
respiratory depression seen in early postnatal life likely represents a remnant adaptation
to life in utero. A ventilatory response to hypoxia in utero would be counterproductive,
because oxygen is supplied via the umbilical vein and an increase in respiratory muscular
activity would only deplete 02 stores without increasing 02 supply. Hypoxic depression,
on the other hand, would serve to decrease fetal movements, thus conserving 02 stores,
and also decrease energy utilization at the cellular level. If this ventilatory depression is
allowed to go unchecked the hypoxemia will eventually lead to cardiac ischemia and
bradycardia.
Events in early postnatal life that may result in hypoxemic ventilatory depression
include obstruction of the nares, as can occur accidentally during breast feeding. This is
often the case when babies ‘turn blue’ during an early breast feeding attempt.
Additionally, a malpositioned airway with pharyngeal obstruction can also result in
impeded ventilation and in hypoxemic ventilatory depression. This is most common in
newly born infants due to the weakness of the pharyngeal and neck musculature and lasck
of head control.
In the vast majority of cases simple stimulation will resolve the hypoxemic
ventilatory depression. However, in rare cases of prolonged hypoxia more aggressive
interventions may be needed, including PPV via BVM or intubation. In cases of
significant myocardial ischemia medications such as epinephrine may be required.
Version1, 4/11/2008
10
Procedure review:
Bag-valve mask ventilation
Correct connections of air tubing
(Taken from Textbook of Neonatal Resuscitation, 5th Ed)
Correct mask fit
Correct mask positioning
(Taken from Textbook of Neonatal Resuscitation, 5th Ed)
Version1, 4/11/2008
11
(Taken from Textbook of Neonatal Resuscitation, 5th Ed)
Providing BVM with proper respiratory rate
Endotracheal; Intubation:
(Taken from Textbook of Neonatal Resuscitation, 5th Ed)
Version1, 4/11/2008
12
Positioning of infant
Intubation landmarks
(Taken from Textbook of Neonatal Resuscitation, 5th Ed)
Intubation procedure
Supporting Literature and Suggested Readings:
Neubauer, J. A., et al. Modulation of respiration during brain hypoxia. Journal of
Applied Physiology. 68(2): 441-451
Kattwinkle, J., Ed. (2005) Textbook of Neonatal Resuscitation, 5th Ed. American
Academy of Pediatrics, American Heart Association.
Version1, 4/11/2008
13