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Station Lead

Dr. Angela Benton and Dr. Kevin Connolly

Objectives for Station 1 - Neonatal Sepsis

  1. Identify abnormal vital signs in a neonate.
  2. Initiate appropriate monitoring.
  3. Recognize the need for IO access when attempts at peripheral IV fail.
    1. Procedural practice at placing IOs.
  4. List the appropriate antibiotics for an infant <2 month old.
  5. Identify the signs of shock in an infant.
  6. Order the appropriate fluid bolus.
  7. Reassess the patient after an intervention.
  8. Procedural practice at performing lumbar punctures. 

Objectives for Station 2 - Pediatric Asthma

  1. List the differential diagnosis for wheezing in a pediatric patient.
  2. Identify the signs of respiratory distress in a pediatric patient.
  3. Describe the different systems available for oxygen delivery.
  4. Initiate appropriate monitoring.
  5. Treat the respiratory distress.


Pediatric Boot Camp Scenarios


Case 1: Sim Baby with Sepsis

Information initially provided to participating teams:

Ex-term now 5 day old baby boy born at home now with a tactile fever at home and a cough, mom brings the baby to the ER and the baby has not been eating and drinking well for the past 2 days. MGM and 3 y/o sister sick (sister in pre-school). Mom doesn't have a thermometer so she doesn't know what his temperature has been. 

 

Initial clinical signs:

Vital signs:  HR 190 (normal range 120-140),  70 (normal range 30-50), 68/41 (SBP 60-100), Temp 38.8 C rectal

Tachypneic but no distress

Tachycardic (no murmurs)

Lethargic, difficult to wake up

Cap refill 4 seconds

 

PMH:  Term, NSVD, no prenatal care, 8 lbs (3.6 kg), no known PMH, PSH, meds or allergies. Has not had any vaccinations or blood work done, never seen by a doctor, lives with parents and 3 y/o sister. 

 

ROS:

Started 2 days ago with congestion and runny nose, has been taking less milk, exclusively breastfed.

Feeding: takes 1-2 oz every 4-6 h (normal 2-3 oz q2-3 hrs).

Wet Diapers: none since yesterday (normal 5-10/day).

Poops: 1 diarrhea poop yesterday, and none this morning (normal 2-10 soft/day).


SH: Lives at home with parents, MGM, and 3 y/o sister. No smoking or pet exposures. No recent travel.

 

Exam:

Vitals taken while baby is lying quietly in mom's arms

HR 190; BP 68/41; RR 70; Temp 38.8 C rectal, O2 sat 99% on room air 

HEENT: sunken fontanelle

CNS: listless, moving all extremities when provoked, intact sucking reflex

cardio: tachycardia, poor peripheral perfusion, capillary refill 4 seconds, equal brachial and femoral pulses

respiratory: tachypnea, mild subcostal retractions, clear bilaterally

GI: wnl

GU: noncircumcised penis; wnl

skin: cool extremities, dry, intact, no rashes or ecchymosis

 

Proposed treatment:

Wash hands

Introduces self

Identify patient

Obtain vitals and place patient on monitor

Performs ABC’s on minimally responsive patient

Monitors level of consciousness

Recognizes septic shock

Calls for help (Code, not RRT because need pharmacy)

Obtain access (will not be able to obtain access with IV), will need IO

-       Discussion points: Where to place IO? Tib/fib

-       Start distally and can can work way proximally

-       Cannot place another IO in area where previously attempted

Provide bolus (push/pull)

Orders appropriate antibiotics (Ampicillin/Gentamicin or Ampicillin/Cefotaxime, NOT Ceftriaxone in infants <1mo)

Orders appropriate rule out sepsis work up

-       CBC with differential, CMP, CRP, urinalysis, urine culture (not just UA with reflex), LP since patient is less than 2 months old, CXR


If proper intervention:

Vitals normalize

If no IO, or antibiotics:

Worsening tachycardia, tachypnea, and hypotension

Minimally unresponsive or unresponsive

Discussion points:

Signs and symptoms of sepsis in Peds

Contraindications for IO

Antibiotic agents and coverage in <2 months old

 

 

Case 2: Sim Junior with Asthma

Information initially provided to participating teams:

4 yo boy with a past h/o wheezing brought to the ED by ambulance. He has had a cough and runny nose for 2 days and this morning awoke in respiratory distress and struggling to breathe.  He is unable to speak in full sentences. Mom is very anxious. EMS has started an IV and started NS at a keep open rate.


Initial clinical signs:

Vital signs:  RR 60, HR 140, BP 110/70, 85% on RA, temp 99.9

Alert and pale

Anxious

Profusely diaphoretic

Flaring and has intercostal and subcostal retractions

 

PMH:  Hospitalized last summer in PICU. No intubations. Uses Albuterol MDI at home on an as needed basis. No controller medication. Last steroid burst 2 months ago. 2 dogs at home and dad smokes (but outside). Triggers are URIs and “cold air”.

 

ROS:  Low grade fevers x 2 days, cough, and runny nose x 2 days. 

 

Studies:

If participants want labs: They are drawn but do not come back for 30 minutes

CXR (if they order) shows hyperexpansion

CBG: (if they ask) 7.35/40/19

 

Proposed treatment:

Wash hands

Introduces self

Identify patient

Obtain vitals and place patient on monitor

Performs respiratory assessment

Gives 02 –preferably with face mask initially

Monitors level of consciousness

Recognizes respiratory distress

Calls for help

Orders Albuterol

Considers CXR

Considers NS bolus

Considers Ipratropium and Solumedrol

Reassess respiratory status

 

If proper intervention:

Decreased wheezing and distress

If no 02 placed:

02 sats drop to low 80’s

If no albuterol:

Worsening tachypnea and tachycardia

Discussion points:

Signs and symptoms of respiratory distress in Peds

02 delivery options

Differential diagnosis for wheezing

 

Resources

Pedi Stat (app on phone  available for 2.99) https://itunes.apple.com/us/app/pedi-stat/id327963391?mt=8

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