Download Environment (if using as a simulation case)

Emma Brown; 4 weeks
Authors: Joseph House, MD and Michele Nypaver, MD
1/31/2011
Reviewer: Stacy Sawtelle, MD
Case Title: Neonatal Hypoglycemia
Target Audience: Emergency Medicine Residents
Primary Learning Objectives: key learning objectives of the scenario
1. Emergency Medicine residents will obtain a bedside glucose level in ill appearing
neonates immediately after airway, breathing and circulatory stabilization.
2. Emergency Medicine residents will articulate the array of clinical presentations of
neonatal hypoglycemia.
3. Emergency Medicine residents will verbalize differential diagnostic considerations
when presented with a finding of hypoglycemia in a neonate and initiate evaluation.
4. Emergency Medicine residents will treat hypoglycemia in neonates in accordance
with Pediatric Emergency Medicine practice.2
5. Emergency Medicine residents will reevaluate glucose status in ill appearing neonates
after intervention in a timely manner.
Secondary Learning Objectives: detailed technical goals, behavioral goals, didactic points
1. Emergency Medicine residents will verbalize the correct use of dextrose
infusions in neonates as well as the risks associated with hyperosmotic infusions..
2. Emergency Medicine residents will recheck a blood glucose level 15-30 minutes after
glucose is administered or sooner if patient seizes or otherwise decompensates.
Critical actions checklist
1.
Resident assesses ABC’s and monitors vital signs
2.
Resident checks bedside (point of care) glucose level
3.
If blood glucose level < 50mg/dL, resident gives 2-3mL/kg of D10W
4.
Resident repeats bedside glucose level15-30 minutes after glucose
replaced or sooner if patient seizes or otherwise decompensates
5.
Resident initiates evaluation of the cause of the hypoglycemia including a
sepsis work-up.
Dangerous Actions
1.
2.
Resident gives IV bicarbonate for low pH
Resident gives D25W or D50W
Environment (if using as a simulation case)
1. Room Set Up – ED, in sim lab or in situ
a. Manikin Set Up
i. Laerdal™ SimBaby or alternative high fidelity simulator
ii. Lines needed: 22G, 24G peripheral IV’s, intraosseous needles
iii. Medications: D5W solution, D10W solution, Dextrose 50%, Sterile
water diluent
b. Props – Vital sign monitoring equipment, airway equipment, code blue cart,
BroselowTM tape
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Emma Brown; 4 weeks
1/31/2011
Roles
1. Nurse
a. Role played by: other residents, students, nurses or actors
b. Actions: places infant on ED gurney, assists in placement of monitors,
establishes IV access and performs bedside glucose testing at the request of
the resident physician. The nurse prompts the resident if the neonate
decompensates or seizes.
2. Parent (mother or father)
a. Role played by: other residents, students, attending or actors
b. Action: gives history
2
Emma Brown; 4 weeks
1/31/2011
For Examiner Only
Authors: Joseph House, MD and Michele Nypaver, MD
Reviewer: Stacy Sawtelle, MD
Case Title: Neonatal Hypoglycemia
CASE SUMMARY
CORE CONTENT AREA
Pediatrics, Endocrine Emergencies
SYNOPSIS OF HISTORY/ Scenario Background
Four week-old female brought in to the Emergency Department by her mother for
vomiting and lethargy. The patient’s twin sister had similar symptoms four days ago, but
they resolved completely after two days. Mom has been giving the patient sips of water
over the last day, which she has kept down. On examination the neonate has poor tone
and minimal respiratory effort. A bedside glucose was found to be 20mg/dL. She was
given a bolus of 3ml/kg of D10W. A repeat glucose was found to be 40mg/dL and she
required another glucose bolus. She was also clinically dehydrated and was given one
20ml/kg boluses of normal saline IV fluid.
Past medical history: twin
Medications and allergies: none
Family and social history: No significant family or social history.
SYNOPSIS OF PHYSICAL
Initial scenario conditions: Temperature 98.2 rectally, Heart rate 160, Respiratory Rate
21, 95% on 4Liters of oxygen. Physical exam initially found patient to be limp with poor
respiratory effort. Mucus membranes are slightly dry on examination. Respiratory
examination shows decreased breath sounds bilaterally, no wheezing, or rhonchi.
Capillary refill is delayed at 4 seconds.
3
Emma Brown; 4 weeks
1/31/2011
For Examiner Only
CRITICAL ACTIONS
SCENARIO BRANCH POINTS/ PLAY OF CASE GUIDELINES
Key teaching points or branch points that result in changes in patient’s condition
1. Critical Action
Assesses ABC’s with monitoring of vital signs
Cueing Guideline: If not rapidly assessed child progresses to seizure like activity.
2. Critical Action
Checks bedside glucose
Cueing Guideline: If not rapidly assessed child progresses to seizure like activity.
3. Critical Action
Treats low glucose with 2-3mL/kg of D10W.
Cueing Guideline: If does not treat when obtains low bedside glucose, the nurse asks, “Is
there is anything that can be given for the low sugar?”
4. Critical Action
Rechecks glucose and treats as outlined in critical action 3.
Cueing Guideline: If the glucose is not rechecked patient begins seizing within 5 min.
5. Critical Action
Initiates evaluation of the cause of the hypoglycemia including a sepsis workup.
Cueing Guideline: If a sepsis evaluation is not initiated after the first dose of glucose is
administered the nurse asks, “What do you think is causing the low sugar, do you want
me to get a urine sample and send labs?”
SCORING GUIDELINES
(Critical Action No.)
1. Score decreases if resident does not quickly assess vital signs
2. Resident fails if he or she does not check bedside glucose
3. Resident fails if he or she does not correctly treat hypoglycemia
4. Resident fails if he or she does not recheck bedside glucose
5. Score decreases if resident does not investigate cause of hypoglycemia with ancillary testing
including a sepsis workup.
4
Emma Brown; 4 weeks
1/31/2011
For Examiner Only
HISTORY
Onset of Symptoms:
Today
Background Info:
4 week-old female presents to the emergency department with
mother with complaints of vomiting and lethargy. Vomiting started
yesterday, but she was able to tolerate some sips of water until today
when the water seemed to just run out of her mouth. Twin sister had
vomiting four days ago, but it resolved after two days.
Chief Complaint:
Vomiting and lethargy
Past Medical Hx:
Full-term vaginal delivery. No problems during the pregnancy or
delivery. She and her sister were discharged home with mother on
day-of-life 2.
Past Surgical Hx:
None.
Habits:
Smoking: No exposure
Family Medical Hx:
Denies
Social Hx:
Lives with mom, dad, and twin sister. Not in daycare
ROS:
List of pertinent positives and negatives: Positive for vomiting and
decreased urine output for one day (only one wet diaper in the last
24 hours). Negative for fevers, diarrhea hematemesis, upper
respiratory symptoms, hematuria, and rash
5
Emma Brown; 4 weeks
1/31/2011
For Examiner Only
PHYSICAL EXAM
Patient Name: Emma Brown
Age & Sex: four week-old female
General Appearance: Well-developed, well-nourished female laying limp on gurney
Vital Signs: Temperature 98.2 rectally, Heart rate 160, Respiratory Rate 21, 95% on 4Liters of
oxygen
Head: normocephalic, fontanelle soft and flat
Eyes: equal and round, reactive to light, does not track or follow with eye movement
Ears: tympanic membranes are clear bilaterally, no erythema, non-bulging
Mouth: no intra-oral lesions, mucus membranes are slightly dry
Neck: supple, no lymphadenopathy, no meningismus
Skin: warm, dry, intact, no rashes, slight tenting, capillary refill 4 seconds
Chest: no apparent tenderness on palpation, equal but diminished chest rise
Lungs: decreased breath sounds, clear to auscultation bilaterally
Heart: sinus rhythm, no murmurs, rubs, or gallops
Back: normal, no sacral dimpling or hair tufts
Abdomen: soft, non-distended, no apparent tenderness, no hepatosplenomegaly, bowel
sounds are present
Extremities: no obvious deformities, no spontaneous movement, capillary refill 4 seconds
Rectal: normal
Pelvic: stable
Neurological: minimal response to tactile stimuli
Mental Status: lethargic
6
Emma Brown; 4 weeks
For Examiner Only
STIMULUS INVENTORY
#1
Emergency Admitting Form
#2
CBC
#3
BMP
#4
U/A
#5
VBG
#6
Toxicology
#7
CXR
#8
CT
#9
Debriefing materials
7
1/31/2011
Emma Brown; 4 weeks
1/31/2011
For Examiner Only
LAB DATA & IMAGING RESULTS
Stimulus #2
Complete Blood Count (CBC)
WBC
20.3/mm3
Hgb
12.6g/dL
Hct
36.9%
Platelets
315/mm3
Differential
Segs
82.6%
Bands
0%
Lymphs
11.6%
Monos
6.9%
Eos
0%
Stimulus #3
Basic Metabolic Profile (BMP)
Na+
135mEq/L
K+
4.8mEq/L
CO2
13mEq/L
Cl98mEq/L
Glucose
8mg/dL
BUN
23mg/dL
Creatinine
0.2mg/dL
Stimulus #4
Urinalysis (U/A)
Color
Sp gravity
Glucose
Protein
Ketone
Leuk. Est.
Nitrite
WBC
RBC
yellow
1.020
100mg/dL
neg
150mg/dL
neg
neg
0-1
0-1
Stimulus #5
Venous Blood Gas
pH
7.20
pCO2
35mm Hg
pO2
43mm Hg
Glu
4mg/gL
Stimulus #6
Toxicology
Serum
Salicylate
Acetaminophen
Tricyclics
ETOH
Neg
Neg
Neg
mg/dl
Urine
Cocaine
Cannabinoids
PCP
Amphetamines
Opiates
Barbiturates
Benzodiazepines
Neg
Neg
Neg
Neg
Neg
Neg
Neg
Verbal Reports
Initial bedside glucose 20mg/dL
After 1st glucose bolus bedside glucose 40mg/dL
After 2nd glucose bolus bedside glucose120mg/dL
Diagnostic Imaging
Stimulus #7
CXR: Hypoinflation, otherwise negative
Stimulus #8
Head CT:
8
Negative
Emma Brown; 4 weeks
1/31/2011
Learner Stimulus #1
ABEM General Hospital
Emergency Admitting Form
Name:
Emma Brown
Age:
4 week old
Sex:
Female
Method of Transportation:
Private car
Person giving information:
Mother
Presenting complaint:
Vomiting and Lethargy
Background: Patient presents to the emergency department with mother with complaint of
vomiting and lethargy. The vomiting started yesterday, but she was able to tolerate some sips of
water until today when the water seemed to just run out of her mouth. Twin sister had vomiting
four days ago, but it resolved after two days.
Triage or Initial Vital Signs
P:
160
R:
21, saturation 95% on 4 Liters Oxygen
T:
98.2 rectally
9
Emma Brown; 4 weeks
Learner Stimulus #2
Complete Blood Count (CBC)
WBC
20.3/mm3
Hgb
12.6g/dL
Hct
36.9%
Platelets
315/mm3
Differential
Segs
82.6%
Bands
0%
Lymphs
11.6%
Monos
6.9%
Eos
0%
10
1/31/2011
Emma Brown; 4 weeks
Learner Stimulus #3
Basic Metabolic Profile (BMP)
Na+
135mEq/L
K+
4.8mEq/L
CO2
13mEq/L
Cl98mEq/L
Glucose
8mg/dL
BUN
23mg/dL
Creatinine
0.2mg/dL
11
1/31/2011
Emma Brown; 4 weeks
Learner Stimulus 4
Urinalysis (U/A)
Color
Sp gravity
Glucose
Protein
Ketone
Leuk. Est.
Nitrite
WBC
RBC
12
yellow
1.020
100mg/dL
neg
150mg/dL
neg
neg
0-1
0-1
1/31/2011
Emma Brown; 4 weeks
Learner Stimulus #5
Venous Blood Gas
pH
pCO2
pO2
Glu
13
7.20
35mm Hg
43mm Hg
4mg/gL
1/31/2011
Emma Brown; 4 weeks
Learner Stimulus #6
Toxicology
Serum
Salicylate
Acetaminophen
Tricyclics
ETOH
Urine
Cocaine
Cannabinoids
PCP
Amphetamines
Opiates
Barbiturates
Benzodiazepines
14
Neg
Neg
Neg
0mg/dl
Neg
Neg
Neg
Neg
Neg
Neg
Neg
1/31/2011
Emma Brown; 4 weeks
Learner Stimulus #7
Diagnostic Imaging
CXR:
15
1/31/2011
Emma Brown; 4 weeks
Learner Stimulus #8
Diagnostic Imaging
Head CT:
Negative
16
1/31/2011
Emma Brown; 4 weeks
1/31/2011
Feedback/ Assessment Forms
Neonatal Hypoglycemia
Candidate ________________________
Examiner _________________________
Critical Actions:





Critical Action #1 (Not assessing ABCs and vital signs results in failure of the case)
Critical Action #2 (Not checking a glucose results in failure of the case)
Critical Action #3 (Not administering glucose correctly results in failure of the case)
Critical Action #4 (Not rechecking a glucose results in a lower score)
Critical Action #5 (Not initiating a sepsis workup results in a lower score)
Dangerous Actions: (Performance of one dangerous action results in failure of the case)
 Dangerous Action #1
 Dangerous Action #2
Overall Score:
 Pass
 Fail
17
Emma Brown; 4 weeks
1/31/2011
Optional Addendum 2:
Core Competency Assessment
Neonatal Hypoglycemia
Candidate ________________________
Does Not Meet
Expectations
Patient Care
Medical
Knowledge
Interpersonal
Skills and
Communication
Professionalism
Practice-based
Learning and
Improvement
Systems-based
Practice
18
Examiner _________________________
Meets
Expectations
Exceeds
Expectations
Emma Brown; 4 weeks
1/31/2011
Addendum 2:
Date:
Examiner:
Examinee(s):
Scoring: In accordance with the Standardized Direct Observational Tool (SDOT)
The learner should be scored (based on level of training) for each item above with one
of the following:
NI = Needs Improvement
ME = Meets Expectations
AE = Above Expectations
NA= Not Assessed
Critical Actions
Assess ABC’s and place patient on
vital signs monitor
Obtain bedside Glucose Check
Recognize hypoglycemia and begin
glucose bolus
Repeat bedside glucose check after
intervention
Repeat glucose bolus if pt still
hypoglycemic
Repeat bedside glucose check (second
time)
NI
ME
AE
NA
Category
PC, MK, PBL
PC, MK
PC, MK, PBL
PC, MK, PBL
PC, MK, PBL
PC, MK, PBL
The score sheet may be used for a variety of learners. Other items may be marked
N/A= not assessed.
19
Emma Brown; 4 weeks
1/31/2011
Category: One or more of the ACGME Core Competencies as defined in the SDOT
PC=
Patient Care
Compassionate, appropriate, and effective for the treatment of health problems and the promotion
of health
MK= Medical Knowledge
Residents are expected to formulate an appropriate differential diagnosis with special attention to
life-threatening conditions, demonstrate the ability to utilize available medical resources effectively,
and apply this knowledge to clinical decision making
PBL= Practice Based Learning & Improvement
Involves investigation and evaluation of their own patient care, appraisal and assimilation of
scientific evidence, and improvements in patient care
ICS= Interpersonal Communication Skills
Results in effective information exchange and teaming with patients, their families, and other health
professionals
P=
Professionalism
Manifested through a commitment to carrying out professional responsibilities, adherence to ethical
principles, and sensitivity to a diverse patient population
SBP= Systems Based Practice
Manifested by actions that demonstrate an awareness of and responsiveness to the larger context
and system of health care and the ability to effectively call on system resources to provide care that
is of optimal value
20
Emma Brown; 4 weeks
1/31/2011
Debriefing Materials:
Initial Debrief Reaction: How did you feel about this case? (looking to elicit simple reaction
words or short sentence from participant)
Quick debrief structure: Examiner should use positive statement: “I observed that you (list
positive actions/verbal reasoning)”
Then examiner asks: “Can you tell me how you thought to (do X, Y, Z positive actions)?” This
will elicit resident to review his/her thinking as they went through the case.
Examiner may then point out opportunities for improvement and move on to educational review.
Educational Review: Unlike adults infants can become hypoglycemic after fasting for 24-36
hours. Clinical presentation of hypoglycemia can vary greatly and is very non-specific. It may
present as anxiety, tremulousness, sweating, confusion, seizures, headache, or fatigue. Any
acutely ill child should have a bedside glucose evaluation if they present with any of these
symptoms. If hypoglycemia is confirmed it should rapidly be corrected with 0.25grams of
dextrose per kilogram of body weight. Neonates should be given glucose in the form of a 10%
dextrose solution. Older children can receive higher concentration of glucose. Depending on the
degree of hypoglycemia and the underlying cause of hypoglycemia repeat glucose boluses may
be needed and in some cases a continuous dextrose infusion is necessary. Glucose should be
rechecked in 15-30minutes after glucose bolus/infusion. Another option for correction of
hypoglycemia is Glucagon (0.02-0.03mg/kg/dose IV, IM, SC)3, however in infants with
underlying glucose storage diseases and those with depleted glycogen stores will not have a
response to this therapy. Also, in ill appearing neonates with hypoglycemia it may assist
consultants to obtain a red top tube of serum (put in refrigerator) prior to glucose treatment;
HOWEVER, treatment should NEVER be delayed while trying to obtain specimens for later use.
After correction of hypoglycemia, the next step is to determine possible causes. It may be
secondary to decreased availability of glucose: Decreased intake (fasting, illness), decrease
absorption (diarrhea), inadequate glycogen reserve, ineffective glyconeogenesis, inability to
mobilize glycogen, or ineffective gluconeogenesis. Hypoglycemia may be due to increased use
of glucose as may be seen with large tumors or hyperinsulinism. It may be due to decreased
availability of alternative fuels: decreased or absent fat stores or inability to oxidize fats. Other
causes when mechanism is unknown or include several of the above causes are: sepsis,
salicylate ingestion, ethanol ingestion, Reye’s syndrome, adrenal insufficiency, hypothyroidism,
or hypopituitarism. Consideration of possible ingestion of diabetic medication should always be
considered. Evaluation for the above causes should be based on history of illness and physical
exam.
During the newborn period, inborn errors of metabolism, hyperinsulinemia, or infant of diabetic
mother, should be considered, as should sepsis. Past the newborn stage, relationship to feeding
should be determined and may give clues to possible underlying cause. If hypoglycemia occurs
shortly after meals consider galactosemia or fructose intolerance. If hypoglycemia occurs
greater than 6 hours after feeding consider defects in gluconeogenesis. Hepatomegaly may
point towards an error in gluconeogenesis or enzyme deficiency in glycogen metabolism.
Examiner then summarizes the debriefing: Initial reactions, positive performance steps,
educational points and specific changes to improve performance.
Keywords for future searching functions:
Hypoglycemia
Infant
21
Emma Brown; 4 weeks
1/31/2011
Newborn
Mental status changes
Seizures
References
1. Sperling MA. Hypoglycemia. In: Kliegman RM, Behrman R, Jenson HB, Stanton BF, eds.
Nelson Textbook of Pediatrics, 18th ed. Philadelphia: Saunders Elsevier 2007: 655.
2. Agus MSD. Endocrine Emergencies. In: Fleisher GR, Ludwig S, Henretis FM, eds. Textbook
of Pediatric Emergency Medicine, 5th ed. Philadelphia: Lippincott Williams & Wilkins 2006:1173.
3. Custer JW. Rau RE. The Harriet Lane Handbook. 18th ed. Philadelphia: Elsevier Mosby
2009: 849.
The resource image is a de-indentified file from the author’s personal library teaching library.
Has this work been previously published? No
Simulation Equipment Checklist
ENVIRONMENT
This scenario requires (checked boxes):
x
x
x
x
x
x
x
x
x
x
Simulator
Type: Laerdal™
SimBaby
Standardized Patient
Non-Invasive BP Cuff
2 lead EKG
Pulse Oximeter
Arterial Line
CVP
PA Catheter
Temperature Probe
Capnograph
Resp Rate Monitor
SP for family member
Additional nurse SP
Other SP
22
x
x
x
ETT
LMA
Laryngoscope
Fiberoptic scope
Gum Bougie
x
Crash Cart
Central line set up
Chest tube set up
Ultrasound Machine