OSCE

Your patient is hypothermic and has arrested. What is your management?

I will start CPR at a rate of 30 to 2. I will start re warming the patient but not applying heat directly to the head. I will use up to three doses of ACLS medications and up to three defib attempts but after three I will stop and generally I will use half dose. I'll give medications at double the dose interval. Above 30 degrees I'll give my medications as usual. We will continue a rest until the patient is a minimum of 32 degrees. If at 32 degrees still in cardiac rest and no other reversible cause is found that is when we will consider ending the resuscitation.

Being called as there is a precipitous delivery in the emergency department. The newborn has come out blue and floppy. Another face is caring for the mother. It was a term delivery. What is your management?

I will declare to the team that this newborn is unwell and needs resuscitation. We will follow the APLS guidelines. In the first 60 seconds I will assume team leadership, call for help including NICU. I will dry and stimulate the newborn and place them on a warm resuscitator. Then if on assessment the heart rate is under 100 or they are gasping or apnea, I will start positive pressure ventilation with a Neopuff, rate of 40 to 60, PEEP of 5, PIP of 30 and will be observing for chest rise and clinical improvement. After the first minute if the heart rate is between 60 and 100 I will continue to attempt to improve ventilation and will consider intubational LMA. If the heart rate is less than 60 at any point I will start CPR, one at a lower third of the sternum using two thumb technique, three chest compress ions to one breath, rate of 120 per minute, depth of one third of chest and will be using 100% FiO2. Concurrently another member of my team will be gaining IV access. Once gained we will give IV adrenaline, 10 to 30 micrograms per kilogram and next we will proceed to intubation. We will also consider a 10 ml per kilo fluid bolus. Next resuscitation will include intra-aneurysia titan, sensor monitoring, monitored normofermia and this infant will go to the NICU, this newborn will go to NICU.