Patient Name Age



Authors: Joseph House, MD and Michele Nypaver, MD 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. Resident gives IV bicarbonate for low pH

2. 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

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

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.

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.

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

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

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

For Examiner Only

LAB DATA & IMAGING RESULTS

Stimulus #2 Stimulus #5

Complete Blood Count (CBC) Venous Blood Gas

WBC 20.3/mm3 pH 7.20

Hgb 12.6g/dL pCO2 35mm Hg

Hct 36.9% pO2 43mm Hg

Platelets 315/mm3 Glu 4mg/gL

Differential

Segs 82.6%

Bands 0%

Lymphs 11.6%

Monos 6.9%

Eos 0%

Stimulus #6

Stimulus #3 Toxicology

Basic Metabolic Profile (BMP) Serum

Na+ 135mEq/L Salicylate Neg

K+ 4.8mEq/L Acetaminophen Neg

CO2 13mEq/L Tricyclics Neg

Cl- 98mEq/L ETOH mg/dl

Glucose 8mg/dL

BUN 23mg/dL Urine

Creatinine 0.2mg/dL Cocaine Neg

Cannabinoids Neg PCP Neg

Stimulus #4 Amphetamines Neg

Urinalysis (U/A) Opiates Neg

Color yellow Barbiturates Neg

Sp gravity 1.020 Benzodiazepines Neg

Glucose 100mg/dL

Protein neg Verbal Reports

Ketone 150mg/dL Initial bedside glucose 20mg/dL

Leuk. Est. neg After 1st glucose bolus bedside glucose 40mg/dL

Nitrite neg After 2nd glucose bolus bedside glucose120mg/dL

WBC 0-1

RBC 0-1 Diagnostic Imaging

Stimulus #7

CXR: Hypoinflation, otherwise negative

Stimulus #8

Head CT: Negative

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

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%

Learner Stimulus #3

Basic Metabolic Profile (BMP)

Na+ 135mEq/L

K+ 4.8mEq/L

CO2 13mEq/L

Cl- 98mEq/L

Glucose 8mg/dL

BUN 23mg/dL

Creatinine 0.2mg/dL

Learner Stimulus 4

Urinalysis (U/A)

Color yellow

Sp gravity 1.020

Glucose 100mg/dL

Protein neg

Ketone 150mg/dL

Leuk. Est. neg

Nitrite neg

WBC 0-1

RBC 0-1

Learner Stimulus #5

Venous Blood Gas

pH 7.20

pCO2 35mm Hg

pO2 43mm Hg

Glu 4mg/gL

Learner Stimulus #6

Toxicology

Serum

Salicylate Neg

Acetaminophen Neg

Tricyclics Neg

ETOH 0mg/dl

Urine

Cocaine Neg

Cannabinoids Neg

PCP Neg

Amphetamines Neg

Opiates Neg

Barbiturates Neg

Benzodiazepines Neg

Learner Stimulus #7

Diagnostic Imaging

CXR:

[pic]

Learner Stimulus #8

Diagnostic Imaging

Head CT: Negative

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

Optional Addendum 2:

Core Competency Assessment

Neonatal Hypoglycemia

Candidate ________________________ Examiner _________________________

| |Does Not Meet Expectations |Meets Expectations |Exceeds Expectations |

|Patient Care | | | |

| | | | |

| | | | |

| | | | |

|Medical Knowledge | | | |

| | | | |

| | | | |

| | | | |

|Interpersonal Skills and | | | |

|Communication | | | |

| | | | |

| | | | |

|Professionalism | | | |

| | | | |

| | | | |

| | | | |

|Practice-based Learning and | | | |

|Improvement | | | |

| | | | |

| | | | |

|Systems-based | | | |

|Practice | | | |

| | | | |

| | | | |

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 |NI |ME |AE |NA |Category |

|Assess ABC’s and place patient on vital signs monitor | | | | |PC, MK, PBL |

|Obtain bedside Glucose Check | | | | |PC, MK |

|Recognize hypoglycemia and begin glucose bolus | | | | |PC, MK, PBL |

|Repeat bedside glucose check after intervention | | | | |PC, MK, PBL |

|Repeat glucose bolus if pt still hypoglycemic | | | | |PC, MK, PBL |

|Repeat bedside glucose check (second time) | | | | |PC, MK, PBL |

The score sheet may be used for a variety of learners. Other items may be marked N/A= not assessed.

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

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

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 |Simulator |

| |Type: Laerdal™ SimBaby |

|x |Standardized Patient |

|x |Non-Invasive BP Cuff |x |ETT | |

|x |2 lead EKG |x |LMA | |

|x |Pulse Oximeter |x |Laryngoscope | |

| |Arterial Line | |Fiberoptic scope | |

| |CVP | |Gum Bougie | |

| |PA Catheter | | | |

|x |Temperature Probe |x |Crash Cart | |

|x |Capnograph | |Central line set up | |

|x |Resp Rate Monitor | |Chest tube set up | |

| | | |Ultrasound Machine | |

|x |SP for family member | |

|x |Additional nurse SP | |

| |Other SP | |

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