CHAPTER 1 Abdominal/Gastroenterology Emergencies
Michele Callahan
Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
NECROTIZING ENTEROCOLITIS
Educational Goals
Learning Objectives
1 Demonstrate focused examination of a neonate (MK, PC).
2 Differentiate between normal neonatal behavior and pathological signs/symptoms that require further workup (MK, PC).
3 Recognize the need for imaging (MK, PC)
4 Demonstrate appropriate care for necrotizing enterocolitis (NEC ) including nil per os (NPO ) status and initiation of intravenous (IV) fluids and IV antibiotics (MK, PC).
5 Communicate effectively with team members to facilitate patient care (ICS, P).
6 Identify need for intensive care and pediatric surgery consultations (MK, P, SBP).
7 Demonstrate empathy and maintain family involvement when treating a pediatric patient (P, ICS).
Critical Actions Checklist
Obtain a full set of vital signs (PC)
Obtain heelstick glucose (PC)
Order appropriate blood tests and imaging studies to evaluate for obstruction, free air, and sepsis (MK).
Early resuscitation with IV fluids and IV antibiotics (PC, MK).
If no IV access, recognition that intraosseous (IO ) is also an option (MK, PC).
Appropriate consultation with pediatric surgery and critical care team (MK, SBP).
Simulation Set‐Up
Environment: Emergency department
Mannequin: Newborn simulator mannequin, wearing a diaper with a onesie over top. Diaper is smeared with activated charcoal to simulate black stool. The simulator may have a weak cry, if this option is available.
Props: To be displayed on a computer/TV screen in the room, or printed out and handed to learners throughout the simulation. Should only be offered to learners if ordered/requested:
Images (see online component for NEC, Scenario 1.1 at https://www.wiley.com/go/thoureen/simulation/workbook2e):Abdominal x‐ray showing distended bowel with early intraluminal gas (Figure 1.1).Abdominal ultrasound showing pneumatosis (Figure 1.2).Radiology interpretation of abdominal x‐ray concerning for NEC (Figure 1.3).Radiology interpretation of abdominal ultrasound showing pneumatosis (Figure 1.4).
Imaging that is not provided but is requested by learners can be reported as normal.
Laboratory tests (see online component as above):Heelstick glucose (Table 1.1).Complete blood count (Table 1.2).Basic metabolic panel (Table 1.3).Liver function panel (Table 1.4).Lipase (Table 1.5).Coagulation panel (Table 1.6).Lactic acid (Table 1.7).C‐reactive protein (Table 1.8).Troponin (Table 1.9).Urinalysis (Table 1.10).Urine microscopy (Table 1.11).
Available supplies:
Pediatric code cart and basic airway supplies, including supplies for intubation.
Pediatric length‐based tape.
Medications:IV fluid bags: 0.9% saline, lactated Ringer's solution (LR ), PlasmaLyte®.
Pre‐labeled bags:Vasopressors (e.g. norepinephrine, dopamine, vasopressin).
Pre‐labeled syringes:Dextrose (10 and 25%) in water.Morphine.Antiemetic.Antibiotics (broad spectrum).Intubation medications (sedatives and paralytics of choice at your facility).
IO device (optional).
Distractor(s): None.
Actors
Patient's parent provides history.
Emergency department (ED) nurse: can help to place the patient on monitor, obtain IV access (IO should be done by learners, if needed), and administer medications/fluids. May cue learners if needed.
Respiratory therapy (available when requested in ED).
Pediatric/neonatal intensive care (PICU/NICU) team member via phone consultation.
Pediatric surgery consultant via phone consultation.
Case Narrative
Scenario Background
A four‐week‐old preterm, female infant born by spontaneous vaginal delivery at 33 weeks of gestation, (birth weight 4 lbs (1.81 kg) presents to the ED for lethargy, decreased feeding, and vomiting with feeds. The patient was in NICU for four weeks but discharged to home three days ago. The patient's hospital stay was complicated by neonatal jaundice and temperature dysregulation, both of which were resolved prior to discharge. For the past two days, the patient's mother has noticed increased difficulty with feeding (formula fed), decreased PO intake, vomiting after feeds, and general sleepiness.
| Chief complaint: | Lethargy, decreased feeding, vomiting. |
| Patient's medical history: | Ex‐33 week, four‐day preemie (current age 37 weeks of gestational age, actual age 4 weeks 3 days). |
| Surgical history: | None. |
| Allergies: | None. |
| Medictions: | Vitamin D supplementation. |
| Social history: | Not in daycare, lives at home with mom; no siblings. |
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Family history:
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