POTD: Neonatal Resuscitation

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We’ll be going over a few high yield topics pertaining to NALS today. 

It’s 7:30 AM, and you’ve just unwrapped your BEC sandwich and taken your first sip of coffee. You’re settling into the morning getting ready for your 12 hour peds shift… until the phone rings, and you get a note: 

“Mother 38w delivered her baby at home 30 minutes ago. Baby is having labored breathing, and is bradycardic. EMS will be here in 2 minutes.”

Take a deep breath. First, remember the basics. If you’re in a facility that has Peds/NICU, call them immediately. Call respiratory. Call pharmacy. Call Hector. Use the resources available to you. 

The set up.

Get the warmer and set it to 25 C

  • Avoid hypothermia in these patients. The goal is > 36.5-37.5C

Grab the Broselow tape so that it’s available for immediate use.
Get the backboard.
Grab the code cart, zoll
Get a towel to warm and dry the baby.
Get your airway equipment ready:

  • Suction x 2, plugged in, ready to go

  • Oxygen: grab the neonatal BVM and plug it into the oxygen port

  • Airway equipment: have both DL/VL equipment,

    • LMA size 1

    • Pre-loaded tubes

      • 2.5 and 3.0 uncuffed tubes

    • Blades: 0 and 1

    • EtCO2

Access: IO gun + pink needles ready for use; umbilical vein catheters (future POTD)

Grab your PALS card or open up your PediStat app
Ultrasound

Assess the patient.

Pediatric assessment triangle:

  • Appearance – crying? Good tone? Tracking?

  • Breathing – nasal flaring? Stridor? Grunting? Head bobbing?

  • Circulation – Pallor? Cyanosis? Mottling?

Off the bat, there are two numbers you need to remember:
HR < 100→ initiate positive pressure ventilation (PPV)
HR < 60→ initiate CPR / epinephrine if this is sustained more than 30 seconds despite adequate ventilation.

  • NOTE: Bradycardia is almost always related to hypoxia, so atropine isn’t routinely indicated for these patients.

Remember, the most important part of neonatal resuscitation is positive pressure ventilation.


PPV.

If the patient is spontaneously breathing but labored, you can place them on CPAP.
Remember, the targeted SpO2 after birth is much lower for neonates, so see the box below. You’re more interested in ventilating than the oxygenation.
For gasping / apneic / HR < 100 patients, initiate PPV. You can use 5 on the PEEP valve.

  • Rate: 40-60 breaths / minute

MR SOPA mnemonic for ventilation tips:

  • Mask, right size

  • Reposition airway

  • Suctioning nares

  • Open mouth

  • Pressure increase to PEEP to ~5

  • Advanced airway: ETT / LMA

BGM.

They also have lower BGMs. Hypoglycemia for neonates is < 30 for a patient < 24 hours old. It’s recommended to give D10 bolus 2ml/kg if the patient is hypoglycemic.

You can give glucagon IM too: 0.03mg/kg max 1mg

CPR.

It’s recommended to secure an airway (supraglottic or ETT) prior to doing compressions) since most these codes are usually due to respiratory events.
The ideal ratio is3 compressions:1 breath

  • Goal is 90 compressions: 30 breaths in one minute

2 thumb compression technique (*preferred) or 2 finger technique
Pulse checks q1 min
Depth: ⅓ chest diameter

Epinephrine.

IV dosing: 0.01mg/kg q3-5min
ETT dosing: You can give epinephrine through the ETT too if you don’t have access yet! AHA recommends a larger dose 0.1mg/kg of 1:1000 ETT

  • Max dose is 10mg, and follow it with a saline flush

I highly recommend reviewing the following flowchart linked.

I hope this was a good refresher on some of the most important concepts. I would love to learn other tips that others have in managing these stressful situations!

References:

https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/neonatal-resuscitation 

https://emergencymedicinecases.com/neonatal-resuscitation/ 


POTD: Test taking tips

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Today I’m going to be covering some test-taking strategies.

Focus on your weaknesses:

Don’t waste too much of your time reinforcing your strengths. Study your weakest topics that you don’t have daily exposure to in residency. If you have very limited time to study, consider filtering your Rosh Review question bank by your weaker topics, like Environmental, Heme/Onc, etc. 

Spaced repetition:

In order to retain information long term, you will likely need spaced repetition of the material. Don’t finish all of the environmental questions 3 months before the test. Try to revisit the material by doing some of those questions again, or by reviewing some of your notes.
Try to incorporate mental repetition into your daily routine. For example, quiz yourself on some topics that you learned earlier that day while you’re on the train or while you’re walking. 

Quick blocks:

Try to study in small blocks more frequently. 

Actively learn:

Don’t just passively nod your head and highlight each wrong answer you get in Rosh Review. Try to mentally quiz yourself after reading the explanations. Consider keeping a document with high yield notes.

Answering the questions:

All questions are created equal, and unanswered questions are marked as incorrect. Give yourself time to finish the test! Don’t spend too long on one question – it’s more important to finish the entire test.

Know your learning style:

Supplement your learning and tailor your study plan to your learning style. There are excellent free videos (https://www.intrainingprep.com/) and EMRAP Crunch Time audio reviews for the boards. 

Never pick an answer that uses “absolute terms:”

Avoid answer choices that include: always / never. 

If in doubt, pick the “long correct” answer: 

The detailed beautifully explained answer choice is often correct. They might include double options, more information, and caveats. 

1-2 days before the test:

Review a high yield document with a bunch of buzzwords and highly tested concepts. I’ve attached one of my favorite ones to this document. This will help refresh concepts you’ve reviewed a few weeks ago. I highly, highly recommend using this!!! I think like 20+ questions last year came up from this document. 

They’re not trying to trick you:

If the question stem obviously sounds like a PE, it’s probably a PE. Don’t overthink it. Just make sure you read the question carefully, and then move on.

I hope this helps! I know most of this is pretty obvious, but trust yourself and go with your gut. 


References:

https://knowledgeplus.nejm.org/blog/10-mistakes-studying-for-the-boards/ 
https://www.roshreview.com/blog/how-to-increase-your-emergency-medicine-board-exam-score-by-10-points/


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POTD: Tips for writing your CV

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I wanted to share some tips for creating an excellent CV. I thought this might be helpful as PGY-2s start thinking about writing their CVs over the summer for jobs/applications. It’s easier to slowly add a line or two over time rather than to frantically create one over 3 days.

Formatting:

  • Keep it organized and professional. Use a simple font and clean headers. Don't try to be original.

  • Put the most important stuff at the top.

  • Order it in reverse chronology – most recent at the top for each section.

  • As a general rule of thumb, try to keep your resume within 1 page. However, your CV can be longer since it is more comprehensive. In medicine, they’ll ask you for your CV, but if you’re applying for something corporate, then they will likely want your resume. (Or both.)

  • Be consistent throughout with your formatting.

  • Save the doc / send it as a pdf

  • Label your pages with your last name & page #.

  • Use bullet points, and try to keep things succinct.

The sections:

  • Of course, start off with some of your personal information. At the minimum, include your name, phone number, and best email address.

  • Organize your CV by having clear headers. As a resident, it’s appropriate to start off your CV with a “Training and Education” header with your residency, medical school, and undergraduate schools listed.

  • Presentations & lectures: include your morning reports, M&Ms, grand rounds presentations, etc. If you’ve presented at national conferences, include that too! Consider breaking out your presentations & lectures as “National” (where you presented at conferences) and then “regional/local” (Maimo/med school presentations.)

  • Publications: designate if it’s peer reviewed vs non-peer reviewed. Use proper citation style.

  • Include your residency & leadership activities. You can group them however you find appropriate, but take some time to brag about your chiefdom, research and QI projects, and extra-clinical stuff (e.g. event medicine, scholarly tracks, med school clubs, etc.) The majority of my interviews were spent on talking about this section. If it's still in progress, just say where you are in the process.

  • Awards - Gold Humanism, AOA, etc.

  • Professional affiliations - SAEM, ACEP, etc.

  • Certifications - don't ask me why, but they want your random certs listed like ACLS, ATLS, etc.

  • Include a hobbies section! People want to get to know you, and it’s okay to be honest and quirky. It can be endearing and a great ice breaker.

Other random tips:

  • For each project or leadership related bullet point that you have, make sure you include the following:

    • What was the deliverable

    • Who was it for

    • What was the impact

    • Your methods

  • Tailor it to the job. For example, I created a little bucket called “International experiences” since I was applying for a Global Health fellowship. Remember, a community job CV will look different from an academic position.

  • Unless it’s super notable, I think high school is too far back to include. But the cool stuff you did in college or med school is great.

Final touches:

  • Get feedback. I sent my resume to 5-6 friends, and 3-4 attendings before ultimately submitting it. You don’t have to take everyone’s advice, but you’ll find most tips to be generally helpful.

  • Be neurotic - people use your CV as a harbinger for your attention to detail and your professionalism. Keep your grammar, spelling, and formatting perfect.