Neonatal Code Cart

The neonatal code cart contains more specialized equipment for resuscitation of neonates, typically <28 days old. 

Having to resuscitate such a tiny baby is a daunting task, and fortunately very rare, but unfortunate as we are not well-versed with all the moving parts. In these cases, just like with the Broselow cart, familiarizing ourselves with the contents of the neonatal code cart will be essential to a proper resuscitation.

Setting the scene...

We get a call that a mother just delivered in the ambulance and the baby is not responsive: not crying, not moving; ETA 5 minutes.

First: ask a PCT to locate the baby warmer and get it to resus 51 along with a bunch of dry towels.

Head to resus 51 and clear all the obstacles to the neonatal code cart and take note of several things outside the code cart that are important:

We open the neonatal airway box which sits on top of the neonatal code cart and hook up the infant ambu bag, have suction ready, and lay out the intubation supplies.

Next, we open the first drawer which is the medications:

As the nurses are opening the rest of the drawers, EMS rolls in with mother and baby, another team is taking care of mom, and the baby is handed over to us into the baby warmer and we are using the abundance of dry towels to dry off the baby and stimulate, stimulate, stimulate!

EMS reports: Baby is mother's 3rd baby, ex-39 weeks female, no known complications during pregnancy as she had no prenatal care, baby is 4kg. Vitals en route: HR 70bpm, O2 sat 85%, BP 65/35, BGM 80

Meanwhile, the nurses are hooking up the baby to the monitor, getting vitals, and attempting to start an IV.

Drawers 2-4 has IV materials, fluids, EKG leads, suction, etc:

It has been 2 minutes since the baby arrived in the ER and the HR is 75 bpm and the baby is not breathing spontaneously or crying. You've already dried, stimulated, suctioned, and have been using the infant ambu bag to give some positive pressure support with good bilateral chest rise and positive breath sounds bilaterally and O2 saturation is 95%.

Someone taking care of the mother comes in and reports that the mother had taken several tabs of morphine for the painful contractions that her father had left over for back pain.

Patient is 4kg, and so 0.1mg/kg is 0.4mg, 0.4mL of Naloxone is given to the patient via IV (can be given IM or through an ETT).

Patient starts breathing spontaneously with O2 sat 100%, heart rate improves to 90, but BP is still 65/35. You ask the nurse to start IV fluids but after the Narcan was administered the IV stopped working and they are having difficulty obtaining a 2nd IV for access.

You decide to do an umbilical vein catheterization and look to the last drawer:

Umbilical vein catheterization:

1. Sterile prep of the umbilical area and drape

2. Securely tie a cord tie around the base of the umbilical stump

3. Cut cord horizontally at the distal end of the stump to expose vessels about 1-2 cm distal to the cord tie

4. Identify the umbilical vein (thin-walled, larger, single vessel vs. two thicker arteries)

5. Dilate gently with forceps and insert catheter (3.5 Fr for neonates <3.5kg, 5Fr for neonates >3.5kg)

6. Aspirate for blood return, then advance to appropriate depth

   • For a full term infant insert to about 4-5cm (about 2cm further than where you get blood return) for emergency access and approximately 10-12cm for long term access (based on umbilicus to shoulder measurement).

7. Flush with saline to ensure patency

8. Secure catheter with umbilical tape or suture

9. Verify position with Chest/abdominal X-ray to confirm tip location at inferior vena cava–right atrial junction, typically at T8–T9

10. Adjust as needed based on imaging

Patient received IV fluids and blood pressure improved to 80/45, vitals otherwise stable. Patient admitted to the NICU.

Takeaways:

• All the equipment and medications used for resuscitations are included in the neonatal code cart. 

  • Streamlines processes as we do not need to waste time and search for the proper equipment when time is so important during a resuscitation.

• Familiarity with the equipment and medications in the code cart helps us prepare for those rare and unexpected resuscitations

• Umbilical vein catheterization can be done for patients who have poor peripheral access, requires further resuscitative medications, or for central venous monitoring.

References:

Aziz K, Lee CHC, Escobedo MB, Hoover AV, Kamath-Rayne BD, Kapadia VS, Magid DJ, Niermeyer S, Schmölzer GM, Szyld E, Weiner GM, Wyckoff MH, Yamada NK, Zaichkin J. Part 5: Neonatal Resuscitation 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics. 2021 Jan;147(Suppl 1):e2020038505E. doi: 10.1542/peds.2020-038505E. Epub 2020 Oct 21. PMID: 33087555.

Chen, Linda & Law, Brenda. (2023). Use of eye-tracking to evaluate human factors in accessing neonatal resuscitation equipment and medications for advanced resuscitation: A simulation study. Frontiers in pediatrics. 11. 1116893. 10.3389/fped.2023.1116893. 

Drone E, Vera AE, Lucas JK. Umbilical venous catheters. In: Ganti L, eds. Atlas of emergency medicine procedures. New York, NY: Springer; 2020

Asthma Management from the ED

We treat a lot of patients with asthma in the ER, and a lot of times our patients have trouble following up with their PCP, establishing care with a new PCP, or even getting insurance. Usually, we discharge patients with just a short-acting beta-agonist (SABA) inhaler like albuterol and possibly a separate inhaled corticosteroid (ICS), but maybe we should consider prescribing combined ICS and long-acting beta-agonist (LABA) inhaler.

Guidelines and Evidence

• Global Initiative for Asthma (GINA) recommends symptom-driven treatment or daily ICS-containing inhalers to reduce severe exacerbation risks

• Formoterol is a LABA with a rapid onset, suitable for both maintenance and rescue therapy

• Multiple studies were done with low dose ICS and combination therapies
  

  • Low-dose ICS in mild asthma reduces severe exacerbations by ~50%, improves symptom control, and enhances quality of life (Reddel 2019 or SYGMA-2)

  • Fixed-dose LABA/ICS used as needed is as effective as regular ICS, reducing hospital visits and daily ICS exposure without increasing adverse events (Crossingham 2021)

  • Budesonide/formoterol improves oxygen saturation, peak expiratory flow rate, and reduces respiratory rates post-treatment (Chew 2012)

Caveat: Noninferiority Study Design

• SYGMA-2 was initially designed as a superiority trial but was later reclassified as a noninferiority trial without clear justification or protocol amendments

• The trial set a noninferiority margin of 20% (rate ratio of 1.2), meaning the as-needed ICS-formoterol regimen could be up to 20% less effective than the standard therapy and still be considered noninferior. The 95% confidence interval for the primary outcome was 0.97 to 1.16, approaching the noninferiority threshold, suggesting a potential risk of inferiority in broader clinical practice.

• Noninferiority does not mean similarity, the trial's design and outcomes need to be carefully interpreted especially when informing global guidelines

Conflict of Interest Concerns

• While investigators collected the SYGMA-2 trial data, the analysis was conducted by employees of the sponsoring pharmaceutical company

• All but two authors disclosed receiving support from the sponsor. Notably, one author served on the Board and Science Committee of GINA. Although these conflicts were declared, the article does not specify how they were addressed or mitigated

• Close ties between study authors and the sponsor raise questions about the impartiality of the evidence informing the GINA guidelines

• The study outcomes and guideline recommendations that favor the sponsor's product is now called into question

Benefits of Discharging with ICS-LABA (e.g., Symbicort)

• Formoterol’s rapid onset makes it suitable as a rescue medication even though it is a LABA

• Improves adherence by simplifying to one inhaler for both rescue and maintenance

• Suggested Prescription: Budesonide/formoterol 80/4.5 μg per puff. Maintenance: 1-2 puffs once or twice daily OR Rescue: 1-2 puffs every 2-4 hours as needed for symptoms

  • Of note, Symbicort is NOT FDA approved as a rescue inhaler

Cost of Symbicort Without Insurance

• The out-of-pocket cost for Symbicort can be substantial:

  • Brand-name Symbicort (80/4.5 mcg): Approximately $344.41 for a 30-day supply.

  • Generic versions: Around $232.12 for the same dosage.

  • Authorized generic (Breyna): Approximately $206.71.

• Some pharmacies offer Symbicort for as low as $97.09 with a GoodRx coupon

• As of June 1, 2024, AstraZeneca has capped the out-of-pocket cost of Symbicort at $35 per month for both insured and uninsured patients (with possible limitations)

Prior Authorizations and Alternative

• Obtaining prior authorization (PA) for medications like Symbicort from the ED is not feasible due to the complex process:

  • Verify the patient's insurance coverage and determine if Symbicort requires prior authorization

  • Access and fill out the required PA forms found on the insurance provider's website

  • Send the completed forms to the insurance company via their preferred method (fax, online portal, etc.)

  • Follow the status of the PA request and provide any additional information if requested

• The other way is to refer your patients and their family members to this site:

  • https://www.azpatientsupport.com/

  • They can obtain a card that caps the cost of Symbicort at 35$ with a valid prescription

Takeaways

• There's evidence supporting the use of ICS-formoterol as both maintenance and rescue therapy, however due to COI and dubious study design the recommendations are called into question

• For patients discharged from the ED with mild to moderate asthma exacerbations, consider prescribing combined ICS/LABA instead of separate albuterol and ICS after shared decision making with patient and family

• Educate your patients on the capped cost of Symbicort and possibly send them with a prescription and a savings card

References:

https://rebelem.com/clinical-conundrum-should-acute-asthma-exacerbations-be-discharged-from-the-ed-with-combination-beta-agonist-corticosteroid-inhalers/

A randomized open-label trial on the use of budesonide/formoterol (Symbicort®) as an alternative reliever medication for mild to moderate asthmatic attacks Chew KS, Kamarudin H, Hashim CW. A randomized open-label trial on the use of budesonide/formoterol (Symbicort®) as an alternative reliever medication for mild to moderate asthmatic attacks. Int J Emerg Med. 2012;5:16. Published 2012 Apr 13. doi:10.1186/1865-1380-5-16 PMID: 22503137

Budesonide/formoterol versus salmeterol/fluticasone for asthma in children: an effectiveness and safety analysis. Jiang P, Zhao L, Yao Z. Budesonide/formoterol versus salmeterol/fluticasone for asthma in children: an effectiveness and safety analysis. J Comp Eff Res. 2021;10(17):1283-1289. doi:10.2217/cer-2021-0142 PMID: 34668718

Combination fixed-dose β agonist and steroid inhaler as required for adults or children with mild asthma: a Cochrane systematic review. Crossingham I, Turner S, Ramakrishnan S, et al. Combination fixed-dose β agonist and steroid inhaler as required for adults or children with mild asthma: a Cochrane systematic review. BMJ Evid Based Med. 2022;27(3):178-184. doi:10.1136/bmjebm-2021-111764 PMID: 34282031

GINA 2019: a fundamental change in asthma management: Treatment of asthma with short-acting bronchodilators alone is no longer recommended for adults and adolescents Reddel HK, FitzGerald JM, Bateman ED, et al. Eur Respir J. 2019;53(6):1901046. doi: 10.1183/13993003.01046-2019. PMID: 31249014

Contrast: PO or no to PO, that is the question.

In the past, we have always used PO and IV contrast for CT abdomen/pelvis scans in studies to "rule out" SBOs, but recently we have been told by the Chief of Surgery Dr. Nicastro that PO contrast is not necessary to rule out SBOs however some surgical residents and attendings may still ask for PO contrast. Here are some learning points so that you can advocate for your patient and discuss with the surgical team about why we may not need PO contrast in your next SBO patient!

Historical Use of PO Contrast in SBO Evaluation

• Early CT protocols included PO and IV contrast for abdominal imaging to better outline the bowel lumen and identify transition points. 

• PO contrast was initially thought to improve diagnostic accuracy by helping to distinguish dilated bowel from collapsed bowel and aiding in localizing the obstruction. (Balthazar 1997)

Advancements in CT Technology

• Multidetector CT scanners introduced in the 2000s drastically improved resolution, allowing clear visualization of bowel loops, wall enhancement, and obstruction points without the need for PO contrast.

• IV contrast became the primary agent for assessing bowel wall integrity, ischemia, and complications, which are critical components in SBO management. (Jaffe 2006; Taylor 2013)

• Evidence showed high diagnostic accuracy (90–95%) with IV contrast alone, questioning the need for PO agents in most cases. (Gore 2000; American College of Radiology 2020)

Other Contraindications for PO Contrast Use

• PO contrast often delays imaging as patients may need 1–2 hours to ingest the contrast and allow it to move through their digestive tract, delaying care. 

• Patients with high-grade SBO may be unable to tolerate oral intake, increasing the risk of vomiting and aspiration. (Maglinte 2013)

• Excessive intraluminal contrast can also obscure bowel wall features, including mural enhancement or signs of ischemia. (Paulson 2005)

However, even though PO contrast may not be useful in suspected high-grade SBOs, it still has its uses if other diagnoses are suspected:

Indications for PO Contrast in CT abdomen/pelvis

• PO contrast can help delineate the transition point in indeterminate, low-grade, or partial obstructions.

• Water-soluble oral contrast (e.g., Gastrografin) may help identify extraluminal leak sites after bowel surgery. 

• PO contrast can help visualize and evaluate known or suspected enteric fistulas between bowel segments or between bowel and other structures (e.g., bladder, skin). 

• Oral contrast can help assess strictures, skip lesions, or fistulas—especially in combination with enterography techniques to evaluate inflammatory bowel disease (IBD). 

• CT Enterography or CT Enteroclysis requires neutral or low-density PO contrast to assess small bowel mucosa and pathology (e.g., Crohn’s disease, obscure GI bleeding). 

• PO contrast may help clarify mass relationships to bowel loops or identify lumen involvement in preoperative planning for known mass lesions. 

Takeaways

• IV contrast-enhanced CT is now the standard for initial SBO evaluation, with PO contrast reserved for select, stable cases of suspected partial obstruction.

• There may still be an indication for PO contrast based on the patient’s clinical stability, level of obstruction, and specific diagnostic question.

References:

Balthazar EJ, et al. “CT of SBO: value in establishing diagnosis and determining degree and cause.” AJR Am J Roentgenol. 1994, 1997.

Gore RM, et al. “Bowel obstruction.” Radiol Clin North Am. 2000.

Jaffe TA, et al. “CT of small-bowel obstruction: how reliable is diagnosis and extent?” AJR Am J Roentgenol. 2006.

Maglinte DDT, et al. “Radiologic diagnosis of small-bowel obstruction: current role and future trends.” Radiol Clin North Am. 2013.

Paulson EK, et al. “Small-bowel obstruction: the role of CT evaluation and contrast agents.” Radiology. 2005.

Taylor GA, et al. “ACR Appropriateness Criteria® on suspected small-bowel obstruction.” J Am Coll Radiol. 2013.

American College of Radiology. “ACR Appropriateness Criteria® Suspected Small-Bowel Obstruction.” 2020.