- Email: [email protected]
Newborn manikins
232
Letters to the Editor
T4 levothyroxine sodium 125 mcg daily. Although altered consciousness associated with incontinence and confusion is most suggestive of a seizure, the prolonged QT interval on the ECG raises other diagnostic possibilities: (a) long QT resulting from either cerebral injury from the fall or from non-traumatic central nervous system disorders (e.g. haemorrhage, tumour) [1], (b) hypothyroidism induced long-QT and torsade-depointes [2] (c) long QT due to other causes (e.g. electrolyte disorders, acute myocardial infarction). However, the prolongation of the QT interval was of the type with a long ST segment with delayed onset of the T waves, and features characteristic of hypocalcemia [3 /5]. On further examination the patient had positive Chvostek’s and Trousseau’s signs. Blood was drawn for laboratory tests. The patient was scheduled to undergo a CT scan of the head on an urgent basis. Before the scan could be performed, however, she suffered generalized tonic /clonic seizures while she was on continuous ECG monitoring. The ECG at that time showed tachycardia. The CT scan revealed cerebellar (Fig. 2) and basal ganglia calcification (Fig. 3). Laboratory studies showed hypocalcemia, hyperphosphatemia, normal serum potassium, magnesium, albumin, creatinine, CK and CK / MB concentration. These findings, in combination with the history of thyroidectomy, suggested hypoparathyroidism. Treatment with intravenous administration of calcium resulted in the resolution of the patient’s symptoms, signs and ECG abnormalities (Fig. 1, bottom panel). She was subsequently treated with oral calcium and alfacalcidol. Low levels of PTH in blood were detected.
References [1] Yamour BJ, Sridharan MR, Rice JF, Flowers NC. Electrocardiographic changes in cerebrovascular hemorrhage. Am Heart J 1980;99:294 /300. [2] Eiferman C, Chanson P, Cohen A, Lubetzki J. Torsade de pointes and QT prolongation in secondary hypothyroidism. Lancet 1988;2(8603):170 /1. [3] McFarlane S, Doty C, Zehtabchi S, Casey G. Generalized seizure in a 30 year old man with presumed intracranial hemorrhage: a case report. J Emerg Med 2000;19:135 /8. [4] Tambyah PA, Ong BK, Lee KO. Reversible Parkinsonism and asymptomatic hypocalcemia with basal ganglia calcification from hypoparathyroidism 26 years after thyroid surgery. Am J Med 1993;94:444 /5. [5] Akiyama T, Batchelder J, Worsman J, Moses HW, Jedlinski M. Hypocalcemic torsade de pointes. Electrocardiology 1987;22:89 / 92.
Anthony Sideris, Gerasimos S. Filippatos *, Dimitra Kardara, Fotios Kardaras Second Department of Cardiology, Evangelismos General Hospital, 10676 Athens, Greece *Corresponding author. Tel.: /30-10-8104367;
fax: /30-10-810-4367. Present address: 28 Doukissis Plakentias Street, 115 23 Ambelokipi, Athens, Greece E-mail address: [email protected] PII: S 0 3 0 0 - 9 5 7 2 ( 0 2 ) 0 0 3 7 5 - 1
Newborn manikins We have read the interesting paper by Howells and Madar [1] that analyses some of the manikins used to teach life support in newborns and infants. We think this sound work merits some comments. We agree with the authors that no optimum newborn manikin is currently available and there is a need for the design and development of such a model for adequate teaching and practice of skills. Indeed it is essential for teachers to know that the current models have significant drawbacks and lack several important characteristics. The ALS Baby† (Laerdal) manikin, despite being the best one at present, as stated by Howells and Madar [1], is an infant, but not a newborn, model. Its main drawback is the airway. The glottis is located so deeply that a long blade laryngoscope is needed to achieve tracheal intubation. In practice, the introduction of a tube into the trachea of this manikin is much more complicated than in real life, especially if the manoeuvre is attempted with avoidance of hyperextension of the neck, as stated in the newborn and infant advanced life support guidelines [2,3]. None of the four manikins tested has an umbilicus and so umbilical vein catheterisation is not possible. This vascular access can be practiced in a separate model of the umbilical cord but in our opinion it is important to integrate the skill in the complete scenario of advanced life support in the newly born. To overcome this problem, we have used two modifications in our courses: / We make a hole in the manikin’s abdominal skin and then introduce the umbilicus model Baby Umbi† (MPL). This model simulates the aspect and touch of the real situation quite well, with two arteries and one vein, both easy to catheterise. / We use frozen segments of human umbilical cords placed on the manikins’s abdominal skin and secured by means of glue or a modified bottle teat. This option gives us a real umbilical cord but it can pose some ethical and legal problems and a risk of transmission of infectious diseases. Aside from the manikins tested, we know of another new newborn manikin, the NRB-100† (MPL) that
Letters to the Editor
incorporates an umbilicus but its characteristics are less than optimal. The general aspects of this manikin also are not adequate. Its size is similar to a newborn but it has a posture in flexion that does not resemble a real newborn requiring life support. The lungs are simple balloons that do not simulate the chest wall movement even if the operator makes a manoeuvre correctly; in addition, the lungs become frequently dislodged and reposition is difficult and time consuming. In conclusion, we agree with Howells and Madar [1] that there is not a completely appropriate model to teach advanced life support of the newborn. There is an urgent need for the design and production of manikins with the shape and characteristics of a real newborn (ideally a newborn at term and another at preterm), bearing in mind that the most important aspects are management of the airway, lungs, chest and umbilical vessels. To achieve this goal, we consider the collaboration between industry engineers and paediatric life support instructors essential.
References [1] Howells R, Madar J. Newborn resuscitation training */which manikin? Resuscitation 2002;54:175 /81.
233
[2] AHA and ILCOR. Pediatric advanced life support. Resuscitation 2000;46:343 /99. [3] AHA and ILCOR. Neonatal resuscitation. Resuscitation 2000;46:401 /16.
Jesu´s Lo´pez-Herce, Angel Carrillo, Antonio Rodrı´guez-Nu´n˜ez* Spanish Paediatric and Neonatal Resuscitation Working Group, Hospital General Universitario Gregorio Maran˜o´n, Madrid, Spain Hospital Clı´nico Universitario de Santiago, Santiago de Compostela, Spain *Corresponding author. Address: Paediatric Emergency and Critical Care Division, Hospital Clı´nico Universitario de Santiago, Choupana, s/n, 15706 Santiago de Compostela, Spain. Tel.: /34-981-950-615; fax: /34-981-950-596
E-mail address: [email protected] PII: S 0 3 0 0 - 9 5 7 2 ( 0 2 ) 0 0 4 0 1 - X
Letters to the Editor
T4 levothyroxine sodium 125 mcg daily. Although altered consciousness associated with incontinence and confusion is most suggestive of a seizure, the prolonged QT interval on the ECG raises other diagnostic possibilities: (a) long QT resulting from either cerebral injury from the fall or from non-traumatic central nervous system disorders (e.g. haemorrhage, tumour) [1], (b) hypothyroidism induced long-QT and torsade-depointes [2] (c) long QT due to other causes (e.g. electrolyte disorders, acute myocardial infarction). However, the prolongation of the QT interval was of the type with a long ST segment with delayed onset of the T waves, and features characteristic of hypocalcemia [3 /5]. On further examination the patient had positive Chvostek’s and Trousseau’s signs. Blood was drawn for laboratory tests. The patient was scheduled to undergo a CT scan of the head on an urgent basis. Before the scan could be performed, however, she suffered generalized tonic /clonic seizures while she was on continuous ECG monitoring. The ECG at that time showed tachycardia. The CT scan revealed cerebellar (Fig. 2) and basal ganglia calcification (Fig. 3). Laboratory studies showed hypocalcemia, hyperphosphatemia, normal serum potassium, magnesium, albumin, creatinine, CK and CK / MB concentration. These findings, in combination with the history of thyroidectomy, suggested hypoparathyroidism. Treatment with intravenous administration of calcium resulted in the resolution of the patient’s symptoms, signs and ECG abnormalities (Fig. 1, bottom panel). She was subsequently treated with oral calcium and alfacalcidol. Low levels of PTH in blood were detected.
References [1] Yamour BJ, Sridharan MR, Rice JF, Flowers NC. Electrocardiographic changes in cerebrovascular hemorrhage. Am Heart J 1980;99:294 /300. [2] Eiferman C, Chanson P, Cohen A, Lubetzki J. Torsade de pointes and QT prolongation in secondary hypothyroidism. Lancet 1988;2(8603):170 /1. [3] McFarlane S, Doty C, Zehtabchi S, Casey G. Generalized seizure in a 30 year old man with presumed intracranial hemorrhage: a case report. J Emerg Med 2000;19:135 /8. [4] Tambyah PA, Ong BK, Lee KO. Reversible Parkinsonism and asymptomatic hypocalcemia with basal ganglia calcification from hypoparathyroidism 26 years after thyroid surgery. Am J Med 1993;94:444 /5. [5] Akiyama T, Batchelder J, Worsman J, Moses HW, Jedlinski M. Hypocalcemic torsade de pointes. Electrocardiology 1987;22:89 / 92.
Anthony Sideris, Gerasimos S. Filippatos *, Dimitra Kardara, Fotios Kardaras Second Department of Cardiology, Evangelismos General Hospital, 10676 Athens, Greece *Corresponding author. Tel.: /30-10-8104367;
fax: /30-10-810-4367. Present address: 28 Doukissis Plakentias Street, 115 23 Ambelokipi, Athens, Greece E-mail address: [email protected] PII: S 0 3 0 0 - 9 5 7 2 ( 0 2 ) 0 0 3 7 5 - 1
Newborn manikins We have read the interesting paper by Howells and Madar [1] that analyses some of the manikins used to teach life support in newborns and infants. We think this sound work merits some comments. We agree with the authors that no optimum newborn manikin is currently available and there is a need for the design and development of such a model for adequate teaching and practice of skills. Indeed it is essential for teachers to know that the current models have significant drawbacks and lack several important characteristics. The ALS Baby† (Laerdal) manikin, despite being the best one at present, as stated by Howells and Madar [1], is an infant, but not a newborn, model. Its main drawback is the airway. The glottis is located so deeply that a long blade laryngoscope is needed to achieve tracheal intubation. In practice, the introduction of a tube into the trachea of this manikin is much more complicated than in real life, especially if the manoeuvre is attempted with avoidance of hyperextension of the neck, as stated in the newborn and infant advanced life support guidelines [2,3]. None of the four manikins tested has an umbilicus and so umbilical vein catheterisation is not possible. This vascular access can be practiced in a separate model of the umbilical cord but in our opinion it is important to integrate the skill in the complete scenario of advanced life support in the newly born. To overcome this problem, we have used two modifications in our courses: / We make a hole in the manikin’s abdominal skin and then introduce the umbilicus model Baby Umbi† (MPL). This model simulates the aspect and touch of the real situation quite well, with two arteries and one vein, both easy to catheterise. / We use frozen segments of human umbilical cords placed on the manikins’s abdominal skin and secured by means of glue or a modified bottle teat. This option gives us a real umbilical cord but it can pose some ethical and legal problems and a risk of transmission of infectious diseases. Aside from the manikins tested, we know of another new newborn manikin, the NRB-100† (MPL) that
Letters to the Editor
incorporates an umbilicus but its characteristics are less than optimal. The general aspects of this manikin also are not adequate. Its size is similar to a newborn but it has a posture in flexion that does not resemble a real newborn requiring life support. The lungs are simple balloons that do not simulate the chest wall movement even if the operator makes a manoeuvre correctly; in addition, the lungs become frequently dislodged and reposition is difficult and time consuming. In conclusion, we agree with Howells and Madar [1] that there is not a completely appropriate model to teach advanced life support of the newborn. There is an urgent need for the design and production of manikins with the shape and characteristics of a real newborn (ideally a newborn at term and another at preterm), bearing in mind that the most important aspects are management of the airway, lungs, chest and umbilical vessels. To achieve this goal, we consider the collaboration between industry engineers and paediatric life support instructors essential.
References [1] Howells R, Madar J. Newborn resuscitation training */which manikin? Resuscitation 2002;54:175 /81.
233
[2] AHA and ILCOR. Pediatric advanced life support. Resuscitation 2000;46:343 /99. [3] AHA and ILCOR. Neonatal resuscitation. Resuscitation 2000;46:401 /16.
Jesu´s Lo´pez-Herce, Angel Carrillo, Antonio Rodrı´guez-Nu´n˜ez* Spanish Paediatric and Neonatal Resuscitation Working Group, Hospital General Universitario Gregorio Maran˜o´n, Madrid, Spain Hospital Clı´nico Universitario de Santiago, Santiago de Compostela, Spain *Corresponding author. Address: Paediatric Emergency and Critical Care Division, Hospital Clı´nico Universitario de Santiago, Choupana, s/n, 15706 Santiago de Compostela, Spain. Tel.: /34-981-950-615; fax: /34-981-950-596
E-mail address: [email protected] PII: S 0 3 0 0 - 9 5 7 2 ( 0 2 ) 0 0 4 0 1 - X