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Simulation Scenarios
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Academy of Pediatrics and the American College of Emergency Physicians. No endorsement of
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that contributors to the APLS materials are knowledgeable authorities in their fields. Readers
are nevertheless advised that the statements and opinions expressed are provided as guidelines
and should not be construed as official policy of the American Academy of Pediatrics or the
American College of Emergency Physicians. The recommendations in these accompanying
materials do not indicate an exclusive course of treatment. Variations, taking into account
individual circumstances, nature of medical oversight, and local protocols, may be appropriate.
The American Academy of Pediatrics, the American College of Emergency Physicians, and the
authors here within disclaim any liability or responsibility for the consequences of any actions
taken in reliance on these statements, opinions, or contents contained within these materials.
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
module
Simulation Scenarios
Contents
Adrenal Insufficiency 1
Blunt Abdominal Trauma—Hypovolemic Shock 4
Cardiogenic Shock Due to Congenital Heart Disease 8
Altered Mental Status 10
Diabetic Ketoacidosis and Cerebral Edema 12
Hyperthermia 15
Hypothermia—Near Drowning 18
Iron Overdose 22
Myocarditis—Cardiogenic Shock 25
Occult Trauma (Intentional Trauma) 27
Postoperative Cardiac Patient—Ventricular Fibrillation 30
Septic Shock 33
Chest Crisis—Sickle Cell Disease 36
Status Asthmaticus 39
Status Epilepticus 42
Stridor Due to Foreign Body 45
Supraventricular Tachycardia 48
Tricyclic Antidepressant Overdose 50
Metabolic Crisis—Hyperammonemia 54
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Adrenal Insufficiency
Adam Cheng, MD, FRCPC, FAAP
Mark Adler, MD
Learning Objectives
• D
escribe the signs and symptoms of an infant presenting with salt-wasting adrenal crisis associated with congenital adrenal hyperplasia
and adrenal insufficiency.
• Demonstrate the treatment of a newborn with salt-wasting crisis.
– Initial stabilizing steps.
– Replacement therapy.
1 Simulation Scenarios
Adrenal Insufficiency
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Scenario Patient Instructor Time,
Stage Condition Intervention Debriefing Notes min
STAGE 2 Condition: REASSESSMENT OF THE PATIENT: 5
• HR remains elevated and BP is now low Circulation:
• Nurse notes aloud, “His hands are just so cold.” • Reassess HR, pulse, capillary refill, BP after bolus
• Blood glucose level is low if bedside testing was performed • Order second bolus, also push
• Laboratory results: sodium 124 mmol/L, potassium 7.8 Medical Management:
mmol/L, bicarbonate 16 mmol/L, BUN and creatinine normal • Consult endocrinologist for treatment guidance; order tests
for age, pH from venous gas 7.26 they might request
Physical Examination • Order IV hydrocortisone
Findings: • Order D10W IV bolus to correct hypoglycemia
• HR 150/min, RR 36/min, oxygen saturation 99% on 100%
• Initiate management of hyperkalemia
oxygen (if placed), BP 73/60 mm Hg
• CNS: cries weakly with painful stimuli
• Respiratory: clear
• CVS: clamped down and cool extremities.
• Abdomen: no hepatosplenomegaly
Abbreviations: BP, blood pressure; BUN, blood urea nitrogen; CBC, complete blood cell count; CNS, central nervous system; CVS, cardiovascular system; D10W, 10% dextrose in water; HR, heart rate; ICU, intensive care unit; IV, intravenous; RR,
respiratory rate.
2 Simulation Scenarios
Adrenal Insufficiency
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Notes
1. Potassium and sodium derangements usually do not require short-term treatment beyond fluid resuscitation and hydrocortisone.
Common Pitfalls
• Intravenous (IV) fluid for volume expansion is not delivered in a rapid and/or controlled manner.
– IV “wide open” fluid administration can lead to very rapid infusion of a whole liter of fluid OR can result in underresuscitation if there is significant re-
sistance to flow (small IV gauge). Infants and small children should always receive resuscitation fluids using a pump or push to allow for observation and
control of fluid delivery. Pressure bags can increase the likelihood of excessive fluid overload.
– Pushing fluid is accomplished by attaching a three-way stopcock in line with the IV catheter and pulling fluid directly from the bag (step 1) and then
switching the stopcock and pushing the fluid into the patient.
• Failing to check a bedside glucose level. Hypoglycemia is not always present in patients with congenital adrenal hyperplasia and salt-wasting crisis, but it can
occur.
• Delaying treatment with hydrocortisone to obtain diagnostic tests.
3 Simulation Scenarios
Adrenal Insufficiency
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Blunt Abdominal Trauma—Hypovolemic Shock
Adam Cheng, MD, FRCPC, FAAP
Mark Adler, MD
Learning Objectives
• Describe the signs and symptoms of a patient with hypovolemic shock.
• Demonstrate the management of circulatory failure due to hypovolemic shock.
– Demonstrate the approach to pediatric trauma: primary and secondary assessment.
– Demonstrate use of fluid resuscitation in patients with profound blood loss.
– Identify and manage abdominal injury in a trauma patient.
– Demonstrate use of rapid infuser in trauma care.
4 Simulation Scenarios
Blunt Abdominal Trauma—Hypovolemic Shock
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Scenario Patient Instructor Time,
Stage Condition Intervention Debriefing Notes min
STAGE 2 Condition: REASSESSMENT OF THE PATIENT: 3
• The patient’s condition has worsened slightly, BP lower, GCS Airway:
score unchanged • Maintain cervical spine precautions
Physical Examination Findings: Breathing:
• Temperature 36°C (96.8°F), HR 170/min, RR 40/min, BP 80/40 • Auscultate chest
mm Hg, saturation 100% with oxygen by mask
Circulation:
• Monitor: sinus tachycardia
• Reassess HR, pulses, BP, capillary refill
• CNS: cervical spine collar on patient; moaning in pain,
• Ask for second bolus of IV normal saline
answers questions, asking for mom, confused at times, GCS
• Reaffirm need for rapid infuser
score of 15
• Order blood
• H/N: cervical spine not tender, no obvious facial injury
Performs Secondary Survey:
• CVS: capillary refill 4 s, pulses palpable but weak
• H/N: pupils equal and reactive to light, facial bones not
• Respiratory: chest clear
tender, neck supple and not tender
• Abdomen: bruising all over abdomen
• Chest: trachea midline, chest clear.
• Neurologic: normal
• CVS: profoundly tachycardic, color mottled now, pulses
• Musculoskeletal: normal
weak, and capillary refill 5 s
• Abdomen: soft. Bowel sounds absent, tender all over
abdomen (screams in pain)
• Pelvis: stable.
• Genitalia: no blood at meatus
• Musculoskeletal: normal
• Back: good rectal tone, no tenderness
Medical Management:
• Pain control: IV morphine
• Immediate consultation: general surgery
• Order radiographs: cervical spine, chest, pelvis
• Insert nasogastric tube
• Insert Foley catheter
5 Simulation Scenarios
Blunt Abdominal Trauma—Hypovolemic Shock
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Scenario Patient Instructor Time,
Stage Condition Intervention Debriefing Notes min
STAGE 3 Condition: REASSESSMENT OF PATIENT: 5
• The patient is less responsive, BP is decreasing, eyes still open, Airway: Intubation:
GCS score of 13 • Prepare for intubation due to decreasing level of
Physical Examination Findings: consciousness
• Temperature 36°C (96.8°F), HR 180/min, RR 40/min, BP 70/30 • Preoxygenate
mm Hg, saturation 100% with oxygen by mask • Prepare equipment and ETCO2
• Monitor: sinus tachycardia • IV atropine
• CNS: cervical spine collar on patient; moaning in pain, • IV ketamine or etomidate
intermittently answers questions, confused and delirious at • IV succinylcholine
times, GCS score of 13. • Check tube placement after intubation, order chest
• H/N: cervical spine not obviously tender, no obvious facial radiograph if intubation is performed
injury
Breathing:
• CVS: capillary refill 5 s, pulses palpable but very weak • Assess chest before and after intubation
• Respiratory: chest clear • Monitor oxygen saturation
• Abdomen: bruising all over abdomen
Circulation:
• Neurologic: normal
• Identify worsening shock
• Musculoskeletal: normal
• Order third bolus of IV normal saline and blood (O negative
if cross-matched not available)
Blood Work:
• WBC 15,500/mm3, hemoglobin 7 g/dL, platelets 500,000/
mm3
• Sodium 135 mmol/L, potassium 4.5 mmol/L, urea
4.2 mmol/L, creatinine 46 mmol/L, glucose normal
• pH 7.20, Pco2 40 mm Hg, Po2 80 mm Hg, bicarbonate
15 mmol/L, base excess −11 mmol/L
Imaging:
• Normal radiographs
Medical Management:
• General surgeon arrives: discuss need to perform CT of the
abdomen vs direct to operating room
• Consider focused abdominal sonography for trauma
• Discuss need for CT of the H/N and chest.
Abbreviations: BP, blood pressure; CNS, central nervous system; CT, computed tomography; CVS, cardiovascular system; ETCO2, end-tidal carbon dioxide; GCS, Glasgow Coma Scale; H/N, head and neck; HR, heart rate; IV, intravenous; RR,
respiratory rate; WBC, white blood cell count.
6 Simulation Scenarios
Blunt Abdominal Trauma—Hypovolemic Shock
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Notes
1. Makeup can be applied to the mannequin to simulate bruises on the abdomen.
2. Use of a prerecorded focused abdominal sonography for trauma (FAST) video can be projected on a computer screen while FAST is being performed
Common Pitfalls
• Failure to stabilize cervical spine during assessment and treatment of patient.
• Failure to perform a complete secondary survey (eg, failure to log roll patient or failure to assess neurologic status of lower extremity).
• Sedation and/or paralysis of patient before completing neurologic assessment of patient.
• Treatment of patient without support of consultants.
7 Simulation Scenarios
Blunt Abdominal Trauma—Hypovolemic Shock
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Cardiogenic Shock Due to Congenital Heart Disease
Adam Cheng, MD, FRCPC, FAAP
Mark Adler, MD
Learning Objectives
• Describe the signs and symptoms of an infant with cardiogenic shock.
• Demonstrate the management of circulatory failure due to cardiogenic shock.
– Obtain a chest radiograph to confirm suspected cause of cardiac shock.
– Use normal saline to expand circulatory volume in a limited manner.
– Obtain consultative services urgently.
8 Simulation Scenarios
Cardiogenic Shock Due to Congenital Heart Disease
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Scenario Patient Instructor Time,
Stage Condition Intervention Debriefing Notes min
STAGE 1, Medical Management:
continued • Order laboratory tests (CBC, electrolytes, venous blood gas,
bedside glucose, consider infection laboratory work at this
time as diagnosis not clear)
• Order ECG and a chest radiograph
Abbreviations: BP, blood pressure; CBC, complete blood cell count; CNS, central nervous system; CVS, cardiovascular system; ECG, electrocardiogram; HR, heart rate; ICU, intensive care unit; IV, intravenous; RR, respiratory rate
Notes
1. Radiography can be performed via a simulator (some models support this) or as a “wet read” result communicated to the team noting the large heart and
fluid overload.
2. The quality of cardiac and respiratory sounds varies considerably among simulator models. Comments from the nurse confederate can help clarify
findings—“I listened at triage and thought I heard a loud murmur.”
Common Pitfalls
• Misrecognition of patient as having respiratory distress due to reactive airway disease and administration of albuterol (salbutamol). Patient will get worse
with this therapy.
• Misrecognition of patient as having sepsis, with excessive fluid delivery, resulting in increasing heart rate and respiratory rate and decreased oxygen
saturations. Nurse confederate notes that the child “looks worse after that bolus.”
– Both of these problems occur when an inadequate history is obtained—the history provided is a clear indication of a primary cardiac cause.
• Treatment of patient without support of consultants. Echocardiography is an important step in management planning, and the initial steps in performing
this test should be started as soon as possible.
9 Simulation Scenarios
Cardiogenic Shock Due to Congenital Heart Disease
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Altered Mental Status
Adam Cheng, MD, FRCPC, FAAP
Mark Adler, MD
Learning Objectives
• Describe the common causes of altered mental status in an infant.
• Demonstrate the treatment of an infant with altered mental status.
– Assessing for possible ingestion.
– Checking glucose at bedside.
– Treating hypoglycemia and confirming that treatment was effective.
10 Simulation Scenarios
Altered Mental Status
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Scenario Patient Instructor Time,
Stage Condition Intervention Debriefing Notes min
STAGE 2 Condition: Medical Management: 5
• Mental status unchanged • Recognize and treat hypoglycemia (5 mL/kg D10W using the
• Blood glucose level is low if measured “rule of 50”—see note below)
Physical Examination Findings: • Perform further ingestion laboratory tests (urine toxicology,
• Vitals unchanged acetaminophen [paracetamol], salicylates, ethanol, +/–
digitalis levels)
Abbreviations: BP, blood pressure; CNS, central nervous system; CVS, cardiovascular system; D10W, 10% dextrose in water; ED, emergency department; HR, heart rate; ICU, intensive care unit; IV, intravenous; RR, respiratory rate.
Notes
1. Rule of 50 = to give half of a gram of glucose per kilogram of body weight, the product of the glucose concentration (eg, D10) and the dose in milliliters per
kilogram should equal 50. Note that this dosing is different than recommended by the Neonatal Resuscitation Program course, and this can be a source of
confusion among participants.
CONCENTRATION DOSE PRODUCT
D10 5 mL/kg 50
D25 2 mL/kg 50
2. To discourage the use of the term “amp,” our practice is to state that we do not have adult amps available at this time.
3. Specific drug screening practices vary. Although polyingestions are more common in adolescents, most of the listed drugs above are high-risk, treatable
entities.
Common Pitfalls
• Participants do not ask about medication in the home but only what the child is taking.
• Participants check the glucose level and treat the patient according to the glucose level but fail to obtain a follow-up glucose measurement.
11 Simulation Scenarios
Altered Mental Status
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Diabetic Ketoacidosis and Cerebral Edema
Adam Cheng, MD, FRCPC, FAAP
Mark Adler, MD
Learning Objectives
• Describe the signs and symptoms of a child presenting with diabetic ketoacidosis (DKA).
• Describe the signs and symptoms of moderate dehydration.
• Demonstrate the treatment of a child with DKA.
– Initial stabilizing steps.
– Management of suspected cerebral edema.
12 Simulation Scenarios
Diabetic Ketoacidosis and Cerebral Edema
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Scenario Patient Instructor Time,
Stage Condition Intervention Debriefing Notes min
STAGE 1, Assesses Hydration:
continued • Capillary refill
• Skin turgor
• Mucous membranes
• Urine output
• Assign degree of dehydration
• Strict monitoring of intake and output
CNS:
• Establish baseline examination
• Express need to monitor for cerebral edema
Medical Management:
• Order blood work: CBC, differential, electrolytes, renal
function, capillary gas, bedside glucose, serum osmolality,
and urine dip for glucose/ketones
• Bedside glucose: critically high
• Urine dip or ketones 4+
• Identify DKA as diagnosis
Begin DKA protocol:
• Have patient weighed/ask for patient weight
• Consider need for IV normal saline bolus (10 mL/kg)
• Calculate IV rate assuming need to replace deficit evenly
over 48 h
• Use appropriate replacement fluid pending laboratory
results
• Order IV insulin infusion
• Use flow sheet to track laboratory results, vital signs
13 Simulation Scenarios
Diabetic Ketoacidosis and Cerebral Edema
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Scenario Patient Instructor Time,
Stage Condition Intervention Debriefing Notes min
STAGE 2, CNS:
continued
• Reassess GCS score
• Institute frequent neuro checks
• Look for Cushing triad, posturing
Medical Management:
• Laboratory results: glucose critically high (at bedside); urine 4+
ketones, 4+ glucose, urine specific gravity (SG) 1.030
• Continue DKA protocol
• Recheck fluid-rate calculations
• Consider impending cerebral edema and transtentorial
herniation
• Call ICU for consultation
• Consider management of increased intracranial pressure:
IV mannitol or 3% sodium chloride solution (ie, hypertonic
saline)
• Repeat bedside glucose measurement
• Order repeat laboratory tests
• Calculate corrected sodium level
• Recognize coexisting hypernatremia and need for slow
rehydration
Abbreviations: BP, blood pressure; CBC, complete blood cell count; CNS, central nervous system; CVS, cardiovascular system; DKA, diabetic ketoacidosis; GCS, Glasgow Coma Scale; HR, heart rate; ICU, intensive care unit; IV, intravenous; RR,
respiratory rate.
Notes
1. Management of DKA involves the preparation and administration of various types of medications and fluids. The realism of the scenario can be increased
by preparing labeled syringes with the names and concentrations of these medications and preparing an intravenous (IV) catheter with a drain so that the
students are able to push fluids through the catheter.
2. Laboratory results should be ready for the students and are best given to them on a slip of paper (as opposed to verbally provided by the instructor).
Common Pitfalls
• IV fluid for volume expansion is delivered too aggressively.
– If the students do this, the instructor can decide to change the scenario slightly and make the child decompensate by altering his level of consciousness
further or have the patient demonstrate signs of increased intracranial pressure.
– Failing to check a bedside glucose level. Instead, the students might only order a glucose measurement to be processed by the laboratory.
– Failure to recognize signs of cerebral edema and thus not preparing medications for management of increased intracranial pressure.
14 Simulation Scenarios
Diabetic Ketoacidosis and Cerebral Edema
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Hyperthermia
Adam Cheng, MD, FRCPC, FAAP
Mark Adler, MD
Learning Objectives
• Recognize the features of environmental hyperthermia.
• Demonstrate the steps in the initial treatment of a hyperthermic infant.
15 Simulation Scenarios
Hyperthermia
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Scenario Patient Instructor Time,
Stage Condition Intervention Debriefing Notes min
STAGE 1, Medical Management:
continued
• Order blood work: CPK, electrolytes, BUN, creatinine, CBC,
LFTs, bedside glucose
• Order ECG
16 Simulation Scenarios
Hyperthermia
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Scenario Patient Instructor Time,
Stage Condition Intervention Debriefing Notes min
STAGE 4 Disposition: • Arrange Disposition to ICU 2
Condition:
• Stable
Physical Examination Findings:
• Temperature 39.2°C (102.6°F), HR 155/min, RR 10/min
(bagged), BP 63/59 mm Hg, saturation 98% with 100%
oxygen
• Monitor: sinus tachycardia
• CNS: unconscious
• CVS: capillary refill 3 s, pulses weak
• Respiratory: clear
• Skin: warm
Abbreviations: BP, blood pressure; BUN, blood urea nitrogen; CBC, complete blood cell count; CNS, central nervous system; CPK, creatine phosphokinase; CPR, cardiopulmonary resuscitation; CVS, cardiovascular system; ECG,
electrocardiogram; ED, emergency department; EMS, emergency medical services; HR, heart rate; ICU, intensive care unit; IO, intraosseous; IV, intravenous; LFTs, liver function tests; RR, respiratory rate; UA, urinalysis.
Common Pitfalls
1. Lack of aggressive active cooling.
2. Failure to consider and look for sequelae of hyperthermia—electrolyte disturbances, hypoglycemia, rhabdomyolysis.
17 Simulation Scenarios
Hyperthermia
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Hypothermia—Near Drowning
Adam Cheng, MD, FRCPC, FAAP
Mark Adler, MD
Learning Objectives
• Describe the definition, signs, and symptoms of hypothermia.
• Demonstrate the treatment of a patient with submersion injury.
– Initial stabilizing steps.
– Recognize the importance of airway management and cervical spine protection in submersion injury.
– Demonstrate passive and active rewarming techniques for hypothermia.
18 Simulation Scenarios
Hypothermia—Near Drowning
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Scenario Patient Instructor Time,
Stage Condition Intervention Debriefing Notes min
Condition: Circulation:
• Apneic and pulseless • Apply monitors
• Temperature 28°C (82.4°F), HR 40/min, RR 0/min, BP NA, • Check pulse, capillary refill, BP
oxygen saturation NA • Identify PEA
• Monitor: sinus bradycardia • Insert IV or IO catheter
• CNS: obtunded, nonresponsive, GCS score 3, cervical spine • Do not order epinephrine (adrenaline) because core
collar on patient, bruises and cuts on face temperature is below 32°C (89.6°F)
• CVS: cap refill 6–7 s, no pulse palpable • Give warmed IV fluids through IO catheter and attempt to
• Respiratory: coarse crackles bilaterally obtain second IV/IO access
• Abdomen: bruising all over abdomen Disability and Exposure:
• Rest of examination results normal • Check GCS score and neurologic status
• Expose patient completely to conduct a secondary survey
• Apply warm blankets
Medical Management:
• Order blood work: arterial blood gas, lactate, electrolytes,
BUN, creatinine, CBC, LFTs, glucose, crossmatch
• Consider internal rewarming techniques: gastric lavage,
bladder irrigation, and possibly peritoneal irrigation
• Activate extracorporeal membrane oxygenation team and
PICU team
19 Simulation Scenarios
Hypothermia—Near Drowning
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Scenario Patient Instructor Time,
Stage Condition Intervention Debriefing Notes min
STAGE 2, Medical Management:
continued
• Chest radiograph: bilateral hazy lung fields, endotracheal
tube in good position
• ABG: pH 6.9, Pco2 15 mm Hg, Po2 60 mm Hg, bicarbonate 3
mmol/L, base excess −27 mmol/L
• Lactate 8.0 mmol/L
• Glucometer: critical low: corrects this with bolus if IV D10W
• Unable to obtain other laboratory tests
Abbreviations: ABG, arterial blood gas; BP, blood pressure; BUN, blood urea nitrogen; CBC, complete blood cell count; CNS, central nervous system; CPR, cardiopulmonary resuscitation; CT, computed tomography; CVS, cardiovascular system;
D10W, 10% dextrose in water; ETCO2, end-tidal carbon dioxide; ED, emergency department; HR, heart rate; ICU, intensive care unit; IO, intraosseous; IV, intravenous; LFTs, liver function tests; NA, not applicable; PEA, pulseless electrical activity;
PICU, pediatric intensive care unit; RR, respiratory rate.
20 Simulation Scenarios
Hypothermia—Near Drowning
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Notes
1. The scenario should begin with two instructors performing cardiopulmonary resuscitation (CPR) on the patient. The history should be taken at the bedside
while CPR is performed.
2. The core temperature should not be provided unless the students ask for it.
3. Makeup or moulage should be used to add bruises to the abdomen.
4. The patient should be made wet by adding some water on the top of the mannequin.
Common Pitfalls
• Failure to consistently maintain cervical spine protection during the resuscitation.
• One common mistake is to aggressively resuscitate the patient with multiple doses of epinephrine (adrenaline) despite the patient being hypothermic
(temperature <32°C [89.6°F]).
• Failure to dry off the patient with a towel.
• Delaying insertion of venous access by attempting multiple intravenous catheter insertions. Ideally, students should start immediately with attempted
intraosseous access.
21 Simulation Scenarios
Hypothermia—Near Drowning
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Iron Overdose
Adam Cheng, MD, FRCPC, FAAP
Mark Adler, MD
Learning Objectives
• Describe the signs and symptoms of an infant with an iron overdose.
• Demonstrate the management of acute iron intoxication.
22 Simulation Scenarios
Iron Overdose
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Scenario Patient Instructor Time,
Stage Condition Intervention Debriefing Notes min
STAGE 2 Condition: REASSESSMENT OF THE PATIENT: 5
• HR remains elevated and BP is now 68/52 mm Hg Airway/Breathing:
• Blood glucose level is slightly elevated if bedside glucose • Reassess airway patency, RR, and saturations
was measured Circulation:
• Venous gas: pH 7.06, Pco2 28 mm Hg, Po2 39 mm Hg, base • Reassess HR, pulse, capillary refill, BP after bolus
excess −20 mmol/L • Order second bolus, also push
• Patient vomits again • Order vasopressor (dopamine) to bedside (“That will take
• Iron overdose exceeds 60 mg/kg body weight (provided if about 10–15 minutes to get from the pharmacy”) in
team asks dose) anticipation of need later
Physical Examination Findings: Medical Management:
• HR 163/min, RR 36/min, oxygen saturation 98% in 100% • If team fails to suspect overdose, can prompt with statement
oxygen (if placed), BP 63/52 mm Hg “Someone has called to inform the mom that a bottle of
• CNS: barely responds to any stimuli sibling medication labeled ferrous sulfate is open and empty
• Respiratory: clear on the floor.”
• CVS: clamped down and cool extremities • Orders additional tests
• Abdomen: no hepatosplenomegaly - Venous gas to assess pH
- Iron, salicylate, and acetaminophen (paracetamol) levels
- Abdominal radiograph for pill fragments (given history of
liquid ingestion)
• Consult poison control for recommendations
Abbreviations: BP, blood pressure; CBC, complete blood cell count; CNS, central nervous system; CVS, cardiovascular system; HR, heart rate; ICU, intensive care unit; IV, intravenous; RR, respiratory rate
23 Simulation Scenarios
Iron Overdose
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Notes
1. Time course of case precludes availability of full electrolyte panel, which would reveal an anion gap acidosis. This could be reported if a rapid electrolyte
test is available.
2. Deferoxamine therapy is not without risks (hypotension), and poison control consultation is recommended even if the team were to come up with this
treatment on its own.
Common Pitfalls
• Intravenous (IV) fluid for volume expansion is not delivered in a rapid and/or controlled manner.
– IV “wide open” fluid administration can lead to very rapid infusion of a whole liter of fluid OR can result in underresuscitation if there is significant resis-
tance to flow (small IV gauge). Infants and small children should always receive resuscitation fluids using either a pump or push to allow for observation
and control of fluid delivery. Pressure bags can increase the likelihood of excessive fluid overload.
– Pushing fluid is accomplished by attaching a three-way stopcock in line with the IV catheter and pulling fluid directly from the bag (step 1) and then
switching the stopcock and pushing the fluid into the patient.
• Failing to consider ingestion as a cause of a septic shock–like picture. Metabolic derangements, both inborn errors and those due to ingestions, can mimic
sepsis. The sudden onset and absence of fever are clues, as is the history of lead toxic effects (suggesting pica) and the chaotic home setting.
• Waiting until the third bolus is started or finished to order pressors. Participants should recognize and anticipate that infant and pediatric pressor drips
must be prepared individually for a patient’s weight and are not stock items because these items are for adults. Depending on the institution, there might
be a significant delay in preparation and delivery of pressor drips.
24 Simulation Scenarios
Iron Overdose
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Myocarditis—Cardiogenic Shock
Adam Cheng, MD, FRCPC, FAAP
Mark Adler, MD
Learning Objectives
• Describe the signs and symptoms of cardiogenic shock.
• Demonstrate the treatment of a child in cardiogenic shock.
– Initial stabilizing steps.
– Order the appropriate investigations.
– Select the appropriate inotrope.
25 Simulation Scenarios
Myocarditis—Cardiogenic Shock
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Scenario Patient Instructor Time,
Stage Condition Intervention Debriefing Notes min
STAGE 2 Condition: REASSESSMENT OF THE PATIENT: 2
• The patient’s condition deteriorates as the BP decreases and Airway:
perfusion worsens after the first bolus of normal saline • Reassess airway
Physical Examination Findings: • Suction airway as needed
• Temperature 39°C (102.2°F), HR 180/min, RR 45/min, BP 70/P Breathing:
mm Hg, oxygen saturation 90% on 100% oxygen • Consider assisting ventilations with anesthesia bag/self-
• Monitor: sinus tachycardia inflating bag
• CNS: drowsy but arousable, GCS score of 12 Circulation:
• CVS: gallop rhythm, soft murmur, cap refill 4 s, pulses weak • Identify worsening shock
• Respiratory: crackles • Order second bolus of IV normal saline
• Abdomen: liver edge palpable • Insert second IV catheter (if not done already)
• Rest of examination results normal Medical Management:
• Order chest radiograph to evaluate for cardiogenic shock
• Order ECG
Abbreviations: BP, blood pressure; BUN, blood urea nitrogen; CBC, complete blood cell count; CNS, central nervous system; CVS, cardiovascular system; ECG, electrocardiogram; GCS, Glasgow Coma Scale; HR, heart rate; INR, international
normalized ratio; IV, intravenous; LFTs, liver function tests; PTT, partial thromboplastin time; RR, respiratory rate
Notes
1. An actor or confederate nurse can be used to report a palpable enlarged liver and prolonged capillary refill.
Common Pitfalls
• Overly aggressive fluid resuscitation and failure to consider cardiogenic shock in the differential diagnosis.
• Delay in ordering antibiotics.
• Ordering a chest radiograph or electrocardiogram are not considered as part of the workup for this patient.
26 Simulation Scenarios
Myocarditis—Cardiogenic Shock
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Occult Trauma (Non-accidental Trauma)
Adam Cheng, MD, FRCPC, FAAP
Mark Adler, MD
Learning Objectives
• Describe the “red flags” in a history that raise concern for non-accidental trauma (and recognize these might or might not be present in all cases).
• Describe the signs and symptoms of an infant with nonoccult multisystem trauma.
• Demonstrate the management of multisystem trauma.
– Conduct a trauma evaluation (primary and secondary survey).
– Consider stabilizing the cervical spine.
– Control airway due to depressed level of consciousness, using appropriate medication.
– Recognize and treat signs of elevated intracranial pressure.
– Consider and evaluate for clinical significant injuries other than head injuries.
27 Simulation Scenarios
Occult Trauma (Non-accidental Trauma)
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Scenario Patient Instructor Time,
Stage Condition Intervention Debriefing Notes min
STAGE 1, – If examined, the left pupil is dilated maximally and fixed; Disability:
continued right is 2–3 mm and barely reactive • Quick neurologic assessment (pupils, response to pain)
• CVS: pulses intact • Assessment of GCS score
• Respiratory: clear and slow Environment and Exposure:
• Abdomen: soft and without hepatosplenomegaly • Remove patient clothing, examine completely
• Extremities/skin: no bruising noted (if asked) • Keep patient euthermic (blanket or warming equipment)
28 Simulation Scenarios
Occult Trauma (Non-accidental Trauma)
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Scenario Patient Instructor Time,
Stage Condition Intervention Debriefing Notes min
STAGE 3, Circulation:
continued • Reassess HR, pulse, capillary refill, BP
Disability:
• Avoid excessive hyperventilation for elevated ICP (see note
below)
• Consider IV mannitol (or other similar agents)
Medical Management:
• Review ordered laboratory test results
Abbreviations: BP, blood pressure; CNS, central nervous system; CT, computed tomography; CVS, cardiovascular system; ETCO2, end-tidal carbon dioxide; GCS, Glasgow Coma Scale; HR, heart rate; ICP, intracranial pressure; IV, intravenous;
LFTs, liver function tests; RR, respiratory rate.
Notes
1. This is an important topic for which some specific management steps vary among institutions. This case content reflects the Advanced Pediatric Life Support recommended
management. The case can be tailored to your institutional practice, as it pertains to rapid sequence drug choices, endotracheal tube type (cuffed or not), use of mannitol or
other osmotic agents, or short-term mild hyperventilation.
2. This case can incorporate intraosseous needle insertion if the simulator permits this procedure—have the nurse confederate report he or she cannot obtain access.
3. This case is written to be only mildly suggestive of non-accidental trauma to prevent immediate identification of the problem to the exclusion of all other causes. It is our
experience that pediatric health care workers are sensitized to the more obvious “red flags” (eg, mom’s boyfriend at home alone with child). Similarly, a bulging fontanelle (which
might be present in a patient) is often so obvious on some simulators as to be a distractor and should be used at the instructor’s discretion after evaluating this functionality on the
simulator device to be used.
4. The role of sonography for trauma is not yet broadly established in pediatrics at this time and is not discussed here.
Common Pitfalls
• Participants do not recognize the severity of the medical condition, with an extended history obtained before resuscitation.
• F ocus on the intracranial process to the exclusion of other injuries. This patient has a grade 5 liver laceration that is currently not causing hemodynamic issues. If the patient
were to go to the operating room (OR) with this injury not identified, the personnel present in the OR (neurosurgeon) would not be the personnel best prepared to deal with
intra-abdominal bleeding.
• The team considers sending the patient for computed tomography (CT) without airway control. The confederate nurse states, “This patient seems too ill to go to CT like this.”
• Team does not know the correct intubation medications. In this case, treatment can be stopped before intubation, and this material can be reviewed as discussed in the text.
• The team intubates the patient without any medications. Allow the case to proceed and discuss afterward the likely impact on intracranial pressure of this approach.
29 Simulation Scenarios
Occult Trauma (Non-accidental Trauma)
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Postoperative Cardiac Patient—Ventricular Fibrillation
Adam Cheng, MD, FRCPC, FAAP
Mark Adler, MD
Learning Objectives
• Describe the signs and symptoms of a child presenting with unstable ventricular tachycardia.
• Describe the signs and symptoms of a child presenting with ventricular fibrillation and cardiac arrest.
• Demonstrate the treatment of a child with unstable ventricular tachycardia.
– Demonstrates knowledge of the Pediatric Advanced Life Support (PALS) unstable ventricular tachycardia algorithm.
• Demonstrate the treatment of a child with ventricular fibrillation.
– Recognize ventricular fibrillation.
– Recognize the importance of high-quality chest compressions and early defibrillation.
– Demonstrates proper use of the defibrillator.
– Demonstrates knowledge of the PALS ventricular fibrillation algorithm.
30 Simulation Scenarios
Postoperative Cardiac Patient—Ventricular Fibrillation
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Scenario Patient Instructor Time,
Stage Condition Intervention Debriefing Notes min
STAGE 1, • Order IV sedative (eg, ketamine) and prepares for
continued synchronized cardioversion (this particular point is
controversial and would be a good discussion point because
the patient might be too unstable to tolerate a sedative)
Medical Management:
• Synchronize cardioversion as per PALS protocol
• Order blood work: CBC, differential, blood culture,
electrolytes, BUN, creatinine, glucose, blood gas, LFTs, PTT,
and INR
31 Simulation Scenarios
Postoperative Cardiac Patient—Ventricular Fibrillation
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Scenario Patient Instructor Time,
Stage Condition Intervention Debriefing Notes min
STAGE 3, • CVS: gallop rhythm, soft murmur, capillary refill 5 s, pulses Medical Management:
continued
very weak • Consult ICU and cardiology personnel
• Respiratory: bilateral crackles • Order ECG and chest radiograph
Abbreviations: BP, blood pressure; BUN, blood urea nitrogen; CBC, complete blood cell count; CNS, central nervous system; CPR, cardiopulmonary resuscitation; CVS, cardiovascular system; ECG, electrocardiogram; ED, emergency
department; GCS, Glasgow Coma Scale; HR, heart rate; ICU, intensive care unit; INR, international normalized ratio; IV, intravenous; IO, intraosseous; LFTs, liver function tests; NA, not applicable; PALS, Pediatric Advanced Life Support; PTT,
partial thromboplastin time; RR, respiratory rate
Notes
1. A dressing or bandage should be applied to the chest to mimic recent cardiac surgery or sternotomy scar.
2. An orientation to the defibrillator should be provided before starting this scenario—ensure the students are aware of how to safely operate the defibrillator.
Common Pitfalls
• Defibrillation of unstable ventricular tachycardia (instead of synchronized cardioversion).
• Management of unstable ventricular tachycardia with medication only.
• Delayed defibrillation after recognition of ventricular fibrillation.
• Delayed initiation of chest compressions after recognition of ventricular fibrillation.
• Management of airway (intubation) before defibrillation or chest compressions while the patient is in ventricular fibrillation.
• Failure to adequately prepare medications for ventricular fibrillation. Instructors should encourage students to prepare epinephrine (adrenaline), amiodarone,
and lidocaine (lignocaine) immediately on recognition of the rhythm.
32 Simulation Scenarios
Postoperative Cardiac Patient—Ventricular Fibrillation
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Septic Shock
Adam Cheng, MD, FRCPC, FAAP
Mark Adler, MD
Learning Objectives
• Describe the signs and symptoms of an infant with septic shock.
• Demonstrate the management of circulatory failure due to sepsis.
– Use of normal saline or lactated Ringer solution to expand circulatory volume.
– Order and deliver a pressor to support blood pressure in a timely manner.
– Recognize the need for hydrocortisone stress dosing for specific pediatric populations (those taking steroid medications).
33 Simulation Scenarios
Septic Shock
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Scenario Patient Instructor Time,
Stage Condition Intervention Debriefing Notes min
STAGE 2 Condition: REASSESSMENT OF THE PATIENT: 3
• HR remains elevated and BP is now 63/52 mm Hg Circulation:
• Nurse notes aloud, “His hands are just so cold.” • Reassess HR, pulse, capillary refill, BP after bolus
• Blood glucose level is normal if bedside glucose test was • Order second bolus, also push
performed • Order vasopressor (dopamine) to bedside (“That will
Physical Examination Findings: take about 10–15 minutes to get from the pharmacy.”) in
• HR 163/min, RR 36/min, oxygen saturation 98% in 100% anticipation of need later
oxygen (if placed), BP 63/52 mm Hg Medical Management:
• CNS: barely responds to any stimuli • Order antibiotics (broad spectrum to include coverage for
• Respiratory: clear pseudomonas, eg, ceftazidime or meropenem/imipenem)
• CVS: clamped down and cool extremities
• Abdomen: no hepatosplenomegaly
Abbreviations: BP, blood pressure; CBC, complete blood cell count; CNS, central nervous system; CVS, cardiovascular system; ED, emergency department; HR, heart rate; ICU, intensive care unit; IV, intravenous; RR, respiratory rate
34 Simulation Scenarios
Septic Shock
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Common Pitfalls
• Intravenous (IV) fluid for volume expansion is not delivered in a rapid and/or controlled manner.
– IV “wide open” fluid administration can lead to very rapid infusion of a whole liter of fluid OR can result in underresuscitation if there is significant resis-
tance to flow (small IV gauge). Infants and small children should always receive resuscitation fluids using either a pump or push to allow for observation
and control of fluid delivery. Pressure bags can increase the likelihood of excessive fluid overload.
– Pushing fluid is accomplished by attaching a three-way stopcock in line with the IV catheter and pulling fluid directly from the bag (step 1) and then
switching the stopcock and pushing the fluid into the patient.
• Withholding antibiotics until either the patient improves or cultures and/or testing is complete. This infant is critically ill and antibiotics should be given as
early as is practical.
• Failing to check a bedside glucose level. Hypoglycemia is a treatable cause of altered mental status, and ill infants with poor glycogen stores and a poor recent
oral intake due to illness are prone to this condition.
• Waiting until the third bolus is started or finished to order pressors. Participants should recognize and anticipate that infant and pediatric pressor drips must
be prepared individually for a patient’s weight and are not stock items because these items are for adults. Depending on the institution, there might be a
significant delay in preparation and delivery of pressor drips.
35 Simulation Scenarios
Septic Shock
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Chest Crisis—Sickle Cell Disease
Adam Cheng, MD, FRCPC, FAAP
Mark Adler, MD
Learning Objectives
• Describe the signs and symptoms of a child presenting with chest crisis and sickle cell disease.
• Demonstrate the treatment for a child with a sickle cell chest crisis.
– Initial stabilizing steps.
– Perform fluid management and resuscitation.
– Understand the importance of repeat assessment in children with chest crisis.
– Demonstrate knowledge of appropriate antibiotic therapy.
36 Simulation Scenarios
Chest Crisis—Sickle Cell Disease
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Scenario Patient Instructor Time,
Stage Condition Intervention Debriefing Notes min
STAGE 1, Medical Management:
continued
• Blood work: CBC, differential, blood culture, gas, electrolytes,
BUN, creatinine, glucose
• IV ceftriaxone and erythromycin
• Chest radiograph
• IV fluids (D5NS) at half to one times maintenance
37 Simulation Scenarios
Chest Crisis—Sickle Cell Disease
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Scenario Patient Instructor Time,
Stage Condition Intervention Debriefing Notes min
STAGE 3 Condition: REASSESS THE PATIENT: 3
• Looks unwell, oxygenation and BP improved slightly Airway:
Physical Examination Findings: • Suction the ETT: some thin mucus or secretions
• Temperature 39.5°C (103°F), HR 130/min, RR 30/min, oxygen Breathing:
saturation 94% intubated and ventilated, BP 80/P mm Hg • Auscultate the chest
• CNS: paralyzed and sedated • Check chest movement and symmetry
• Respiratory: diffuse crackles bilaterally with poor air entry to Circulation:
right • Check pulse and BP
• CVS: pulses weak, capillary refill 4 s • Consider repeat IV fluid bolus for hypotension
• Order inotrope infusion and titrates infusion to increase the
BP
Medical Management:
• Call ICU consultant for help
• Prepare for transport
• Follow up on chest radiograph
• Consider adding vancomycin
Abbreviations: ABG, arterial blood gas; BP, blood pressure; BUN, blood urea nitrogen; CBC, complete blood cell count; CNS, nervous system; CPAP, continuous positive airway pressure; CVS, cardiovascular system; D5NS, 5% dextrose in
normal saline; ETT, endotracheal tube; HR, heart rate; ICU, intensive care unit; IV, intravenous; RR, respiratory rate
Common Pitfalls
• Overly aggressive fluid resuscitation, leading to pulmonary edema and respiratory failure.
• Delayed administration of antibiotics.
• Failure to reassess patient and delayed recognition of respiratory decompensation.
38 Simulation Scenarios
Chest Crisis—Sickle Cell Disease
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Status Asthmaticus
Adam Cheng, MD, FRCPC, FAAP
Mark Adler, MD
Learning Objectives
• Describe the signs and symptoms of a child presenting in status asthmaticus.
• Recognize the signs and symptoms of respiratory failure.
• Demonstrate the treatment of a child with status asthmaticus.
– Initial stabilizing steps.
– Demonstrate knowledge of medical management of status asthmaticus.
– Understand dangers of intubating a sick asthmatic patient.
39 Simulation Scenarios
Status Asthmaticus
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Scenario Patient Instructor Time,
Stage Condition Intervention Debriefing Notes min
STAGE 2 Condition: REASSESSMENT OF THE PATIENT: 3
• After the back to back albuterol (salbutamol) and Airway:
ipratropium, patient is still unwell • Suction the airway
• Coughing persistently • Reposition the head with head tilt, chin lift, jaw thrust
• Persistent respiratory distress (recognizing this child is distressed and vomiting, might be
• Child suddenly vomits profusely better to have him on his side as well)
Physical Examination Findings: • Reapply oxygen mask
• Temperature 38°C (100.4°F), HR 150/min, RR 40/min, oxygen Breathing:
saturation 92% in 100% oxygen, BP 100/55 mm Hg • Reassess breathing and RR
• CNS: gagging, irritable, coughing persistently • Call for help from respiratory therapy (if not done already)
• Respiratory: diffuse wheezes bilaterally with indrawing, • Give continuous albuterol (salbutamol) via nebulization
tracheal tug, and worsening retractions Circulation:
• CVS: pulses strong, capillary refill 2 s • Reassess HR, pulse, capillary refill, BP
• Rest of examination results normal • IV access
• Give steroids (IV) because he might have vomited oral
steroids
• Give magnesium sulfate (IV)
Medical Management:
• Perform blood work with IV start: CBC, differential, culture,
electrolytes, gas
• Get immediate chest radiograph and give antibiotics if signs
of focal consolidation
40 Simulation Scenarios
Status Asthmaticus
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Scenario Patient Instructor Time,
Stage Condition Intervention Debriefing Notes min
STAGE 3, Breathing:
continued
• Reassess breathing and RR
• Obtain chest radiograph if not already done by now
Circulation:
• Reassess HR, pulse, capillary refill, BP
Medical Management:
• Call ICU for help
• Consider IV aminophylline or IV b-agonist.
• Consider BiPAP or CPAP
Abbreviations: BiPAP, bilevel positive airway pressure; BP, blood pressure; CBC, complete blood cell count; CNS, central nervous system; CPAP, continuous positive airway pressure; CVS, cardiovascular system; ED, emergency department;
ETCO2, end-tidal carbon dioxide; ETT, endotracheal tube; HR, heart rate; ICU, intensive care unit; IV, intravenous; RR, respiratory rate; URI, upper respiratory tract infection.
Notes
1. “Albuterol” is the drug name in the United States. In many other countries the drug name is “salbutamol.”
2. Albuterol (salbutamol) and ipratropium bromide should ideally be administered via metered-dose inhaler.
Common Pitfalls
• Overventilation of the patient—leads to breath stacking and potential for pneumothorax or depressed cardiac return and eventual cardiac arrest.
• Early intubation attempt without consideration of other possible management options (eg, magnesium sulfate, noninvasive ventilation).
41 Simulation Scenarios
Status Asthmaticus
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Status Epilepticus
Adam Cheng, MD, FRCPC, FAAP
Mark Adler, MD
Learning Objectives
• Describe the signs and symptoms of a child presenting in status epilepticus.
• Demonstrate the treatment of a child with status epilepticus.
– Initial stabilizing steps.
– Understand complications associated with the treatment of status epilepticus.
– Demonstrate knowledge of rapid sequence intubation for a seizing patient.
42 Simulation Scenarios
Status Epilepticus
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Scenario Patient Instructor Time,
Stage Condition Intervention Debriefing Notes min
STAGE 2 Condition: REASSESSMENT OF THE PATIENT: 3
• Actively seizing patient, child vomiting profusely and Airway:
frothing at the mouth, then desaturates • Maintain the airway: jaw thrust, chin lift, head tilt
Physical Examination Findings: • Suction vigorously
• Temperature 39.5°C (103°F), HR 160/min, RR 25/min, BP • Consider intubation and prepares equipment
110/P mm Hg, saturation 85% in room air Breathing:
• Monitor: sinus tachycardia • Increase oxygen delivery to 100% by using nonrebreather
• CNS: seizing still mask
• CVS: normal heart sounds, capillary refill 2 s, pulses strong • Prepare self-inflating bag
• Respiratory: poor air entry bilaterally Circulation:
• Rest of examination results normal • IV access two times
• Check HR, BP, capillary refill, pulses
• Cycle BP every 3–5 min
Medical Management:
• Laboratory test results come back:
– Sodium 130 mmol/L, potassium 3.5 mmol/L, glucose
normal
– ABG: pH 7.15, Pco2 60 mm Hg, Po2 90 mm Hg, bicarbonate
20 mmol/L, base excess −7 mmol/L
43 Simulation Scenarios
Status Epilepticus
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Scenario Patient Instructor Time,
Stage Condition Intervention Debriefing Notes min
STAGE 3, Medical Management:
continued
• Call ICU
• Start infusion of other anticonvulsants (good discussion
point); options include levetiracetam (often given first line
instead of fosphenytoin) and phenobarbital
• IV antibiotics (cefotaxime/vancomycin or similar and
acyclovir) to cover the possibilities of bacterial meningitis
and herpes encephalitis
Abbreviations: ABG, arterial blood gas; BP, blood pressure; CBC, complete blood cell count; CNS, central nervous system; CVS, cardiovascular system; ED, emergency department; ETCO2, end-tidal carbon dioxide; HR, heart rate; ICU, intensive
care unit; IV, intravenous; PR, per rectum; RR, respiratory rate
Notes
1. Playing a video of a seizing child helps to add realism to the simulation.
2. Medications ordered will be institution specific. If your institution uses fosphenytoin, consider having the patient be normotensive and instead focus on
airway management of the seizing patient.
Common Pitfalls
• Failure to insert multiple intravenous catheters, thus delaying adjunct therapies (eg, antibiotics or fluids).
• Delay in checking bedside glucose level.
• Assumption that seizures have “stopped” after paralytic is given for intubation
44 Simulation Scenarios
Status Epilepticus
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Stridor Due to Foreign Body
Adam Cheng, MD, FRCPC, FAAP
Mark Adler, MD
Learning Objectives
• Describe the possible causes of stridor in an infant.
• Demonstrate the management of upper airway obstruction due to a foreign body.
45 Simulation Scenarios
Stridor Due to Foreign Body
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Scenario Patient Instructor Time,
Stage Condition Intervention Debriefing Notes min
STAGE 2 Condition: REASSESSMENT OF THE PATIENT: 5
• Airway obstruction (complete) Airway (ENT/anesthesia consultant not present yet):
• Occurs at 4 min regardless of actions OR if the health care • Lay child flat
workers look in mouth with tongue blade, force oxygen • Attempt to bag-mask patient with neck properly positioned
mask on to child, or place IV catheter and using two-person technique
Physical Examination Findings: • When this fails to work, perform direct laryngoscopy and
• Immediately: respiratory effort without stridor; rapidly remove small foreign body
lapses until unconsciousness Circulation:
• RR: initially 40/min but then decreases to 0/min in 30 s • Monitor decreasing vital signs, prepare to start
• HR: increases to 170/min in first minute then decreases to compressions if HR decreases below 60/min
65/min in next 90 s
• BP: 70/58 mm Hg
• Saturation: decreases from 88% to 30% in 30 s
Abbreviations: BP, blood pressure; CNS, central nervous system; CVS, cardiovascular system; ED, emergency department; ENT, ear, nose, throat; ETT, endotracheal tube; HR, heart rate; ICU, intensive care unit; IV, intravenous; RR, respiratory rate.
46 Simulation Scenarios
Stridor Due to Foreign Body
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Notes
1. It is easier to decrease and leave the respiratory rate at zero to both observe the quality of bagging and to avoid the participants being confused by the
simulator’s breathing effort.
2. This case can be changed to have foreign body below the vocal cords and having the participants intubate and push the foreign body into the right mainstem
bronchus. The point of having the removable foreign body is to reinforce the Magill forceps as a useful tool.
3. For simulators that support obstructing air entry into the lungs, simulators should be turned on when obstruction occurs to stop chest movement. This can
be a tangible visual cue that improves the case realism.
Common Pitfalls
• Beginning to treat for croup rather than aspiration.
• Trigger obstruction by stimulating child. This child should be taken to the operating room by an ear, nose, and throat surgeon and/or anesthesia personnel
where a controlled evaluation and removal can be performed. Ideally, the child is placed in a parent’s lap awaiting this event.
• Once complete obstruction occurs, failing to attempt airway evaluation and removal of obstruction or attempting intubation. The child now has an emergent
condition that cannot await airway expertise.
47 Simulation Scenarios
Stridor Due to Foreign Body
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Supraventricular Tachycardia
Adam Cheng, MD, FRCPC, FAAP
Mark Adler, MD
Learning Objectives
• Describe the signs and symptoms of an infant with supraventricular tachycardia.
• Demonstrate the management of stable supraventricular tachycardia using chemical cardioversion with appropriate monitoring.
48 Simulation Scenarios
Supraventricular Tachycardia
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Scenario Patient Instructor Time,
Stage Condition Intervention Debriefing Notes min
STAGE 2, – Having ECG machine connected and running during
continued
conversion attempt
• Deliver first adenosine bolus (no or brief effect) after
considering contacting cardiology or intensive care support
personnel
Abbreviations: BP, blood pressure; CNS, central nervous system; CVS, cardiovascular system; ECG, electrocardiogram; HR, heart rate; ICU, intensive care unit; IV, intravenous; RR, respiratory rate.
Notes
1. Some institutions have specific guidelines about the presence of cardiology personnel at chemical cardioversion. If this is required, anticipation of this need
should be discussed (calling as early as practical).
2. Simulating the patient monitor changes typically seen with cardioversion requires some practice and might not be an ideal representation of the clinical
experience (eg, longer pause, delay in rhythm change on monitor). Testing of this effect on the planned device is recommended.
Common Pitfalls
• Problems with delivering the adenosine in a rapid push/rapid flush manner.
• Electrical cardioversion in this stable patient (less common).
49 Simulation Scenarios
Supraventricular Tachycardia
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Tricyclic Antidepressant Overdose
Lina Al-Bakry, MD
Adam Cheng, MD, FRCPC, FAAP
Mark Adler, MD
Learning Objectives
• Describe the signs and symptoms of the anticholinergic toxidrome.
• Demonstrate the treatment of a child with tricyclic antidepressant (TCA) intoxication.
– Initial stabilizing steps.
– Identify tachyarrhythmia secondary to TCA intoxication.
– Manage TCA intoxication with appropriate supportive and therapeutic interventions.
50 Simulation Scenarios
Tricyclic Antidepressant Overdose
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Scenario Patient Instructor Time,
Stage Condition Intervention Debriefing Notes min
STAGE 1, Disability:
continued
• Eyes closed intermittently, opens eyes with stimulation
• Moans and vocalizes with stimuli.
• Localizes to painful stimuli, otherwise no movement
• Pupils 5 mm, sluggish reaction symmetrically
Expose the Patient:
• Warm, dry skin
• No rash, no petechiae
• Identify abnormality on cardiac tracing (sinus tachycardia
with wide QRS)
• Identify need for 12-lead ECG
• Order blood work: CBC, differential, electrolytes, glucose,
creatinine, BUN, serum osmolality, blood gas, serum
acetaminophen and aspirin levels, urine toxicology screen
51 Simulation Scenarios
Tricyclic Antidepressant Overdose
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Scenario Patient Instructor Time,
Stage Condition Intervention Debriefing Notes min
STAGE 2, Medical Management:
continued
• IV sodium bicarbonate bolus
• Glucometer: normal results
• Continuous ECG monitoring
• Call for ICU consultation
• Call for toxicology consultation/poison control
Abbreviations: BP, blood pressure; BUN, blood urea nitrogen; CBC, complete blood cell count; CNS, central nervous system; CVS, cardiovascular system; ECG, electrocardiogram; ETCO2, end-tidal carbon dioxide; ETT, endotracheal tube; HR,
heart rate; ICU, intensive care unit; IV, intravenous; PALS, Pediatric Advanced Life Support; RR, respiratory rate.
52 Simulation Scenarios
Tricyclic Antidepressant Overdose
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Notes
1. Have someone serve as poison control personnel and provide advice to the medical team over the telephone.
2. “Albuterol” is the drug name in the United States. In many other countries the drug name is “salbutamol.”
Common Pitfalls
• Delay in eliciting further history, thus leading to delay in making the diagnosis.
• Failure to recognize and anticipate the potential cardiac complications of TCA overdose.
53 Simulation Scenarios
Tricyclic Antidepressant Overdose
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Metabolic Crisis—Hyperammonemia
Adam Cheng, MD, FRCPC, FAAP
Mark Adler, MD
Debra Weiner, MD
Learning Objectives
• Describe the common causes of vomiting and lethargy in a neonate.
• Demonstrate the treatment of a neonate with altered mental status and suspected metabolic crisis.
– Manage airway, breathing, and circulation.
– Check appropriate laboratory test results—glucose at bedside, blood gas, and serum ammonia.
– Treat hypoglycemia and confirm that treatment was effective.
– Treat acidosis.
– Arrange for treatment of hyperammonemia.
54 Simulation Scenarios
Metabolic Crisis—Hyperammonemia
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Scenario Patient Instructor Time,
Stage Condition Intervention Debriefing Notes min
STAGE 1, Medical Management:
continued
• Order a bedside glucose, electrolytes, BUN, creatinine, LFTs,
ammonia, blood gas, CBC, blood culture, urine, urine culture
tests, blood to hold for possible additional studies
• Orders IV fluid bolus of 10 mL/kg of normal saline
55 Simulation Scenarios
Metabolic Crisis—Hyperammonemia
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Scenario Patient Instructor Time,
Stage Condition Intervention Debriefing Notes min
STAGE 3, • Respiratory: clear Breathing:
continued
• Abdomen: soft and without hepatosplenomegaly • Reassess breathing
• Extremities/skin: no bruising noted • Start to provide manual ventilation to the patient
Circulation:
• Reassess blood pressure, pulse, capillary refill
• Give IV normal saline bolus
Medical Management:
• Call for ICU consultation
• Order dose of lorazepam for suspected seizure
• Call for metabolism consultation if not already done
• Administer bicarbonate
• Arrange for hemodialysis, give sodium phenylacetate,
sodium benzoate if hemodialysis will be delayed
Abbreviations: ABG, arterial blood gas; BP, blood pressure; BUN, blood urea nitrogen; CBC, complete blood cell count; CNS, central nervous system; CVS, cardiovascular system; D10W, 10% dextrose in water; ED, emergency department;
ETCO2, end-tidal carbon dioxide; HR, heart rate; ICU, intensive care unit; IV, intravenous; LFTs, liver function tests; RR, respiratory rate; WBC, white blood cell count.
Notes
1. Consider inborn error of metabolism (IEM) with, not after, other potential diagnoses. History and laboratory findings (hypoglycemia, acidosis,
hyperammonemia, neutropenia, anemia) are most suggestive of organic acidemia. Other IEMs most likely to present with catastrophic decompensation in a
neonate include aminoacidopathies, urea cycle defects, fatty acid oxidation defects, and mitochondrial disorders.
2. Recognize that results of a newborn screen might not be available at 1 week of age or that child might not have had a newborn screen.
3. Normal pregnancy, delivery, and examination findings are not uncommon with IEM.
4. Family history might be negative given autosomal recessive inheritance of most IEMs.
5. Physical examination findings usually normal except for acute manifestations of illness.
6. Manifestations of seizure in neonates might be subtle. For seizures unresponsive to conventional treatment, consider pyridoxine, folate, and/or biotin.
7. Perform laboratory tests to evaluate for IEMs before any treatment, including glucose or fluids. Initial laboratory tests include bedside glucose, electrolytes,
blood urea nitrogen, creatinine, glucose, blood gas, complete blood cell count, blood culture, liver function tests, ammonia, urine, and urine culture. If
hypoglycemia, acidosis, and/or hyperammonemia are present, send serum samples for amino acids, acylcarnitine profile, and ketones measurement and urine
samples for organic acids and urine acylglycine measurement. Consider taking lactate and pyruvate samples. Blood samples for IEM studies can be sent on
newborn screen filter paper. Lactate and pyruvate samples require special tubes.
8. Consultation with metabolism specialist recommended if laboratory test results support suspicion of IEM.
9. Bicarbonate to correct acidosis. No consensus on pH for which to give or dose; consider for pH less than 7.0 to 7.2.
10. Hemodialysis for hyperammonemia. Extracorporeal membrane oxygenation hemodialysis is faster than conventional dialysis but has increased risks in
neonates. Sodium phenylacetate or sodium benzoate should be administered per package insert directions if there will be a delay in hemodialysis.
56 Simulation Scenarios
Metabolic Crisis—Hyperammonemia
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
Common Pitfalls
• Potential diagnosis of IEM is not considered until late, which increases the risk of long-term disease and/or death.
• Participants check and treat the glucose level but fail to obtain a follow-up glucose measurement. A high concentration of glucose is not always maintained
with maintenance fluids.
• Acidosis is not treated.
• Ammonia is not checked.
• Failure to recognize and treat seizure.
57 Simulation Scenarios
Metabolic Crisis—Hyperammonemia
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians