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Simulation Scenarios

module Simulation Scenarios

This material is made available as part of the professional education programs of the American Academy of Pediatrics and the American College of Emergency Physicians. No endorsement of any product or service should be inferred or is intended. Every effort has been made to ensure 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

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Simulation Scenarios

module Simulation Scenarios

Contents

Adrenal Insufficiency

4

Cardiogenic Shock Due to Congenital Heart Disease

Altered Mental Status

Diabetic Ketoacidosis and Cerebral Edema Hyperthermia 15

Hypothermia—Near Drowning

Iron Overdose

Myocarditis—Cardiogenic Shock

Occult Trauma (Intentional Trauma)

10

Blunt Abdominal Trauma—Hypovolemic Shock

1

12

18

25

22

27

Postoperative Cardiac Patient—Ventricular Fibrillation

33

Chest Crisis—Sickle Cell Disease

Status Asthmaticus Status Epilepticus

Septic Shock

36

39

42

8

30

Stridor Due to Foreign Body Supraventricular Tachycardia

Stridor Due to Foreign Body Supraventricular Tachycardia

45

48

Tricyclic Antidepressant Overdose Metabolic Crisis—Hyperammonemia

50

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

• Describe 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.

Simulator: Infant Simulator

Scenario

 

Patient

 

Instructor

Time,

Stage

Condition

Intervention

Debriefing Notes

min

STAGE 1

 

History

Take a History:

 

5

• Three-week-old boy with unremarkable history, referred to emergency department from physician’s office with a low serum sodium level (126 mmol/L)

• No ill contacts

• No medications

• No allergies

• Mother’s pregnancy was normal; she recalls no abnormal test results

• Poor feeding over last week, spitting up more in past few days

• Triage nurse was worried about how ill the child appears

• No fever

• You arrive to assess the patient

• Sleeping through feeding time last few days, slept most of the last 12 h

 

Weight:

3 kg

• Has lost weight since last family physician visit

Condition:

Airway:

Very unwell, listless

• Listen for breath sounds, present

Physical Examination Findings:

• Apply oxygen via nonrebreather mask at 15 L/min

• Temperature 36.2°C (97.2°F), HR 152/min, RR 36/min, oxygen saturation 98% in room air, BP 72/58 mm Hg

• CNS: asleep, wakes briefly with painful stimulation

 

Breathing:

• Apply monitors, including oxygen saturation and blood pressure

• CVS: pulses present centrally, absent peripherally

• Auscultate chest and observe respiratory rate

• Respiratory: clear

Circulation:

• Abdomen: no hepatosplenomegaly

• Assess pulse, HR, capillary refill, BP

• Extremities/skin: capillary refill >4 s

• Ask nurse for an IV catheter to be placed

• Ask for normal saline or lactated Ringer solution bolus of 20 mL/kg to be given quickly (push)

Medical Management:

Order laboratory tests: (CBC, electrolytes, blood cultures, venous blood gas, bedside glucose)

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 mmol/L, bicarbonate 16 mmol/L, BUN and creatinine normal for age, pH from venous gas 7.26

Medical Management:

• Consult endocrinologist for treatment guidance; order tests they might request

Physical Examination Findings:

• HR 150/min, RR 36/min, oxygen saturation 99% on 100% oxygen (if placed), BP 73/60 mm Hg

• CNS: cries weakly with painful stimuli

• Order IV hydrocortisone

• Order D10W IV bolus to correct hypoglycemia

• Initiate management of hyperkalemia

• Respiratory: clear

• CVS: clamped down and cool extremities.

• Abdomen: no hepatosplenomegaly

STAGE 3

Condition:

REASSESSMENT OF THE PATIENT:

 

5

• “He is looking around more now.”

Circulation:

• Improved perfusion and alertness after second bolus

Reassess HR, pulse, capillary refill, BP

Physical Examination Findings:

Medical Management:

• HR 138/min, RR 36/min, BP 78/48 mm Hg, saturation 98% on room air

Order recheck of electrolytes after bolus therapy

Disposition:

• Abdomen: no hepatosplenomegaly

Arrange for neonatal or pediatric ICU for monitoring and frequent laboratory work until stabilized or plan for transport to tertiary care facility (depending on presenting facility resources)

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.

Simulator: Pediatric Simulator

Scenario

Patient

 

Instructor

Time,

Stage

Condition

Intervention

Debriefing Notes

min

STAGE 1

History:

TAKE A HISTORY:

 

2

• Five-year-old boy

From Paramedics:

• Playing in the driveway

• Initially delirious, screaming, GCS score of 15/15

• Found by parents crushed and trapped underneath garage door

• Extraction took 10 min in total

• IV antecubital one time

• Garage door directly over his abdomen

• Given normal saline. 20 mL/kg

• No witnesses to the incident

• Transport time, 15 min

• Ambulance arrived within 12 min

PRIMARY SURVEY MANAGEMENT:

Weight:

Airway:

18 kg

Assess airway, talk to the patient

Condition:

Breathing:

• Moaning in pain

• Check oxygen saturation

• Temperature 36°C (96.8°F), HR 150/min, RR 30/min, BP 85/50

• Apply monitors

mm

Hg, oxygen saturation 96% room air

• Auscultate chest

• Monitor: sinus tachycardia

• Check for chest rise

• CNS: cervical collar on patient; moaning in pain, answers

• Apply 100% oxygen

Circulation:

questions, asking for mom, confused at times, GCS score of 15.

• cervical spine not tender, no obvious facial injury

• capillary refill 4 s, pulses palpable but weak

• Respiratory: chest clear

• Abdomen: bruising all over abdomen

• Neurologic: normal

• Musculoskeletal: normal

H/N:

CVS:

• Apply monitors

• Check pulse, capillary refill, BP

• Identify the rhythm

• Check first IV catheter, asks for second large-bore IV catheter

• Ask for rapid infuser and bolus of IV normal saline

• Order trauma blood work, including type and cross.

• Activate trauma team/call for help

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

• Ask for second bolus of IV normal saline

• CNS: cervical spine collar on patient; moaning in pain, answers questions, asking for mom, confused at times, GCS score of 15

• cervical spine not tender, no obvious facial injury

H/N:

• Reaffirm need for rapid infuser

• Order blood

• capillary refill 4 s, pulses palpable but weak

CVS:

Performs Secondary Survey:

• Respiratory: chest clear

• Abdomen: bruising all over abdomen

• Neurologic: normal

• Musculoskeletal: normal

• H/N: pupils equal and reactive to light, facial bones not tender, neck supple and not tender

• Chest: trachea midline, chest clear.

• CVS: profoundly tachycardic, color mottled now, pulses 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 consciousness

Physical Examination Findings:

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 ETCO 2

Monitor: sinus tachycardia

• IV atropine

CNS: cervical spine collar on patient; moaning in pain, intermittently answers questions, confused and delirious at times, GCS score of 13.

• IV ketamine or etomidate

• IV succinylcholine

• Check tube placement after intubation, order chest radiograph if intubation is performed

H/N:

cervical spine not obviously tender, no obvious facial

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/mm 3 , hemoglobin 7 g/dL, platelets 500,000/

mm

3

Sodium 135 mmol/L, potassium 4.5 mmol/L, urea 4.2 mmol/L, creatinine 46 mmol/L, glucose normal

pH

7.20, Pco 2 40 mm Hg, Po 2 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; ETCO 2 , 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.

Simulator: Infant Simulator

Scenario

 

Patient

 

Instructor

Time,

Stage

Condition

Intervention

Debriefing Notes

min

STAGE 1

 

History:

Take a History:

 

5

• Five-month-old boy with history of poor feeding and weight loss for past month

• No ill contacts

• No upper respiratory tract infection symptoms, no diarrhea

• Sent from physician’s office for evaluation

• Takes a long time to eat and tires out; sweats a lot with feeding

• You are called to evaluate patient

• Was noted to have a “hole in the heart” on a prenatal ultrasonogram but had no murmur at birth—no follow-up was performed

 

Weight:

5 kg

Condition:

• No allergies

Very unwell, gray, with respiratory distress

• Reflux medications started for poor feeding

Physical Examination Findings:

• Approximately 0.5-kg weight lost during last 2 wk

• Temperature 37.3°C (99°F), HR 158/min, RR 58/min, oxygen saturation 91% in room air, BP 72/58 mm Hg

Airway:

• Listen for breath sounds

• CNS: cries weakly, lays still in bed

• Apply oxygen via nonrebreather mask at 15 L/min

• CVS: pulses present centrally, weak peripherally

Breathing:

• Respiratory: bilateral crackles, retractions

• Apply monitors, including oxygen saturation and blood pressure

• Auscultate chest and observe respiratory rate

• Abdomen: liver is firm and enlarged to the umbilicus in the midclavicular line

• Extremities/skin: capillary refill approximately 3 s

Circulation:

• Assess pulse, HR, capillary refill, BP

• Murmur and gallop rhythm heard

• Ask nurse to obtain IV access

• Ask for normal saline or lactated Ringer solution bolus of 5 or 10 mL/kg

• Palpate abdomen for organomegaly as a sign of right heart failure

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

STAGE 2

Condition:

REASSESSMENT OF THE PATIENT:

 

7

• Condition is unchanged

Circulation:

• Venous gas reveals acidosis (pH 7.21, Pco 2 28 mm Hg, Po 2 32 mm Hg, base excess −16 mmol/L)

• Nurse cannot obtain IV access; intraosseous needle placed by participant

• Blood glucose level is normal

• Reassess HR, pulse, capillary refill, BP after bolus

• Chest radiograph reveals marked cardiomegaly with pulmonary markings consistent with fluid overload

• Call for cardiologist to consult and perform echocardiography; if not locally available, begin process of transferring patient

Physical Examination Findings:

• HR 163/min, RR 60/min, oxygen saturation 98% in 100% oxygen (if placed), BP 78/53 mm Hg

• Consider IV furosemide for fluid overload

• Consider afterload reduction (eg, milrinone)

• Examination findings unchanged

Medical Management:

Consider bicarbonate for acidosis

STAGE 3

Condition:

REASSESS THE PATIENT:

 

5

Patient stabilizes

Disposition:

Physical Examination Findings:

• Arrange for ICU admission or transport to tertiary care facility (depending on presenting facility resources)

HR 162/min, RR 52/min, BP 78/62 mm Hg, saturation 98% on nonrebreather mask

• Obtain second IV access other than intraosseous access

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.

Simulator: Infant Simulator

Scenario

 

Patient

 

Instructor

Time,

Stage

Condition

Intervention

Debriefing Notes

min

STAGE 1

 

History:

Take a History:

 

3–4

Eleven-month-old found unresponsive, was with grandmother, who is his usual babysitter

• No allergies

• Patient takes no medications

Brought to ED by grandmother

• No ill contacts

Unresponsive at triage, brought to resuscitation bay

• No idea at all what has happened

You

are called to assess patient

• No history of trauma or fall

Weight:

• No other children in home

9 kg

• If asked specifically, grandmother takes oral sulfonylurea (glyburide), which she keeps in a bedside drawer

Condition:

Infant is pink and well-perfused but comatose

 

Airway:

Physical Examination Findings:

Listen for breath sounds

• Temperature 37.2°C (99°F), HR 94/min, RR 28/min, oxygen saturation 98% in room air, BP 89/66 mm Hg

• CNS: unresponsive to painful stimulation if given. Pupils 3

Breathing:

• Apply monitors, including oxygen saturation and blood pressure

 

mm

and reactive bilaterally

• Auscultate chest and observe respiratory rate

• pulses intact

CVS:

Circulation:

• Respiratory: clear

• Assess pulse, HR, capillary refill, BP

• Abdomen: soft and without hepatosplenomegaly

• Ask nurse to obtain IV access

• Extremities/skin: no bruising noted (if asked specifically)

Disability:

Quick neurologic assessment (pupils, response to pain)

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 “rule of 50”—see note below)

• Blood glucose level is low if measured

Physical Examination Findings:

• Perform further ingestion laboratory tests (urine toxicology, acetaminophen [paracetamol], salicylates, ethanol, +/– digitalis levels)

Vitals unchanged

STAGE 3

 

Condition:

Medical Management:

 

5

• Patient is now more awake and cries

• Order recheck of glucose level in 15–30 min

• HR 125/min, RR 28/min, BP 85/62 mm Hg, saturation 98% on room air

• Recognize need to provide supplementary IV glucose and admit due to long-acting oral diabetic agent

Disposition:

Hospital or ICU for frequent IV glucose level checks

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

participants. CONCENTRATION DOSE PRODUCT D10 5 mL/kg 50 D25 2 mL/kg 50 D50 Not recommended due

D25

2 mL/kg

50

D50

Not recommended due to high osmolarity

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.

Simulator: Pediatric Simulator

Scenario

 

Patient

 

Instructor

Time,

Stage

Condition

Intervention

Debriefing Notes

min

STAGE 1

 

History:

Takes a History:

 

5

• Six-year-old girl

• Excessive drinking, bedwetting, and increasing tiredness

• Two-week history of fever and lethargy

• “Growing but not gaining weight”

• Very unwell in last 24 h: excessively drowsy, very poor energy, difficulty breathing, abdominal pains

• Unwell for 36 h with increasing fatigue, vague abdominal pain

 

Weight:

• Polyuria, polydipsia, enuresis, 5-kg weight loss

20 kg

• No vomiting

Condition:

• Becoming progressively lethargic today

Looks unwell; GCS score of 13 (motor response 6, vocal response 4, eye response 3)

• Medical history: unremarkable

Airway:

Physical Examination Findings:

• Assess airway

• Temperature 37.4°C (99.3°F), HR 160/min, RR 30/min, BP 90/50 mm Hg, oxygen saturation 98% on room air

• Provide head tilt, chin lift, jaw thrust as needed

Breathing:

• Very flushed cheeks

• Check oxygen saturation

• Monitor: sinus tachycardia

• Auscultate chest

• CNS: sleepy, pupils normal

• Identify Kussmaul respirations

• CVS: normal heart sounds, capillary refill 3 s, pulses weak

Circulation:

• Respiratory: Kussmaul respirations, lung fields clear

• Apply monitors

• Mucous membranes: mouth/lips very dry, crying a few tears

• Check HR, BP, capillary refill

• Abdomen: mild diffuse tenderness

• Insert IV catheter, keeps patient nothing by mouth

• Identify sinus tachycardia

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

STAGE 2

Condition:

REASSESSMENT OF THE PATIENT:

 

5

Patient less responsive, GCS score decreasing

Airway:

Physical Examination Findings:

• Suction the airway

• GCS score of 8 (motor response 3, vocal response 3, eye response 2)

• Reposition the head with head tilt, chin lift, jaw thrust

• Reapply oxygen mask

• Temperature 37.5°C (99.5°F), HR 120/min, RR 24/min, BP 110/60 mm Hg, oxygen saturation 98% on room air

 

Breathing:

• Reassess

• Monitor: sinus tachycardia

• Prepare for possible intubation: draws up rapid sequence intubation medication

• CNS: grumpy and tired, mumbling, eyes closed

• CVS: normal HS, capillary refill 2 s, pulses still weak

Circulation:

• Respiratory: a bit less labored

Reassess HR, BP, capillary refill

• Abdomen: seems less tender

 

• Rest of examination results unchanged

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.

Simulator: Infant Simulator

Scenario

Patient

   

Instructor

Time,

Stage

Condition

Intervention

Debriefing Notes

min

STAGE 1

History:

 

Take a History:

 

5

Eight-month-old infant was unintentionally left in a car for

• Previously healthy

2

h; temperature outside was 32.2°C (90°F)

• No medications or allergies

Child was apneic, pulseless, and cyanotic

• Immunizations up to date

CPR

was initiated by paramedics with bag-mask ventilation.

• Paramedics have been doing CPR for 5 min

Child brought to ED by paramedics with CPR in progress

Airway:

Weight:

 

• Continue bag-mask ventilation

8

kg

• Clear or suction the airway

Condition:

 

• Prepare for possible intubation (gathers equipment)

• Apneic and now with faint pulses (EMS reports pulse return at arrival)

Breathing:

• Check oxygen saturation

• Temperature 42°C (107.6°F), HR 185/min, RR 0/min, BP 62/50

• Apply monitors

 

mm

Hg, oxygen saturation 93% (bag-mask)

• Auscultate chest

• Monitor: sinus tachycardia

• Check for adequacy of chest rise with bagging

• CNS: obtunded, nonresponsive

Circulation:

• Cardiovascular: capillary refill 6–7 s, weak pulse centrally

• Apply monitors

• Respiratory: coarse crackles bilaterally

• Check pulse, capillary refill, BP

• Abdomen: soft, no organomegaly

• Establish IO access (IV attempts fail)

• Skin: hot, dry

• Give 20-mL/kg normal saline bolus

• Order vasopressor (dobutamine vs dopamine, avoids primarily α-agonists)

Disability and Exposure:

• Check neurologic status

• Remove clothes

• Active cooling measures: cooling blanket, ice bags, lower room temperature, peritoneal lavage (latter rarely used)

• Monitor rectal temperature

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

STAGE 2

Condition:

REASSESSMENT OF THE PATIENT:

 

5

Some cooling has occurred

 

Airway:

Physical Examination Findings:

• May consider intubation

• Temperature 40.5°C (105°F), HR 169/min, RR 20/min (bagged), BP 65/59 mm Hg, oxygen saturation 98%

• Bagged at rate of 8–10/min

Breathing:

• Monitor: sinus tachycardia

Not breathing spontaneously

• CNS: obtunded, nonresponsive

Circulation:

• CVS: weak pulses

• Place urinary catheter to assess renal function

• Respiratory: clear

• Begin dobutamine or dopamine

• Abdomen: soft

Medical Management:

• Skin warm and dry

Send urine sample for myoglobin/UA

Laboratory test results:

 

• Glucose level normal

• Electrolytes (from laboratory or gas tests if ordered): sodium 148 mmol/L, potassium 4.6 mmol/L, chloride 110 mmol/L, calculated bicarbonate 8 mmol/L, ionized calcium 1.01 mmol/L

STAGE 3

Condition:

REASSESS THE PATIENT:

 

5

Improvement

 

Airway:

Physical Examination Findings:

Reassess airway (considers intubation if not already done)

• Temperature 39.6°C (103.3°F), HR 159/min, RR 10/min (bagged), BP 63/59 mm Hg, saturation 98% with 100% oxygen

Breathing:

Assess breathing

Circulation:

• Monitor: sinus tachycardia

Titrate pressors

• CNS: unconscious

Medical Management:

• CVS: capillary refill 4 s, pulses weak

• Consider further management for possible rhabdomyolysis (furosemide and/or mannitol)

• Respiratory: clear

• Skin: warm

• Notify critical care personnel

Laboratory test results:

CPK, 400 IU/L; UA and hemoglobin

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.

Simulator: Pediatric Simulator

Scenario

Patient

 

Instructor

Time,

Stage

Condition

Intervention

Debriefing Notes

min

STAGE 1

History:

Take a History:

 

3

• Six-year-old boy

• Previously healthy

• Was boating with his father when the small boat inadvertently hit a large wave and flipped over

• No medications or allergies

• Immunizations up to date

• Child was not wearing a life jacket

• Paramedics have been doing CPR for 10 min

• Father survived and swam with unconscious child to shore

Airway:

• CPR initiated on the scene and 911 called

• Maintain cervical spine precautions

• On arrival, paramedics noted child was apneic, pulseless, and cyanotic

• Take over bagging and CPR immediately

• Clear or suction the airway

• CPR was initiated by paramedics with bag-mask ventilation and cervical collar applied

• Identify needs for immediate intubation

• Intubate patient without sedation or paralysis

• Child brought to ED by paramedics with CPR in progress

Breathing:

Weight:

• Check oxygen saturation

20 kg

• Apply monitors

 

• Auscultate chest

• Check for adequacy of chest rise after tube is placed

• Identify that ETCO 2 detection not helpful because child is pulseless

• Order chest radiograph to confirm tube placement

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, oxygen saturation NA

• Check pulse, capillary refill, BP

• Identify PEA

• Monitor: sinus bradycardia

• Insert IV or IO catheter

• CNS: obtunded, nonresponsive, GCS score 3, cervical spine collar on patient, bruises and cuts on face

• Do not order epinephrine (adrenaline) because core 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 obtain second IV/IO access

• Respiratory: coarse crackles bilaterally

• 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

STAGE 2

 

Condition:

REASSESSMENT OF THE PATIENT:

 

2

The patient’s condition has not changed apart from an increase in the temperature.

Airway:

• Intubate patient

Physical Examination Findings:

• Bag at rate of 8–10/min

• Temperature 33°C (91.4°F), HR 45/min, RR 10/min (bagged), BP NA, oxygen saturation NA

• Maintain cervical spine precautions

Breathing:

• Monitor: sinus bradycardia

Not breathing spontaneously

• CNS: obtunded, nonresponsive, GCS score of 3, cervical spine collar on patient, bruises and cuts on face

Circulation:

• Continue CPR

• CVS: cap refill 6–7 s, no pulse palpable

• Identify PEA, temperature has increased now to 33°C

• Respiratory: coarse crackles bilaterally

 

(91.4°F).

• Abdomen: bruising all over abdomen

• Deliver defibrillation at 2 J/kg

• Rest of examination results normal

• Continue CPR and order epinephrine (adrenaline) via IO catheter

• Continue CPR

• Give IV normal saline fluid bolus

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, Pco 2 15 mm Hg, Po 2 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

STAGE 3

 

Condition:

REASSESS THE PATIENT:

 

5

The patient is back to a perfusing rhythm

Airway:

Physical Examination Findings:

• Intubate and sedate

• Temperature 35°C (95°F), HR 80/min, RR 10/min (bagged), BP 60/P mm Hg, saturation 91% with 100% oxygen

• Maintain cervical spine precautions

 

Breathing:

• Monitor: sinus rhythm

Assess breathing

• CNS: intubated and unconscious

Circulation:

• CVS: capillary refill 4 s, pulses weak

• Identify hypotension

• Respiratory: coarse crackles bilaterally

• Identify sinus rhythm

• Abdomen: bruising all over the abdomen

• Stop chest compressions

• Rest of examination results normal

• Give IV normal saline fluid bolus

• Order inotrope infusion IV (dopamine or epinephrine [adrenaline])

• Arrange transfer to ICU for admission to hospital

Medical Management:

• Perform CT scan of head, neck, and abdomen

• Consult general surgeon

• Consult neurosurgeon

• Notify parents

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; ETCO 2 , 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.

Simulator: Infant Simulator

Scenario

 

Patient

 

Instructor

Time,

Stage

Condition

Intervention

Debriefing Notes

min

STAGE 1

 

History:

Take a History:

 

5

• Twelve-month-old boy found at home sleepy

• No ill contacts

• No preceding illness

• No medications

• Chaotic home setting with four other children and a single mother, shares home with another family

• Patient has vomited at home and had loose stools

• If asked, sibling is receiving iron supplementation for anemia

 

Weight:

• Mom has large bottle of iron liquid medication at home

10 kg

Airway:

Condition:

• Listen for breath sounds, present

Ill appearance and tachypnea, sleepy

• Apply oxygen via nonrebreather mask at 15 L/min

Physical Examination Findings:

 

Breathing:

• Temperature 36.6°C (97.9°F), HR 158/min, RR 42/min, oxygen saturation 97% in room air, BP 68/42 mm Hg

• Apply monitors, including oxygen saturation and blood pressure

• CNS: asleep, wakes briefly with stimulation

• Auscultate chest and observe respiratory rate

• CVS: pulses present centrally, absent peripherally

Circulation:

• Respiratory: clear

• Assess pulse, HR, capillary refill, BP

• Abdomen: no hepatosplenomegaly

• Ask nurse to place IV catheter

• Extremities/skin: capillary refill approximately 3 s

• Ask for normal saline or lactated Ringer solution bolus of 20 mL/kg to be given quickly (push)

Medical Management:

Order laboratory tests (CBC, electrolytes, coagulation studies, blood cultures, venous blood gas, bedside glucose)

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 was measured

Reassess airway patency, RR, and saturations

Circulation:

• Venous gas: pH 7.06, Pco 2 28 mm Hg, Po 2 39 mm Hg, base excess −20 mmol/L

• Reassess HR, pulse, capillary refill, BP after bolus

• Order second bolus, also push

• Patient vomits again

• Order vasopressor (dopamine) to bedside (“That will take about 10–15 minutes to get from the pharmacy”) in anticipation of need later

• Iron overdose exceeds 60 mg/kg body weight (provided if team asks dose)

Physical Examination Findings:

Medical Management:

• HR 163/min, RR 36/min, oxygen saturation 98% in 100% oxygen (if placed), BP 63/52 mm Hg

• If team fails to suspect overdose, can prompt with statement “Someone has called to inform the mom that a bottle of sibling medication labeled ferrous sulfate is open and empty on the floor.”

• CNS: barely responds to any stimuli

• Respiratory: clear

• 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

STAGE 3

Condition:

REASSESSMENT OF THE PATIENT:

 

5

• “He doesn’t seem much better.”

Circulation:

• Remains tachycardic after second bolus

Reassess HR, pulse, capillary refill, BP

• Poison control recommends treatment with IV deferoxamine

Medical Management:

Physical Examination Findings:

• Order third bolus of IV saline push

• Unchanged from stage 2 except that HR is now 150/min and BP is 66/52 mm Hg

• Begin administration of dopamine as it arrives, titrates to improve BP (this happens when dopamine is running at 10 mcg/kg/min)

• Abdomen: no hepatosplenomegaly

• Consult intensive care service for admission

• Order deferoxamine as recommended

STAGE 4

Condition:

REASSESS THE PATIENT:

 

5

Patient improves with vasopressor support

Disposition:

Physical Examination Findings:

Arrange for ICU admission or transport to tertiary care facility (depending on presenting facility resources)

• HR 148/min, BP 78/62 mm Hg, saturation 98% on nonrebreather mask

• Extremities feel warmer

 

• Child is somewhat more alert

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.

Simulator: Pediatric Simulator

Scenario

Patient

   

Instructor

Time,

Stage

Condition

Intervention

Debriefing Notes

min

STAGE 1

History:

 

Take a History:

 

3

• Five-year-old boy

• Previously healthy

• Cough, runny nose, and fever for 5 d

• Other kids at school sick with similar cough, cold symptoms

• Diaphoretic and chills today

• Unwell today, slept most of the day

• Short of breath and felling unwell

• Woke up, vomited five times

• Taken to the emergency department for assessment

• Diaphoretic and chills

Weight:

20 kg

• Given acetaminophen (paracetamol) only

Airway:

Condition:

Looks very unwell, toxic

• Talk to the patient

• Optimize airway position: head tilt, chin lift, jaw thrust

Physical Examination Findings:

Temperature 39°C (102.2°F), HR 170/min, RR 40/min, BP 95/P

Breathing:

• Check oxygen saturation

 

mm

Hg, oxygen saturation 88% on room air

• Give 100% oxygen

• Auscultate chest

Monitor: sinus tachycardia

CNS: awake, GCS score of 15

Circulation:

• Ask for monitors

CVS:

gallop rhythm, soft murmur, cap refill 3 s, pulses weak

• Check pulse, capillary refill, BP

• Identify the rhythm (sinus tachycardia) and recognizes uncompensated shock

Respiratory: crackles bilaterally

Abdomen: liver edge palpable

Rest

of examination results normal

• Insert IV catheter two times (large bore)

 

• Order IV normal saline bolus

Medical Management:

• Order blood work: CBC, differential, blood culture, electrolytes, BUN, creatinine, glucose, blood gas, LFTs, PTT, and INR

• Order IV antibiotics

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- inflating bag

Monitor: sinus tachycardia

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

STAGE 3

Condition:

 

REASSESSMENT OF THE PATIENT:

 

5

The

patient’s perfusion is getting worse with the second

 

Airway:

fluid

bolus

• Reassess airway

Physical Examination Findings:

• Suction airway as needed

Temperature 39°C (102.2°F), HR 180/min, RR 45/min, BP 65/P mm Hg, oxygen saturation 92% on 100% oxygen with assisted ventilations

• Prepare for rapid sequence intubation

Breathing:

 

Assist ventilations with anesthesia bag/self-inflating bag

Monitor: sinus tachycardia

Circulation:

CNS: drowsy but arousable, GCS score of 12

• Identify worsening shock

CVS:

gallop rhythm, soft murmur, cap refill 5 s, pulses weak

• Order IV inotrope infusion for suspected cardiogenic shock (dopamine/milrinone/epinephrine [adrenaline]).

Respiratory: crackles

Abdomen: liver edge palpable

Medical Management:

Rest

of examination results normal

Chest radiograph: bilateral hazy, wet lung fields with an enlarged heart

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.

Simulator: Infant Simulator IMPORTANT REMINDER: If required, change the lens of the simulator to simulate dilated pupil on the LEFT.

Scenario

Patient

 

Instructor

Time,

Stage

Condition

Intervention

Debriefing Notes

min

STAGE 1

History:

Take a History:

 

3–4

• Six-month-old child found by parent in crib, unarousable after nap

• No allergies

• No medications

• Babysitter put him down a few hours ago, thought he was fine

• No ill contacts

• No idea at all what has happened

• Child was completely well when parent left this morning

• No history of trauma or fall

• Triage nurse has rushed patient back to resuscitation room because he is barely responsive at triage

• No other children in home

• Babysitter has been with them approximately 1 month

• You arrive to assess the patient

Airway:

Weight:

• Listen for breath sounds, present but slow

7 kg

• Apply oxygen via nonrebreather mask at 15 L/min

Condition:

Breathing:

Infant is pink and well perfused but comatose

• Apply monitors, including oxygen saturation and BP

Physical Examination Findings:

• Auscultate chest and observe respiratory rate

• Temperature 37.2°C (99°F), HR 104/min, RR 12/min, oxygen saturation 97% in room air, BP 89/66 mm Hg

Circulation:

• Assess pulse, HR, capillary refill, BP

• CNS: unresponsive, if painful stimulation is given (nailbed pressure or sternal rub, demonstrate EXTENSOR posturing:

• Ask nurse to obtain IV access, ideally two larger IV catheters

 

“The child did this [demonstrate] when you did that?”)

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