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EclampsiaCase

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SectionI:ScenarioDemographics

ScenarioTitle: EclampsiaDateofDevelopment: 06/04/2015(DD/MM/YYYY)

TargetLearningGroup: Juniors(PGY1–2) Seniors(PGY≥3) AllGroupsSectionII:ScenarioDevelopers

ScenarioDeveloper(s): KylaCaners

Affiliations/Institution(s): McMasterUniversityContactE-mail(optional): kcaners@gmail.com

SectionIII:CurriculumIntegration

LearningGoals&ObjectivesEducationalGoal: Topracticethemanagementofeclampsia,arelativelyrarepresentationwith

importantcriticalcarestepsinitsmanagement.CRMObjectives: Communicateeffectivelywithteamandconsultantstoprovideexpedientpatient

care.MedicalObjectives: 1) Recognizepotentialpre-eclampsia/HELLPandinitiateappropriatediagnostic

workup.2) Administerappropriatedoseofmagnesiumsulfateforeclampsia,including

repeateddoses.3) Recognizeapneaasapossibleconsequenceofmagnesiumadministrationand

appropriatelyworkthroughdifferentialdiagnosisandmanagementofapnea.

CaseSummary:BriefSummaryofCaseProgressionandMajorEvents30year-oldfemale,G1P0at32weeks,presentstotheEDwithheadache,blurredvision,nausea,andvomiting.HerarrivalBPis165/115.Astheteamcoordinatesherinitialworkup,thepatientwillbegintoseize.Shewillnotstopseizinguntilmagnesiumsulfateisgiven.Thepatientwillthenrequireintubationforrespiratorydepression.ThecasewillendpostintubationwhenthepatienthasbeenreferredtoOB.

ReferencesMarx,J.A.,Hockberger,R.S.,Walls,R.M.,&Adams,J.(2013).Rosen'semergencymedicine:Conceptsandclinicalpractice.St.Louis:Mosby.MageeLA,PelsA,HelewaH,etal.SOGCClinicalPracticeGuideline:Diagnosis,evaluationandmanagementofthehypertensivedisordersofpregnancy:executivesummary.JObstetGynaecolCan2014;36(5):416–438

EclampsiaCase

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SectionIV:ScenarioScript

A.ScenarioCast&RealismPatient: ComputerizedMannequin Realism:

Selectmostimportantdimension(s)

ConceptualMannequin PhysicalStandardizedPatient Emotional/ExperientialHybrid Other:TaskTrainer N/A

Confederates BriefDescriptionofRoleNurse Simulatesseizureswhenappropriatebothbyshakingbedandbystating“Ithink

thepatientisseizing.”

B.RequiredMonitorsEKGLeads/Wires TemperatureProbe CentralVenousLineNIBPCuff DefibrillatorPads CapnographyPulseOximeter ArterialLine Other:

C.RequiredEquipmentGloves NasalProngs ScalpelStethoscope VenturiMask TubeThoracostomyKitDefibrillator Non-RebreatherMask CricothyroidotomyKitIVBags/Lines BagValveMask ThoracotomyKitIVPushMedications Laryngoscope CentralLineKitPOTabs VideoAssistedLaryngoscope ArterialLineKitBloodProducts ETTubes Other:IntraosseousSet-up LMA Other:

D.MoulagePillow/clothestomimicappearanceofpregnantpatient.Appropriateadjunctstohelpsimulateseizure.

E.ApproximateTiming

Set-Up: 5min Scenario: 15min Debriefing: 20min

EclampsiaCase

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SectionV:PatientDataandBaselineState

A.ClinicalVignette:ToReadAloudatBeginningofCaseMirandaHammpresentstoyourlocaltertiarycareEDcomplainingofaheadache.Sheisa30yearoldG1P0at32weeks.Shehashadaheadachesincelastnight.Thismorningshestartedfeelingnauseousandbeganvomiting.Nowhervisionfeelsblurred,soshecameforassessment.

B.PatientProfileandHistoryPatientName:MirandaHamm Age:30 Weight:75kgGender: M F CodeStatus:FullChiefComplaint:headacheHistoryofPresentingIllness:Headachesincelastnight.Circumferentialandpounding.Thoughtitwashernormalmigrainebutwasafraidtotakeanymedicationbecauseofpregnancy.Thenstartedhavingnauseaandvomiting.Didn’treallysleepallnight.Nowheadacheisworseandvisionfeelsblurry.She’sneverhadblurredvisionbefore.PastMedicalHistory: Migraines Medications: None. Allergies:None.SocialHistory:Liveswithhusband.FamilyHistory:Norelevantdisorders.ReviewofSystems: CNS: Headachesincelastnight,circumferentialandpounding.

HEENT: Blurredvisionthismorning.“FeelslikeI’mlookingthroughfog.”CVS: Nil.RESP: Nil.GI: Nauseousalldayyesterday.Vomitinglastnightandthis

morning.GU: Nil.MSK: Nil. INT: Nil.C.BaselineSimulatorStateandPhysicalExam

NoMonitorDisplay MonitorOn,nodatadisplayed MonitoronStandardDisplayHR:110/min BP:175/115 RR:20/min O2SAT:96%RARhythm:Sinustach T:36.5oC Glucose:6.4mmol/L GCS:15(E4V5M6)GeneralStatus:Well-looking,butappearsinpain.CNS: A+Ox3.Nofacialasymmetry.Nofocaldeficits.Reflexes2+.HEENT: PERLA3mm.Nopapilledema.CVS: NormalS1/S2.Nomurmur.RESP: Innodistress.Appropriatelytachypneicforpregnancy.ABDO: Gravid,non-tenderuterus.SomeRUQtenderness.IfFHRchecked,it’s160.GU: Nil.MSK: Nil. SKIN: Nil.

EclampsiaCase

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SectionVI:ScenarioProgression

ScenarioStates,ModifiersandTriggersPatientState PatientStatus LearnerActions,Modifiers&TriggerstoMovetoNextState1.BaselineStateRhythm:SinustachHR:110/minBP:175/115RR:20/minO2SAT:96%T:36.5oC

A+Ox3.Answeringquestions.Slightlytachypneic.RUQtenderness.

LearnerActions- IV,monitors- AssessFHR(160)- Bloodworkandurinalysis- HxandPx

ModifiersChangestopatientconditionbasedonlearneractionTriggersForprogressiontonextstate-3minutesà2.Seizure

2.SeizureHRà130

Activelyseizing.Nursetocuelearners(Ithinkshe’sseizing!)andinitiateseizure.

LearnerActions- AdministerMgSO44givbolusthen1-2g/hriv- Checkcapsugar(6.4)- CallOB/GYNfordelivery

Modifiers-BenzogivenànochangetoseizuresTriggers-MgSO4givenà3.Apnea

3.ApneaHRà110RRà6à0O2SATà90à88%BPà165/115

Notseizing.RRslowlydecreasingwithassociateddesaturations.Notresponsive.

LearnerActions- InitiateBVM- StopMgSO4infusion- GiveCagluconate1giv- Administerinduction- Administerparalytic

Modifiers-BVMinitiatedàO2SAT93%-PropofolormidazolamforinductionàBP160/110-CalciumgluconateànoeffectTriggers-Intubatedà4.Post-intubation

4.Post-intubationHRà110RRà12(vent)O2SATà98%BPà165/115

Intubatedandsedated.

LearnerActions- CallOB/GYN- CallICU- Post-intubationCXR- RestartMgSO4infusion- Labetololorhydralazine- ConsiderCThead

Modifiers-AntihypertensiveàBP145/100Triggers-Antihypertensivegivenà5.Resolution-15minà5.Resolution

5.ResolutionBPà145/100

Intubatedandsedated.

OB/GYNarrivestotakepatientforC/S.àTeamtoexplaincasetoconsultant.Endscenario.

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SectionVIII:DebriefingGuide

GeneralDebriefingPlanIndividual Group WithVideo WithoutVideo

ObjectivesEducationalGoal: Topracticethemanagementofeclampsia,arelativelyrarepresentationwith

importantcriticalcarestepsinitsmanagement.CRMObjectives: Communicateeffectivelywithteamandconsultantstoprovideexpedient

patientcare.MedicalObjectives: 1) Recognizepotentialpre-eclampsia/HELLPandinitiateappropriate

diagnosticworkup.2) Administerappropriatedoseofmagnesiumsulfateforeclampsia,

includingrepeateddoses.3) Recognizeapneaasapossibleconsequenceofmagnesium

administrationandappropriatelyworkthroughdifferentialdiagnosisandmanagementofapnea.

SampleQuestionsforDebriefing1) Whatisthedosingformagnesiumsulfateineclampsia?Inpre-eclampsia?2) Whenshouldyouconsiderananti-hypertensiveineclampsia?3) Whydidthispatientbecomeapneic?Whataretheotherassociatedsideeffectsofmagnesium?What

isapossibletreatmenttoreversetheseeffects?KeyMoments

Recognitionofpossiblepre-eclampsiaHELLPsyndromeandinitiationofkeybloodwork.AdministeringMgSO4totreateclampsia.RecognizingapneaassideeffectofMgSO4.