module simulation scenariosmodule simulation scenarios contents adrenal insufficiency 1 blunt...

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

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


1 Simulation Scenarios Adrenal Insufficiency

Adrenal Insufficiency

Adam Cheng, MD, FRCPC, FAAPMark Adler, MD

Learning Objectives

• Describethesignsandsymptomsofaninfantpresentingwithsalt-wastingadrenalcrisisassociatedwithcongenitaladrenalhyperplasia and adrenal insufficiency.

• Demonstratethetreatmentofanewbornwithsalt-wastingcrisis.– Initial stabilizing steps.– Replacement therapy.

Simulator: Infant Simulator

Scenario Stage

Patient Condition Intervention

Instructor Debriefing Notes

Time, min

STAGE 1 History• Three-week-oldboywithunremarkablehistory,referredto

emergencydepartmentfromphysician’sofficewithalowserumsodiumlevel(126mmol/L)

• Mother’spregnancywasnormal;sherecallsnoabnormaltestresults

• Triagenursewasworriedabouthowillthechildappears• Youarrivetoassessthepatient

Weight: • 3kg

Condition: • Veryunwell,listless

Physical Examination Findings:• Temperature36.2°C(97.2°F),HR152/min,RR36/min,oxygen

saturation98%inroomair,BP72/58mmHg• CNS:asleep,wakesbrieflywithpainfulstimulation• CVS:pulsespresentcentrally,absentperipherally• Respiratory:clear• Abdomen:nohepatosplenomegaly• Extremities/skin:capillaryrefill>4s

Take a History: • Noillcontacts• Nomedications• Noallergies• Poorfeedingoverlastweek,spittingupmoreinpastfew

days• Nofever• Sleepingthroughfeedingtimelastfewdays,sleptmostof

thelast12h• Haslostweightsincelastfamilyphysicianvisit

Airway:• Listenforbreathsounds,present• Applyoxygenvianonrebreathermaskat15L/min

Breathing: • Applymonitors,includingoxygensaturationandblood

pressure• Auscultatechestandobserverespiratoryrate

Circulation:• Assesspulse,HR,capillaryrefill,BP• AsknurseforanIVcathetertobeplaced• AskfornormalsalineorlactatedRingersolutionbolusof20

mL/kgtobegivenquickly(push)

Medical Management:• Orderlaboratorytests:(CBC,electrolytes,bloodcultures,

venousbloodgas,bedsideglucose)

5



Scenario Stage



Time, min

STAGE 2 Condition:• HRremainselevatedandBPisnowlow• Nursenotesaloud,“Hishandsarejustsocold.”• Bloodglucoselevelislowifbedsidetestingwasperformed• Laboratoryresults:sodium124mmol/L,potassium7.8

mmol/L,bicarbonate16mmol/L,BUNandcreatininenormalforage,pHfromvenousgas7.26

Physical Examination Findings:

• HR150/min,RR36/min,oxygensaturation99%on100%oxygen(ifplaced),BP73/60mmHg

• CNS:criesweaklywithpainfulstimuli• Respiratory:clear• CVS:clampeddownandcoolextremities.• Abdomen:nohepatosplenomegaly

REASSESSMENT OF THE PATIENT:Circulation:

• ReassessHR,pulse,capillaryrefill,BPafterbolus• Ordersecondbolus,alsopush

Medical Management:• Consultendocrinologistfortreatmentguidance;ordertests

theymightrequest• OrderIVhydrocortisone• OrderD10WIVbolustocorrecthypoglycemia• Initiatemanagementofhyperkalemia

5

STAGE 3 Condition:• “Heislookingaroundmorenow.”• Improvedperfusionandalertnessaftersecondbolus

Physical Examination Findings:• HR138/min,RR36/min,BP78/48mmHg,saturation98%on

roomair• Abdomen:nohepatosplenomegaly

REASSESSMENT OF THE PATIENT:

Circulation:• ReassessHR,pulse,capillaryrefill,BP

Medical Management:• Orderrecheckofelectrolytesafterbolustherapy

Disposition:• ArrangeforneonatalorpediatricICUformonitoring

andfrequentlaboratoryworkuntilstabilizedorplanfortransporttotertiarycarefacility(dependingonpresentingfacilityresources)

5

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.



Notes

1.Potassiumandsodiumderangementsusuallydonotrequireshort-termtreatmentbeyondfluidresuscitationandhydrocortisone.

Common Pitfalls

• Intravenous(IV)fluidforvolumeexpansionisnotdeliveredinarapidand/orcontrolledmanner.– IV“wideopen”fluidadministrationcanleadtoveryrapidinfusionofawholeliteroffluidORcanresultinunderresuscitationifthereissignificantre-

sistancetoflow(smallIVgauge).Infantsandsmallchildrenshouldalwaysreceiveresuscitationfluidsusingapumporpushtoallowforobservationandcontroloffluiddelivery.Pressurebagscanincreasethelikelihoodofexcessivefluidoverload.

– Pushingfluidisaccomplishedbyattachingathree-waystopcockinlinewiththeIVcatheterandpullingfluiddirectlyfromthebag(step1)andthenswitchingthestopcockandpushingthefluidintothepatient.

• Failingtocheckabedsideglucoselevel.Hypoglycemiaisnotalwayspresentinpatientswithcongenitaladrenalhyperplasiaandsalt-wastingcrisis,butitcanoccur.

• Delayingtreatmentwithhydrocortisonetoobtaindiagnostictests.


4 Simulation Scenarios Blunt Abdominal Trauma—Hypovolemic Shock

Blunt Abdominal Trauma—Hypovolemic Shock


Learning Objectives

• Describethesignsandsymptomsofapatientwithhypovolemicshock.• Demonstratethemanagementofcirculatoryfailureduetohypovolemicshock.

– Demonstrate the approach to pediatric trauma: primary and secondary assessment.– Demonstrateuseoffluidresuscitationinpatientswithprofoundbloodloss.– Identify and manage abdominal injury in a trauma patient.– Demonstrate use of rapid infuser in trauma care.

Simulator: Pediatric Simulator

Scenario Stage



Time, min

STAGE 1 History: • Five-year-oldboy• Playinginthedriveway• Foundbyparentscrushedandtrappedunderneathgarage

door• Garagedoordirectlyoverhisabdomen• Nowitnessestotheincident• Ambulancearrivedwithin12min

Weight:• 18kg

Condition:• Moaninginpain• Temperature36°C(96.8°F),HR150/min,RR30/min,BP85/50

mmHg,oxygensaturation96%roomair• Monitor:sinustachycardia• CNS:cervicalcollaronpatient;moaninginpain,answers

questions,askingformom,confusedattimes,GCSscoreof15.

• H/N:cervicalspinenottender,noobviousfacialinjury• CVS:capillaryrefill4s,pulsespalpablebutweak• Respiratory:chestclear• Abdomen:bruisingalloverabdomen• Neurologic:normal• Musculoskeletal:normal

TAKE A HISTORY:

From Paramedics:• Initiallydelirious,screaming,GCSscoreof15/15• Extractiontook10minintotal• IVantecubitalonetime• Givennormalsaline.20mL/kg• Transporttime,15min

PRIMARY SURVEY MANAGEMENT:

Airway:• Assessairway,talktothepatient

Breathing:• Checkoxygensaturation• Applymonitors• Auscultatechest• Checkforchestrise• Apply100%oxygen

Circulation:• Applymonitors• Checkpulse,capillaryrefill,BP• Identifytherhythm• CheckfirstIVcatheter,asksforsecondlarge-boreIVcatheter• AskforrapidinfuserandbolusofIVnormalsaline• Ordertraumabloodwork,includingtypeandcross.• Activatetraumateam/callforhelp

2



Scenario Stage



Time, min

STAGE 2 Condition:• Thepatient’sconditionhasworsenedslightly,BPlower,GCS

scoreunchanged

Physical Examination Findings:• Temperature36°C(96.8°F),HR170/min,RR40/min,BP80/40

mmHg,saturation100%withoxygenbymask• Monitor:sinustachycardia• CNS:cervicalspinecollaronpatient;moaninginpain,

answersquestions,askingformom,confusedattimes,GCSscoreof15

• H/N:cervicalspinenottender,noobviousfacialinjury• CVS:capillaryrefill4s,pulsespalpablebutweak• Respiratory:chestclear• Abdomen:bruisingalloverabdomen• Neurologic:normal• Musculoskeletal:normal


Airway:• Maintaincervicalspineprecautions

Breathing:• Auscultatechest

Circulation:• ReassessHR,pulses,BP,capillaryrefill• AskforsecondbolusofIVnormalsaline• Reaffirmneedforrapidinfuser• Orderblood

Performs Secondary Survey:• H/N:pupilsequalandreactivetolight,facialbonesnot

tender,necksuppleandnottender• Chest:tracheamidline,chestclear.• CVS:profoundlytachycardic,colormottlednow,pulses

weak,andcapillaryrefill5s• Abdomen:soft.Bowelsoundsabsent,tenderallover

abdomen(screamsinpain)• Pelvis:stable.• Genitalia:nobloodatmeatus• Musculoskeletal:normal• Back:goodrectaltone,notenderness

Medical Management:• Paincontrol:IVmorphine• Immediateconsultation:generalsurgery• Orderradiographs:cervicalspine,chest,pelvis• Insertnasogastrictube• InsertFoleycatheter

3



Scenario Stage



Time, min

STAGE 3 Condition:• Thepatientislessresponsive,BPisdecreasing,eyesstillopen,

GCSscoreof13

Physical Examination Findings:• Temperature36°C(96.8°F),HR180/min,RR40/min,BP70/30

mmHg,saturation100%withoxygenbymask• Monitor:sinustachycardia• CNS:cervicalspinecollaronpatient;moaninginpain,

intermittentlyanswersquestions,confusedanddeliriousattimes,GCSscoreof13.

• H/N:cervicalspinenotobviouslytender,noobviousfacialinjury

• CVS:capillaryrefill5s,pulsespalpablebutveryweak• Respiratory:chestclear• Abdomen:bruisingalloverabdomen• Neurologic:normal• Musculoskeletal:normal

REASSESSMENT OF PATIENT:

Airway: Intubation:• Prepareforintubationduetodecreasinglevelof

consciousness• Preoxygenate• PrepareequipmentandETCO2

• IVatropine• IVketamineoretomidate• IVsuccinylcholine• Checktubeplacementafterintubation,orderchest

radiographifintubationisperformed

Breathing:• Assesschestbeforeandafterintubation• Monitoroxygensaturation

Circulation:• Identifyworseningshock• OrderthirdbolusofIVnormalsalineandblood(Onegative

ifcross-matchednotavailable)

Blood Work:• WBC15,500/mm3,hemoglobin7g/dL,platelets500,000/

mm3

• Sodium135mmol/L,potassium4.5mmol/L,urea4.2mmol/L,creatinine46mmol/L,glucosenormal

• pH7.20,Pco240mmHg,Po280mmHg,bicarbonate15mmol/L,baseexcess−11mmol/L

Imaging:• Normalradiographs

Medical Management:• Generalsurgeonarrives:discussneedtoperformCTofthe

abdomenvsdirecttooperatingroom• Considerfocusedabdominalsonographyfortrauma• DiscussneedforCToftheH/Nandchest.

5

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.



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

• Failuretostabilizecervicalspineduringassessmentandtreatmentofpatient.• Failuretoperformacompletesecondarysurvey(eg,failuretologrollpatientorfailuretoassessneurologicstatusoflowerextremity).• Sedationand/orparalysisofpatientbeforecompletingneurologicassessmentofpatient.• Treatmentofpatientwithoutsupportofconsultants.


8 Simulation Scenarios Cardiogenic Shock Due to Congenital Heart Disease

Cardiogenic Shock Due to Congenital Heart Disease


Learning Objectives

• Describethesignsandsymptomsofaninfantwithcardiogenicshock.• Demonstratethemanagementofcirculatoryfailureduetocardiogenicshock.

– 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.


Scenario Stage



Time, min

STAGE 1 History:• Five-month-oldboywithhistoryofpoorfeedingandweight

lossforpastmonth• Sentfromphysician’sofficeforevaluation• Youarecalledtoevaluatepatient

Weight: • 5kg

Condition: • Veryunwell,gray,withrespiratorydistress

Physical Examination Findings:• Temperature37.3°C(99°F),HR158/min,RR58/min,oxygen

saturation91%inroomair,BP72/58mmHg• CNS:criesweakly,laysstillinbed• CVS:pulsespresentcentrally,weakperipherally• Respiratory:bilateralcrackles,retractions• Abdomen:liverisfirmandenlargedtotheumbilicusinthe

midclavicularline• Extremities/skin:capillaryrefillapproximately3s

Take a History: • Noillcontacts• Noupperrespiratorytractinfectionsymptoms,nodiarrhea• Takesalongtimetoeatandtiresout;sweatsalotwithfeeding• Wasnotedtohavea“holeintheheart”onaprenatal

ultrasonogrambuthadnomurmuratbirth—nofollow-upwasperformed

• Noallergies• Refluxmedicationsstartedforpoorfeeding• Approximately0.5-kgweightlostduringlast2wk

Airway:• Listenforbreathsounds• Applyoxygenvianonrebreathermaskat15L/min

Breathing:• Applymonitors,includingoxygensaturationandblood


Circulation:• Assesspulse,HR,capillaryrefill,BP• Murmurandgalloprhythmheard• AsknursetoobtainIVaccess• AskfornormalsalineorlactatedRingersolutionbolusof5

or10mL/kg• Palpateabdomenfororganomegalyasasignofrightheart

failure

5


9 Simulation Scenarios Cardiogenic Shock Due to Congenital Heart Disease

Scenario Stage



Time, min

STAGE 1, continued

Medical Management:• Orderlaboratorytests(CBC,electrolytes,venousbloodgas,

bedsideglucose,considerinfectionlaboratoryworkatthistimeasdiagnosisnotclear)

• OrderECGandachestradiograph

STAGE 2 Condition:• Conditionisunchanged• Venousgasrevealsacidosis(pH7.21,Pco228mmHg,Po232

mmHg,baseexcess−16mmol/L)• Bloodglucoselevelisnormal• Chestradiographrevealsmarkedcardiomegalywith

pulmonarymarkingsconsistentwithfluidoverload

Physical Examination Findings:• HR163/min,RR60/min,oxygensaturation98%in100%

oxygen(ifplaced),BP78/53mmHg• Examinationfindingsunchanged


Circulation:• NursecannotobtainIVaccess;intraosseousneedleplaced

byparticipant• ReassessHR,pulse,capillaryrefill,BPafterbolus• Callforcardiologisttoconsultandperform

echocardiography;ifnotlocallyavailable,beginprocessoftransferringpatient

• ConsiderIVfurosemideforfluidoverload• Considerafterloadreduction(eg,milrinone)

Medical Management:• Considerbicarbonateforacidosis

7

STAGE 3 Condition:• Patientstabilizes

Physical Examination Findings:• HR162/min,RR52/min,BP78/62mmHg,saturation98%on

nonrebreathermask

REASSESS THE PATIENT:

Disposition: • ArrangeforICUadmissionortransporttotertiarycare

facility(dependingonpresentingfacilityresources)• ObtainsecondIVaccessotherthanintraosseousaccess

5

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

Notes1. 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

fluidoverload.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• Misrecognitionofpatientashavingrespiratorydistressduetoreactiveairwaydiseaseandadministrationofalbuterol(salbutamol).Patientwillgetworse

with this therapy.• Misrecognitionofpatientashavingsepsis,withexcessivefluiddelivery,resultinginincreasingheartrateandrespiratoryrateanddecreasedoxygen

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.

• Treatmentofpatientwithoutsupportofconsultants.Echocardiographyisanimportantstepinmanagementplanning,andtheinitialstepsinperformingthis test should be started as soon as possible.


10 Simulation Scenarios Altered Mental Status

Altered Mental Status


Learning Objectives

• Describethecommoncausesofalteredmentalstatusinaninfant.• Demonstratethetreatmentofaninfantwithalteredmentalstatus.

– Assessing for possible ingestion.– Checking glucose at bedside.– Treating hypoglycemia and confirming that treatment was effective.


Scenario Stage



Time, min

STAGE 1 History:• Eleven-month-oldfoundunresponsive,waswith

grandmother,whoishisusualbabysitter• BroughttoEDbygrandmother• Unresponsiveattriage,broughttoresuscitationbay• Youarecalledtoassesspatient

Weight: • 9kg

Condition:• Infantispinkandwell-perfusedbutcomatose


saturation98%inroomair,BP89/66mmHg• CNS:unresponsivetopainfulstimulationifgiven.Pupils3

mmandreactivebilaterally• CVS:pulsesintact• Respiratory:clear• Abdomen:softandwithouthepatosplenomegaly• Extremities/skin:nobruisingnoted(ifaskedspecifically)

Take a History: • Noallergies• Patienttakesnomedications• Noillcontacts• Noideaatallwhathashappened• Nohistoryoftraumaorfall• Nootherchildreninhome• Ifaskedspecifically,grandmothertakesoralsulfonylurea

(glyburide),whichshekeepsinabedsidedrawer

Airway:• Listenforbreathsounds



Circulation:• Assesspulse,HR,capillaryrefill,BP• AsknursetoobtainIVaccess

Disability:• Quickneurologicassessment(pupils,responsetopain)

3–4


11 Simulation Scenarios Altered Mental Status

Scenario Stage



Time, min

STAGE 2 Condition:• Mentalstatusunchanged• Bloodglucoselevelislowifmeasured

Physical Examination Findings:• Vitalsunchanged

Medical Management:• Recognizeandtreathypoglycemia(5mL/kgD10Wusingthe

“ruleof50”—seenotebelow)• Performfurtheringestionlaboratorytests(urinetoxicology,

acetaminophen[paracetamol],salicylates,ethanol,+/–digitalislevels)

5

STAGE 3 Condition:• Patientisnowmoreawakeandcries• HR125/min,RR28/min,BP85/62mmHg,saturation98%on

roomair

Medical Management:• Orderrecheckofglucoselevelin15–30min• RecognizeneedtoprovidesupplementaryIVglucoseand

admitduetolong-actingoraldiabeticagent

Disposition:• HospitalorICUforfrequentIVglucoselevelchecks

5

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 5mL/kg 50

D25 2mL/kg 50

D50 Notrecommendedduetohighosmolarity

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.Specificdrugscreeningpracticesvary.Althoughpolyingestionsaremorecommoninadolescents,mostofthelisteddrugsabovearehigh-risk,treatable

entities.

Common Pitfalls

• Participantsdonotaskaboutmedicationinthehomebutonlywhatthechildistaking.• Participantschecktheglucoselevelandtreatthepatientaccordingtotheglucoselevelbutfailtoobtainafollow-upglucosemeasurement.


12 Simulation Scenarios Diabetic Ketoacidosis and Cerebral Edema

Diabetic Ketoacidosis and Cerebral Edema


Learning Objectives

• Describethesignsandsymptomsofachildpresentingwithdiabeticketoacidosis(DKA).• Describethesignsandsymptomsofmoderatedehydration.• DemonstratethetreatmentofachildwithDKA.

– Initial stabilizing steps.– Management of suspected cerebral edema.


Scenario Stage



Time, min

STAGE 1 History: • Six-year-oldgirl• Two-weekhistoryoffeverandlethargy• Veryunwellinlast24h:excessivelydrowsy,verypoor

energy,difficultybreathing,abdominalpains

Weight: • 20kg

Condition: • Looksunwell;GCSscoreof13(motorresponse6,vocal

response4,eyeresponse3)

Physical Examination Findings:• Temperature37.4°C(99.3°F),HR160/min,RR30/min,BP

90/50mmHg,oxygensaturation98%onroomair• Veryflushedcheeks• Monitor:sinustachycardia• CNS:sleepy,pupilsnormal• CVS:normalheartsounds,capillaryrefill3s,pulsesweak• Respiratory:Kussmaulrespirations,lungfieldsclear• Mucousmembranes:mouth/lipsverydry,cryingafewtears• Abdomen:milddiffusetenderness

Takes a History:• Excessivedrinking,bedwetting,andincreasingtiredness• “Growingbutnotgainingweight”• Unwellfor36hwithincreasingfatigue,vagueabdominal

pain• Polyuria,polydipsia,enuresis,5-kgweightloss• Novomiting• Becomingprogressivelylethargictoday• Medicalhistory:unremarkable

Airway:• Assessairway• Provideheadtilt,chinlift,jawthrustasneeded

Breathing:• Checkoxygensaturation• Auscultatechest• IdentifyKussmaulrespirations

Circulation:• Applymonitors• CheckHR,BP,capillaryrefill• InsertIVcatheter,keepspatientnothingbymouth• Identifysinustachycardia

5



Scenario Stage



Time, min

STAGE 1,continued

Assesses Hydration:• Capillaryrefill• Skinturgor• Mucousmembranes• Urineoutput• Assigndegreeofdehydration• Strictmonitoringofintakeandoutput

CNS:• Establishbaselineexamination• Expressneedtomonitorforcerebraledema

Medical Management:• Orderbloodwork:CBC,differential,electrolytes,renal

function,capillarygas,bedsideglucose,serumosmolality,andurinedipforglucose/ketones

• Bedsideglucose:criticallyhigh• Urinediporketones4+• IdentifyDKAasdiagnosis

Begin DKA protocol:• Havepatientweighed/askforpatientweight• ConsiderneedforIVnormalsalinebolus(10mL/kg)• CalculateIVrateassumingneedtoreplacedeficitevenly

over48h• Useappropriatereplacementfluidpendinglaboratory

results• OrderIVinsulininfusion• Useflowsheettotracklaboratoryresults,vitalsigns

STAGE 2 Condition: • Patientlessresponsive,GCSscoredecreasing

Physical Examination Findings:• GCSscoreof8(motorresponse3,vocalresponse3,eye

response2)• Temperature37.5°C(99.5°F),HR120/min,RR24/min,BP

110/60mmHg,oxygensaturation98%onroomair• Monitor:sinustachycardia• CNS:grumpyandtired,mumbling,eyesclosed• CVS:normalHS,capillaryrefill2s,pulsesstillweak• Respiratory:abitlesslabored• Abdomen:seemslesstender• Restofexaminationresultsunchanged

REASSESSMENT OF THE PATIENT:Airway:

• Suctiontheairway• Repositiontheheadwithheadtilt,chinlift,jawthrust• Reapplyoxygenmask

Breathing:• Reassess• Prepareforpossibleintubation:drawsuprapidsequence

intubationmedication

Circulation:• ReassessHR,BP,capillaryrefill

5



Scenario Stage



Time, min

STAGE 2, continued

CNS:• ReassessGCSscore• Institutefrequentneurochecks• LookforCushingtriad,posturing

Medical Management:• Laboratoryresults:glucosecriticallyhigh(atbedside);urine4+

ketones,4+glucose,urinespecificgravity(SG)1.030• ContinueDKAprotocol• Recheckfluid-ratecalculations• Considerimpendingcerebraledemaandtranstentorial

herniation• CallICUforconsultation• Considermanagementofincreasedintracranialpressure:

IVmannitolor3%sodiumchloridesolution(ie,hypertonicsaline)

• Repeatbedsideglucosemeasurement• Orderrepeatlaboratorytests• Calculatecorrectedsodiumlevel• Recognizecoexistinghypernatremiaandneedforslow

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.ManagementofDKAinvolvesthepreparationandadministrationofvarioustypesofmedicationsandfluids.Therealismofthescenariocanbeincreasedby preparing labeled syringes with the names and concentrations of these medications and preparing an intravenous (IV) catheter with a drain so that the studentsareabletopushfluidsthroughthecatheter.

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

• IVfluidforvolumeexpansionisdeliveredtooaggressively.– 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.


15 Simulation Scenarios Hyperthermia

Hyperthermia


Learning Objectives

• Recognizethefeaturesofenvironmentalhyperthermia.• Demonstratethestepsintheinitialtreatmentofahyperthermicinfant.


Scenario Stage



Time, min

STAGE 1 History: • Eight-month-oldinfantwasunintentionallyleftinacarfor

2h;temperatureoutsidewas32.2°C(90°F)• Childwasapneic,pulseless,andcyanotic• CPRwasinitiatedbyparamedicswithbag-maskventilation.• ChildbroughttoEDbyparamedicswithCPRinprogress

Weight: • 8kg

Condition: • Apneicandnowwithfaintpulses(EMSreportspulsereturn

atarrival)• Temperature42°C(107.6°F),HR185/min,RR0/min,BP62/50

mmHg,oxygensaturation93%(bag-mask)• Monitor:sinustachycardia• CNS:obtunded,nonresponsive• Cardiovascular:capillaryrefill6–7s,weakpulsecentrally• Respiratory:coarsecracklesbilaterally• Abdomen:soft,noorganomegaly• Skin:hot,dry

Take a History: • Previouslyhealthy• Nomedicationsorallergies• Immunizationsuptodate• ParamedicshavebeendoingCPRfor5min

Airway:• Continuebag-maskventilation• Clearorsuctiontheairway• Prepareforpossibleintubation(gathersequipment)

Breathing: • Checkoxygensaturation• Applymonitors• Auscultatechest• Checkforadequacyofchestrisewithbagging

Circulation:• Applymonitors• Checkpulse,capillaryrefill,BP• EstablishIOaccess(IVattemptsfail)• Give20-mL/kgnormalsalinebolus• Ordervasopressor(dobutaminevsdopamine,avoids

primarilyα-agonists)

Disability and Exposure:• Checkneurologicstatus• Removeclothes• Activecoolingmeasures:coolingblanket,icebags,lower

roomtemperature,peritoneallavage(latterrarelyused)• Monitorrectaltemperature

5



Scenario Stage



Time, min

STAGE 1, continued

Medical Management: • Orderbloodwork:CPK,electrolytes,BUN,creatinine,CBC,

LFTs,bedsideglucose• OrderECG

STAGE 2 Condition: • Somecoolinghasoccurred

Physical Examination Findings:• Temperature40.5°C(105°F),HR169/min,RR20/min

(bagged),BP65/59mmHg,oxygensaturation98%• Monitor:sinustachycardia• CNS:obtunded,nonresponsive• CVS:weakpulses• Respiratory:clear• Abdomen:soft• Skinwarmanddry

Laboratory test results: • Glucoselevelnormal• Electrolytes(fromlaboratoryorgastestsifordered):sodium

148mmol/L,potassium4.6mmol/L,chloride110mmol/L,calculatedbicarbonate8mmol/L,ionizedcalcium1.01mmol/L


• Mayconsiderintubation• Baggedatrateof8–10/min

Breathing:• Notbreathingspontaneously

Circulation:• Placeurinarycathetertoassessrenalfunction• Begindobutamineordopamine

Medical Management:• Sendurinesampleformyoglobin/UA

5

STAGE 3 Condition:• Improvement

Physical Examination Findings:• Temperature39.6°C(103.3°F),HR159/min,RR10/min

(bagged),BP63/59mmHg,saturation98%with100%oxygen

• Monitor:sinustachycardia• CNS:unconscious• CVS:capillaryrefill4s,pulsesweak• Respiratory:clear• Skin:warm

Laboratory test results: • CPK,400IU/L;UAandhemoglobin

REASSESS THE PATIENT:Airway:

• Reassessairway(considersintubationifnotalreadydone)

Breathing:• Assessbreathing

Circulation:• Titratepressors

Medical Management:• Considerfurthermanagementforpossiblerhabdomyolysis

(furosemideand/ormannitol)• Notifycriticalcarepersonnel

5



Scenario Stage



Time, min

STAGE 4 Disposition:Condition:

• Stable

Physical Examination Findings:• Temperature39.2°C(102.6°F),HR155/min,RR10/min

(bagged),BP63/59mmHg,saturation98%with100%oxygen

• Monitor:sinustachycardia• CNS:unconscious• CVS:capillaryrefill3s,pulsesweak• Respiratory:clear• Skin:warm

• ArrangeDispositiontoICU 2

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.


18 Simulation Scenarios Hypothermia—Near Drowning

Hypothermia—Near Drowning


Learning Objectives

• Describethedefinition,signs,andsymptomsofhypothermia.• Demonstratethetreatmentofapatientwithsubmersioninjury.

– Initial stabilizing steps.– Recognize the importance of airway management and cervical spine protection in submersion injury.– Demonstrate passive and active rewarming techniques for hypothermia.


Scenario Stage



Time, min

STAGE 1 History:• Six-year-oldboy• Wasboatingwithhisfatherwhenthesmallboat

inadvertentlyhitalargewaveandflippedover• Childwasnotwearingalifejacket• Fathersurvivedandswamwithunconsciouschildtoshore• CPRinitiatedonthesceneand911called• Onarrival,paramedicsnotedchildwasapneic,pulseless,

andcyanotic• CPRwasinitiatedbyparamedicswithbag-maskventilation

andcervicalcollarapplied• ChildbroughttoEDbyparamedicswithCPRinprogress

Weight: • 20kg

Take a History: • Previouslyhealthy• Nomedicationsorallergies• Immunizationsuptodate• ParamedicshavebeendoingCPRfor10min

Airway:• Maintaincervicalspineprecautions• TakeoverbaggingandCPRimmediately• Clearorsuctiontheairway• Identifyneedsforimmediateintubation• Intubatepatientwithoutsedationorparalysis

Breathing: • Checkoxygensaturation• Applymonitors• Auscultatechest• Checkforadequacyofchestriseaftertubeisplaced• IdentifythatETCO2detectionnothelpfulbecausechildis

pulseless• Orderchestradiographtoconfirmtubeplacement

3



Scenario Stage



Time, min

Condition: • Apneicandpulseless• Temperature28°C(82.4°F),HR40/min,RR0/min,BPNA,

oxygensaturationNA• Monitor:sinusbradycardia• CNS:obtunded,nonresponsive,GCSscore3,cervicalspine

collaronpatient,bruisesandcutsonface• CVS:caprefill6–7s,nopulsepalpable• Respiratory:coarsecracklesbilaterally• Abdomen:bruisingalloverabdomen• Restofexaminationresultsnormal

Circulation:• Applymonitors• Checkpulse,capillaryrefill,BP• IdentifyPEA• InsertIVorIOcatheter• Donotorderepinephrine(adrenaline)becausecore

temperatureisbelow32°C(89.6°F)• GivewarmedIVfluidsthroughIOcatheterandattemptto

obtainsecondIV/IOaccess

Disability and Exposure:• CheckGCSscoreandneurologicstatus• Exposepatientcompletelytoconductasecondarysurvey• Applywarmblankets

Medical Management: • Orderbloodwork:arterialbloodgas,lactate,electrolytes,

BUN,creatinine,CBC,LFTs,glucose,crossmatch• Considerinternalrewarmingtechniques:gastriclavage,

bladderirrigation,andpossiblyperitonealirrigation• Activateextracorporealmembraneoxygenationteamand

PICUteam

STAGE 2 Condition:• Thepatient’sconditionhasnotchangedapartfroman

increaseinthetemperature.

Physical Examination Findings:• Temperature33°C(91.4°F),HR45/min,RR10/min(bagged),

BPNA,oxygensaturationNA• Monitor:sinusbradycardia• CNS:obtunded,nonresponsive,GCSscoreof3,cervical

spinecollaronpatient,bruisesandcutsonface• CVS:caprefill6–7s,nopulsepalpable• Respiratory:coarsecracklesbilaterally• Abdomen:bruisingalloverabdomen• Restofexaminationresultsnormal


• Intubatepatient• Bagatrateof8–10/min• Maintaincervicalspineprecautions

Breathing:• Notbreathingspontaneously

Circulation:• ContinueCPR• IdentifyPEA,temperaturehasincreasednowto33°C

(91.4°F).• Deliverdefibrillationat2J/kg• ContinueCPRandorderepinephrine(adrenaline)viaIO

catheter• ContinueCPR• GiveIVnormalsalinefluidbolus

2



Scenario Stage



Time, min

STAGE 2, continued

Medical Management:• Chestradiograph:bilateralhazylungfields,endotracheal

tubeingoodposition• ABG:pH6.9,Pco215mmHg,Po260mmHg,bicarbonate3

mmol/L,baseexcess−27mmol/L• Lactate8.0mmol/L• Glucometer:criticallow:correctsthiswithbolusifIVD10W• Unabletoobtainotherlaboratorytests

STAGE 3 Condition:• Thepatientisbacktoaperfusingrhythm

Physical Examination Findings:• Temperature35°C(95°F),HR80/min,RR10/min(bagged),BP

60/PmmHg,saturation91%with100%oxygen• Monitor:sinusrhythm• CNS:intubatedandunconscious• CVS:capillaryrefill4s,pulsesweak• Respiratory:coarsecracklesbilaterally• Abdomen:bruisingallovertheabdomen• Restofexaminationresultsnormal


Airway:• Intubateandsedate• Maintaincervicalspineprecautions

Breathing:• Assessbreathing

Circulation:• Identifyhypotension• Identifysinusrhythm• Stopchestcompressions• GiveIVnormalsalinefluidbolus• OrderinotropeinfusionIV(dopamineorepinephrine

[adrenaline])• ArrangetransfertoICUforadmissiontohospital

Medical Management:• PerformCTscanofhead,neck,andabdomen• Consultgeneralsurgeon• Consultneurosurgeon• Notifyparents

5

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.



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

• Failuretoconsistentlymaintaincervicalspineprotectionduringtheresuscitation.• Onecommonmistakeistoaggressivelyresuscitatethepatientwithmultipledosesofepinephrine(adrenaline)despitethepatientbeinghypothermic

(temperature <32°C [89.6°F]).• Failuretodryoffthepatientwithatowel.• Delayinginsertionofvenousaccessbyattemptingmultipleintravenouscatheterinsertions.Ideally,studentsshouldstartimmediatelywithattempted

intraosseous access.


22 Simulation Scenarios Iron Overdose

Iron Overdose


Learning Objectives

• Describethesignsandsymptomsofaninfantwithanironoverdose.• Demonstratethemanagementofacuteironintoxication.


Scenario Stage



Time, min

STAGE 1 History: • Twelve-month-oldboyfoundathomesleepy• Noprecedingillness• Chaotichomesettingwithfourotherchildrenandasingle

mother,shareshomewithanotherfamily

Weight: • 10kg

Condition: • Illappearanceandtachypnea,sleepy


saturation97%inroomair,BP68/42mmHg• CNS:asleep,wakesbrieflywithstimulation• CVS:pulsespresentcentrally,absentperipherally• Respiratory:clear• Abdomen:nohepatosplenomegaly• Extremities/skin:capillaryrefillapproximately3s

Take a History: • Noillcontacts• Nomedications• Patienthasvomitedathomeandhadloosestools• Ifasked,siblingisreceivingironsupplementationforanemia• Momhaslargebottleofironliquidmedicationathome




Circulation:• Assesspulse,HR,capillaryrefill,BP• AsknursetoplaceIVcatheter• AskfornormalsalineorlactatedRingersolutionbolusof20


Medical Management:• Orderlaboratorytests(CBC,electrolytes,coagulation

studies,bloodcultures,venousbloodgas,bedsideglucose)

5



Scenario Stage



Time, min

STAGE 2 Condition:• HRremainselevatedandBPisnow68/52mmHg• Bloodglucoselevelisslightlyelevatedifbedsideglucose

wasmeasured• Venousgas:pH7.06,Pco228mmHg,Po239mmHg,base

excess−20mmol/L• Patientvomitsagain• Ironoverdoseexceeds60mg/kgbodyweight(providedif

teamasksdose)


oxygen(ifplaced),BP63/52mmHg• CNS:barelyrespondstoanystimuli• Respiratory:clear• CVS:clampeddownandcoolextremities• Abdomen:nohepatosplenomegaly

REASSESSMENT OF THE PATIENT:Airway/Breathing:

• Reassessairwaypatency,RR,andsaturations

Circulation:• ReassessHR,pulse,capillaryrefill,BPafterbolus• Ordersecondbolus,alsopush• Ordervasopressor(dopamine)tobedside(“Thatwilltake

about10–15minutestogetfromthepharmacy”)inanticipationofneedlater

Medical Management:• Ifteamfailstosuspectoverdose,canpromptwithstatement

“Someonehascalledtoinformthemomthatabottleofsiblingmedicationlabeledferroussulfateisopenandemptyonthefloor.”

• Ordersadditionaltests- VenousgastoassesspH

- Iron,salicylate,andacetaminophen(paracetamol)levels

- Abdominalradiographforpillfragments(givenhistoryofliquidingestion)

• Consultpoisoncontrolforrecommendations

5

STAGE 3 Condition:• “Hedoesn’tseemmuchbetter.”• Remainstachycardicaftersecondbolus• PoisoncontrolrecommendstreatmentwithIVdeferoxamine

Physical Examination Findings:• Unchangedfromstage2exceptthatHRisnow150/minand

BPis66/52mmHg• Abdomen:nohepatosplenomegaly

REASSESSMENT OF THE PATIENT:Circulation:

• ReassessHR,pulse,capillaryrefill,BP

Medical Management:• OrderthirdbolusofIVsalinepush• Beginadministrationofdopamineasitarrives,titratesto

improveBP(thishappenswhendopamineisrunningat10mcg/kg/min)

• Consultintensivecareserviceforadmission• Orderdeferoxamineasrecommended

5

STAGE 4 Condition:• Patientimproveswithvasopressorsupport

Physical Examination Findings:• HR148/min,BP78/62mmHg,saturation98%on

nonrebreathermask• Extremitiesfeelwarmer• Childissomewhatmorealert

REASSESS THE PATIENT:Disposition:

• ArrangeforICUadmissionortransporttotertiarycarefacility(dependingonpresentingfacilityresources)

5

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



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)fluidforvolumeexpansionisnotdeliveredinarapidand/orcontrolledmanner.–IV“wideopen”fluidadministrationcanleadtoveryrapidinfusionofawholeliteroffluidORcanresultinunderresuscitationifthereissignificantresis-

tancetoflow(smallIVgauge).Infantsandsmallchildrenshouldalwaysreceiveresuscitationfluidsusingeitherapumporpushtoallowforobservationandcontroloffluiddelivery.Pressurebagscanincreasethelikelihoodofexcessivefluidoverload.

–Pushingfluidisaccomplishedbyattachingathree-waystopcockinlinewiththeIVcatheterandpullingfluiddirectlyfromthebag(step1)andthenswitchingthestopcockandpushingthefluidintothepatient.

• Failingtoconsideringestionasacauseofasepticshock–likepicture.Metabolicderangements,bothinbornerrorsandthoseduetoingestions,canmimicsepsis. The sudden onset and absence of fever are clues, as is the history of lead toxic effects (suggesting pica) and the chaotic home setting.

• Waitinguntilthethirdbolusisstartedorfinishedtoorderpressors.Participantsshouldrecognizeandanticipatethatinfantandpediatricpressordripsmust 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.


25 Simulation Scenarios Myocarditis—Cardiogenic Shock

Myocarditis—Cardiogenic Shock


Learning Objectives

• Describethesignsandsymptomsofcardiogenicshock.• Demonstratethetreatmentofachildincardiogenicshock.

– Initial stabilizing steps.– Order the appropriate investigations.– Select the appropriate inotrope.


Scenario Stage



Time, min

STAGE 1 History:• Five-year-oldboy• Cough,runnynose,andfeverfor5d• Diaphoreticandchillstoday• Shortofbreathandfellingunwell• Takentotheemergencydepartmentforassessment

Weight: • 20kg

Condition: • Looksveryunwell,toxic

Physical Examination Findings:• Temperature39°C(102.2°F),HR170/min,RR40/min,BP95/P

mmHg,oxygensaturation88%onroomair• Monitor:sinustachycardia• CNS:awake,GCSscoreof15• CVS:galloprhythm,softmurmur,caprefill3s,pulsesweak• Respiratory:cracklesbilaterally• Abdomen:liveredgepalpable• Restofexaminationresultsnormal

Take a History: • Previouslyhealthy• Otherkidsatschoolsickwithsimilarcough,coldsymptoms• Unwelltoday,sleptmostoftheday• Wokeup,vomitedfivetimes• Diaphoreticandchills• Givenacetaminophen(paracetamol)only

Airway:• Talktothepatient• Optimizeairwayposition:headtilt,chinlift,jawthrust

Breathing: • Checkoxygensaturation• Give100%oxygen• Auscultatechest

Circulation:• Askformonitors• Checkpulse,capillaryrefill,BP• Identifytherhythm(sinustachycardia)andrecognizes

uncompensatedshock• InsertIVcathetertwotimes(largebore)• OrderIVnormalsalinebolus

Medical Management:• Orderbloodwork:CBC,differential,bloodculture,

electrolytes,BUN,creatinine,glucose,bloodgas,LFTs,PTT,andINR

• OrderIVantibiotics

3


26 Simulation Scenarios Myocarditis—Cardiogenic Shock

Scenario Stage



Time, min

STAGE 2 Condition:• Thepatient’sconditiondeterioratesastheBPdecreasesand

perfusionworsensafterthefirstbolusofnormalsaline

Physical Examination Findings:• Temperature39°C(102.2°F),HR180/min,RR45/min,BP70/P

mmHg,oxygensaturation90%on100%oxygen• Monitor:sinustachycardia• CNS:drowsybutarousable,GCSscoreof12• CVS:galloprhythm,softmurmur,caprefill4s,pulsesweak• Respiratory:crackles• Abdomen:liveredgepalpable• Restofexaminationresultsnormal


• Reassessairway• Suctionairwayasneeded

Breathing:• Considerassistingventilationswithanesthesiabag/self-

inflatingbag

Circulation:• Identifyworseningshock• OrdersecondbolusofIVnormalsaline• InsertsecondIVcatheter(ifnotdonealready)

Medical Management:• Orderchestradiographtoevaluateforcardiogenicshock• OrderECG

2

STAGE 3 Condition:• Thepatient’sperfusionisgettingworsewiththesecond

fluidbolus

Physical Examination Findings:• Temperature39°C(102.2°F),HR180/min,RR45/min,BP

65/PmmHg,oxygensaturation92%on100%oxygenwithassistedventilations

• Monitor:sinustachycardia• CNS:drowsybutarousable,GCSscoreof12• CVS:galloprhythm,softmurmur,caprefill5s,pulsesweak• Respiratory:crackles• Abdomen:liveredgepalpable• Restofexaminationresultsnormal


• Reassessairway• Suctionairwayasneeded• Prepareforrapidsequenceintubation

Breathing:• Assistventilationswithanesthesiabag/self-inflatingbag

Circulation:• Identifyworseningshock• OrderIVinotropeinfusionforsuspectedcardiogenicshock

(dopamine/milrinone/epinephrine[adrenaline]).

Medical Management:• Chestradiograph:bilateralhazy,wetlungfieldswithan

enlargedheart

5

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

• Overlyaggressivefluidresuscitationandfailuretoconsidercardiogenicshockinthedifferentialdiagnosis.• Delayinorderingantibiotics.• Orderingachestradiographorelectrocardiogramarenotconsideredaspartoftheworkupforthispatient.


27 Simulation Scenarios Occult Trauma (Non-accidental Trauma)

Occult Trauma (Non-accidental Trauma)


Learning Objectives

• Describethe“redflags”inahistorythatraiseconcernfornon-accidentaltrauma(andrecognizethesemightormightnotbepresentinallcases).• Describethesignsandsymptomsofaninfantwithnonoccultmultisystemtrauma.• Demonstratethemanagementofmultisystemtrauma.

– 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 Stage



Time, min

STAGE 1 History: • Six-month-oldchildfoundbyparentincrib,unarousable

afternap• Babysitterputhimdownafewhoursago,thoughthe

wasfine• Childwascompletelywellwhenparentleftthismorning• Triagenursehasrushedpatientbacktoresuscitationroom

becauseheisbarelyresponsiveattriage• Youarrivetoassessthepatient

Weight: • 7kg

Condition: • Infantispinkandwellperfusedbutcomatose


saturation97%inroomair,BP89/66mmHg• CNS:unresponsive,ifpainfulstimulationisgiven(nailbed

pressureorsternalrub,demonstrateEXTENSORposturing:“Thechilddidthis[demonstrate]whenyoudidthat?”)

Take a History:• Noallergies• Nomedications• Noillcontacts• Noideaatallwhathashappened• Nohistoryoftraumaorfall• Nootherchildreninhome• Babysitterhasbeenwiththemapproximately1month

Airway:• Listenforbreathsounds,presentbutslow• Applyoxygenvianonrebreathermaskat15L/min

Breathing: • Applymonitors,includingoxygensaturationandBP• Auscultatechestandobserverespiratoryrate

Circulation:• Assesspulse,HR,capillaryrefill,BP• AsknursetoobtainIVaccess,ideallytwolargerIVcatheters

3–4



Scenario Stage



Time, min

STAGE 1, continued

–Ifexamined,theleftpupilisdilatedmaximallyandfixed;rightis2–3mmandbarelyreactive

• CVS:pulsesintact• Respiratory:clearandslow• Abdomen:softandwithouthepatosplenomegaly• Extremities/skin:nobruisingnoted(ifasked)

Disability:• Quickneurologicassessment(pupils,responsetopain)• AssessmentofGCSscore

Environment and Exposure:• Removepatientclothing,examinecompletely• Keeppatienteuthermic(blanketorwarmingequipment)

STAGE 2 Condition:• Mentalstatusunchanged• Bloodglucoselevelisnormalifobtained• BPisincreasingandHRisslowingsteadily

Physical Examination Findings:• HR94/min,RR6–8/min(irregularifthisisasupported

feature),BP106/88mmHg(ifsimulatorsupports,thistrendcanbesettoprogressoverthefirst4–5min)

• CNS:unchanged• Respiratory:clear,rateisnowslower• CVS:unchanged• Abdomen:somewhatmorefullthanbefore,no

organomegaly


Airway/Breathing:• Prepareforintubationduetopoormentalstatus• Gathernecessarymaterials(SOAPmnemonic)

–Suction

–Oxygenequipment(bag-mask,endotrachealtube,qualitativeETCO2detector,orETCO2monitor)

–Airwayequipment(laryngoscopeandblade)

–Pharmacy:rapidsequencemedication

Circulation:• Considerfluidmanagementinlightofsignsofintracranial

pressure

Disability:• Mayelevateheadofbed• Consultneurosurgery

Medical Management:• Orderlaboratorytests(LFTswithorwithoutpancreatic

enzymestoscreenforabdominaltrauma,typeandcross)• OrderCTscanofheadandabdomen,notifyscannerof

arrivalassoonaspatientisintubated

3

STAGE 3 Condition:• Unchangedexceptforcontinuingtrend(HR82/min,BP

110/92mmHg)–Orderingachestradiograph

• Securetube(canbedonebynurseconfederate)

INTUBATION:

Airway/Breathing:• Completerapidsequenceintubation

–Considerlidocaine(lignocaine)premedication

–Sedationmedication

–Paralyticmedication

–Tubeplacedwithoptionalcricoidpressure

• Tubeplacementconfirmedby:–Auscultation

–Directvisualizationofchestmovement

–ETCO2detector

5



Scenario Stage



Time, min

STAGE 3, continued


Disability:• AvoidexcessivehyperventilationforelevatedICP(seenote

below)• ConsiderIVmannitol(orothersimilaragents)

Medical Management:• Revieworderedlaboratorytestresults

STAGE 4 Condition:• Stable(seenote)

REASSESS THE PATIENT:Disposition:

• ArrangefortransportforCTscanwithappropriatestaff(someonewhocouldreintubateifairwayislost)

• Notifysurgeonofabdominalfindings• Notifyparents• Plansocialworkconsultandreportofsuspectedchildabuse

5

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.

Notes1. Thisisanimportanttopicforwhichsomespecificmanagementstepsvaryamonginstitutions.ThiscasecontentreflectstheAdvancedPediatricLifeSupportrecommended

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

otherosmoticagents,orshort-termmildhyperventilation.

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. Thiscaseiswrittentobeonlymildlysuggestiveofnon-accidentaltraumatopreventimmediateidentificationoftheproblemtotheexclusionofallothercauses.Itisour

experiencethatpediatrichealthcareworkersaresensitizedtothemoreobvious“redflags”(eg,mom’sboyfriendathomealonewithchild).Similarly,abulgingfontanelle(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.

• Focusontheintracranialprocesstotheexclusionofotherinjuries.Thispatienthasagrade5liverlacerationthatiscurrentlynotcausinghemodynamicissues.Ifthepatient

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-abdominalbleeding.

• Theteamconsiderssendingthepatientforcomputedtomography(CT)withoutairwaycontrol.Theconfederatenursestates,“ThispatientseemstooilltogotoCTlikethis.”

• Teamdoesnotknowthecorrectintubationmedications.Inthiscase,treatmentcanbestoppedbeforeintubation,andthismaterialcanbereviewedasdiscussedinthetext.

• Theteamintubatesthepatientwithoutanymedications.Allowthecasetoproceedanddiscussafterwardthelikelyimpactonintracranialpressureofthisapproach.


30 Simulation Scenarios Postoperative Cardiac Patient—Ventricular Fibrillation

Postoperative Cardiac Patient—Ventricular Fibrillation


Learning Objectives

• Describethesignsandsymptomsofachildpresentingwithunstableventriculartachycardia.• Describethesignsandsymptomsofachildpresentingwithventricularfibrillationandcardiacarrest.• Demonstratethetreatmentofachildwithunstableventriculartachycardia.

– Demonstrates knowledge of the Pediatric Advanced Life Support (PALS) unstable ventricular tachycardia algorithm.• Demonstratethetreatmentofachildwithventricularfibrillation.

– Recognize ventricular fibrillation.– Recognizetheimportanceofhigh-qualitychestcompressionsandearlydefibrillation.– Demonstrates proper use of the defibrillator.– Demonstrates knowledge of the PALS ventricular fibrillation algorithm.


Scenario Stage



Time, min

STAGE 1 History:• Four-year-oldboy• Recentcardiacsurgeryforcongenitalheartdisease4dago• Vomitedthreetimestoday• Feelingunwell,lightheaded• TakentotheEDforassessment

Weight: • 20kg

Condition:• Looksveryunwell,toxic

Physical Examination Findings:• Temperature37.4°C(99.3°F),HR170/min,RR35/min,BP

60/PmmHg,oxygensaturation88%inroomair• Monitor:ventriculartachycardia• CNS:drowsyanddifficulttoarouse,GCSscoreof10• CVS:galloprhythm,loudmurmur,caprefill4s,pulsesweak• Respiratory:clear• Restofexaminationresultsnormal

Take a History: • Unwelltoday,sleptmostoftheday• Difficulttoawakenthisafternoon,broughttoED

Airway:• Talktothepatient• Openairway• Headtilt,chinlift,jawthrust• Prepareforrapidsequenceintubation

Breathing: • Checkoxygensaturation• Apply100%oxygenbymask• Auscultatechest

Circulation:• Applymonitors• Checkpulse,capillaryrefill,BP• Identifyunstableventriculartachycardia• InsertIVcatheter2times

5



Scenario Stage



Time, min

STAGE 1, continued

• OrderIVsedative(eg,ketamine)andpreparesforsynchronizedcardioversion(thisparticularpointiscontroversialandwouldbeagooddiscussionpointbecausethepatientmightbetoounstabletotolerateasedative)

Medical Management:• SynchronizecardioversionasperPALSprotocol• Orderbloodwork:CBC,differential,bloodculture,

electrolytes,BUN,creatinine,glucose,bloodgas,LFTs,PTT,andINR

STAGE 2 Condition:• Thepatientisunconscious,GCSscoreof3• Rhythm:ventricularfibrillation

Physical Examination Findings:• Temperature37.4°C(99.3°F),HRNA,RR0/min,BPNA,

oxygensaturationNA• Monitor:ventricularfibrillation• CNS:GCSscoreof3• CVS:capillaryrefill8s,pulsesnotpalpable• Respiratory:clear• Restofexaminationresultsnormal


Airway:• Recheckairway• Intubatepatientnowwithoutsedationorparalysis

Breathing:• Reassessbreathing• Manuallyprovidethepatientwithventilatoryassistance

Circulation:• Identifyventricularfibrillation• StartCPRimmediatelywithbackboardinplace• Defibrillationat2J/kgthenCPRasperPALSprotocol• ContinueCPRandthendefibrillatesagainat4J/kg• GiveIV/IOepinephrine(adrenaline)• Reassesspulseandrhythm

3

STAGE 3 Condition: • Looksveryunwell,toxic,rhythmchangestonormalsinus

rhythm

Physical Examination Findings:• Temperature37.4°C(99.3°F),HR80/min,RR6/min,BP70/P

mmHg,oxygensaturation90%withbagging• Monitor:sinusrhythm• CNS:unresponsive,intubated,GCSscoreof3


Airway:• Recheckairwayandtube

Breathing:• Reassessbreathing• Continuetobagventilatethepatient

Circulation:• Identifychangetosinusrhythm,checksforpulse• StopCPR• Administernormalsalinebolus• Startinotropeinfusion:dopamineorepinephrine

(adrenaline)

2



Scenario Stage



Time, min

STAGE 3, continued

• CVS:galloprhythm,softmurmur,capillaryrefill5s,pulsesveryweak

• Respiratory:bilateralcrackles

Medical Management:• ConsultICUandcardiologypersonnel• OrderECGandchestradiograph

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

• Defibrillationofunstableventriculartachycardia(insteadofsynchronizedcardioversion).• Managementofunstableventriculartachycardiawithmedicationonly.• Delayeddefibrillationafterrecognitionofventricularfibrillation.• Delayedinitiationofchestcompressionsafterrecognitionofventricularfibrillation.• Managementofairway(intubation)beforedefibrillationorchestcompressionswhilethepatientisinventricularfibrillation.• Failuretoadequatelypreparemedicationsforventricularfibrillation.Instructorsshouldencouragestudentstoprepareepinephrine(adrenaline),amiodarone,

and lidocaine (lignocaine) immediately on recognition of the rhythm.


33 Simulation Scenarios Septic Shock

Septic Shock


Learning Objectives

• Describethesignsandsymptomsofaninfantwithsepticshock.• Demonstratethemanagementofcirculatoryfailureduetosepsis.

– 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).


Scenario Stage



Time, min

STAGE 1 History:• Seven-month-oldboy,intreatmentforacutelymphocytic

leukemiapresentswithtemperaturesto39.6°C(103.3°F)(temporal)

• Decreasedactivitysinceyesterday• Chemotherapylastgiven4dago,don’tknowwhatdrugs

weregiven• Triagenursewasworriedhowlittleherespondedtoher

examination• Youarrivetoassessthepatient

Weight:• 7kg

Condition: • Veryunwell,listless,feelswarmovercorebuthandsarecool

Physical Examination Findings:• Temperature39.6°C(103.3°F),HR158/min,RR36/min,

oxygensaturation96%inroomair,BP72/58mmHg• CNS:asleep,wakesbrieflywithpainfulstimulation• CVS:pulsespresentcentrally,absentperipherally• Respiratory:clear• Abdomen:nohepatosplenomegaly• Extremities/skin:capillaryrefill>4s,scatteredpetechiae

Take a History:• Noillcontacts• Hasadouble-lumenport• Hashadonepreviousadmissionforfeverandneutropenia

at1monthage• VomitedonceenroutetotheED• Takestrimethoprim-sulfamethoxazole3dperweek,got

ibuprofenattriage;istakingprednisoneaspartofhischemotherapy

• Allergictovancomycin(redmansyndrome)




Circulation:• Assesspulse,HR,capillaryrefill,BP• Asknursetoaccessport• AskfornormalsalineorlactatedRingersolutionbolusof20


Medical Management:• Orderlaboratorytests(CBC,electrolytes,coagulation

studies,bloodcultures,venousbloodgas,bedsideglucose)

3–4



Scenario Stage



Time, min

STAGE 2 Condition:• HRremainselevatedandBPisnow63/52mmHg• Nursenotesaloud,“Hishandsarejustsocold.”• Bloodglucoselevelisnormalifbedsideglucosetestwas

performed


oxygen(ifplaced),BP63/52mmHg• CNS:barelyrespondstoanystimuli• Respiratory:clear• CVS:clampeddownandcoolextremities• Abdomen:nohepatosplenomegaly


Circulation:• ReassessHR,pulse,capillaryrefill,BPafterbolus• Ordersecondbolus,alsopush• Ordervasopressor(dopamine)tobedside(“Thatwill

takeabout10–15minutestogetfromthepharmacy.”)inanticipationofneedlater

Medical Management:• Orderantibiotics(broadspectrumtoincludecoveragefor

pseudomonas,eg,ceftazidimeormeropenem/imipenem)

3

STAGE 3 Condition:• “Hedoesn’tseemmuchbetter.”• Remainstachycardicaftersecondbolus

Physical Examination Findings:• Unchangedfromstage2exceptthatHRisnow150/minand

BPis66/52mmHg• Abdomen:nohepatosplenomegaly



Medical Management:• OrderthirdbolusofnormalsalineIVpush• Begindopamineasitarrives,titratestoimproveBP(this

happenswhendopamineisrunningat10mcg/kg/min)• Orderhydrocortisonestressdosegivenpatient’sdaily

prednisone(canaskforhelpwithdosing)• Consultintensivecareservice

5

STAGE 4 Condition:• Patientimproves

Physical Examination Findings:• HR148/min,BP78/62/min,saturation98%on100%oxygen• Extremitiesfeelwarmer• Childissomewhatmorealert


Disposition:• ArrangeforICUadmissionortransporttotertiarycare

facility(dependingonpresentingfacilityresources)

5

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



Common Pitfalls

• Intravenous(IV)fluidforvolumeexpansionisnotdeliveredinarapidand/orcontrolledmanner.– IV“wideopen”fluidadministrationcanleadtoveryrapidinfusionofawholeliteroffluidORcanresultinunderresuscitationifthereissignificantresis-

tancetoflow(smallIVgauge).Infantsandsmallchildrenshouldalwaysreceiveresuscitationfluidsusingeitherapumporpushtoallowforobservationandcontroloffluiddelivery.Pressurebagscanincreasethelikelihoodofexcessivefluidoverload.

– Pushingfluidisaccomplishedbyattachingathree-waystopcockinlinewiththeIVcatheterandpullingfluiddirectlyfromthebag(step1)andthenswitchingthestopcockandpushingthefluidintothepatient.

• Withholdingantibioticsuntileitherthepatientimprovesorculturesand/ortestingiscomplete.Thisinfantiscriticallyillandantibioticsshouldbegivenasearly as is practical.

• Failingtocheckabedsideglucoselevel.Hypoglycemiaisatreatablecauseofalteredmentalstatus,andillinfantswithpoorglycogenstoresandapoorrecentoral intake due to illness are prone to this condition.

• Waitinguntilthethirdbolusisstartedorfinishedtoorderpressors.Participantsshouldrecognizeandanticipatethatinfantandpediatricpressordripsmustbe 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.


36 Simulation Scenarios Chest Crisis—Sickle Cell Disease

Chest Crisis—Sickle Cell Disease


Learning Objectives

• Describethesignsandsymptomsofachildpresentingwithchestcrisisandsicklecelldisease.• Demonstratethetreatmentforachildwithasicklecellchestcrisis.

– Initial stabilizing steps.– Performfluidmanagementandresuscitation.– Understand the importance of repeat assessment in children with chest crisis.– Demonstrate knowledge of appropriate antibiotic therapy.


Scenario Stage



Time, min

STAGE 1 History:• Seven-year-oldboy• Knownhomozygoussicklecelldisease.• Feverthisafternoon• Coughing2timesperday• Feelingunwellandbroughttothehospital• Initialoxygensaturationattriageis88%inroomair

Weight:• 22kg

Condition: • Veryunwell,listless,feelswarmovercorebuthandsarecool


saturation88%inroomair,BP95/PmmHg• CNS:awakeandalert• Respiratory:diffusecracklesbilaterallywithpoorairentryto

right• CVS:pulsesstrong,capillaryrefill2s• Musculoskeletal:nobonytendernessorpain• Restofexaminationresultsnormal

Take a History:• Multiplepreviousadmissions• HistoryofchestcrisistwotimeswithadmissiontoICUfor

exchangetransfusion• Sepsisonetime,dactylitisonetime,bony(vaso-occlusive)

crisisfivetimes• Takingprophylacticantibiotics• Immunizationsuptodate

Airway:• Opentheairway• Headtilt,chinlift,jawthrust

Breathing: • Applymonitors• Auscultatechestandobservesrespiratoryrate• Oxygensaturation• Applyoxygen(100%)• Getself-inflatingbagready

Circulation:• Assesspulse,HR,capillaryrefill,BP• ObtainIVaccess

2



Scenario Stage



Time, min

STAGE 1, continued

Medical Management:• Bloodwork:CBC,differential,bloodculture,gas,electrolytes,

BUN,creatinine,glucose• IVceftriaxoneanderythromycin• Chestradiograph• IVfluids(D5NS)athalftoonetimesmaintenance

STAGE 2 Condition:• Looksunwell,moderate-severedistress,notoxygenating

wellwithfacemaskoxygen,bloodpressuredecreasing,andperfusionworsening

Physical Examination Findings:• Temperature39.5°C(103°F),HR130/min,RR38/min,

saturation88%with100%oxygen,BP70/PmmHg• CNS:becomingmoredrowsy• Respiratory:diffusecracklesbilaterallywithpoorairentryto

right• CVS:pulsesweak,capillaryrefill4s• Restofexaminationresultsnormal


• Suctiontheairway• Repositiontheheadwithheadtilt,chinlift,jawthrust• Reapplyoxygenmask

Intubation:• Preparation/equipment• Preoxygenation;RR12–15./min• Cricoidpressure• Premedication:IVatropine• Sedation:IVketamine• Paralysis:IVsuccinylcholineorrocuronium• IntubatewithETT• Checktubeplacementwithend-tidalcarbondioxide,

auscultationandchestradiograph

Breathing:• ReassessbreathingandRR• Callforhelp• Considerusinghigh-flowoxygenoranesthesiabagto

providesomeCPAP• Supportventilation:bag-maskventilation

Circulation:• ReassessHR,pulse,capillaryrefill,BP• IVaccessobtainedbynow• Givenormalsalinebolusthenrepeatsasnecessary• PerformABGmeasurement

5



Scenario Stage



Time, min

STAGE 3 Condition: • Looksunwell,oxygenationandBPimprovedslightly


saturation94%intubatedandventilated,BP80/PmmHg• CNS:paralyzedandsedated• Respiratory:diffusecracklesbilaterallywithpoorairentryto

right• CVS:pulsesweak,capillaryrefill4s


• SuctiontheETT:somethinmucusorsecretions

Breathing:• Auscultatethechest• Checkchestmovementandsymmetry

Circulation:• CheckpulseandBP• ConsiderrepeatIVfluidbolusforhypotension• Orderinotropeinfusionandtitratesinfusiontoincreasethe

BP

Medical Management:• CallICUconsultantforhelp• Preparefortransport• Followuponchestradiograph• Consideraddingvancomycin

3

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

• Overlyaggressivefluidresuscitation,leadingtopulmonaryedemaandrespiratoryfailure.• Delayedadministrationofantibiotics.• Failuretoreassesspatientanddelayedrecognitionofrespiratorydecompensation.


39 Simulation Scenarios Status Asthmaticus

Status Asthmaticus


Learning Objectives

• Describethesignsandsymptomsofachildpresentinginstatusasthmaticus.• Recognizethesignsandsymptomsofrespiratoryfailure.• Demonstratethetreatmentofachildwithstatusasthmaticus.

– Initial stabilizing steps.– Demonstrate knowledge of medical management of status asthmaticus.– Understand dangers of intubating a sick asthmatic patient.


Scenario Stage



Time, min

STAGE 1 History: • Five-year-oldboy• Knowntohaveasthma• Takingalbuterol(salbutamol)andfluticasonepuffersat

home• Increasingcoughandshortnessofbreathathometoday• Febrile• Initialoxygensaturationattriageis88%inroomair• TreatedbyEDnursingstaffrightawayandgivenalbuterol

(salbutamol)andipratropiumbromide• Youarrivetoassessthepatient.

Weight: • 20kg

Condition: • Veryunwell,severedistress

Physical Examination Findings:• Temperature38°C(100.4°F),HR130/min,RR36/min,oxygen

saturation88%inroomair,BP110/50mmHg• CNS:awakeandalert• CVS:pulsesstrong,capillaryrefill2s• Respiratory:scattered,diffusewheezesbilaterally,

retractions• Restofexaminationresultsnormal

Take a History: • RecentcontactwithyoungersiblingwithURIsymptoms• FourpreviousadmissionsandoncetotheICU,never

intubated• Vomitedonceathome• Tookalbuterol(salbutamol),twopuffssixtimesathome

withnoimprovement,thencametotheED

Airway:• Talktothepatient• Suctionsecretions• Callforhelp:respiratorytherapy

Breathing: • Applymonitors,includingoxygensaturation• Auscultatechestandobserverespiratoryrate• Applyoxygenvianonrebreather(100%)ORmovedirectlyto

secondnebulization• Consideralbuterol(salbutamol)andipratropiumbromide

backtobackthreetimesintotal• Getanesthesiabagorself-inflatingbagready.• Giveoralsteroid(dexamethasoneorprednisoloneor

prednisone)orparenteralsteroid

Circulation:• Assesspulse,HR,capillaryrefill,BP

2



Scenario Stage



Time, min

STAGE 2 Condition:• Afterthebacktobackalbuterol(salbutamol)and

ipratropium,patientisstillunwell• Coughingpersistently• Persistentrespiratorydistress• Childsuddenlyvomitsprofusely

Physical Examination Findings:• Temperature38°C(100.4°F),HR150/min,RR40/min,oxygen

saturation92%in100%oxygen,BP100/55mmHg• CNS:gagging,irritable,coughingpersistently• Respiratory:diffusewheezesbilaterallywithindrawing,

trachealtug,andworseningretractions• CVS:pulsesstrong,capillaryrefill2s• Restofexaminationresultsnormal


• Suctiontheairway• Repositiontheheadwithheadtilt,chinlift,jawthrust

(recognizingthischildisdistressedandvomiting,mightbebettertohavehimonhissideaswell)

• Reapplyoxygenmask

Breathing:• ReassessbreathingandRR• Callforhelpfromrespiratorytherapy(ifnotdonealready)• Givecontinuousalbuterol(salbutamol)vianebulization

Circulation:• ReassessHR,pulse,capillaryrefill,BP• IVaccess• Givesteroids(IV)becausehemighthavevomitedoral

steroids• Givemagnesiumsulfate(IV)

Medical Management:• PerformbloodworkwithIVstart:CBC,differential,culture,

electrolytes,gas• Getimmediatechestradiographandgiveantibioticsifsigns

offocalconsolidation

3

STAGE 3 Condition:• Yourpatientseemstobeworkinghardertobreath• Severerespiratorydistress• Nolongerrespondingtoverbalcommands

Physical Examination Findings:• Temperature39°C(102.2°F),HR160/min,RR40/min,BP

110/55mmHg,oxygensaturation84%in100%oxygen.• CNS:drowsy• Respiratory:diffusewheezes,retractions• CVS:wellperfused,capillaryrefill2s• Restofexaminationresultsunchangedfromabove


• Suctiontheairway• Repositiontheheadwithheadtilt,chinlift,jawthrust• Reapplyoxygenmask• Considertowelrollatthispoint

If learner proceeds with intubation:• Preparation/equipment• Preoxygenation;RR,8–12/minwithprolongedexpiratory

phase• Cricoidpressure• Premedication:IVatropine• Sedation:ketamineIV.• Paralysis:IVsuccinylcholine• IntubatewithETT5.0cuffed• ChecktubeplacementwithETCO2,auscultation,chest

radiograph• Nasogastrictubeplacement

5



Scenario Stage



Time, min

STAGE 3, continued

Breathing:• ReassessbreathingandRR• Obtainchestradiographifnotalreadydonebynow


Medical Management:• CallICUforhelp• ConsiderIVaminophyllineorIVb-agonist.• ConsiderBiPAPorCPAP

STAGE 4 Condition:• Patientconditiondeterioratesafterintubation

Physical Examination Findings:• Verydifficulttoprovideventilation• Poorchestrisebilaterally• Temperature38°C(100.4°F),HR80/min,RRbagging,

saturation78%in100%oxygen,BP80/50mmHg• CNS:sedated/paralyzed• Respiratory:poorchestriseandairentrybilaterallywith

wheezing• CVS:pulsesweak,capillaryrefill4s


• SuctiontheETT:somethinmucusorsecretions• Considerdirectvisualizationofthetubewithlaryngoscope

Breathing:• Auscultatethechest• Checkforsignsoftensionpneumothorax(tracheamidline,

bloodpressure,percussionofchest,jugularvenouspressure)

• Givecontinuousnebulizedin-linealbuterol(salbutamol)• Checkoxygen/equipment• Bag-maskventilatesataslowerratewithaprolonged

expiratoryphase

Circulation:• InsertsecondIVcatheter• GiveIVbolusofnormalsaline

5

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)andipratropiumbromideshouldideallybeadministeredviametered-doseinhaler.

Common Pitfalls

• Overventilationofthepatient—leadstobreathstackingandpotentialforpneumothoraxordepressedcardiacreturnandeventualcardiacarrest.• Earlyintubationattemptwithoutconsiderationofotherpossiblemanagementoptions(eg,magnesiumsulfate,noninvasiveventilation).


42 Simulation Scenarios Status Epilepticus

Status Epilepticus


Learning Objectives

• Describethesignsandsymptomsofachildpresentinginstatusepilepticus.• Demonstratethetreatmentofachildwithstatusepilepticus.

– Initial stabilizing steps.– Understand complications associated with the treatment of status epilepticus.– Demonstrate knowledge of rapid sequence intubation for a seizing patient.


Scenario Stage



Time, min

STAGE 1 History: • Four-year-oldboy• Highfeverfor3d• Headacheandneckpainfor2d• Irritabletoday• Founddrowsyandunresponsiveathomeonthefloor• ParamedicsbringingchildtotheED• Seizingenroutefor5min

Weight: • 15kg

Condition: • Activelyseizingpatientonarrival

Physical Examination Findings:• Temperature39.5°C(103°F),HR160/min,RR25/min,BP

110/PmmHg,oxygensaturation92%inroomair• Monitor:sinustachycardia• CNS:seizing(generalized)• CVS:normalheartsounds,capillaryrefill2s,pulsesstrong• Respiratory:clear,poorairentrybilaterally• Restofexaminationresultsnormal

Take a History: • Previouslyhealthy,nopriorseizures• Unimmunized

Airway:• Openairway• Headtilt,chinlift,jawthrust• Suction• Assignsomeonetoattendtoairway• Callrespiratorytherapyforhelp

Breathing: • Checkoxygensaturation• Applymonitors• Applyoxygenbymask• Auscultatechest

Circulation:• Applymonitors• Checkpulse,capillaryrefill,BP• IVaccessnotobtainableinitially

Medical Management:• Checkglucoselevel:5.0mmol/L(90mg/dL)(normal)• GivelorazepamordiazepamPR,thenIVlorazepamtwotimes• Orderphenytoin/fosphenytoin• Orderbloodwork:CBC,electrolytes,bloodgas,lactate,renal

function,bloodculture• Orderantibiotics:ceftriaxone,vancomycin,acyclovir

2



Scenario Stage



Time, min

STAGE 2 Condition: • Activelyseizingpatient,childvomitingprofuselyand

frothingatthemouth,thendesaturates

Physical Examination Findings:• Temperature39.5°C(103°F),HR160/min,RR25/min,BP

110/PmmHg,saturation85%inroomair• Monitor:sinustachycardia• CNS:seizingstill• CVS:normalheartsounds,capillaryrefill2s,pulsesstrong• Respiratory:poorairentrybilaterally• Restofexaminationresultsnormal


• Maintaintheairway:jawthrust,chinlift,headtilt• Suctionvigorously• Considerintubationandpreparesequipment

Breathing:• Increaseoxygendeliveryto100%byusingnonrebreather

mask• Prepareself-inflatingbag

Circulation:• IVaccesstwotimes• CheckHR,BP,capillaryrefill,pulses• CycleBPevery3–5min

Medical Management:• Laboratorytestresultscomeback:

–Sodium130mmol/L,potassium3.5mmol/L,glucosenormal

–ABG:pH7.15,Pco260mmHg,Po290mmHg,bicarbonate20mmol/L,baseexcess−7mmol/L

3

STAGE 3 Condition: • Activelyseizingpatient,bloodpressureandrespiratoryrate

starttodecrease

Physical Examination Findings:• Temperature39.5°C(103°F),HR160/min,RR12/min,BP70/P

mmHg,saturation89%inroomair• Monitor:sinustachycardia• CNS:seizing• CVS:normalheartsounds,capillaryrefill3–4s,pulsesweak• Respiratory:poorairentrybilaterally• Restofexaminationresultsnormal

REASSESSMENT OF PATIENT:Airway: Intubation:

• Preoxygenation• Premedication:IVatropineIVoptional• Cricoidpressure• Sedation:IVketamine,IVmidazolam,IVthiopental,orIV

propofol• Paralysis:IVsuccinylcholine• ChecktubeplacementwithETCO2detector,auscultationof

chest,observationofchestriseandorderchestradiograph

Breathing:• Reassessbreathing• Starttoprovideventilatoryassistancetothepatient

Circulation:• Identifyhypoxiaandworseninghypotension• Reassessbloodpressure,pulse,capillaryrefill• GiveIVnormalsalinebolus

5



Scenario Stage



Time, min

STAGE 3, continued

Medical Management:• CallICU• Startinfusionofotheranticonvulsants(gooddiscussion

point);optionsincludelevetiracetam(oftengivenfirstlineinsteadoffosphenytoin)andphenobarbital

• IVantibiotics(cefotaxime/vancomycinorsimilarandacyclovir)tocoverthepossibilitiesofbacterialmeningitisandherpesencephalitis

STAGE 4 Condition: • Activelyseizingpatient,bloodpressurestilllow,butoxygen

saturationsimprovedafterintubation

Physical Examination Findings:• Temperature39.5°C(103°F),HR160/min,RR12/min,BP70/P

mmHg,saturation95%withoxygen• Monitor:sinustachycardia• CNS:generalized,tonic-clonicseizure• CVS:normalheartsounds,capillaryrefill2s,pulsesstrong• Respiratory:shallowairentrybilaterally• Restofexaminationresultsnormal

REASSESSMENT OF PATIENT:Airway:

• Secureendotrachealtube

Breathing:• Reassessbreathing• Continuetoprovidemanualventilationtothepatient

Circulation:• Identifyworseninghypotension• Reassessbloodpressure,pulse,capillaryrefill• GiveanotherIVnormalsalinebolus

Medical Management:• Callintensivecarespecialistforconsultation• Considerrectalparaldehyde(notavailableintheUnited

Statesbutmightbeavailableinothercountries)• ConsiderIVmidazolaminfusionoranadditionaldoseof

phenytoin/fosphenytoin/phenobarbital/levetiracetam

5

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

• Failuretoinsertmultipleintravenouscatheters,thusdelayingadjuncttherapies(eg,antibioticsorfluids).• Delayincheckingbedsideglucoselevel.• Assumptionthatseizureshave“stopped”afterparalyticisgivenforintubation


45 Simulation Scenarios Stridor Due to Foreign Body

Stridor Due to Foreign Body


Learning Objectives

• Describethepossiblecausesofstridorinaninfant.• Demonstratethemanagementofupperairwayobstructionduetoaforeignbody.

Simulator: Infant Simulator NOTE: Simulator should be placed in a sitting position at the beginning of case and a small object placed in the hypopharynx as the foreign body (eg,toy,pencap,rolled-uppieceofmedicaltape).

Scenario Stage



Time, min

STAGE 1 History:• Twelve-month-oldwithsuddenonsetofstridorand

respiratorydistress• ParentsrushedhimtotheEDforevaluation• Youarecalledtoseethepatient

Weight: • 10kg

Condition: • Alertandanxious,sittinguprightinbed


saturation88%inroomair,BP85/68mmHg• CNS:alert• CVS:pulsespresent• Respiratory:clear• Extremities/skin:capillaryrefill<2s

Take a History: • Noillcontacts• Hasbeenwell• Nomedications• Noallergies• Wasplayingunsupervisedinplayroomandmomheard

coughingandthennoticedthetroublebreathingwhensheenteredroom

Airway:• Listenforbreathsounds,stridoreasilynoted,childissitting

anddoesnotwishtobemovedfromsittingposition• Askforbag-mask,suction,laryngoscope,ETT,andMagill

forcepstobedside


pressure• Auscultatechestandobserverespiratoryrate• Ifhealthcareworkerattemptstoplacemaskorinspect

mouth,state“childbecomesmoreanxiousandpushesyouaway—doyouwantmetoholdthechild?”

Circulation:• Assesspulse,HR,capillaryrefill,BP

Medical Management:• RequestENToranesthesiaconsultation• Minimizestimuli:nopainfulprocedures

3–4



Scenario Stage



Time, min

STAGE 2 Condition:• Airwayobstruction(complete)• Occursat4minregardlessofactionsORifthehealthcare

workerslookinmouthwithtongueblade,forceoxygenmaskontochild,orplaceIVcatheter

Physical Examination Findings:• Immediately:respiratoryeffortwithoutstridor;rapidly

lapsesuntilunconsciousness• RR:initially40/minbutthendecreasesto0/minin30s• HR:increasesto170/mininfirstminutethendecreasesto

65/mininnext90s• BP:70/58mmHg• Saturation:decreasesfrom88%to30%in30s

REASSESSMENT OF THE PATIENT:Airway (ENT/anesthesia consultant not present yet):

• Laychildflat• Attempttobag-maskpatientwithneckproperlypositioned

andusingtwo-persontechnique• Whenthisfailstowork,performdirectlaryngoscopyand

removesmallforeignbody

Circulation:• Monitordecreasingvitalsigns,preparetostart

compressionsifHRdecreasesbelow60/min

5

STAGE 3 Recovery:• Patientisnoweasilybagged

Physical Examination Findings:• HRandsaturationreturntonormal• RRremainszeroasbaggingcontinues


Airway:• Continuetobagpatient• Placenasogastrictubetoavoidstomachdistension• Maychoosetointubate(canstopcasebeforethisis

completefortimeconstraints)• Chestradiographtoassessforotherpossibleforeignbodies

(ifradio-opaque)

Disposition:• ICUforobservation

3–5

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.



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

• Beginningtotreatforcroupratherthanaspiration.• Triggerobstructionbystimulatingchild.Thischildshouldbetakentotheoperatingroombyanear,nose,andthroatsurgeonand/oranesthesiapersonnel

where a controlled evaluation and removal can be performed. Ideally, the child is placed in a parent’s lap awaiting this event. • Oncecompleteobstructionoccurs,failingtoattemptairwayevaluationandremovalofobstructionorattemptingintubation.Thechildnowhasanemergent

condition that cannot await airway expertise.


48 Simulation Scenarios Supraventricular Tachycardia

Supraventricular Tachycardia


Learning Objectives

• Describethesignsandsymptomsofaninfantwithsupraventriculartachycardia.• Demonstratethemanagementofstablesupraventriculartachycardiausingchemicalcardioversionwithappropriatemonitoring.


Scenario Stage



Time, min

STAGE 1 History:• Seven-month-oldgirlwithfussinessandpoorfeedingfor

approximately1day• Noupperrespiratorytractsymptomsorfever• Sentfromphysician’sofficebecauseoffastheartrate

Weight: • 7kg

Condition: • Alertbutcranky,pale


saturation98%inroomair,BP79/65mmHg• CNS:alert• CVS:pulsespresent• Respiratory:clear• Abdomen:liveredgeapproximately2cmbelowcostal

margin• Extremities/skin:capillaryrefillapproximately2s

Take a History: • Noillcontacts• Nofamilyhistoryofheartproblems• Givenibuprofenwithoutreliefbutnocoldmedications• Noallergies

Airway:• Listenforbreathsounds,present

Breathing: • Applymonitors.Includingoxygensaturationandblood

pressure• Applyoxygenmask• Auscultatechestandobserverespiratoryrate


Medical Management:• OrderanECG• Attemptvagalmaneuvers

3–4

STAGE 2 Condition:• HRremainselevated


oxygen(ifplaced),BP81/68mmHg


Circulation:• ReassessHR,pulse,capillaryrefill,BPafterbolus• Orderadenosine• Describetonurseconfederatehowtodelivermedication

whenasked(“Iamnotsurehowtogivethismedication.”)• Prepareforconversionby:

–Ensuringavailabilityofdefibrillator(mightormightnotconnectpads)

3


49 Simulation Scenarios Supraventricular Tachycardia

Scenario Stage



Time, min

STAGE 2, continued

–HavingECGmachineconnectedandrunningduringconversionattempt

• Deliverfirstadenosinebolus(noorbriefeffect)afterconsideringcontactingcardiologyorintensivecaresupportpersonnel

STAGE 3 Condition:• Infantcrieswhenmedicationgiven• HRremainselevated

Physical Examination Findings:• Unchangedfromstage2



Medical Management:• Orderarepeatdoseofadenosine

5

STAGE 4 Condition:• Patientimproves(HR145/minandsinus)

Physical Examination Findings:• HR148/min,BP78/62/min,saturation98%on

nonrebreathermask• Childismorecomfortable

REASSESS THE PATIENT:• Disposition:• ArrangeforICUorcardiologyadmissionortransportto

tertiarycarefacility(dependingonpresentingfacilityresources)

5

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

• Problemswithdeliveringtheadenosineinarapidpush/rapidflushmanner.• Electricalcardioversioninthisstablepatient(lesscommon).


50 Simulation Scenarios Tricyclic Antidepressant Overdose

Tricyclic Antidepressant Overdose

LinaAl-Bakry,MDAdam Cheng, MD, FRCPC, FAAPMark Adler, MD

Learning Objectives

• Describethesignsandsymptomsoftheanticholinergictoxidrome.• Demonstratethetreatmentofachildwithtricyclicantidepressant(TCA)intoxication.

– Initial stabilizing steps.– Identify tachyarrhythmia secondary to TCA intoxication.– Manage TCA intoxication with appropriate supportive and therapeutic interventions.


Scenario Stage



Time, min

STAGE 1 History:• Four-year-oldboy,broughtinbyparents• Foundextremelysleepyafterdinner,slumpedoveron

couch,minimallyresponsive• Nofeverorantecedentillness• Previouslywell

Weight: • 15kg


saturation98%inroomair,BP85/50mmHg• CNS:eyesclosedintermittently,nospontaneousmovement,

intermittentverbalization• Respiratory:spontaneousrespirations,noabnormalbreath

sounds,airentryisnormal• CVS:palpablepulses,slightlycoolextremities,normalheart

sounds,tachycardia• Abdomen:nobowelsounds,palpablefullbladder

Take a History:• Nosickcontacts• Nopriorhistoryofseizures• Nohistoryoftrauma• Noallergies• Nomedications• Supervisedbymotherallday• GrandparentsarrivedfromEnglandjustbeforedinner• Notsureifthereareprescriptionmedicationsinthehome

Airway:• Talktothepatient• Optimizeairwayposition:headtilt,chinlift,jawthrust

Breathing: • Checkoxygensaturation• Applymonitors• Provideoxygen• Auscultatechest

Circulation:• Applymonitors• Checkpulse,capillaryrefill,BP—skinfeelswarmanddry• StartIVaccess

2



Scenario Stage



Time, min

STAGE 1, continued

Disability:• Eyesclosedintermittently,openseyeswithstimulation• Moansandvocalizeswithstimuli.• Localizestopainfulstimuli,otherwisenomovement• Pupils5mm,sluggishreactionsymmetrically

Expose the Patient:• Warm,dryskin• Norash,nopetechiae• Identifyabnormalityoncardiactracing(sinustachycardia

withwideQRS)• Identifyneedfor12-leadECG• Orderbloodwork:CBC,differential,electrolytes,glucose,

creatinine,BUN,serumosmolality,bloodgas,serumacetaminophenandaspirinlevels,urinetoxicologyscreen

STAGE 2 Condition:• Thepatient’sconditionevolves—worseninglevelof

consciousness.

Physical Examination Findings:• Temperature37.5°C(99.5°F)orally,HR150/min,RR24/min,

saturation98%with100%oxygen,BP85/50mmHg• CNS:eyesclosed,nospontaneousmovement,moaning,

infrequentverbalization• Chest:spontaneousrespirations,noabnormalairentryor

breathsounds• CVS:palpablepulses,slightlycoolextremities,normalheart

sounds,tachycardia• Abdomen:nobowelsounds,palpablefullbladder

Parentcallsontelephone—grandmotherhas20–30missingantidepressantpillsfromhermedicationcabinet


• Prepareequipmentforintubation• Preparemedicationforrapidsequenceintubation

Intubation:• Preparation/equipment• Preoxygenation.• Cricoidpressure• Premedication:IVatropine• Sedation:IVketamine• Paralysis:IVsuccinylcholine• IntubatewithETT• ChecktubeplacementwithETCO2,auscultation,andchest

radiograph

Breathing:• Reassessmentofbreathing,auscultation—nochange• Apply100%oxygen—nochangeinclinicalappearance

Circulation:• ReassessHR,pulse,BP• ConsidergivingIVbolusofnormalsaline

3



Scenario Stage



Time, min

STAGE 2, continued

Medical Management:• IVsodiumbicarbonatebolus• Glucometer:normalresults• ContinuousECGmonitoring• CallforICUconsultation• Callfortoxicologyconsultation/poisoncontrol

STAGE 3 Condition:• Thepatient’sconditionevolves:ventriculartachycardia

Physical Examination Findings:• Temperature37.5°C(99.5°F)orally,HR180/min,RR10/min,

saturation98%,BP85/50mmHg• CNS:eyesclosed,nospontaneousmovement—paralyzed

andsedated• Respiratory:airentryequal• CVS:palpablepulses,slightlycoolextremities,capillaryrefill

2s• Abdomen:nobowelsounds,palpablefullbladder

REASSESSMENT OF PATIENT:Airway:

• Positionairway• Oropharyngealairway—stillinplace

Breathing:• Reassessauscultation,breathing• Manualventilation—patientintubated

Circulation:• ReassessHR,pulse,BP,capillaryrefill• GivesIVnormalsalinebolus• ECG:ventriculartachycardia

Medical Management:• FollowPALSprotocol• Prepareforsynchronizedcardioversion• Consultcardiologist

5

STAGE 4 Condition:• Patientconditiondeterioratesafterintubation

Physical Examination Findings:• Verydifficulttoventilate• Poorchestrisebilaterally• Temperature38°C(100.4°F),HR80/min,RRbagging,

saturation78%in100%oxygen,BP80/50mmHg• CNS:sedated/paralyzed• Respiratory:poorchestriseandairentrybilaterallywith

wheezing• CVS:pulsesweak,capillaryrefill4s


• SuctiontheETT:somethinmucusorsecretions• Considerdirectvisualizationofthetubewithlaryngoscope

Breathing:• Auscultatethechest• Checkforsignsoftensionpneumothorax(tracheamidline,

bloodpressure,percussionofchest,jugularvenouspressure)• Givecontinuousnebulizedinlinealbuterol(salbutamol)• Checkoxygen/equipment• Bag-maskventilateataslowerratewithaprolonged

expiratoryphase

Circulation:• InsertsecondIVcatheter• GiveIVbolusofnormalsaline

5

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.



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

• Delayinelicitingfurtherhistory,thusleadingtodelayinmakingthediagnosis.• FailuretorecognizeandanticipatethepotentialcardiaccomplicationsofTCAoverdose.


54 Simulation Scenarios Metabolic Crisis—Hyperammonemia

Metabolic Crisis—Hyperammonemia

Adam Cheng, MD, FRCPC, FAAP Mark Adler, MDDebraWeiner,MD

Learning Objectives

• Describethecommoncausesofvomitingandlethargyinaneonate.• Demonstratethetreatmentofaneonatewithalteredmentalstatusandsuspectedmetaboliccrisis.

– 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.

Scenario Stage



Time, min

STAGE 1 History:• One-week-oldwithprogressivepoorfeeding,vomiting,and

lethargyforthepast3d• BroughttoEDbyparents• Looksveryunwellattriage,broughttoresuscitationroom• Youarecalledtoassesspatient

Weight: • 3kg

Condition: • Infantispaleandlethargic,looksunwell


saturation98%inroomair,BP75/40mmHg• CNS:eyesopenspontaneously,pupils3mmandreactive

bilaterally• CVS:pulsesintactbutweakCapillaryrefill3s• Respiratory:clear• Abdomen:softandwithouthepatosplenomegaly• Extremities/skin:looseskinfolds,nobruisingnoted

Take a History: • Term,birthweight3.3kg,uncomplicatedpregnancy,

delivery• Nomedicationsornoallergies• Spittingupfirstfewdaysoflife,duringlast3dincreased

frequencyandamount,todayfourtimes• Weightcurrently10%lessthanbirthweight• Nofever,diarrhea,rash• Nosickcontactsortravel

Airway:• Listenforbreathsounds




Disability:• Quickneurologicassessment(pupils,responsetopain)

3–4



Scenario Stage



Time, min

STAGE 1, continued

Medical Management:• Orderabedsideglucose,electrolytes,BUN,creatinine,LFTs,

ammonia,bloodgas,CBC,bloodculture,urine,urineculturetests,bloodtoholdforpossibleadditionalstudies

• OrdersIVfluidbolusof10mL/kgofnormalsaline

STAGE 2 Condition: • Infantminimallyresponsivetopainfulstimulus.Doesnot

openeyesspontaneously,noverbalization/cooing


saturation94%in100%oxygen,BP70/30mmHg• CNS:unresponsive,unconscious,pupils3mmandreactive

bilaterally• CVS:pulsesintactbutweak,capillaryrefill4s• Respiratory:clear• Abdomen:softandwithouthepatosplenomegaly• Extremities/skin:nobruisingnoted


• Maintaintheairway:jawthrust,chinlift,headtilt• Suctionvigorously• Prepareintubationequipment

Breathing:• Increaseoxygendeliveryto100%byusingnonrebreather• Assistventilationsasrequired

Circulation:• EnsureIVaccesstwotimes• RecheckHR,BP,capillaryrefill,pulses• CycleBPevery3–5min

Medical Management:• Laboratorytestresultscomeback:

–Sodium135mmol/L,potassium3.5mmol/L,glucose35mg/dL(low)

• AdministerD10W,0.5g/kgIV• ABG:pH7.05,Pco230mmHg,Po290mmHg,bicarbonate8

mmol/L,baseexcess−20mmol/L• Ammonia,350µg/dL(205µmol/L).• WBCandhemoglobinlevelnormal• Metabolicorgeneticsconsultation

5

STAGE 3 Condition: • Neonatestillunresponsive,doesnotopeneyes

spontaneouslyortopainfulstimuli,noverbalization/cooing,intermittentjitteringmovementsofbotharmsandstiffeningsuspiciousforseizures


saturation94%in100%oxygen,BP70/30mmHg• CNS:unresponsive,unconscious,pupils3mmandreactive

bilaterally• CVS:pulsesintactbutweak,capillaryrefill4s


Airway: Intubation:• Preoxygenation• Premedication:IVatropineoptional• Cricoidpressure• Sedation:discussion:etomidatevsotheroptions:midazolam

plusIVfentanyl• Paralysis:IVrocuroniumorIVsuccinylcholine• ChecktubeplacementwithETCO2detector,auscultationof

chest,observationofchestrise,andorderchestradiograph

5



Scenario Stage



Time, min

STAGE 3, continued

• Respiratory:clear• Abdomen:softandwithouthepatosplenomegaly• Extremities/skin:nobruisingnoted

Breathing:• Reassessbreathing• Starttoprovidemanualventilationtothepatient

Circulation:• Reassessbloodpressure,pulse,capillaryrefill• GiveIVnormalsalinebolus

Medical Management:• CallforICUconsultation• Orderdoseoflorazepamforsuspectedseizure• Callformetabolismconsultationifnotalreadydone• Administerbicarbonate• Arrangeforhemodialysis,givesodiumphenylacetate,

sodiumbenzoateifhemodialysiswillbedelayed

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. Manifestationsofseizureinneonatesmightbesubtle.Forseizuresunresponsivetoconventionaltreatment,considerpyridoxine,folate,and/orbiotin. 7. PerformlaboratoryteststoevaluateforIEMsbeforeanytreatment,includingglucoseorfluids.Initiallaboratorytestsincludebedsideglucose,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/orhyperammonemiaarepresent,sendserumsamplesforaminoacids,acylcarnitineprofile,andketonesmeasurementandurinesamples 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.



Common Pitfalls

• PotentialdiagnosisofIEMisnotconsidereduntillate,whichincreasestheriskoflong-termdiseaseand/ordeath.• Participantscheckandtreattheglucoselevelbutfailtoobtainafollow-upglucosemeasurement.Ahighconcentrationofglucoseisnotalwaysmaintained

withmaintenancefluids.• Acidosisisnottreated.• Ammoniaisnotchecked.• Failuretorecognizeandtreatseizure.


module simulation scenariosmodule simulation scenarios contents adrenal insufficiency 1 blunt...

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