Human Patient Simulation

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Human Patient Simulation

Title: Chronic Severe Salicylate Toxicity

Target Audience:Lower and Upper Level Resident

Learning Objectives:

-Primary

–Recognize a critical patient and begin immediate advanced cardiac life support (ACLS)

–Recognize severe salicylate toxicity

–Improve care transition by contacting referring facility

-Secondary

–Successfully implement ACLS x 3 rounds with proper drug dosages

–Obtain additional history from referring facility during code situation

–Treat salicylate toxicity with bicarbonate drip, fluids, vasopressors, and transfer to higher level of care

-Critical Actions Checklist

⁪ACLS

⁪Intern performing high quality Cardiopulomonary Resuscitation (CPR)

⁪Intubation / Rapid Sequence Intubation (RSI) meds

⁪get history from assisted living facility

⁪recognize salicylate toxicity

⁪Intraosseous (I/O) access

⁪Bolus intravenous fluids (IVF)

⁪Bicarbonate drip

⁪Vasoconstrictive agents

⁪Transfer to higher level of care

Environment:

-Environment

–Rural 12 bed Emergency Department with hospitalist back up

-Manikin Set Up

–I/O lines

–Code cart

–Intubation equipment

–Code drugs

–RSI drugs

-Props

–Electrocardiogram (EKG) with sinus tachycardia after successful ACLS

–Chest X-Ray (CXR) with pulmonary edema and successful intubation

-Distractors

–The extremis of the patient can distract from taking a thorough history and the need to call the referring facility.

Actors: (All roles may be played by residents participating)

-Resident running the case

-Nurse to place I/O and obtain additional history

-Assisted living facility nurse

-Intern/ junior resident who will intubate the patient and perform correct CPR

-Another resident to be the attending or Medical Intensive Care Unit (MICU) consultant at another hospital (able to give recommendations)

Case Narrative:

-Chief Complaint

–Change in mental status followed by respiratory collapse

-History

–66 year female is brought to the Emergency Department by ambulance from local assisted living facility for increased confusion. EMS brought her in. She was initially confused and disorientated. She suffered respiratory collapse immediately before arrival so they began to use bag mask valve to ventilate patient. If called, the nurse at the nursing home will reveal that the patient has had chronic knee pain which has increased recently and has been taking large amounts of aspirin and BC Powder.

-Additional history given only if asked

–The patient has complained to nursing staff about her chronic arthritis in her backs and knees for several months.

–She takes aspirin daily and sometimes goes through a bottle every “few days” along with BC powder.

–She has been losing her ability to hear over the past 2 months.

-Past Medical History

–Mild hypertension (HTN). The nursedoesn’t think she has any history of coronary artery disease (CAD), diabetes mellitus (DM),or cerebrovascular accident (CVA). She doesn’t see a doctor on a regular basis. No history of depression.

-Social History

– Long time smoker, no alcohol, lives along in assisted living facility, husband dies 10 years ago

-Medications

–Aspirin

–BC Powder

–HCTZ

-Surgical History – none

-Allergies – none

-Review of Systems – unable to provide given condition

-Physical Exam

–Glasgow Coma Scale 3, pulseless, ashen, apneic, no signs of trauma, no deformities

–Head, Eyes, Ears, Nose, Throat (HEENT) – normocephalic atraumatic, pupils 5mm bilaterally and sluggishly reactive, no extraocular eye movements, gag reflex intact

–Respiratory – apneic

–Cardiovascular – no central pulses

–Abdomen – soft, non distended

–Extremities – no gross deformities or ecchymosis

–Neurological – GCS 3

–Skin – mottled, pale, cool

-Scenario Branch Points

–On arrival, resident should immediately recognize that ACLS should be implemented. After three rounds of CPR and code drugs, a slight pulse will return. Airway should be secured during resuscitation. As it will be difficult to obtain peripheral IV access, an I/O needle should be placed for immediate access to give code drugs. During the course of CPR, additional history from the referring facility should be obtained by another health care provider which will lead to clues of chronic salicylate toxicity with end organ failure. Calling the assisted living facility will reveal that the patient takes a bottle of aspirin every few days and has been complaining of hearing loss. This should clue the resident to search for salicylate toxicity and treat with a sodium bicarbonate continuous infusion as she is severely acidemic with end organ failure. A bicarbonate drip should be implemented. Vasopressors and a large amount of IVF will be required. Patient will need increasing peak end expiratory pressure for pulmonary edema. If performed, a computerized tomography scan (CT) of the brain will be negative. She will need to be transferred to an intensive care setting..

Instructors Notes:

-Tips to Keep the Scenario Flowing

–The director should emphasize the critical condition of the patient on arrival

–Allow 3 rounds of ACLS before return of spontaneous circulation

–Encourage the resident to obtain additional history

–Focus on proper intubation techniques by the intern

–Focus on proper I/O technique by the resident and/or nurse

–Make sure the resident uses proper drug dosages

–Do not let the patient die

–The patient will survive if given IVF and vasopressor medications

The proctor of the simulation case should act as the MICU consultant. They should ask the resident why they believe this patient is coding and help guide the resident through a differential.

-Tips to Direct Actors

–The nurse at the assisted living facility should inform of the aspirin use only if called and asked about patient’s medications.

–The director should only give information when acting as a MICU consultant.

-Scenario Steps

–ACLS

–Intubation

–IVF

–Recognize chronic and severe salicylate toxicity

–Bicarbonate drip

–Vasoactive agents

–Increasing vent requirements

–Transfer to higher level of care.

-Imaging and Labs

–CXR – pulmonary edema

–Labs – high anion gap metabolic acidosis, respiratory acidosis, renal failure, rhabdomyolysis, hyperkalemia

–Salicylate Level – 61

–Urine Drug Screen – negative

–Cardiac Enzymes – negative

–CT head negative

–Arterial Blood Gas – metabolic acidosis and respiratory acidosis (because of respiratory collapse)

–Lactate – 8

–Thyroid Stimulating Hormone–within normal limits

Debriefing Plan:

-Topics to discuss

–What are the drugs used during ACLS?

–What is the difference between acute and chronic salicylate toxicity and who is at risk?

–How do you mix and start a bicarbonate drip?

–Should dialysis be a consideration for this patient?

–How can transfer of care and communication be improved?

Pilot Testing and Revision:

-Number of Participants – 5

-Evaluation form for participants – generic handout

Authors:

-JohnB.SeymourM.D.University of North Carolina Department of Emergency Medicine, PGY – 3

-RochelleChijiokeM.D.University of North Carolina Department of Emergency Medicine, PGY - 2

-KevinBieseM.D.University of North Carolina Department of Emergency Medicine, Associate Professor and Residency Director

-Graham Snyder M.D. Wake Med Health and Hospitals Department of Emergency Medicine, Assistant Program Director and Simulation Director

-Jan Busby-Whitehead M.D. University of North Carolina Division of Geriatric Medicine/ Institute on Aging, Professor and Chief