Candidate Name______Date______

Examiner Name______Examiner Signature______

Oral Station Scenario

Febrile Seizure

Dear Examiner,

This scenario is a 4 year old male with febrile seizures. The child’s is in the father’s arms. It is a nice summer day in June (90 degrees F) in Curry Village

The goal of this scenario is to assess the candidate’s ability to: perform an appropriate scene size up; primary, secondary, and verbal survey; gather the pertinent positives; eliminate the pertinent negatives; determine a diagnosis; deliver a verbal report; handle any psychosocial concerns; deliver appropriate treatment and transport; and make sound judgments.

Have the pt seize until the medic administers a benzodiazepine. After the medic administers the benzodiazepine- the pt stops seizing. Have the pt remain postictal until the medic check a glucose level. The glucose level should be 40mg/dL. If the medic administers dextrose- then have the pt regain normal mentation slowly. If the medic does not check glucose- keep the pt postictal.

This scenario attempts to determine whether the candidate has the competence to treat febrile seizures. It also seeks to determine if the candidate will manage the patient’s airway appropriately. It seeks to determine if the candidate understands that benzodiazipines should not be given unless the pt is actively seizing = 3 or more seizures in 5 minutes or any seizure lasting > 5 minutes The scenario seeks to determine if the candidate will reassess the patient’s condition after each intervention.

Please choose one of the following interpersonal relations interactions to weave into your call:

1.Family member involved: “Hey! What are you doing!” – in an aggressive,

confrontational, hysterical manner

2.Doctor insists on controlling the scene: “I’m a doctor. I am in

control. Step aside.” [podiatrist, psychiatrist, emergency room or other physician]

3.Patient is refusing treatment: “Well, I’ve decided that I don’t want to go

to the hospital.” – patient being belligerent and adamant.

  1. Create a challenging situation which requires the candidate to deal with psychosocial concerns.

MANDATORY ACTIONS:

Performed an appropriate and organized scene size up; initial assessment, physical exam, & verbal survey; start an IV, perform BLS before ALS. Protect the pt from further injury during the seizure. Cooling measures: loosen clothing and/or remove outer clothing/blanket. Benzodiazepines should not be given unless the pt is actively seizing – 3 or more seizures in 5 minutes or any seizure lasting > 5 minutes. Administer midazolam IV 0.1mg/kg (max 2mg) q 3min prn (max 5 doses) or IN 0.1mg/kg (max 2mg) via MAD q 3min (max 5 doses) or IM 0.15 mg/kg (max 5mg) q 10min prn (max 3 doses). Determine blood glucose and treat PRN. Pts who are 6 years if febrile and has regained normal mental status = 0-6 years acetaminophen 20mg/kg (max 1,000mg) PO every 4-6 hours, not to exceed 4,000mg/24 hrs.

POTENTIALLY HARMFUL/DANGEROUS ACTIONS ORDERED/PERFORMED

Under or overdosing the patient

No reassessment of the patient

Placing any object in the pt’s mouth while the pt is seizing

Failure to immobilize the pt’s spine if necessary

Or any other actions by omission or commission that you deem harmful or dangerous

Instructions to the candidate
This is the Live Simulated 911 Emergency in which you are responsible for all aspects of scene management and patient care for a given case.
Remember that you must verbalize every action. I will provide assessment findings and other information only at your request. Conduct yourself as if I am the patient, and ask me any questions you would normally ask a patient in this situation
Verbalize all interventions, ask any questions, and verbalize any orders you would normally give in the field as if this were a real call. Throughout the case, assume that medical direction grants permission for you to perform any intervention you request. In other words, you are on standing orders for all procedures and treatments.
I will acknowledge your interventions and may ask you for additional information as needed. You will also be required to complete a simulated radio report of this call, just like you would in the field. I will act as the receiving facility whenever you are ready to contact them.
Do you have any questions? [Answer any questions].
Background and Dispatch Information For the Candidate:
A 40 year old man runs up to you while you are on patrol at Curry Village. The man is holding a 4 year old male patient. The patient is actively having a generalized tonic-clonic seizure. The father tells you that his son has been seizing for 5 minutes and that his son seemed to be coming down with the flu and those symptoms started at 9am today. It is now noon.

SCENARIO FORM

Febrile Seizure

performed/

verbalized

Yes “x” / SCENE SIZE UP
BSI
Scene safety / Safe
# of patients / 1
Mechanism of injury/nature of illness (need for additional resources) / Called for an unknown medical aid
Spinal Immobilization
INITIAL SURVEY
General Impression / 4 y/o male incontinent of urine in father’s arms having full body generalized seizures- tonic clonic.
AVPU (Introduction & chief complaint)
Airway | Gag Reflex / You can’t check a gag reflex because the pt’s jaw is clenched shut
Breathing - rate & quality / 6/minute and gasping
Circulation (one of the following)
a. radial pulse -rate &
quality / You can not get a radial pulse because the pt’s seizing too much
b. skin signs / Pt’s skin appear cyanotic, hot, dry
c. capillary refill / >2 seconds
Obvious external bleeding / none
PHYSICAL EXAM & ASSESSMENT
GCS / Unresponsive – 3
Orientation / Unresponsive
Skin signs / Pt’s skin appear cyanotic, hot, dry
Pupils / Unreactive- mid ranged
Lung sounds / Unable to ascertain because the pt is gasping
Abdomen / Does not appear discolored or distended
Head to Toe survey / No obvious visual or palpable trauma – incontinent of urine
VERBAL SURVEY
Hx / None
Meds / None
Allergies / NKA
Chief Complaint / seizure
OPQRST / Onset - . Provocation – . Palliation-. Quality –. Region, Radiation, Reoccurrence – . Severity – Time –
Ever experienced this before or done this before? When? and other details. / No
SAMPLE | PASTE | PASTMEDS
SYMPTOM BAGS: Pertinent Positives & Pertinent Negatives
Hx: DM, CAD, MI, CHF, CABG, renal failure, HTN, CVA, HIV, Seizures, COPD, Psych, Surgeries, Trauma, cancer, Alcohol, other drugs
Standard Monitoring & Management Considerations
Position | Spinal Immobilization
VS | Temperature / Unable to ascertain VS while pt is seizing | pt’s skin very hot to the touch
SpO2 with no oxygen
Airway & Oxygen: Suction | O2 | NC | Mask | OPA | NPA | BVM | Combitube | King (circle those the candidate chooses)
SpO2 with oxygen / The oxygen saturation will not read while the pt is seizing
Saline lock or IV
10gtt/ml set or 60 gtt/ml set (circle one)
Size of IV catheter: 14, 16, 18, 20, 22, 24 (circle one)
Location of IV: hand, forearm, antecubital fossa, external jugular, great saphenous, other
IV type: NR, LR, D5W
Bag size: 250, 500, 1,000 mL (circle one)
Blood glucose analysis / 40mg/dl
SPECIFIC MANAGEMENT = PROTOCOL
Left lateral recumbent unless there’s a need for spinal immobilization
Protect the pt from further injury by padding or moving objects PRN; do not forcibly restrain the pt
Cooling measures: loosen clothing and/or remove outer clothing/blanket
  • Benzodiazepines should not be given unless the pt is actively seizing – 3 or more seizures in 5 minutes or any seizure lasting > 5 minutes
  • Administer midazolam
  • IV 0.1mg/kg (max 2mg) q 3min prn (max 5 doses)
  • IN 0.1mg/kg (max 2mg) via MAD q 3min (max 5 doses)
  • IM 0.15 mg/kg (max 5mg) q 10min prn (max 3 doses).

Reassess VS, mental status, pt. complaint
  • If blood sugar is low:
  • ≥2 yrs: 1 amp D50 IV (1 amp = 25g in 50ml).
  • If medications are administered to raise the blood glucose- another glucose analysis should be performed and additional hyperglycemic agents should be administered PRN (and another glucose analysis should be performed PRN)

Reassess VS, mental status, pt. complaint
  • Pts who are postictal should receive antipyretics PRN.
  • Pts who are 6 years if febrile and has regained normal mental status = 0-6 years acetaminophen 20mg/kg (max 1,000mg) PO every 4-6 hours, not to exceed 4,000mg/24 hrs.

Reassess VS, mental status, pt. complaint

Integration

1.Interpersonal Relations: Established rapport and interacted in an organized, therapeutic manner

Choose one of the following:

1.Family member involved: “Hey! What are you doing!” – in an aggressive, confrontational, hysterical

manner

2.Doctor insists on controlling the scene: “I’m a doctor. I am in

control. Step aside.” [podiatrist, psychiatrist, or other physician]

3.Patient is refusing treatment: “Well, I’ve decided that I don’t want to go

to the hospital.” – patient being belligerent and adamant.

4.Create a challenging situation which requires the candidate to deal with psychosocial concerns.

2.Please state your field impression (diagnosis):

Answer should be:

Febrile seizure.

3.Give me the rationale for your diagnosis:

Answer should be:

The febrile seizure symptom bag was heaviest (pertinent positive) and the other symptom bags of hypertensive emergency, hyperglycemia, hypoglycemia, and meningitis were empty or relatively empty (pertinent negatives).

  1. Give me the pathophysiology of your Dx.

Answer should be:

Febrile seizures occur in young children at a time in their development when the seizure threshold is low. This is a time when young children are susceptible to frequent childhood infections such as upper respiratory infectio, otitis media, viral syndrome, and they respond with comparably higher temperatures than adults. Animal studies suggest a possible role of endogenous pyrogens, such as interleukin 1beta, that, by increasing neuronal excitability, may link fever and seizure activity. Preliminary studies in children appear to support the hypothesis that the cytokine network is activated and may have a role in the pathogenesis of febrile seizures, but the precise clinical and pathological significance of these observations is not yet clear.

5.Give me the rationale for your treatments (medications or other invasive measures). Why does this treatment work in this particular medical setting?

Answer should be:

Acetaminophen reduces fever by acting directly on hypothalamic heat-regulating centers, which increases dissipation of body heat via vasodilation and sweating. Ibuprofen reduces fever by inhibiting the formation of prostaglandins. Diazepam stops or reduces subsequent febrile seizures by modulating postsynaptic effects of GABA-A transmission, resulting in an increase in presynaptic inhibition.

6.Give me a verbal report

The essential elements of a report, in an order that is efficient and effective, are:

1) identify unit and level of provider (can utilize the name of the provider giving the report as well as the unit identification)

2) estimated time of arrival

3) current patient condition

4) patient’s age and sex

5) mental status

6) chief complaint

7) brief, pertinent history of the present illness

8) major past illnesses

9) baseline vital signs

10) pertinent findings of the physical exam

11) emergency medical care given

12) response to emergency medical care