Simulation Scenario Template

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Simulation Scenario Template

© 2019 EMSIMCASES.COM and the Emergency Medicine Simulation Education Researchers of Canada (EM-SERC) Page 1 This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.

Section 1: Case Summary

Scenario Title:

Keywords: CHF, Pneumothorax, lung POCUS

Brief Description of Case: CHF pulmonary edema, Pneumothorax while on BiPAP

Goals and Objectives

Educational Goal: Clinical application of lung POCUS interpretation Objectives:

(Medical and CRM) Acute dyspnea assessment using lung ultrasound Re-evaluate clinical change using lung ultrasound

Non-Invasive ventilation indications and contraindications

Identify complications of Non Invasive Ventilation ie. pneumothorax EPAs Assessed:

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Simulation Scenario Template

Section 2A: Initial Patient Information

A. Patient Chart

Patient Name: Theresa Ho Age: 64 Gender: F Weight: 64kg

Presenting complaint: Shortness of Breath

Temp: 36.5 HR: 110 BP: 130/74 RR: 34 O2Sat: 86% FiO2: 6L NRB

Cap glucose: 8 GCS: 15 (E4 V5 M6 )

Triage note:

4 days of worsening shortness of breath. Unable to walk from the bedroom to the bathroom today so her partner called 911. Brought in by EHS on NRB. Significant increased work of breathing. Able to speak in two word answers.

Allergies: none Past Medical History:

CAD – CABG 2016

COPD – 40 pack year smoking history Type 2 Diabetes

Hypothyroidism Hypertension

Current Medications:

ASA 81mg PO daily Bisoprolol 5mg PO daily Lasix 40mg PO BID

Levothyroxine 75mcg PO daily Amlodipine 10mg PO daily

Section 2B: Extra Patient Information

A. Further History

Include any relevant history not included in triage note above. What information will only be given to learners if they ask? Who will provide this information (mannequin’s voice, confederate, SP, etc.)?

Medications not in blister pack. Patient mentions missing doses of her medications for about a week including the water pills.

B. Physical Exam

List any pertinent positive and negative findings

Cardio: regular rhythm, no extra heart sounds Neuro: GCS 15, not drowsy Resp: diffuse crackles and wheeze, indrawing, dyspneic Head & Neck: nil acute

Abdo: benign MSK/skin: nil acute

Other: pitting edema to her knees, she says she always has some degree of swelling, might be more now, not sure

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Simulation Scenario Template

Section 3: Technical Requirements/Room Vision

A. Patient

Mannequin (specify type and whether infant/child/adult) - ADULT Standardized Patient

Task Trainer Hybrid

B. Special Equipment Required

POCUS machine, Computer / Tablet to display POCUS images

C. Required Medications

Lasix, ASA, Salbutamol, Ipratropium, Methylprednisone, Prednisone, Nitroglycerin, Ketamine, Fentanyl, Lorazepam

D. Moulage

N/A

E. Monitors at Case Onset

Patient on monitor with vitals displayed Patient not yet on monitor

F. Patient Reactions and Exam

Include any relevant physical exam findings that require mannequin programming or cues from patient (e.g. – abnormal breath sounds, moaning when RUQ palpated, etc.) May be helpful to frame in ABCDE format.

If available – coarse crackles and wheeze, increased respiratory rate, short 2 word sentences as answers.

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Simulation Scenario Template

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Section 5: Scenario Progression

Scenario States, Modifiers and Triggers

Patient State/Vitals

Patient Status

Learner Actions, Modifiers & Triggers to Move to Next State

Facilitator Notes

1. Baseline State Rhythm: Sinus HR: 110 BP: 160/74 RR: 34 O2SAT: 86%

T: 36.5^oC GCS: 15

Tachypnea, 2 word dyspnea, interactive and alert but

working hard to breathe

Expected Learner Actions Apply Monitors

Consider DDx for dyspnea Empiric Medications

Modifiers

- Baseline clinical status unchanged

- pCXR occupied in ICU (unavailable for 10 min)

Triggers

- Empiric medications given without improvement

Empiric Medications

- Learner to decide etiology of dyspnea and administer CHF or COPD medications

- Should use POCUS, do not need to prompt if they don’t yet

- No medication will help significantly

2.

HR: 120 sinus BP 190/74 RR: 40 O2 Sat: 84%

T: 36.5 GCS 15

Still alert

Ongoing tachypnea and dyspnea

unchanged with meds

Expected Learner Actions Identify need for NIPPV Learners should POCUS BiPAP applied

Targeted medication (Lasix, ASA, nitro spray

Modifiers

- Baseline clinical status unchanged

- POCUS available - NIPPV available

Triggers

- BiPAP applied, patient will initially improve

POCUS Findings: Diffuse B lines to apex, bilateral simple pleural effusions. (Clips: 1 and 2)

POCUS Findings: decreased LV systolic function (Clips: 3 and 4)

Note: advanced learner will comment B lines at apex rules out pneumothorax as etiology of dyspnea

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Simulation Scenario Template

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3.

HR: 100 BP 155/72 RR: 25 T: 36.5 GCS: 15

Still alert

Tachypnea significantly improves on BiPAP

Expected Learner Actions Learners MUST POCUS (prompt if not)

Modifiers

-BiPAP is now on

Triggers

- Sudden severe right chest pain, tachypnea worsens, O2 sats drop

Prompt: if learner applied BiPAP before POCUS, prompt them to scan lungs now by asking “what is the etiology of this patients shortness of breath?”

4.

HR: 140 BP: 80/50 RR: 50 GCS 15:

Still alert

SEVERE left sided chest pain

Expected Learner Actions Immediately remove BiPAP Place on NRB

POCUS for pneumothorax

Modifiers

- POCUS to diagnose pneumothorax

Triggers

- STOP case when identify pneumothorax

POCUS Finding: pneumothorax on anterior right chest (Clip 5)

Prompt: learner to describe how to treat tension pneumothorax (finger decompression then surgical chest tube)

END CASE

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Simulation Scenario Template

Appendix B: ECGs, X-rays, Ultrasounds and Pictures

Video 1- B lines

Video 2 – pleural effusions

Video 3 – Decreased LV systolic function Long Axis view Video 4 – Decreased LV systolic function short axis view Video 5 – Decreased LV systolic function Apical 4 Chamber Image 6 – CXR

Video 7 – Left anterior chest lung slide Video 8 – Right anterior chest no lung slide

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Appendix C: Facilitator Cheat Sheet & Debriefing Tips

Include key errors to watch for and common challenges with the case. List issues expected to be part of the debriefing discussion.

Supplemental information regarding any relevant pathophysiology, guidelines, or management information that may be reviewed during debriefing should be provided for facilitators to have as a reference.

Explain rationale and differential for acute dyspnea.

Identify critical decision making points and how / if POCUS was used

Educational Resource: Western Sono

1. Image Acquisition https://westernsono.ca/screencasts/lung-ultrasound/lung-ultrasound-acquisition-tutorial-2/

2. Image Interpretation https://westernsono.ca/screencasts/lung-ultrasound/lung-ultrasound-image- interpretation-tutorial/

References

1. Western Sono westernsono.ca