November 2010 - POGOe



MedEd Portal / POGOe

Human Patient Simulation

• Title: Mesenteric Ischemia

• Target Audience: Emergency Medicine Resident

• Learning Objectives:

- Primary

– Recognize mesenteric ischemia

– Recognize that elderly people with acute abdominal pain have significant mortality and morbidity

- Secondary

– Recognize when the patient is decompensating and intervene with appropriate actions (Intravenous Fluids (IVF), blood, pressors, consultation, antibiotics)

- Critical Actions Checklist

– volume resuscitation

– pain control

– recognize Atrial Fibrillation (Afib) on Electrocardiogram (EKG)

– order abdominal Computerized Tomography (CT) if patient is stable

– Ultrasound (FAST) if patient decompensates

– antibiotics

– type and cross

– Nasogastric tube (NGT)

– surgical consultation

– consider anticoagulation but do not administer as patient is heme positive

• Environment:

- Environment

– 25 bed Emergency Department (ED) in community hospital

- Manikin Set Up

– Code cart

– Intubation equipment

– Code drugs

– Rapid Sequence Intubation (RSI) drugs

– Bedside ultrasound

- Props

– EKG with Afib with rapid ventricular response (RVR)

– Negative FAST initially, then positive for blood later in the simulation

– Computerized Tomography – mesenteric ischemia

- Distractors

– Patient keeps asking for medicine during the history making it challenging for resident to obtain information

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

- Resident running the case

- Nurse to place IVFs and give medications

- Respiratory tech

- Another resident to be the Surgery or Medical Intensivist (MICU) consultant (able to give recommendations if necessary)

• Case Narrative:

- Chief Complaint: Abdominal Pain

- History: Seventy-seven year-old female presents with abdominal pain for the past 3 hours. It started soon after she finished eating lunch today. She saw her primary care doctor today who set her up for an outpatient abdominal ultrasound next week to evaluate her gallbladder. Her abdominal pain is generalized. She has had some loose stools, vomiting, and feels more short of breath lately. She states that she “just doesn’t feel well.”

- Additional history given only if asked: There is history of “poor circulation” in her legs. Patient also notes that she’s lost 10 pounds without trying in the last 6 weeks. She’s had a similar pain episode once before 2-3 years ago.

- Past Medical History (Hx): peptic ulcer disease, hypertension, hyperlipidemia

- Social Hx: Retired schoolteacher who lives in a retirement community.

- Medications: Hydrochlorothiazide; Zocor

- Surgical Hx: Partial hysterectomy when she was 38 years old; carpal tunnel release surgery

- Allergies: Penicillins

- Review Of Systems: Subjective fevers and occasional chest discomfort

- Physical Exam

– Blood Pressure 179/95, Heart Rate 111, Respiratory Rate 25, Temperature 37.2, Oxygen Saturation 94% on room air

– Glasgow Coma Scale (GCS) 15 in mild distress, clutching her abdomen

– Head Eyes Ears Nose Throat – normocephalic atraumatic, pupils 3mm bilaterally and reactive, extraocular eye movements are intact

– Respiratory – tachypnea; clear lungs bilaterally

– Cardiovascular – tachycardia, irregularly irregular

– Abdomen – soft, diffuse tenderness, a little more so in the epigastric region, no guarding or rebound, minimally diminished bowel sounds; no organomegaly

– Rectal- heme positive

– Extremity – no gross deformities; evidence of peripheral vascular disease in lower extremities bilaterally

– Neuro – Moves all extremities well

– Skin –pale, cool

• Instructors Notes:

- Tips to Keep the Scenario Flowing

– The patient should start out with relatively normal vital signs and progressively worsen throughout the simulation

– Pain is not eased with intravenous (IV) opioids and the patient keep asking for more medication

– The resident should provide IVF and check an EKG early on

– Patient’s abdomen becomes progressively more painful and peritoneal- emphasize the importance of serial abdominal exams

- Tips to Direct Actors

– The director should help the resident form a wide differential concerning the patient’s abdominal pain.

- Scenario Steps

– Optimal Management Path

• Resident realizes the many causes of abdominal pain in an elderly patient and forms a wide differential: gallbladder or liver etiology, pancreatitis, bowel obstruction, gastrointestinal (GI) bleed/peptic ulcers, appendicitis, volvulus, mesenteric ischemia. The resident orders labwork including CBC, Chem 10, LFTs, lipase, amylase, and lactate. A 3 way abdominal film will be unremarkable. An abdominal CT should be ordered as well. An EKG and cardiac enzymes should be ordered based on her additional history of chest discomfort and shortness of breath. The EKG will demonstrate new onset atrial fibrillation. This finding should clue the resident in to mesenteric ischemia. Surgery and intensivist consultations should be called.

– Potential Complications Path

• If the patient fails to recognize mesenteric ischemia in a timely manner, the patient decompensates and becomes septic quickly, requiring fluids, blood, and pressors.

– Potential Errors Path

• The resident may not order an EKG and treat the atrial fibrillation with RVR which could progress into an unstable rhythm

• The resident may proceed with GI bleed treatment pathway due to the heme positive stool

• Based on prior history of needing an ultrasound, the resident may order an abdominal or right upper quadrant ultrasound, delaying the definitive diagnosis.

- Imaging and Labs

– CBC: WBC 16, Hgb 8.6, Hct 26, Plts 214

– Chem 10: Na 135, K 3.6, Cl 101, CO3 22, BUN 12, Creat 1.3, Ca 8, Mg 2.1, Phos 4.3

– Lactate 6.4

– LFTs: AST 34, ALT 32, Alk Phos 121, Tbili 0.8

– Lipase 24

– Amylase 189

– D-dimer 301

– 3 way abdominal film: WNL

– CT abdomen and pelvis: superior mesenteric ischemia

– EKG: Atrial fibrillation with RVR

• Debriefing Plan:

- Topics to discuss

– What is the classic triad of superior mesenteric artery embolism?

– What is the definitive treatment for mesenteric ischemia?

– What are the most common causes of mesenteric ischemia?

• Pilot Testing and Revision:

- Number of Participants – 4

- Evaluation form for participants – generic handout

• Authors:

- John B. Seymour, MD. University of North Carolina Department of Emergency Medicine.

- Rochelle Chijioke, MD. University of North Carolina Department of Emergency Medicine.

- Amar Patel, MS. Director of the Center for Innovative Learning at WakeMed Health & Hospitals.

- Graham Snyder, MD. Assistant Professor and Medical Director of the Center for Innovative Learning at WakeMed Health & Hospitals

- Kevin Biese. MD, MAT. University of North Carolina Department of Emergency Medicine, Assistant Professor and Residency Director

- Jan Busby-Whitehead, MD. University of North Carolina Professor & Chief, Division of Geriatric Medicine; Director, Center for Aging and Health.

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