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Section 1: Case SummaryScenario Title:Nightmares Course: HyperkalemiaKeywords:Medicine, Cardiology, ACLSBrief Description of Case:This case involves the diagnosis and management of hyperkalemia. If not treated appropriately the patient will progress to ventricular fibrillation arrest.Goals and ObjectivesEducational Goal:Recognition of hyperkalemic emergency and treatment of hemodynamically unstable bradycardiaObjectives:(Medical and CRM)Review an approach to and differential for bradycardiaProvide specific treatment for severe hyperkalemiaPrioritize initial investigations and therapies Maintain situation awareness of an unstable patientCommunicate the clinical situation clearly to consultantsEPAs Assessed:TD 1: Recognizing the unstable/critically ill patient, mobilizing the health care team and supervisor, and initiating basic life support. Learners, Setting and PersonnelTarget Learners:? Medical Students? Junior Residents? Senior Residents? Staff Physicians? Inter-professional? OtherLocation:? Sim Lab? In Situ? OtherRecommended Number of Facilitators:Instructors: 1Confederates: 1Sim Techs: 1Scenario DevelopmentDate of Development:2015Scenario Developer(s):Dr. Tim ChaplinAffiliations/Institutions(s):Queen’s UniversityContact E-mail:Last Revision Date:Jan 10/2020Revised By:Dr. Chris HeydVersion Number:1.1Section 2A: Initial Patient InformationPatient ChartPatient Name: Doug SmithAge: 67Gender: MaleWeight: 80kgPresenting complaint: Generally unwell / Medication errorTemp: 36.5HR: 40BP: 90/50RR: 18O2Sat: 99%FiO2: room airTriage note: You’ve been called to assess a 67M on the general medical floor. He was admitted 3 days ago for a community acquired pneumonia and is now awaiting discharge home once out-patient services can be put in place. He was noted to be hypokalemic on labs this morning (3.2 mEq/L) and the daytime resident ordered KCl 10mEq in 100cc NS bolus, to be given once. On her initial assessment, the overnight nurse found that he was actually placed on an infusion over the last 10 hours and the patient is now confused and bradycardic.Allergies: NKDAPast Medical History: HTNCOPDSmokerCurrent Medications: IV KCl replacementCeftriaxoneAzithromycinRamiprilHCTZSection 2B: Extra Patient InformationA. Further HistoryPatient vague and repetitive, unable to provide any useful history.B. Physical ExamMental status: mild confusion, repetitivenessOtherwise unremarkable examSection 3: Technical Requirements/Room VisionA. Patient? Mannequin (Adult)? Standardized Patient? Task Trainer? HybridB. Special Equipment RequiredStandard airway equipmentDefibrillatorC. Required MedicationsACLS medsSalbutamol nebulizerInsulin/glucoseD. MoulageIV line in placeE. Monitors at Case Onset? Patient on monitor with vitals displayed? Patient not yet on monitorF. Patient Reactions and ExamConfusionSection 4: Confederates and Standardized PatientsConfederate and Standardized Patient Roles and ScriptsRoleDescription of role, expected behavior, and key moments to intervene/prompt learners. Include any script required (including conveying patient information if patient is unable)RNYou are concerned about Doug Smith, a patient you’ve had for the last 2 shifts. On evening rounds you have found him to be bradycardic and feeling “unwell”. You note that he has been receiving IV potassium continuously over the course of the day – there seems to have been a clerical error and he received 10 times the ordered dose. You explain this to the resident on his/her arrival.Section 5: Scenario ProgressionScenario States, Modifiers and TriggersPatient State/VitalsPatient StatusLearner Actions, Modifiers & Triggers to Move to Next State Facilitator Notes1. Baseline StateRhythm: Sinus bradyHR: 40BP: 90/60RR: 18O2SAT: 99%T: 36.5oC GCS: 13 (E4V4M5)ConfusionRepetitiveExpected Learner Actions FORMCHECKBOX Brief history & physical FORMCHECKBOX Call for help FORMCHECKBOX Ask for recent labs FORMCHECKBOX Place on monitor FORMCHECKBOX Place defib pads FORMCHECKBOX EKG (peaked Ts)Modifiers Changes to patient condition based on learner actionTriggers For progression to next state- 3 min → 2. Worsening- All actions complete→ 2. Worsening2. WorseningHR 30BP: 70/40GCS: 10 (E3V2M5)More lethargicJust moansExpected Learner Actions FORMCHECKBOX IV Calcium gluconate amps x3 FORMCHECKBOX Insulin regular 10 units IV /2 amps D50W FORMCHECKBOX Salbutamol 20mg nebulized FORMCHECKBOX Consider atropine and dopamine/epinephrine as per ACLS guidelines for unstable bradycardia FORMCHECKBOX EKG (sinusoid)Modifiers- Atropine → no change- First Ca → HR 35, BP 80/50Triggers- Second Ca → 4. Stabilization- 6 min → 3. VF arrest3. VF arrestRhythm: VFHR --BP: --/--GCS: 3VSAExpected Learner Actions FORMCHECKBOX Check pulse FORMCHECKBOX CPR FORMCHECKBOX Defibrillation FORMCHECKBOX IV CalciumModifiersTriggers- Ca + Defib → 2. WorseningRN may need to prompt for status change. Can prompt for Ca if leader has not yet considered it.4. StabilizationHR 55BP: 100/60GCS: 15AlertCooperativeExpected Learner Actions FORMCHECKBOX Consider other hyperK treatments such as bicarbonate, diuresis/dialysis FORMCHECKBOX Repeat EKG FORMCHECKBOX Call most responsible physician FORMCHECKBOX Call nephrology FORMCHECKBOX Consider/discuss disclosure of errorModifiersTriggers- All actions complete → SMR arrives for handover end of caseTeam leader should hand over case to MRP or other appropriate consultant.Appendix A: Laboratory ResultsCBC WBC 6.1 Hgb 145 Plt 223Lytes Na 138 K 8.2 Cl 107 HCO3 24 Urea 5.5 Cr 108 Glucose 5.6Appendix B: ECGs, X-rays, Ultrasounds and PicturesPeaked TsSinusoid C: Facilitator Cheat Sheet & Debriefing TipsInclude 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. Review the initial approach to bradycardia (ie DIE mnemonic: drugs, ischemia, electrolytes… or any other mnemonic you like!)Discuss the approach to the patient with symptomatic bradycardiaReview the medical treatment for severe hyperkalemiaReview the options for help during the night (senior resident, RACE team, on-call staff)References1. ACLS Bradycardia with a Pulse algorithm2. . ................
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