I



Title: Lethargic Infant / Pediatric Septic Shock

I. Target Audience: EM residents, medical students, nurses, paramedics

II. Learning Objectives or Assessment Objectives

A. Primary

i. Recognition and management of altered mental status in infants

ii. Recognition and management of seizures in infants

iii. Recognition and management of shock and cardiovascular collapse in infants

iv. Involvement of family in termination of resuscitation efforts

B. Secondary

i. Appropriate vascular access

ii. Appropriate airway management

iii. Appropriate drug dosing and tube sizing

iv. Appropriate CPR

C. Critical actions checklist

i. Recognizes altered mental status

ii. Performs primary survey, obtains all vital signs

iii. Establishes appropriate team roles

iv. Establishes IV/IO access

v. Obtains bedside glucose measurement

vi. Recognizes shock

vii. Initiates fluid resuscitation with pressurized crystalloid

viii. Initiates early antibiotic administration

ix. Administers appropriate medication to control seizures

x. Recognizes airway/respiratory compromise

xi. Performs bag-valve-mask ventilation

xii. Performs RSI using appropriate drugs and drug dosing, appropriate tube sizing and placement depth

xiii. Recognizes absent pulse/circulatory collapse

xiv. Initiates CPR at appropriate rate and depth

xv. Administers appropriate medications for brady/asystolic arrest

xvi. Involves family appropriately in termination of efforts

xvii. Terminates resuscitation at appropriate time

III. ACGME Competencies Assessed

A. Patient Care

B. Medical Knowledge

C. Interpersonal/Communication Skills

D. Professionalism

E. System-Based Practice

IV. Environment and Props

A. Simulation Center Setup – ED resuscitation bay

B. Manikin Setup

i. infant simulator (Baby Ryan - METI)

ii. moulage with diaper

iii. seizure simulator (“Bumble Ball”, Ertl Toys) – Place between the legs of the manikin, cover with sheet and activate manually at the appropriate time. No previous citation known documenting this application.

C. Props

i. IV catheters (22g, 24 g)

ii. IV tubing and IVF (normal saline) setup

iii. IO needles

iv. 60 cc syringe and 3-way stopcock

v. Broselow tape

vi. medications (IV) – water (with one exception) in labeled syringes

1. naloxone

2. D50 (to be diluted)

3. midazolam

4. lorazepam

5. phenobarbital

6. phenytoin

7. etomidate

8. succinylcholine

9. rocuronium

10. vecuronium

11. propofol (milk in labeled syringe)

12. ceftriaxone

13. acyclovir

14. vancomycin

15. epinephrine

16. atropine

vii. medications (PR) – (bacitracin gel in labeled syringe)

1. diazepam

viii. airway supplies

1. laryngoscope with blades

2. ETT (3.5, 4.0, 4.5) with stylet

3. Ambu with mask

4. CO2 detector

5. needle cricothyrotomy setup (14 g angiocath, O2 tubing/flow valve, tubing connector, 50 psi O2 source, Luer-lock, tape, 3 cc syringe, 7 ETT adapter)

ix. ECG – pediatric sinus tachycardia

x. CXR – pre and post intubation

V. Actors

A. Roles – nurse x 2, mother/father, paramedics, physician(s), critical care consultant

B. Who may play them – other residents, other students, nurses, paramedics, actors

C. Action Role (supportive)

VI. Case Narrative

A. Scenario Background – Information for participants

10 month old male presents via EMS with altered mental status. He felt “a little warm” prior to putting him to bed, but was otherwise normal. Mother went to check on him this morning and found him in his crib lethargic and difficult to arouse. She also notes that he feels “hot”. She tried putting him in a cool bath, but “he wouldn’t stay awake”. She then called EMS. Paramedics found the child to be lethargic and minimally responsive with a HR of 180, RR of 60, pulse oximetry of 90% on room air. They were unable to establish an IV and transported him to the hospital.

The patient was born at term via SVD after an uncomplicated pregnancy. He has no known past medical history, takes no medications, and has no known allergies. He has had his 2- and 4-month immunizations. (immunization hx given if asked).

B. Scenario conditions initially

On arrival to the ED, the patient is placed in the resuscitation bay, where he is noted to be lethargic and warm. Vital signs: HR 180, RR is 60, BP (if asked) 60/20, pulse ox 93% on 10L/min of O2 via NRB, temp 39.5° C. Primary survey reveals: airway patent, no pooled secretions; breathing rapid, BS symmetric; circulation - weak symmetric femoral and brachial pulses. After a primary survey and before establishment of an IV, the patient begins to have a generalized tonic-clonic seizure.

C. Scenario branch points

i. Seizure – The patient will have a mild desaturation during the seizure. O2 via NRB should be maintained. BVM is acceptable. IV/IO access should be obtained and benzodiazepines administered to control seizures. If appropriate medications are dosed correctly, seizure will stop. If participants are unable to obtain IV or IO access, then rectal/buccal benzodiazepines are temporarily acceptable alternatives.

ii. Airway/Respiratory compromise – after the seizure stops, the patient will initially have spontaneous respirations at a RR of 40, then gradually slow while O2 saturations gradually fall. BVM should be restarted/initiated and RSI begun. O2 saturation should drop to 80% then rapidly below 50% if no airway intervention is initiated. Bradycardia should accompany any O2 saturation below 80%. O2 saturation will increase to 90% (and HR to 160) with BVM alone. RSI should be performed and, after successful completion, vitals should return to HR 160, BP 60/40, O2 sat 100% on FIO2 1.0. IF BVM is not initiated or endotracheal intubation is unsuccessful, the patient should arrest.

iii. Cardiovascular collapse – Shortly after intubation, the patient will lose his pulse. The monitor will show progressive bradycardia and an undetectable BP (even if pulselessness is not initially recognized). CPR should be initiated and appropriate medications given (epinephrine, atropine). Primary survey should be repeated (reassess airway, breath sounds, pulse). After the first round of medications is administered, the patient will transiently regain a pulse (approx 1 minute, HR 100) then lose it again. BP undetectable. CPR should be restarted. Bradycardia will deteriorate to asystole. All further resuscitative efforts will fail. Participants should recognize futility of efforts and family should be informed and be given option of being in the room when efforts are terminated and patient pronounced dead.

VII. Instructors Notes

A. Tips to keep scenario flowing

i. Patient should seize almost immediately after he is on the bed.

ii. If too much time is taken in controlling seizure, obtaining IV/IO access or airway control, or if participants fail to recognize and manage shock (administer crystalloid via syringe/3-way stopcock or similar device), then the patient should arrest.

iii. Allow some time during the recovery phases for participants to verbalize and initiate IVF and antibiotics.

iv. After the patient arrests a second time, allow participants to initiate another round of meds but make it obvious that all further efforts will fail. The patient should rapidly decline to asystole. The preceptor should say “All further efforts are unsuccessful”. The participants should then proceed to inform and involve family (if not already done).

VIII. Debriefing Plan

A. Method – group

B. Debriefing materials – video, competency form

C. Rules for debriefing – facilitated discussion

D. Questions related to debriefing

i. Discussion of critical actions

ii. Differential diagnosis of altered mental status in infants

iii. Rapid assessment of critically ill infants

iv. Key procedural interventions in critically ill infants

v. Review of appropriate medications and dosing

vi. Discuss termination of resuscitative efforts and involvement of family

E. Additional points related to pediatric death

This aspect of the case has the potential to be particularly disturbing to the participant. Debriefing should include assurances that the case is designed to result in the death of the simulated patient regardless of interventions. Evaluation should be based on the path taken to that inevitability using the competency checklist and video. In pilot testing, a few participants were more disturbed than others by the outcome but accepted the inevitability once it was revealed to them. The emotional experience without prior knowledge of the outcome was felt to be a valuable experience by both the participants and faculty preceptors. In conjunction with this high-fidelity simulation, actors may be used to simulate parents/relatives during a supervised death notification exercise.

IX. Pilot Testing and Revisions

A. Numbers of participants – 4-5 participants per group, 33 residents total (15 acted as team leaders). Piloted 5/30/07.

B. Performance expectations, anticipated/observed management errors

i. Recognition of altered mental status/lethargy

ii. Recognition of airway/respiratory compromise

iii. Recognition of shock/cardiovascular collapse

iv. Appropriate medications and dosing

C. Competency evaluations of team leaders

i. 14 participants rated “meets expectations”

ii. 1 participant rated “below expectations”

D. Simulator states

i. See below

ii. All transitions were manual

iii. Option to create distinct mild/mod/severe states prior to “resp arrest”.

iv. Option to create Collapse I (first collapse) and Collapse II state if unable to ‘go backward’ in programming once they get to Recovery C.

E. Simulator failure

i. Two episodes of tracheal tears in “Ryan”. Suggested technical improvement to manikin. Fabric tape worked as a temporary patch.

X. References

Hazinski MF, Zaritsky AL, Nadkarni VM, Hickey RW, Schexnayder SM, Berg RA, eds. PALS Provider Manual. American Academy of Pediatrics, American Heart Association, 2002. ISBN 0-87493-322-6.

Evaluation Form adapted from The Standardized Evaluation Methods Committee, CORD-EM Sharepoint.

Stewart RD. Manual Translaryngeal Jet Ventilation. Emergency Medicine Clinics of North America 1989;7(1):155-164.

Patel RG. Percutaneous transtracheal jet ventilation: A safe, quick, and temporary way to provide oxygenation and ventilation when conventional methods are unsuccessful. Chest 1999;116:1689-94.

XI. Authors and affiliations

Thomas P. Noeller, MD FACEP

Assistant Professor

Department of Emergency Medicine

Case Western Reserve University School of Medicine

Attending Physician

MetroHealth Medical Center

Cleveland, Ohio

Email: tnoeller@

Michael D. Smith, MD

Senior Clinical Instructor

Department of Emergency Medicine

Case Western Reserve University School of Medicine

Attending Physician

MetroHealth Medical Center

Cleveland, Ohio

Email: msmith2@

Competency Form

(Format Adapted from The Standardized Evaluation Methods Committee, CORD-EM Sharepoint)

Pediatric Resuscitation Team Leader

Resident: ____________________________ Date: __________________

_________ Obtains info from available sources (patient, medics, family, police). (PC, SBP)

_________ Organizes team/assigns duties to specific members of the team. (ICS, P)

_________ Provides clear instructions to team throughout resuscitation. (ICS)

_________ Appears confident and calm & asks for help if needed. (ICS, P)

_________ Performs primary survey, obtains all vital signs (PC)

_________ Establishment of IV/IO access (PC)

_________ Obtains bedside glucose measurement (PC)

_________ Recognizes shock (PC, MK)

_________ Initiates fluid resuscitation with pressurized crystalloid (PC, MK)

_________ Initiates early antibiotic administration (PC, MK)

_________ Appropriate medication administration to control seizures (MK)

_________ Recognition of airway/respiratory compromise (PC, MK)

_________ Performs bag-valve-mask ventilation effectively (PC)

_________ Performs RSI using appropriate drugs/dosing, tube sizing and depth (PC, MK)

_________ Recognizes absent pulse/circulatory collapse (PC)

_________ Initiates CPR at appropriate rate and depth (PC)

_________ Administers appropriate medications for brady/asystolic arrest (MK)

_________ Terminates resuscitation and involves family in termination of efforts (PC, P, ICS)

Below Expectations Meets Expectations Above Expectations

Overall Comments:

Faculty Signature: _____________________ Printed:_____________________

Resident Signature: _____________________

Simulator states

I. Baseline

a. Vitals HR 180, BP 60/20 (displayed if asked), RR 60, O2 sat 93% on 10L/min NRB.

b. BP should increase (and pulse quality improved) to 80/40 if 20 cc/kg fluid bolus given at any point, 90/50 if a second bolus is given

c. O2 sat should rapidly decline to 80% if O2 is not placed on patient

d. Spontaneous breathing

e. Symmetric breath sounds

f. Weak femoral and brachial pulses

g. Pupils midrange

II. Seizure

a. Generalized tonic/clonic activity (manually activate Bumble Ball)

b. Vitals HR 200, BP unobtainable, RR 40, O2 sat 90% if O2 in place

c. Labored, shallow respirations with upper airway sounds

d. O2 saturation should drop to 80%, then fall rapidly to 50% if no O2 or assisted ventilation.

e. HR should fall rapidly from 200 to 120 to 80 to 40 when O2 saturation drops below 80%. (hypoxia = bradycardia).

f. Can use states mild (HR 120, RR 30, O2 sat 80%), moderate (HR 80, RR 20, O2 sat 70%), severe (HR 40, RR 10, O2 sat 60%) respiratory distress. Tend to go to mild respiratory distress state for most groups followed by Recovery A if benzodiazepine administered rapidly.

g. Pupils dilated

III. Recovery A

a. Vitals HR 160, RR 40, BP 60/20, O2 sat 90%

IV. Respiratory Arrest

a. No BVM/No intubation

i. HR falling 160 (sinus tachycardia) to 40 (sinus bradycardia), RR 0, BP 60/20 then unobtainable (progression to cardiovascular collapse) if rechecked, O2 sat falling 80% to 50%. Can use mild, moderate, severe respiratory distress states.

ii. Respiratory arrest state HR 40, RR 0, BP 60/20, O2 saturation 50%

iii. Pulses weak then absent, if applicable

V. Recovery B

a. +BVM/No intubation

i. HR 160 (sinus tachycardia), RR 0 (assisted only), BP 60/40, O2 sat 90%

ii. Pulses weak

b. Intubated

i. HR 160 (sinus tachycardia), RR 0 (assisted), BP 60/40, O2 sat 100% if bagging adequately or on vent

ii. Pulses weak

VI. Cardiovascular Collapse / Arrest

a. Vitals - monitor HR 40 (narrow complex bradycardia), RR 0 (assisted), BP undetectable, O2 sat undetectable.

b. Absent pulse

c. If epinephrine/atropine given, HR increases to 100, pulse returns. (Recovery C)

d. 1 minute after return of pulse, HR begins to fall, patient becomes pulseless, no BP obtainable. Can go back to recovery C temporarily if epinephrine given, but each time return to collapse state and ultimately, death.

VII. Recovery C

a. Intubated, HR 100, weak pulse, RR 0 (assisted), BP unobtainable, O2 sat unobtainable

VIII. Death

Transitions

I. Baseline to seizure after primary survey

II. Seizure to recovery A after lorazepam/diazepam/midazolam administered and seizure stops

III. Recovery A to respiratory arrest after 1 minute

IV. Respiratory arrest to recovery B if successful airway management

V. Respiratory arrest to cardiovascular collapse/arrest if inadequate airway intervention after 1 minute

VI. Recovery B to cardiovascular collapse/arrest 4 minutes after successful airway intervention

VII. Cardiovascular collapse/arrest to recovery C after appropriate CPR, epinephrine/atropine.

VIII. Recovery C to Cardiovascular collapse/arrest then Death after 1 minute

[pic]

-----------------------

CPR/epi/atropine No

CPR/epi/atropine Yes

4 minutes

Mild

Mod

Sev

BVM/RSI No

BVM/RSI Yes

Resp Arrest

CV Arrest

Recovery C

Seizure

Recovery A

Recovery B

Benzo No

After Primary Survey

Death

Benzo Yes

1 minute

Baseline

1 minute

CV Arrest

Sev

Mod

Mild

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download