Goals and objectives - Lippincott Williams & Wilkins



Goals and objectivesTechnical and non-technicalSTATUS EPILEPTICUSOct-Nov 2015Scenario B (ESETT)The focus of this simulation is around:1. Early recognition of status epilepticus, including differential diagnosis (potential for trauma, metabolic, infectious, atypical febrile; less likely ingestion given age)2. Proper ABCs3. Proper airway management, as needed4. Compliance with revised Status Epilepticus Algorithm, as well as introduction to ESETT 5. Review the need to run flush behind ESETT drug-this is a change from earlier sims6. ReassessmentsTarget participants (roles, specialty)Emergency medicine care providers potentially involvement of neurology and critical care in consultationClinical setting (ED, OR, patient room) sim lab or in situED in situBasic scenario information(outline)You receive a 3-year old male by squad. Parents could not arouse infant from nap, noticed him to be “jerking” and called 911. Recent history that he was “not eating well” with vomiting over last 24 hours. No urine output in 12 hours. Has a history of two febrile seizures, but no fever this time per family. No home daily AEDs, but has rescue rectal Diastat. As this episode seemed different and longer to family, they gave 5mg Diastat rectally. They repeated this 5mg more time just as squad was arriving. Squad could not obtain IV access, so gave Versed IM in route. Total estimated seizure activity on arrival is at least 12 minutes (5 or more minutes at home, 7 minutes in route). No improvement with the two doses of Diastat rectally (total 10 mg given) and the one dose of Versed IM (total 3mg).Simulator to be usedGaumard Toddler (or similar)Fluids and medications to have availableFluids: Normal saline, dextrose (D10 or D25)AEDs: midazolam, lorazepam, phosphenytoin, Keppra, valproic acidRSI meds: lidocaine, etomidate, succinylcholine, rocuronium, vecuronium, fentanylEquipment needed ( IV’s, ET tubes, Chest tubes,)PPEB/P cuff, monitor leads, pulse oximetryB-BoardIV/IO suppliesIV pump, syringe pump(s)MonitorsAirway equipment: BVM setup, ETT tubes, laryngoscope and blades, stylets, suction, StorzPaperwork, labs, X rays and EKG’s, photos, videosX-ray: Chest (which result is normal), although will need a set of post-intubation films – one with ETT in trachea, one with ETT in right main stemLab Values: I-stat: pH =7.22, PCO2 = 65, PO2 = 155, HCO3 18, BD -5,Glucose 85, iCa 1.09, Na 136, K 4.4CBC with WBC 10.9, H/H 12.8/38, plts 153Lactate 2.3UDS: (-)Medication interventionUse of AEDs as per revised Status Epilepticus Algorithm or enroll into ESETTRSI medications: most likely will use RSI, lidocaine (possibility of NAT/head injury??), etomidate and succ – rocuronium would be fine also, but concern that it will be difficult to assess clinical seizure activityAirway intervention (oxygen, BVM, intubation)Initial Non-Rebreather or CPAP mask for increase oxygen demands Anticipate need for assisted ventilation – CPAP, BiPAP, BVMAnticipate need for advanced airway - appropriate sized blade/ETT, RSI meds as abovePhysiologic intervention(CPR)Aggressive use of AEDs to abort status, while watching for potential side effects/progression that include:Respiratory Failure - Assisted Ventilation and OxygenationCirculatory Collapse – IVF resuscitation, CPRProcedures and other interventionsRequires IV access – initially PIV; IO if cannot get (or do not give them) PIV or if goes into arrest and no access presentNumber of and education of instructors1 facilitator, but ideally two with one MD, one RN1-2 simulation specialistEvaluation tools and measurement points Compliance with revised Status Epilepticus Algorithm and introduction to ESETT enrollmentAdvance organizer/pretest and how deliveredStatus Epilepticus Algorithm will be sent out by end of September 2015, with copies replaced in STS and Liberty Big RoomESETT details should be sent out by investigators and CRCs early in OctoberPersonnel-simulation specialist,Actors/family membersConsider actor as significant figure with knowledge of patient history to give details to staff who may request further detailed historyEstimated time to run simulation and debriefingSimulation 10 minutesDebriefing 10 minutesSpecial Modifications/Moulage neededNoneNeed for reevaluation (time frame)Will run a series of these in Oct & Nov 2015 to monitor for compliance with revised Status Epilepticus Algorithm and introduction to ESETTFlowchart for scenario development-2308708510891Other potential errors that can be made:Giving multiple doses of benzos leads to respiratory depression and hypotensionNot being aggressive in AEDs leads to prolonged status and more difficulty stopping00Other potential errors that can be made:Giving multiple doses of benzos leads to respiratory depression and hypotensionNot being aggressive in AEDs leads to prolonged status and more difficulty stoppingGive dose of benzo via IOActive, generalized seizure activityEstablish ABCsPlace on O2, attach monitorsIV/IO access2nd IV: I-stat, red top tube, CBC, blood cx, renalOrder lorazepam or versedAssess ABCs, but delay in interventions:Placed on O2Multiple IV attempts, slow to attempt IO accessNo meds asked forFailure to assess ABCs as focused on seizure onlyOrders on lorazepamIV attempts, No oxygen placedHR 190s, BP 66/38, RR 20s, sats 96%, seizingHR 180s, BP UTO, RR 20s, sats 86%, seizingGive dose of benzo (lorazepam IV/IO or versed IM/buccal/IN)Order 2nd line AED or ENROLL in ESETTConsult neurologyMaintain oxygenation, assess ventilationConsider causes of status epilepticusContinues to miss IV attempts, so places IOOrders benzo to be given IONo bloodwork doneGives lorazepam IM, as cannot get IV and didn’t try IOLoad with blinded 2nd line agent over 10 minutesOrder pentobarbital (3rd line agent) to bedsideMaintain oxygenation, assess ventilationPlaces on oxygen, but no BVMQuestions pulse ox, moves to other locationOrders 2nd dose of ativanHistory as aboveExam: Pale, mottled, active generalized seizure activityBP=128/79, RR=20s, HR=160s T=37.2, Sats 94%RABS clear; No murmur or gallop, abd soft/ND, Cap refill 3 sec seconds, intact central an distal pulses.HR 160s, BP 120/70, RR 20s, sats 96%, seizingHR 190s, BP 60/40, RR 20s; sats 94%; seizingHR 160s, BP 115/65, RR 20s; sats 94%; seizingI-stat as aboveHR 120s, BP UTO, RR 10s, sats 60s, seizingBecomes apneic and bradycardic, leading to arrestLoad with pentobarbital and then begin dripConsult PICUMaintain oxygenation, assess ventilation5 minutes3 minutes2 minutes2 minutes5 minutes2 minutes2 minutesALTERNATE PROCESSDelay ActionINCORRECT PROCESSFail to ActHR 160s, BP 113/68, RR 10s, sats 90%, seizing10 minutesGive dose of benzo via IOActive, generalized seizure activityEstablish ABCsPlace on O2, attach monitorsIV/IO access2nd IV: I-stat, red top tube, CBC, blood cx, renalOrder lorazepam or versedAssess ABCs, but delay in interventions:Placed on O2Multiple IV attempts, slow to attempt IO accessNo meds asked forFailure to assess ABCs as focused on seizure onlyOrders on lorazepamIV attempts, No oxygen placedHR 190s, BP 66/38, RR 20s, sats 96%, seizingHR 180s, BP UTO, RR 20s, sats 86%, seizingGive dose of benzo (lorazepam IV/IO or versed IM/buccal/IN)Order 2nd line AED or ENROLL in ESETTConsult neurologyMaintain oxygenation, assess ventilationConsider causes of status epilepticusContinues to miss IV attempts, so places IOOrders benzo to be given IONo bloodwork doneGives lorazepam IM, as cannot get IV and didn’t try IOLoad with blinded 2nd line agent over 10 minutesOrder pentobarbital (3rd line agent) to bedsideMaintain oxygenation, assess ventilationPlaces on oxygen, but no BVMQuestions pulse ox, moves to other locationOrders 2nd dose of ativanHistory as aboveExam: Pale, mottled, active generalized seizure activityBP=128/79, RR=20s, HR=160s T=37.2, Sats 94%RABS clear; No murmur or gallop, abd soft/ND, Cap refill 3 sec seconds, intact central an distal pulses.HR 160s, BP 120/70, RR 20s, sats 96%, seizingHR 190s, BP 60/40, RR 20s; sats 94%; seizingHR 160s, BP 115/65, RR 20s; sats 94%; seizingI-stat as aboveHR 120s, BP UTO, RR 10s, sats 60s, seizingBecomes apneic and bradycardic, leading to arrestLoad with pentobarbital and then begin dripConsult PICUMaintain oxygenation, assess ventilation5 minutes3 minutes2 minutes2 minutes5 minutes2 minutes2 minutesALTERNATE PROCESSDelay ActionINCORRECT PROCESSFail to ActHR 160s, BP 113/68, RR 10s, sats 90%, seizing10 minutes ................
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