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INSTRUCTOR GUIDE FOR CALCIUM CHANNEL ANTAGONIST OVERDOSE SIMULATION SCENARIO

I. Title: Calcium Channel Antagonist (CCA) Overdose

II. Target Audience: Healthcare providers and teams who care for pediatric health emergencies, including but not limited to pediatric and emergency medicine residents, pediatric emergency medicine fellows, pediatric and emergency medicine physicians, nursing, respiratory therapy, and other allied health professionals.

III. Overview

This case centers on an adolescent patient with altered mental status and suspected toxic ingestion. Learners should recognize and appropriately manage suspected CCA toxicity, demonstrate appropriate airway and circulatory management, manage seizure activity, demonstrate appropriate consultation of a toxicologist, and provide patient disposition to a pediatric critical care unit.

IV. Purpose

This case was designed to teach emergency medicine physicians, pediatricians, and other healthcare providers about the clinical presentation, stabilization, and medical management of the patient with suspected or proven toxic ingestion of CCAs. Simulation was chosen because, in contrast to traditional lectures, it allows for team-based practice and fine-tuning of a systematic approach to acutely ill patients in a safe learning environment. The overall goal is enhanced recognition and management of pediatric patients with high-acuity, low-frequency toxicologic emergencies.

V. Conceptual background

Prior to development of this simulation scenario, our fellowship included lecture-based teaching on toxicology topics based on the ACGME PEM core content outline. This case was developed to ensure a systematic opportunity for each trainee to practice acute recognition, differential diagnosis, evaluation, and management of toxicology emergencies.

A group of content experts from PEM and toxicology reviewed ACGME content guidelines for toxicology. This scenario was written initially by a single author, reviewed by multiple authors for content and clarity, piloted prior to the actual simulation day, and revised based on feedback.

VI. Implementation

This case requires use of Laerdal SimMan 3G and its associated software and program files. This scenario was conducted in a resuscitation room equipped with standard pediatric resuscitation equipment, including airway equipment, monitors and defibrillators, IV access, and standard resuscitation drugs. This scenario was designed to take 10-15 minutes to complete with 30 minutes immediately following to debrief.

Scenario participants include 1-2 physicians and a nurse. One facilitator is needed to run the Laerdal software and 1-2 facilitators should serve as over-the-phone consultants and conduct a debriefing with the learning materials provided. In addition, this scenario calls for a confederate to play the role of the EMS provider. The confederate should have direct communication with a facilitator (via earpiece or in person) to assist in prompting participants when/if deviation from the scenario algorithm occurs. Confederates are also given notecards printed with specific physical exam findings and lab values to hand to participants when prompted (see Appendix C).

For our scenario, a cord attached from the mannequin’s arm to a bicycle brake was used to simulate upper extremity “twitching,” however seizure activity can be simulated with vibrating mechanisms or provided as a verbal cue to participants.

VII. Limitations

Mental status, capillary refill, and the presence or absence of neurologic manifestations are often difficult to simulate. Notecards and verbal cues should be provided by the confederate for clarity. Our workshop included only PEM fellows and nurses, and therefore has not been evaluated with other learner groups. We also did not include a didactic session with the scenario, but feel this may have been helpful to the participants’ overall learning experience.

VIII. Learning Objectives

a. Primary:

i. Recognition and management of child with suspected toxic ingestion

ii. Recognition and management of CCA ingestion and toxicity

iii. Recognition of suicidal intent

iv. Assignment of team roles, including team leader

v. Demonstrate appropriate communication with family members

b. Secondary:

i. Demonstrate appropriate airway management

ii. Demonstrate appropriate circulatory support

iii. Demonstrate closed-loop communication and shared mental model

iv. Demonstrate appropriate subspecialty consultation with Toxicology and/or Poison Center

v. Provide appropriate patient disposition and transition of care

c. Critical Actions Checklist (see Appendix B, checklist):

i. Establishment of team roles, including team leader

ii. Timely placement of cardiac monitors and vital signs

iii. Recognition of circulatory dysfunction (hypotension and bradycardia)

iv. Recognition of CCA on medication list

v. Basic airway management (oxygen administration, bag valve mask ventilation)

vi. Recognition and appropriate management of CCA ingestion and toxicity with calcium infusion and high-dose insulin

vii. Management of hypotension with saline bolus infusions and pressors (norepinephrine)

viii. Management of bradycardia with atropine or CPR

ix. EKG requested and heart block recognized

x. Management of complete heart block with transcutaneous pacing

xi. Additional labs requested

xii. Advanced airway management (endotracheal intubation)

xiii. Central line placement for continuous calcium infusion

xiv. Poison Center or toxicology consultation

xv. Disposition to pediatric intensive care unit

d. Optimal sequence of critical actions: expected sequence as above

e. Duration to critical actions: total scenario to be completed within 15 minutes of start

IX. Environment:

a. Lab Set Up: This scenario has been run in the simulation lab in a large simulation room with control room. It could also be run in an emergency room, including in a resuscitation or trauma bay, a decontamination area, or a regular room.

b. Mannequin Set Up:

i. High-fidelity adult-sized mannequin (Laerdal SimMan 3G or similar) with ability to simulate seizure

ii. Female patient moulage, street clothing, bilateral 4 mm pupils

iii. Lines needed: PIV upper extremity

iv. Central line task trainer at bedside with central venous catheter and kit available

v. Drugs needed: Activated charcoal, rapid sequence intubation medications (etomidate, succinylcholine, rocuronium, versed); insulin, glucose (D25), calcium chloride and/or calcium gluconate, other resuscitation medications including norepinephrine and/or dopamine

c. Props:

i. Basic airway and code cart

ii. Notecards with medications, exam updates, and lab results (see Appendix C)

iii. Cell phone with text message reading “I love u. I hope u miss me!”

iv. EKGs: Sinus bradycardia with heart rate in 50’s

Complete heart block

d. Distracters: none

X. Actors

a. Roles:

EMS: Provide sign-out to the team after transporting the patient from home. Gives history of present illness and provides list of medications found by patient. Keeps scenario flowing by handing out notecards to team lead with lab updates and specifics of physical exam.

Mother: Arrives after EMS report, is frantic and appropriately concerned about her daughter, informs team about patient’s history of depression and reiterates recent breakup; shows text message from patient to ex-boyfriend that reads, “I love u. I hope u miss me!”.

b. Who may play them:

Mother may be played by anyone. EMS can be played by any medical provider with general experience in pediatric or emergency medical conditions

XI. Case Narrative (what the learner will experience)

a. EMS has just transported a 16 year old female with history of depression to the EC with altered mental status. Pt was found by her parents on the floor of their home bathroom surrounded by multiple empty pill bottles of both old and current family medications. The event occurred approximately 6 hours ago, which was the last time the parents saw her prior to going out on a dinner date. Approximate number of the following medications were missing from the bottles (written down by EMS and handed to team lead on arrival, see notecards, Appendix B):

EMS started a peripheral IV and gave a dose of naloxone in the field without improvement of her mental status. Mom arrives after EMS report is given. When mom arrives, she is frantic and scared, and shows the team leader a recent text message on the patient’s cell phone to her ex-boyfriend that reads, “I love u. I hope u miss me!”

Team should recognize CCA toxicity. Patient is bradycardic and hypotensive on arrival with a GCS of 9. Basic airway and circulatory measures should be performed (O2, starting a second PIV, and IVF bolus administration), and labs obtained (glucose, calcium). Hypotension will be unresponsive to IV fluid bolus administration and pressor support with norepinephrine and/or dopamine. Resuscitation measures should include IV fluid bolus administration, IV calcium administration, high-dose insulin administration, and pressor support with norepinephrine and/or dopamine. A central line trainer should be available at the bedside for calcium chloride infusions. Treatment measures for bradycardia may include atropine, CPR, or transcutaneous pacing. An advanced airway (endotracheal intubation) will be necessary. The patient has a 30-second generalized, tonic-clonic seizure in Act 4 (if not already intubated with RSI/paralyzed). Benzodiazapines may be used to treat the seizure activity while the patient is actively resuscitated. Poison Center and/or a toxicologist should be consulted. Pediatric Intensive Care Unit consultation, along with transfer of care, is necessary prior to the end of the scenario.

b. Scenario Background given to participants

i. Chief complaint: 16 year old female with ingestion and altered mental status

ii. Past medical history: Depression, is followed by a psychologist and a psychiatrist

iii. Meds and allergies: Prozac 40 mg once daily, NKDA

iv. Family/social history: Lives with parents and 10 year old brother. Pt broke up with her boyfriend last week, whom she had been dating for 1 year.

c. Scenario conditions initially

ACT 1

EMS narrative: “This is a 16 year old female with history of depression, found by her parents on the floor in her home bathroom drowsy and altered, surrounded by several empty bottles of medication. The parents estimated how many pills were gone from each bottle, but we don’t have an exact number (hands list of meds to team lead, Appendix B). She’s been pretty sleepy since we picked her up, GCS between 8 and 10. We tried a dose of Narcan but she didn’t improve. We placed a right arm PIV. Mom was right behind us so she should be on her way.”

Initial Exam:

Primary:

Vital Signs: BP 70/40 HR 40 RR 20 T98 94%

Airway: patent

Breathing: shallow respirations

Circulation: cool extremities, weak central pulses, cap refill 5 seconds

Secondary:

HEENT: no signs of trauma; pupils 4 mm and reactive bilaterally; OP clear

Lungs: clear bilaterally; shallow respirations

Cardiac: slow rate, no murmur

Abdomen: soft, nontender

Extremities: no edema or deformities

Skin: cool extremities, weak central pulses, delayed cap refill (5 sec)

Neurologic: Pt is lethargic, GCS 9 (E=2 V=3 M=4)

--Monitors placed, O2 administration, recognition of bradycardia and hypotension

--2nd PIV should be placed

--CCA ingestion should be recognized as cause of altered mentation and vital sign instability

d. Scenario branch points (see Appendix A, scenario algorithm)

ACT 2

Pt persistently lethargic with hypotension and bradycardia.

--Labs drawn, continue basic airway management; repeated saline boluses do not correct patients’s hypotension; EKG performed, sinus bradycardia

--Labs: finger stick glucose 320

ACT 3

Persistent lethargy/heart block

--Lab results given to team lead (ionized calcium 0.6; calcium 5.1)

--Calcium infusion initiated

--High-dose insulin therapy initiated for improvement in seizure activity and end of scenario

--Atropine results in transient improvement in HR,

--Patient develops complete heart block if calcium and high-dose insulin not administered; transcutaneous pacing may be attempted, but is ineffective

--Norepinephrine results in transient improvement in blood pressure

--Continue basic airway management and consider RSI/endotracheal intubation

ACT 4

Pt has a 30 second generalized, tonic-clonic seizure (if not already intubated and paralyzed at this time and/or if calcium and high-dose insulin infusion not adminstered).

--Central line placement for ongoing calcium chloride infusions

--Toxicology and ICU consults, transfer care to ICU

XII. Instructors Notes (what the instructor must do to create the experience)

a. Tips to keep scenario flowing in lab and via computer

i. See triggers located on Scenario Algorithm, Appendix A, for changes in vital signs and mannequin findings

ii. EMS provided with a headset to receive information directly from SIM instructors running the computers/mannequin. Actors are also given a set of notecards (Appendix C) to hold during scenarios with lab results and patient descriptors not apparent to the learners (e.g. capillary refill 5 seconds; patient is lethargic). Actors are directed over headset to give participants specific cards if prompted.

iii. Tips to direct actors- EMS provided with a headset to receive information directly from SIM instructors running the computers/mannequins. Actors are also given a set of notecards (Appendix C) to hold during scenarios with lab results and patient descriptors not apparent to the learners (e.g. capillary refill 5 seconds; patient is lethargic). Actors are directed over headset to give participants specific cards if prompted.

b. Scenario programming

i. This scenario is easily run “on-the-fly” (without a program) by an experienced mannequin operator. The scenario management path, as well as potential complications and errors, are shown in Appendix A.

XIII. Debriefing Plan

a. Method of debriefing-The scenario was debriefed by physician simulation instructors who had been trained in debriefing methods including debriefing with good judgment and Advocacy-Inquiry. In addition, pediatric toxicologists participated in the debriefings as content experts.

b. Actual debriefing materials-

See Appendix B for Critical Actions Checklist, Appendix D for Debriefing Content

i. Instructors watched the scenario using the Critical Actions Checklist, and used that to guide their debriefing.

ii. The Debriefing Content form summarized the key medical information about CCA toxicity.

c. Rules for the debriefing

i. Basic Assumption-All learners are motivated, intelligent adults who are already well-trained, and are participating in the simulation to further their learning. Scenarios are chosen because they provide challenges that may be uncommon clinically, difficult, or critical. Mistakes are expected and welcomed as learning opportunities.

ii. Confidentiality-Performance in all simulations is confidential. The specific contents of the simulation should also be kept confidential.

iii. Fiction Contract-All learners and instructors agree to suspend disbelief and work to make the scenario as realistic as possible, recognizing that simulation is not the same as reality.

iv. Debriefings took place in a separate room from the scenario, and had video available for review as needed.

XIV. Pilot Testing and Revisions

a. Pilot Testing-completed at the Texas Children’s Hospital Simulation Center on July 21st, 2012.

b. Numbers of Participants- A total of 12 pediatric emergency medicine fellows and 4 pediatric emergency medicine nurses participated in the scenario, divided into 4 groups.

c. Performance expectations, anticipated management mistakes-Participants were informed that this was a non-graded interactive learning experience (similar to other simulation days they had previously experienced). They were informed that scenarios were chosen specifically to be challenging and that mistakes are both expected and welcomed as learning opportunities.

d. Evaluation form for participants-All participant filled out a course evaluation at the end of the simulation day, which included specific feedback about scenarios, content, and instructors. Based on this feedback, scenarios were modified for future use.

e. Scenario Revision: scenario revisions were performed in May 2013, May 2014, and June 2014

XV. Authors and their affiliations

a. Elaine Fielder MD, Department of Pediatrics, Section of Emergency Medicine, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX.

b. Daniel Lemke MD, Department of Pediatrics, Section of Emergency Medicine, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX.

c. Cara Doughty MD, MEd, Department of Pediatrics, Section of Emergency Medicine Baylor College of Medicine, Texas Children’s Hospital, Houston, TX.

| | | |

Appendix B: Critical Actions Checklist

|Step |Time Completed |Comments (Who, Praise, Problems, Gaps) |

|Establishment of team roles | | |

|Recognition of altered mental status | | |

|Cardiac monitors placed/vital signs obtained| | |

|Recognition of circulatory dysfunction | | |

|(hypotension/bradycardia) | | |

|CCA identified as etiology of toxicity | | |

|Basic airway management (O2, BVM) | | |

|IV fluid administration | | |

|Labs requested | | |

|IV Calcium administration (Ca chloride once | | |

|central line placed) | | |

|High-dose insulin/glucose administration | | |

|Norepinephrine administration | | |

|Atropine administration | | |

|Recognition of hypocalcemia | | |

|Central line placement | | |

|Heart block recognized | | |

|Seizure activity recognized | | |

|Benzodiazepine administration | | |

|Communication provided to family | | |

|Poison center/Toxicology consultation | | |

|Admit to PICU | | |

Appendix C: Notecards with exam updates/lab results

1. Patient is lethargic, GCS 9

2. Capillary refill 5 seconds

3. Cool extremities

4. Medications (approximate number of tablets missing):

a. Ibuprofen 200 mg (10 tabs)

b. Zantac 150 mg (5 tabs)

c. Verapamil 120 mg SR (10 tabs)

d. Valtrex 1 gram (5 tabs)

5. Labs:

a. Point of care glucose: 320

b. VBG:

c. Chemistries:

d. iCa: 0.6, Ca: 5.1

Appendix D: Debriefing Content

I. Calcium channel antagonist (CCA) ingestion

a. Mechanism of action:

• Calcium plays a crucial role in cellular movement and transport, electrical activation of excitable cells, and various enzymatic reactions throughout the body

• In myocytes, calcium influx via calcium channels promotes intracellular release of calcium by the sarcoplasmic reticulum, allowing a coupling with troponin and thereby facilitating the contraction of myocardial cells

• Slowed pacemaker activity in the sinoatrial and atrioventricular nodes

• Decreased atrioventricular node conduction

• Vasodilation of vascular smooth muscle

• Bradycardia results from poisoning the SA node, which may forebode complete heart block.

• Tachycardia may also occur with CCA overdose, especially with dihydropyridine toxicity (nifedipine)

• The cardiovascular disorders related to CCA toxicity are thought to be a direct consequence of an excessive blockade of the L-type calcium channel in myocardial and vascular smooth muscle membranes: by preventing calcium influx into cells, CCAs decrease cardiac inotropy, dromotropy and chronotropy, as well as vascular tone.

• Antagonism of calcium channels in vascular smooth muscle results in relaxation and dilatation

• Blockade of L-type calcium channels impairs insulin release by the pancreatic β-islet cells and impairs glucose uptake by tissues by altering sensitivity to insulin

• Inhibit calcium influx into pancreatic beta cells, leading to hyperglycemia and a relative hypoinsulinemic state that impairs normal metabolism and use of carbohydrates by cardiac myocytes

b. Side effects/clinical presentation:

• Hypotension or shock due to cardiac dysfunction (bradycardia, conduction delay and negative inotropy) and peripheral vasodilation; complete heart block, junctional rhythm

• Poor tissue perfusion results in metabolic acidosis

• Profound bradycardia, tachycardia, hypotension, metabolic acidosis, hyperglycemia, and a shock state can occur

• CNS sedation, coma, seizures – severe CNS depression is rare unless profound bradycardia and hypotension is present

c. Toxic dose:

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