Human Patient Simulation

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Human Patient Simulation

Title: Altered Mental Status

Target Audience:Resident

Learning Objectives:

-Primary

–Recognize a septic patient

–Identify etiology of sepsis

Urosepsis and Sacral Decubitus Ulcer

–Full physical exam to identify infected sacral ulcer

–Appropriate management of sepsis

–Contacting referring facility and/ or family

–Diagnose delirium

-Secondary

–Aggressive resuscitation

–TransfusePacked Red Blood Cells (PRBC)

–Central Venous Pressure (CVP)by ultrasound

–Vasopressors

–Identify Do Not Intubate (DNI) status and do not intubate the patient

-Critical Actions Checklist

⁪2 large bore intravenous access (IV)

⁪Oxygen

⁪Monitor

⁪Blood and Urine Cultures

⁪Appropriate Labs

⁪Chest X-ray (CXR)

⁪Identify Pyelonephritis

⁪Identify Infected Sacral Decubitus Ulcer

⁪Antibiotics

⁪PRBCs transfusion

⁪Vasopressors

⁪Patient is a DNI

⁪Do not intubate patient

⁪Intensive Care Unit (ICU) consultation

⁪Surgery Consultation

Environment:

-Environment

–Rural Emergency Department

-Manikin Set Up

–Elderly female

-Props

–Sacral decubitus ulcer prop

–Foley catheter containing cloudy yellow fluid

–Electrocardiogram (EKG)

–CXR

–DNI Sheet (can be faxed in)

–Ultrasound (U/S) video showing Inferior Vena Cava (IVC) compression

–CAM-ICU worksheet

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

-Resident Physician

-Nurse

-Intern

-Family Member

Case Narrative:

-Chief Complaint

–Altered Mental Status

-History

–Patient is an 82 year old female who presents from a nursing home via EMS for evaluation of altered mental status and fever. Per paramedics, the nursing home staff noted a fever of 102.2 and the patient has not been as alert as she was 2 days ago. She has been a resident there for two months while trying to rehabilitate from a hip fracture.

-Additional history given only if asked

–If called, the nurse at the nursing home states she usually takes care of the patient during the week and last Friday she was doing well, but something happened over the weekend. The nurse at the nursing home (or the husband)can also tell the team

She still is not getting out of bed.
She had a Foley catheter placed recently.
Her Primary Medical Doctor (PMD) is treating her with amoxicillin.
The patient has a son, but he only has been to the nursing home once or twice to see his mother.
Patient resuscitation status is DNI.
The only way to obtain this information is to contact the referring nursing home or the patient’s husband.

-Past Medical History

–Hypertension (HTN)

–Urinary Tract Infection (UTI)

–Dementia

–Hyperlipidemia

-Social History

–Pt used to live at home with her husband. He was her primary caretaker until she fell and suffered a hip fracture.

–No alcohol, tobacco, or drug use

-Medications

–Amoxicillin for UTI over the past few days

–Memantine, Atorvastatin, Hydrochlorothiazide, Atenolol, Lantus, Enoxaparin

-Surgical History

–Hip fracture 2 months ago status-post arthroplasty

–Hysterectomy

-Allergies

–No known drug allergies (NKDA)

-Review of Systems

–Deconditioning, decreasing appetite, fevers,

–No shortness of breath, no cough

–No chest pain or palpitations

–No vomiting, no dysphagia, no abdominal pain, no bloody stools

–No focal weakness or numbness, no headache

–Delirium for the past 48 hours

–No lower extremity edema

–Mild diaphoresis, no rashes or lesions

-Physical Exam

–Heart Rate (HR) 123, Blood Pressure (BP) 82/45, Respiratory Rate (RR) 31, O2 – 95% on room air, Temperature 39.1

–Accucheck – 52 (only if asked for)

–General – Lethargic, moaning, Glasgow Coma Scale – 11(eyes 3, Verbal 4, Movement 4)

–Head, Eyes, Ears, Nose Throat (HEENT) – dry mucous membranes, no meningismus, pupils equally reactive and responsive to light and accommodation (PERRLA)

–Cardiovascular (CVS) – tachycardic, regular rhythm and rate , no murmurs, rubs, or gallops, no palpable distal pulses, but palpable femoral and carotid

–Respiratory – tachypnea, clear to auscultation bilaterally with no wheezes, rales, or rhonchi

–Abdominal – wincing and increased moaning with suprapubic palpation, no rebound or guarding, rectal hemoccult negative

–Genitourinary – Foley catheter in place with cloudy urine

–Extremities – no edema, no rashes

–Skin –no cyanosis

–Only if asked for (patient turned)

Large 10 cm sacral decubitus ulcer stage 4 with surrounding erythema, yellowish-green base, and foul sweet smell.

-Scenario Branch Points

–The resident participant must identify the septic patient. This will be evident through her general appearance, physical exam, and vital signs.

–The etiology of her sepsis is obtained not only by labs (UTI / pyelonephritis), but also by a thorough physical exam. Only if she is rolled with they identify the infected decubitus ulcer, suspicious for pseudomonas.

–Aggressive resuscitation should be initiated with IVF, antibiotics, and vasopressors.

–Fluid resuscitation can be guided by a CVP through a central venous line or by evaluating IVC compression with and ultrasound.

–Antibiotic coverage must be tailored to include methicillin resistant Staphylococcus aureus, Pseudomonas, and urinary flora.

–The patient will require at least 4 liters of fluid resuscitation, 2 units of PRBCs, and vasopressors before vital signs, urinary output, or perfusion will improve.

–The patient will appear to need mechanical ventilation, but this should not be done. The resident needs to obtain the patient’s code status, and this can only be done by contacting her husband.

–If the patient is intubated, her husband will spontaneously arrive in the Emergency Department requesting she be taken off the ventilator.

–The resident should consult both the Medical intensivist and Surgeon for evaluation and admission.

Instructors Notes:

-Tips to Keep the Scenario Flowing

–The director should give the paramedic report

–The director should answer questions as if they were the patient

–Make the patient be very vague, altered and toxic appearing

–Do not give tips regarding the presence of a sacral decubitus ulcer.

–The patient must not improve unless the appropriate amounts of fluids are given.

–The patient’s appearance, vitals and perfusion will not improve with only 1-2 liters of IVF and vasopressors.

–Allow the resident to intubate the patient if they so choose.

–If intubated, the patient’s husband will arrive in the ER with disapproval of the decision to intubate and request she be taken off the ventilator.

-Tips to Direct Actors

–Nurses will be new grads and unfamiliar with management of sepsis. They will need specific drug dosages and instructions for what type of IV access, lines, etc…

–The Patient’s Husband - You will be very clear regarding the patient’s DNI status if contacted over the phone. If not contacted and the patient is intubated, you should let your disappointment be known once you arrive to the Emergency Department. Request that your wife’s breathing tube be removed.

-Scenario Steps

–Optimal Management Path

Identify sepsis and likely etiology (UTI, pyelonephritis, infected sacral decubitus ulcer)
IV fluid Resuscitation guided by CVP (via central venous line or IVC using U/S)
Blood and urine cultures
Tailored antibiotics
Contacting family
Respecting patient’s DNI status

–Potential Errors Path

Not recognizing sepsis
Not obtaining cultures
Not rolling the patient and identifying the sacral decubitus ulcer likely infected with pseudomonas
Under resuscitation with not enough IV fluids
Starting vasopressors without completely resuscitating the patient with IV fluids beforehand
Not contacting family members
Intubating the patient

-Imaging and Labs

–CBC – WBC 18, Hgb 7, Hct 26, Plt 180

–Chem 7 – Na 148, K 4.9, Cl 111, CO2 13, BUN 64, Cr 1.9, Glu 180

–Lactate – 7.2

–U/A – WBC >182, Many Bacteria, + LE, + Nitrates

–ABG 7.21 / 29 / 158 / 14 / 95% / - 11

Debriefing Plan:

-Topics to discuss

–Identifying the signs and symptoms of Systemic Inflammatory Response Syndrome and Sepsis

–The importance of physical exam

–Correct Management of Sepsis

–Management of DNR/DNI patient’s and how to update a patient’s DNR/DNI status in the Emergent Department

–The importance of contacting referring facility and/ or family.

–Importance and techniques for diagnosing delirium.

Pilot Testing and Revision:

-Number of Participants – 4

-Anticipated Management Mistakes

–Under resuscitation

–No antibiotics

–Intubation

–Not identifying sacral decubitus ulcer

-Evaluation form for participants – generic handout

Authors:

-JohnB.SeymourM.D.University of North Carolina Department of Emergency Medicine, PGY – 3

-RochelleChijiokeM.D.University of North Carolina Department of Emergency Medicine.

-KevinBieseM.D.University of North Carolina Department of Emergency Medicine, Associate Professor and Residency Director

-Graham Snyder M.D. Wake Med Health and Hospitals Department of Emergency Medicine, Assistant Program Director and Simulation Director

-Jan Busby-Whitehead M.D. University of North Carolina Division of Geriatric Medicine/ Institute on Aging, Professor and Chief