Simulation Interest Group Scenario Template
Status Asthmaticus with Development of
Tension Pneumothorax Post-intubation
Raymond P. Ten Eyck, MD, MPH
Wright State University Boonshoft School of Medicine
Date: April 15, 2007
I. Title…………………………………………………………………………….2
II. Target Audience………………………………………………………………..2
III. Learning Objective or Assessment Objectives…………………………………2
A. Primary……………………………………………………………………..2
B. Secondary…………………………………………………………………..2
C. Critical Actions……………………………………………………………..2
IV. Environment…………………………………………………………………....3
V. Actors…………………………………………………………………………..4
VI. Case Narrative………………………………………………………………… 4
VII. Instructor’s Notes………………………………………………………………5
VIII. Debriefing Plan………………………………………………………………...5
IX. Pilot Testing and Revisions……………………………………………………6
X. Authors and Affiliations………………………………………………………..6
XI. References……………………………………………………………………...7
XII. Attachments……………………………………………………………………7
Lab...…………………………………………………………………………...8
Evaluation Grid……………………………………………………………….11
Debriefing Slides……………………………………………………………...13
I. Title: Status Asthmaticus with Development of Tension Pneumothorax Post- Intubation
II. Target Audience: Emergency Medicine Residents
III. Learning Objectives or Assessment Objectives
A. Primary
1. Demonstrate rapid primary survey assessment to detect patient’s respiratory distress with initiation of emergent interventions including supplemental oxygen, pharmacotherapy, and assuring patient’s airway is protected.
2. Know the indications and contraindications for rapid sequence induction for intubation of an emergent patient with respiratory failure.
3. Recognize the clinical findings that should arouse suspicion of tension pneumothorax in the clinical course of managing an intubated patient with respiratory failure.
4. Perform a successful needle decompression of a tension pneumothorax.
5. Demonstrate successful placement of a chest tube following needle decompression (with confirmation of appropriate placement).
B. Secondary
1. Demonstrate a focused history and physical exam to assess the nature and severity of respiratory distress and factors influencing the optimal approach to airway control.
2. Demonstrate ability to recognize clinical features of respiratory failure requiring definitive airway control and to interpret accompanying ancillary studies.
3. Know the appropriate agents for RSI based on the patient’s underlying condition.
4. Demonstrate appropriate intubation technique including the avoidance of prolonged (>30 second) attempts if difficulty is experienced.
5. Demonstrate appropriate use of a consultant to provide a definitive airway if an emergent airway cannot be secured.
6. Understand the risk factors and the basic mechanism for tension pneumothorax.
7. Demonstrate a concise, focused verbal report and produce a comprehensive, focused written ED record.
C. Critical actions: (Checklist incorporated into assessment tool –Attachment 2)
1. Recognize the patient’s initial respiratory distress with wheezing and history of asthma.
2. Initiate immediate treatment including high flow oxygen.
3. Recognize failure to respond to initial intervention and continue aggressive treatment while assessing for the appropriate method of definitive airway control if the patient continues to deteriorate.
4. Secure a definitive airway.
5. Obtain a consult to help achieve a definitive airway if stabilization is achieved with a temporizing device.
6. Complete a focused, detailed reassessment once patient starts to deteriorate following a temporary post-intubation improvement.
7. Early detection of tension pneumothorax on reassessment.
8. Proceed rapidly to needle decompression when the patient starts to show signs of cardiovascular and respiratory decompensation with the development of a tension pneumothorax.
9. Placement of a chest tube immediately after successful needle decompression of the tension pneumothorax.
10. Frequent reassessment of vital signs particularly after interventions.
IV. Environment
A. Lab Set Up – Emergency Department
B. Manikin Set Up:
1. SimMan
2. Peripheral IV line
3. Medications needed
- Nebulized Albuterol
- Nebulized Atrovent
- IV Solumedrol
- IV MgSO4
- IV Lidocaine for bolus injection
- IV Ketamine
- IV Succinylcholine
- Alternate RSI medications
- Lidocaine for local anesthesia for chest tube
C. Props
- ECG – Sinus tachycardia
- X-ray – Initial CXR – Normal
- Post Intubation CXR – Normal with correctly positioned ET tube
- CXR at point of deterioration – Tension pneumothorax with ET
Tube correctly positioned
- Post Chest Tube – Left sided chest tube with expanded
lung and ET tube in place
- Special airway equipment – Rescue airway devices including
Combitube, LMA and cricothyrotomy kit
- Chest tube tray and pleurovac
D. Distracters – Monitor alarms
V. Actors
A. Roles
- Nurse – Played by another trainee or a faculty member. He/she will
Correctly perform ordered nursing tasks.
- Nursing Assistant - Played by another trainee or a faculty member.
He/she will correctly perform ordered nursing assistant tasks.
- Consultant – Played by a faculty member. He/she will successfully place
a definitive airway if trainee can only attain a rescue airway
- Respiratory therapy – Played by another trainee or a faculty member.
He/she will appropriately perform respiratory therapist tasks as ordered.
VI. Case Narrative
A. Scenario Background Given to Participants
B. Chief complaint - Given medic report with CC: 52 YO male with acute SOB. Additional information on the medic report:
1. HPI – Sitting at home watching TV and experienced onset of SOB which worsened over an hour despite treatment with his hand held MDI bronchodilator. Given 2 treatments with nebulized bronchodilators in the ambulance without improvement
2. MEDS – Combivent MDI, Singulair, Lisinopril, hydrochlorothiazide
3. PMH – Hypertension, Asthma
4. SH – 20 Pk-Yr smoking Hx,
C. Scenario conditions initially
1. History patient gives – Speaking in short phrases; he confirms the EMS history and provides no further information regarding precipitating causes.
2. Patients initial exam and physiology:
Pulse 100, BP 154/92, R 40, T 98, Pulse ox:4 L/min nasal O2 88%
HEENT – WNL
Neck – No JVD
Lungs – Bilateral wheezes
Heart – Rapid regular rhythm, S1, S2 – WNL, No M, G or R
Abd – Soft, non-tender
Neuro - WNL
D. Scenario branch points
1. Pharmacotherapy for asthma – No improvement à deterioration
2. RSI and intubation – Respiratory failure controlled and patient stabilizes temporarily
3. About 3-4 minutes after stabilizing, the patient experiences a precipitous fall in BP, and pulse ox with increasing pulse rate
4. If tension pneumothorax is not recognized/treated – Cardiovascular collapse à V-fib
5. V-fib shocked – Reverts to sinus tachycardia and hypotension. If not immediately decompressed, patient deteriorates to asystole in two minutes and cannot be resuscitated.
6. Tension pneumothorax treated with needle decompression – Patient stabilizes.
7. Chest tube placed – Patient remains stable
8. If chest tube not placed within five minutes of decompression, patient deteriorates again and requires another needle or immediate chest tube placement.
VII. Instructors Notes
A. If trainee orders a CXR when patient starts to deteriorate and does not detect the problem, then the radiologist (instructor) calls him/her and reports that the patient has a tension pneumothorax.
B. If ET tube is pulled when patient deteriorates (because trainee cannot confirm placement). The “can’t intubate/can’t ventilate” controls are triggered by the instructor.
C. If the trainee can only secure a rescue airway and he/she doesn’t call anesthesia for assistance securing a definitive airway, then review the proper action during the debriefing.
D. All actors will perform tasks within the skill set for their simulation role in an appropriate manner if asked. They will not make suggestions unless asked by the trainee.
E. Scenario programming – Preprogrammed SimMan sequence of actions and events.
F. Optimal management path – Place patient on monitor, oxygen, start IV, administer repeat nebulized bronchodilators (with or without subcutaneous epinephrine) administer IV solumedrol, and intubate using RSI. Patient stabilizes and then suddenly deteriorates due to development of a spontaneous pneumothorax. Trainee must quickly recognize the problem, decompress the tension pneumothorax and then quickly place a chest tube under controlled conditions. Admit to ICU.
1. Potential complications paths and error paths
- Premature deterioration if respiratory distress is not addressed acutely.
- Premature deterioration if trainee is unable to intubate or secure a rescue airway. (NOTE: Instructor should trigger the “intubate” event for successful ET tube placement or successful placement of a rescue airway if trainee cannot intubate)
- Following post-intubation stabilization, the patient develops a spontaneous pneumothorax which rapidly evolves to a tension pneumothorax with rapid deterioration of vital signs. If not decompressed, the patient deteriorates to V-fib. The patient will convert back to sinus tachycardia with a single shock. If the tension pneumothorax is not decompressed, he will deteriorate to asystole after two minutes and will not be resuscitated.
- If the trainee does not place a chest tube immediately after decompression, the decompression catheter will close off within a few minutes and the tension pneumothorax will recur.
2. Program debugging – Since trainees may take actions that were not anticipated, the trends built into the program may not represent the physiologic condition that you are trying to simulate at certain points. An immediate course of action is to end the programmed scenario and complete the exercise under manual control.
VIII. Debriefing Plan
A. Method of debriefing
- Group debriefing is recommended. Whether the support team is made up of faculty or other trainees, the teaching points and review of events are best accomplished with all team members present.
- Use video to review technical proficiency issues and to review the trainee’s performance in the areas of communication, team management, multitasking and resource utilization.
B. Actual debriefing materials - PowerPoint slides to be used in formal slide presentation or as a script for an onsite debriefing. (Attachment 1)
C. Rules for the debriefing – Feedback will be factual, focused on performance and key learning objectives. Issues discussed in the simlab stay in the simlab unless the session was previously set up as an assessment and the trainee agreed to have the results shared with an interested third party.
D. Questions to facilitate the debriefing - Solicit trainee’s perception of how he/she did, discuss specific performance issues and then review the key teaching points outlined in the slides.
IX. Pilot Testing and Revisions
A. Numbers of participants – Initial pilot testing was accomplished by running the simulation on the computer a number of times without using the manikin. It was then tested using a faculty member, unfamiliar with the case, in the role of the trainee. A third year emergency medicine resident was then evaluated with the simulation.
B. Performance expectations, anticipated management mistakes
- The EM resident will be able to recognize and appropriately manage status asthmaticus. He/she will recognize the patient’s failure to respond to appropriate treatment and initiate timely control of the airway while continuing to treat the underlying process. He/she may have difficulty trouble shooting the recurrent deterioration following initial stabilization. He/she is expected to place a chest tube in a timely manner following decompression of the tension pneumothorax.
C. Evaluation form for participants – Trainees performance will be evaluated using a modified electronic version of the Council of Emergency Medicine Directors’ Standardized Direct Observational Assessment Tool -- EM Outcomes Assessment (Attachment 2).
X. Author and affiliation
Raymond P. Ten Eyck, MD, MPH, FACEP
Associate Professor
Simulation Laboratory Director
Department of Emergency Medicine
Wright State University Boonshoft School of Medicine
XI. References
1. Council of Emergency Medicine Directors’ Standardized Direct Observational Assessment Tool -- EM Outcomes Assessment.
http://www.emtests.com/2006%20Material/CORD%20SDOT%202005.doc
April 1, 2007.
2. Saadeh C, Malacara J, Goldman, M: Emedicine – Status Asthmaticus
http://www.emedicine.com/med/topic2169.htm
April 15, 2007.
3. Shayne P, Gallahue F, Rinnert S, et al. Reliability of a Core Competency
Checklist Assessment in the Emergency Department: The Standardized
Direct Observation Assessment Tool. Acad. Emerg. Med. July 2006; 13(7);
727-732.
XII. Attachments
1. Case lab results
2. Modified SDOT case evaluation – Excel file
3. Copy of PowerPoint debriefing (Actual PowerPoint also submitted as separate file)
XIII. Separate files Submitted
1. Case flowchart Page 1 - JPEG file
2. Case flowchart Page 2 – JPEG file
3. ECG – JPEG file
4. CXR with ETT, left sided chest tube and central line
1
Dayton General Hospital
Last Name / First Name / Age / SexBailey / George / 52 / MF
********************* ARTERIAL BLOOD GAS*********************
pH pCO2 pO2 Bicarb O2 Sat Base Escess
mmHg mmHg mmol/L % mEq/L
HIGH 7.45 45 100 27 100 +2
LOW 7.35 35 80 21 94 -2
7.32 50 52 25 85 0
Bottom of Form
G. Dayton General Hospital
Last Name / First Name / Age / SexBailey / George / 52 / MF
***************** B-NATRIURETIC PEPTIDE *****************
BNP
PG/ML
HIGH 100
LOW
50
Bottom of Form
H. Dayton General Hospital
Last Name / First Name / Age / SexBailey / George / 52 / MF
**************** COAGULATION STUDIES ****************
PT INR PTT
SEC SEC
<12.3 1 <29
13 1.0 30
Bottom of Form
I. Dayton General Hospital
Last Name / First Name / Age / SexBailey / George / 52 / MF
***************************** CHEMISTRY ********************************
NA K CL CO2 BUN CRE GLUC CA
MG/DL MG/DL MEQ/L MEQ/L MEQ/L MEQ/L MEQ/L IU/L
HIGH 145 5.0 107 33 24 1.3 109 11
LOW 135 3.5 98 22 6 0.7 70 8
144 4.4 102 20 15 1.1 122 10
J. Dayton General Hospital
Last Name / First Name / Age / SexBailey / George / 52 / MF
*********************** HEMATOLOGY - HEMAGRAM **************************
RBC HGB HCT MCV MCH MCHC RDW
MIL G/DL % u3 PG %
HIGH 5.68 17.6 51.5 99 33.8 34.9 15.0
LOW 4.30 13.1 39.0 85 28.7 33.0 11.7
5.4 16 47 90 30 35 13
********************* HEMATOLOGY - DIFFERENTIAL ************************
PLAT WBC BAND SEG LYMPH MONO EOS BASO
THOU/UL THOU % % % % % %
HIGH 393 10.5 82 41 13 5 1
LOW 154 4.0 <10 45 9 4 0 0
317 6.2 1 70 17 9 3 0
********************* HEMATOLOGY - DIFFERENTIAL ***********************
RBC MORPHOLOGY WBC MORPHOLOGY PLT MORPHOLOGY
NORMAL NORMAL NORMAL
NI = Needs Improvement ME = Meets Expectations AE = Exceeds Expectations Core Competency Score
Trainee:Instructor:
During Simulation / NI / ME / AE / N/A / Core
Competencies
Involved / PC / MK / ICS / PR / SBP
1. Introduces self and efficiently establishes a respectful and effective communication with patient. / ICS, PR
2. Gathers essential and accurate information from patient and EMS (precipitating events, duration, severity, med use including recent steriods, prior intubion, accompanying chest pain, and exacerbating/relieving factors) / PC, SBP
3. Evaluates the airway and presenting vital signs; listens to the heart and lungs. / PC
4. Sequences critical actions in patient care Recognizes respiratory distress with hypoxia Initiates high flow O2 and bronchodilator Rx Recognizes respiratory failure and provides airway control Provides rescue airway and gets help if unable to intubate Focused/detailed reassessment when Pt deteriorates again Detects tension pneumothorax - Needle decompresses Places chest tube immediately following decompression / MK
5. Competently performs RSI or rescue airway; Needle decompression; Tube thoracostomy; Defibrillation if required / MK, PC
6. Communicates clearly/concisely/professionally with staff regarding medications, preparation for intubation, decompression of tension pneumothorax and tube thoracostomy. / ICS, PR
7. Anticipates possibility of failure to respond to Rx of status asthmaticus and prepares RSI meds/equipment / ICS,SBP,PR
8. Clinical charting is timely, legible, and succinct, and reflects ED course and decision-making. / PC, PR
9. Prioritizes patients appropriately by acuity and waiting time (if part of a multiple patient scenario) / SBP
10. Can handles distractions while maintaining patient care priorities / SBP
11. Reevaluates patient after starting O2/bronchodilators; following intubation including 2° and 3° confirmation; When VS start to deteriorate after initial stabilization; Following needle decompression; Following tube thoracotomy / PC
12. Documents reassessment and response to therapeutic intervention. / PC
13. Presents the patient clearly and concisely. / MK, PC
14. Carries out appropriate/admission/transfer plan, including notification of accepting MD as indicated / PC, SBP
During Debriefing
15. Makes informed decisions method of airway control using patient information and preferences, scientific evidence and clinical judgment / PC
16. Understands indications and contraindications of a therapy or procedure. / MK
17. Explains an appropriate differential, plan, response, and disposition / PC, MK
18. Can explain the pathologic basis for management / MK
1