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“Simwars” Case Template

Scenario overview

Critical actions

  • (List 3-5 Critical Actions)

Teaching Objectives

  • Clinical and medical management
  • Communication and Teamwork

Supplies & Moulage

Images

  • (CXR, EKG, CT)

Actors and roles

  • (Nurse, EMS, Family member)

Case Flow/Timeline

Key Action Items – Related to teaching points.

Scenario Overview

36-year-old-male, BIBA, s/p jumping off of a 3-story fire escape to get away from DEA. As per DEA, they were notified about drug activity in a building. When they responded and broke down the door, they found the patient swallowing something wrapped in a clear bag. They chased the patient onto the fire escape when the patient jumped off from the third floor onto the concrete sidewalk. Witnesses saw the patient hit his head. Patient is agitated and uncooperative screaming about his right chest that hurts.

Critical Actions

  • CT head
  • Chest tube placement
  • Control environment, i.e. police
  • Intubation
  • Benzodiazepine

Teaching Objectives

  • Clinical and Medical Mangement
  • Recognition and management of Traumatic Brain Injury
  • Recognition of and management of Sympathomemetic overdose – stuffer
  • Illustrate proper sedation and management in an agitated patient
  • Recognition and management of pneumothorax
  • Communication and Teamwork
  • Identify team roles and leader
  • Conflict resolution with police

Supplies & Moulage

  • Handcuffs
  • Simulator clothes
  • C collar
  • Head injury with blood and gauze

Images

  • CXR – Pneumothorax
  • EKG – Sinus Tachycardia
  • CT head – Normal CT

Actors and roles

  • DEA/Police: Police is in the trauma bay trying to get information from the patient. They are being obstructive to care. Refusing to leave. (States patient has had multiple priors and “I’m gotta find out who his dealer is!!!”)
  • EMS: EMS states, they found patient in handcuffs with police. Patient was AxOx2, uncooperative and cursing. + Head trauma. Moving all extremities symmetrically. Trying to get out of the cuffs.
  • Patient: Agitated, swearing, refusing to cooperate with EMS and police.
  • ER Tech: Facilitates management of case with key exam findings and physical exam items not reproducible on simulator.
  • Surgery

Case Flow/Timeline

TIME 0NOTIFICATION: 36-year-old fall from 2-3 stories. BP 185/110 HR 145 RR 22 Sat 100% on NRB

What does the pt. look like?

Pt is agitated and uncooperative, blood on occiput

Vitals:

BP 185/110 P 155 RR 24 T 100.1 F Sat 100% on NRB

IV: none

Monitor: ST at 145

Physical exam:

Gen: AxOx2 (person, place, 2004 July), agitated and uncooperative, swearing

Heent: 6 mm and reactive

Neck: Collar – no stepoff

Chest: Decreased BS on right, + crepitus, normal BS on left

Heart: Tachy rate without M/R/G

Abdomen: NT, ND, no R/G/R, hyperactive bowel sounds

Rectal: guaic neg if done, normal tone

Skin: sweaty

Ext: no C/C/E

Neuro: AxOx2, moving all extremities symmetrically, CN2-12 grossly intact

FAST: Normal if done

TIME 1MIN-2 MIN (Initial State – Pneumothorax & Agitation & Police)

Vitals - BP 185/110 P 155 RR 24 T 100.1 F Sat 100% on NRB

Pneumothorax -> if no chest tube will desaturate to 85% rapidly -> if intubated without chest tube will desaturate rapidly

Right sided chest tube

Pain medicine (rib fracture) -> no pain meds, unable to get chest tube

Agitation -> if not sedation, more agitated, unable to do exam

Ativan for sedation (2-4mg)

Scene control (Police) -> cannot proceed until police removed from bedside

Remove Police from the bedside

TIME 2 MIN- 4 MIN (Trauma management)

Trauma management

Two large bore IV

Disability

Exposure

Labs (type and cross)

Trauma team – Wants to wait till he drinks contrast

CXR, Pelvis, C spine

CT head/Chest/Abd/Pelvis

Exam

TIME 4-5 MIN (Herniation and Intubation)

Patient becomes increasingly lethargic unresponsive

Starts to brady down with irregular breathing pattern

VS BP 205/120 HR 55 RR 6-12 Sat 93% on NRB

Intubation with RSI and brain protection

BP management

Labs:

SMA-7 (nl) ,

CBC (nl) ,

PT/PTT/INR (nl),

Etoh level 140

Other tox negative

CT results:

Head CT (+ epidural and subdural bleed);

C-Spine: normal

CT – chest/abd/pelvis - negative

TIME 6-7 MIN (Head bleed)

Elevated ICP management

Neurosurgery

ICP monitoring

Elevate head

Hyperventilate

Mannitol

Maintain BP and Sat

Sedation/Ativan

Key Action Items

  • Actions for Trauma
  • (1 Min) ABC – recognition of pneumothorax
  • (2-4 Min) ATLS
  • (5-6 Min) CT of Head and C-spine; give results
  • Trauma Surgery consult
  • Control environment – Get police away from patient
  • Actions for Airway Management
  • Chest tube
  • RSI with in-line stabilization
  • Actions for increased ICP/Bleed
  • Maintain MAP
  • Elevate head
  • Sedation
  • Hyperventilate
  • Mannitol
  • Surgery
  • ICP monitoring
  • Actions for Cocaine overdose
  • Sedation with benzos
  • R/O other overdose
  • EKG
  • CT head
  • Final Actions:
  • Neurosurgery
  • NSICU
  • Ventriculostomy

Critical Actions

  • CT head
  • Chest tube placement
  • Control environment, i.e. police
  • Intubation
  • Benzodiazepine