Simulation Scenario

Synopsis of case

A 65 y/o male with a history of hypertension, hyperlipidemia, and atrial fibrillation presents to the ED via autorickshaw after a road traffic accident while driving home. The patient was not seatbelted in the driver seat, awake and talking, but with laboured respirations and severe pain. When the patient arrives at the ED, evaluation should include a primary survey and communication with bystanders. As a part of the trauma workup, the patient should also receive an eFAST, spinal immobilisation and may receive pelvic stabilisation with a pelvic binder. The patient will have signs of trauma on his chest requiring an ICD. On a secondary survey, the patient will be found to be lethargic and progressively confused. Blood sugar levels should be checked and treated. The patient will require intubation for airway protection. The intubation may require additional support with a bougie. History will reveal that the patient intentionally ingested his medications (beta blocker). The patient will have persistent bradycardia despite medical management with a beta-blocker toxicity. May initially be treated with medical management. The patient will then develop unstable vitals and should prompt transcutaneous pacing. The patient should be dispositioned to the Cardiac ICU in conjunction with trauma/toxicology as consults.

Case evaluation

procedures

•  Critically re-evaluate patient primary survey, e-FAST, c-collar

•  Identify pneumothorax on eFAST and chest x-ray, with hypoxia requiring chest tube placement

• progressive hypoxia/difficult intubation - use of bougie

• Unstable bradycardia, appropriate management + cutaneous pacing

• appropriate use of consultants and transfer of care

communication and teamwork between all healthcare providers

• summarising the progression of the case at regular intervals

• closed-loop communication with any orders and procedures

• identifying all key problems and addressing the issues when appropriate

•  communication with family

Scoring: In accordance with the Standardized Direct Observational Tool (SDOT)

Team leader 1

• Identified Issues

• Performed critical actions

• Summarize case

• Role in wrap-up session

Procedure Person1

Examiner Person 1

SIM Case 1

The bystanders brought a patient, Mr. Ravi Bhat, a 65-year-old male, who was a driver in a road traffic accident approximately 1 hour before arrival. He was found in the driver's seat, not seatbelted but in distress.

Vitals were HR 94, SBP 112/70, Pulse Ox 87% on RA, and RR 32

Upon arrival at Patient Name: Mr. Ravi Bhat, Age 65

HISTORY: Onset of Symptoms: The Patient was feeling unwell for the last few hours 

Background Info: Patient was on the way to the hospital when he felt dizzy and crashed into the car in front of him. Found awake, disoriented and talking but with laboured respirations

Past Medical Hx: Past Surgical Hx: None

Medications: Metoprolol, Atorvastatin

Hypertension, Hyperlipidemia, Atrial Fibrillation, Depression

Allergies: None

Habits: Social Hx: Smoking: None ETOH/ Drugs: None

Married, lives with wife, works as an accountant

ROS: Dizziness, generalised pain, difficulty breathing

Part 1

The bystanders brought a patient, Mr. Ravi Bhat, a 65-year-old male, who was a driver in a road

traffic accident approximately 1 hour before arrival. He was found in the driver's seat, not seatbelted

but in distress.

Vitals were HR 94, SBP 112/70, Pulse Ox 87% on RA, and RR 32

Upon arrival at Patient Name: Mr. Ravi Bhat, Age 65

HISTORY

Onset of Symptoms: The Patient was feeling unwell for the last few hours

Background Info: Patient was on the way to the hospital when he felt dizzy and crashed

into the car in front of him. Found awake, disoriented and talking but with laboured respirations

Past Medical Hx: Past Surgical Hx: None

Medications: Metoprolol, Atorvastatin

Hypertension, Hyperlipidemia, Atrial Fibrillation, Depression

Allergies: None

Habits: Social Hx: Smoking: None ETOH/ Drugs: None

Married, lives with wife, works as an accountant

ROS: Dizziness, generalised pain, difficulty breathingPART 1/ TEAM LEADER 1: CRITICAL ACTIONS

● obtains brief report from bystanders

● directs Examining resident 1 for evaluations of primary survey:

Primary Survey:

#1 Vital Signs Initial: HR 94, SBP 112/70, Pulse Ox 87% on RA, and RR 32

General appearance - patient with increased work of breathing, moaning in pain

Airway: Airway clear

Breathing: Decreased breath sounds on R SIDE, tachypneic

Circulation: 2+ pulses throughout, < 3 sec cap refill

Disability: GCS 15, PERRLA, RBS 100

Exposure: abrasions, bruising, no obvious deformity

Secondary Survey:

HEENT: clear airway

Eyes Pupils 3 mm, Ears: Normal Mouth/Nares: normal

Neck: No crepitus or gross deformities/masses/hematomas

Skin: Diaphoretic; capillary refill less than 3 seconds

Chest: Bilateral chest rise, RIGHT CHEST WITH bruising, decreased breath sounds on R

Side

Heart: NORMAL RATE, no murmurs, no rubs

Abdomen: no scars, no organomegaly.

Pelvic: stable

Genito-Urinary: normal, no blood at the meatus.

Extremities: moving all extremities, hematomas and abrasions

Neurological: Alert AOX4, moving all extremities. GCS 15

Rectal: no gross blood, normal tone

Pelvis: normal, non-tender

Spine: non-tender midline

Back: abrasions

Synopsis of case

4 year old boy presents to the ED with severe asthma exacerbation. He should be treated aggressively with albuterol, steroids, magnesium, and epinephrine. Nursing is unable to obtain IV - resident should place IO. Patient becomes progressively hypoxic with resultant bradycardia while preparing for intubation. . Bradycardia should be treated with atropine. Despite this, patient will ultimately suffer a cardiac arrest - initial rhythm PEA, treated with epinephrine.

Second rhythm check SVT, treated with cardioversion. ROSC will be obtained and post-ROSC care including TTM Should be completed.