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Congestive Heart Failure PARAMEDIC SIM Acute Flash Pulmonary Edema Scenario Information Title: Date Created: Target Audience: Scenario Author: Congestive Heart Failure February 10 2016 PCP I PCP II PCP ACP CCP Will Johnston Author Contact: [email protected] Scenario Overview Paramedics are called code 4 in the middle of the night for a 56 year old female acutely short of breath. On arrival the Paramedics find the patient extremely short of breath and diaphoretic. The patient’s husband reports that the patient was hospitalized for a similar incident 3 weeks ago and had to be intubated. The patient has diffuse coarse crackles in all lung fields. The patient should be treated with CPAP or BiPAP as well as sublingual Nitroglycerine. Scenario Objectives, Summary, NOCPS, and Expectations Learning Objectives: Associated NOCPs Paramedic GRS1 Expectations: React to changes in patient conditions Employ proper judgement in management of severe pulmonary edema Employ proper anaphylaxis management and treatment 4.5.n – Obtain 12-Lead electrocardiogram and interpret findings 5.8.h – Administer medication via the sublingual route 6.1.a – Provide care to patient experiencing signs and symptoms involving the cardiovascular system 6.3.a – Conduct ongoing assessments based on patient presentations and interpret findings 6.3.b – Redirect priorities based on assessment findings Situational Awareness: recognize the seriousness of patient condition History Gathering: use the husband to get a full patient history Patient Assessment: thorough examination including respiratory and cardiovascular assessment Decision Making: early decision to administer CPAP and Nitroglycerine Resource Utilization: utilize patient’s family for history Communication: effective crisis communication with patient and family Procedural Skill: proper 12 lead placement, Nitroglycerine administration, and CPAP application 1. Tavares W, Boet S, Theriault R, Mallette T, Eva KW. Global rating scale for the assessment of paramedic clinical competence. Prehospital emergency care. 2012 Dec 5;17(1):57-67. Congestive Heart Failure PARAMEDIC SIM Scenario Preparation Patient Requirements Moulage Patient Instructions Cyanosis to patient’s lips (blue makeup) Patient is extremely short of breath and one word dyspneic Patient is extremely diaphoretic (sprayed with water) Patient can answer questions but very slowly Patient tells Paramedics that he ‘can’t breathe” Props Chair Table Glass of water Additional Equipment and Props Equipment BLS Bag Monitor/Defibrillator Symptom relief kit Oxygen bag Scene Set-Up The patient should be siting at a table hunched over in a tri-pod like position Husband greets Paramedics at the door Bystander Husband can communicate all of patient’s medical information and history Dispatch Information Code 4 to a home for a patient short of breath, history of heart problems, FRI negative with a cough. Congestive Heart Failure PARAMEDIC SIM Patient Information Patient Name: Stephanie Sagoda Age:56 Weight: 55g Gender: Female Chief Complaint: Short of breath History of Present: Patient awoke approximately 20 minutes prior to call for Paramedics with extreme shortness of breath. Patient was hospitalized 2 weeks prior from a similar incident for which he was intubated. Allergies NKA SAMPLE History: Medications ASA, Atrovent, Carvedilol, Clopidogrel, Crestor, Furosemide, Lansoprazole Past History CABG 6 months prior, CHF, Renal Failure, HTN, High Cholesterol Oral Intake Normal OPRST (If Applicable) Additional Information Onset Unable to determine Provocation Unable to determine Palliation Unable to determine Quality Unable to determine Radiation Unable to determine Severity Unable to determine Time Bystanders state approximately 10 minutes prior to arrival Patient should be getting increasingly short of breath throughout the call Physical Findings Primary Survey: Airway Breathing Circulation Auscultation Distal Pulses Shock Profound cyanosis to the lips and face Shallow and laboured breathing Rapid central pulses, pale, warm skin Crackles throughout all lung fields Weak distal pulses Diaphoretic, warm, pale Secondary Survey : Head Neck Chest Back Pelvis Legs Extremities Some cyanosis to lips Unremarkable Shallow but equal chest rise and fall Unremarkable Unremarkable Unremarkable No edema, weak peripheral pulses Congestive Heart Failure PARAMEDIC SIM Vital Signs, Expected Actions, and Modifiers Patient states change throughout the scenarios. Generally a scenario will include 3 patient states. You may have more than 3 patient states if you have a very dynamic scenario or if there are a number of potential patient modifiers. Patient State 1: State: Baseline TRIGGER: Start of the Scenario Vital Signs Expected Actions 130 HR Good primary assessment consisting including 79% (84%) SPO2 auscultation 204/140 BP History taken from wife, minimizing need for patient to 48 talk RR 22 CO2 Oxygen administered 37.4 Temp Nitroglycerine administered as per local protocols diaphoretic, Skin CPAP Administered as per local protocols Pale 15 GCS ++ Pupils 5.1 BGL Sinus Tach ECG Sinus Tach 12 Lead Modifiers If oxygen is administered increase O2 saturation to 84% Nitro and CPAP administered saturations increase and remain at 84% No Nitro or CPAP by 6:00mins move to State 3 Nitro administered (State 2) Or Scenario ends at 12:00 minutes Trigger Patient State 2: State: Post- Nitro/CPAP TRIGGER: Nitro AND/OR CPAP is administered Vital Signs Expected Actions 136 HR Nitro every 5 minutes as per local protocols 84% SPO2 CPAP titrated every 5 minutes 180/104 BP Patient transported in a semi-sitting position 48 RR IV started as per local protocols 26 CO2 37.4 Temp Patient denies any relief from either CPAP/NITRO or a diaphoretic, combination of both Skin Pale 15 GCS ++ Pupils 5.1 BGL Sinus Tach ECG Sinus Tach 12 Lead Modifiers If patient is not transported in a semi sitting position, move to state 3 If Nitro is not repeated and CPAP not titrated move to state 3 Trigger End of Scenario (12 Minutes) Congestive Heart Failure PARAMEDIC SIM Patient State 3: State: Severe Distress TRIGGER: No treatment/change, not appropriate transport Vital Signs Expected Actions 190 HR Insertion of an oropharyngeal airway 64% SPO2 Proper ventilation technique 180/130 BP Medication is discontinued 64 RR Epinephrine is administered accoriding to local protocols 15 CO2 (0.5mg IM) 36.6 Temp Diaph Skin E4,V2,M5 GCS ++ Pupils 5.1 BGL Tachy w/ ECG PVC Tachy 12 Lead w/PVC Modifiers If Nitro/CPAP are started or titrated if already started move to stage 2 If patient is returned to the semi sitting position return to stage 2 End of Scenario (12 minutes ) Trigger
