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Download Fall with ST Elevation MI Case - 44 KB
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MedEd Portal/ POGOe Human Patient Simulation Title: - Target Audience: - Medical Students, Emergency Medicine Residents Learning Objectives: - - - Wrist Pain Primary – Recognize wrist fracture – Recognize ST elevation myocardial infarction Secondary – EKG within ten minutes – No Aspirin given allergy – Send patient to the catheterization lab Critical Actions Checklist – Upper Extremity Deformity – IV (Intravenous Access) – O2 (oxygen) – Monitor – EKG within ten minutes of arrival – Accucheck – No Aspirin – Nitroglycerin – Heparin – Plavix – Splint – Cardiac Catheterization Environment: - Environment – Tertiary Care Center Manikin Set Up – Basic Simulation Man Props – EKG showing STEMI – EKG showing ventrilcular tachycardia – X-ray showing wrist fracture – Splinting Material Actors: (All roles may be played by residents participating) - Distractors – The patient becomes very agitated when his wrist is examined. Lead Physician Intern Nurse Patient’s Wife Case Narrative: - Chief Complaint – Wrist Pain - History – – Pt is a 68 year male who presents by private vehicle for evaluation of wrist pain. He has a deformity to his wrist and is in significant pain and distress. The patient has a history of severe Parkinson’s dementia. According to his wife, he fell at his house and now has wrist pain. - Additional history (only given if specifically asked for) – The patient had an unwitnessed fall in his living room approximately thirty minutes prior to arrival. – If asked about details of the patient’s fall, his wife will reveal she found him unconscious. – Despite his baseline Parkinson’s, his wife feels like he is more agitated responsive and irritable. – He has been vomiting. – No other history or review of symptoms can be obtained secondary to his condition. - Past Medical History – Parkinson’s Dementia – ***Other Past Medical History only given if specifically asked for: Coronary Artery Disease Hypertension Diabetes Hyperlipidemia - Social History – The patient lives at home with his wife under the assistance of a daily home health nurse. - Medications – Metoprolol, Lisinopril, Namenda, Sinemet, Glipizide, Lantus - Surgical History – Cardiac catheterization with a stent five years ago - Allergies – Aspirin - Anaphylaxis - Review of Systems (obtained from patient’s wife) – Pt has been excessively fatigued and had non-coffee ground emesis twice this am. – Patient and wife are unable to provide much more history secondary to his dementia - Physical Exam – Blood Pressure 172/110, Heart Rate 97, Respiratory Rate 26, Oxygen Saturation 98% on room air, Temperature 36.8 – Elderly appearing male who appears in mild distress and moderate pain. His is sitting up in the stretcher moaning, rocking back and forth, and holding his wrist. There is non-bloody gastric emesis on the bed sheets. – Head, Eyes, Ears, Nose and Throat – normocephalic, atraumatic, pupils equally responsive and reactive to light and accommodation – Respiratory – clear to auscultation bilaterally – Cardiovascular – tachycardic, pulses 2+ in bilateral upper and lower extremities – Abdomen – soft, non tender, non distended – Extremities – dinner fork deformity to the right wrist, able to wiggle fingers, – Neurological – neurologically intact, able to wiggle fingers on right hand, sensation in right hand is intact – Skin – diaphoretic, no abrasions - Scenario Branch Points – The patient is an elderly male who presents to the Emergency Department for evaluation of wrist pain after a fall. He is unable to provide a complete history given his underlying severe Parkinson’s Dementia. – The resident needs to recognize the patient’s upper extremity deformity and splint appropriately if time allows. – The resident needs to obtain a thorough history regarding the patient’s fall to trigger a syncope workup. Part of the syncope work up will include an EKG and accucheck – – – Electrocardiogram (EKG) should be done within ten minutes An EKG needs to be obtained within ten minutes or the patient will have a ventricular tachycardia arrest. If this occurs the patient will can be successfully defibrillated. A subsequent EKG will reveal an anterior ST segment elevation myocardial infarction (STEMI). Once the STEMI is recognized, the patient should be treated appropriately Oxygen No aspirin – pt has anaphylaxis o The patient’s wife will provide this information only if asked about allergies Nitroglycerin Heparin Plavix Cardiology should be consulted and the patient should be immediately taken to the cardiac catheterization lab Instructors Notes: - Tips to Keep the Scenario Flowing – The Simulation Director should emphasize the patient appears in much more physical distress then should be caused by a wrist fracture. – Have the patient’s wife stay in the room. – The patient will not respond to any questions, should only be moaning in pain, and the only way to obtain a history is through the patient’s wife. – The patient should have another syncopal episode if an EKG is not obtained within five to ten minutes. – If the patient has ventricular tachycardia arrest, one attempt at cardioversion will be successful. – Any EKG thereafter should show an STEMI – The patient should not have an anaphylactic reaction, even if given aspirin Notify the resident after the case of the patient’s allergy. Encourage the resident to notify the cardiologist that the patient was given aspirin. – Once the STEMI is recognized the patient should be sent to the cardiac catheterization lab as soon as possible. - Tips to Direct Actors – The patient’s wife should remain vague about the fall. It was unwitnessed and she found him unconscious. - Scenario Steps – Optimal Management Path Recognize wrist fracture Obtain thorough history to reveal syncopal episode Obtain an EKG within five to ten minutes Identify STEMI Do not give Aspirin secondary to allergy If time permits, splint the forearm prior to patient going to cardiac catheterization lab. – Potential Complications Path Do not recognize that patient is in distress Do not obtain history revealing syncopal episode Patient has another syncopal episode with ventricular tachycardia Potential Errors Path Administering Aspirin No EKG within ten minutes – - Debriefing Plan: - Imaging and Labs – CBC – within normal limits (wnl) – Chem 10 – wnl – Coags – wnl – CXR – wnl – Urinalysis - wnl – Right wrist xray – Colles’ Fracture – EKG anterior STEMI Ventricular Tachycardia Topics to discuss – Differential diagnosis for syncope/ unwitnessed fall – Management of STEMI – Challenges of history taking in setting of dementia/ delirium – Causes of delirium Pilot Testing and Revision: - Number of Participants – 4 Anticipated Management Mistakes Not recognizing STEMI Giving Aspirin Not splinting wrist Incomplete history taking Evaluation form for participants – generic handout Authors: - John B. Seymour, MD. University of North Carolina Department of Emergency Medicine. - Rochelle Chijioke, MD. University of North Carolina Department of Emergency Medicine. - Amar Patel, MS. Director of the Center for Innovative Learning at WakeMed Health & Hospitals. - Graham Snyder, MD. Assistant Professor and Medical Director of the Center for Innovative Learning at WakeMed Health & Hospitals - Kevin Biese. MD, MAT. University of North Carolina Department of Emergency Medicine, Assistant Professor and Residency Director - Jan Busby-Whitehead, MD. University of North Carolina Professor & Chief, Division of Geriatric Medicine; Director, Center for Aging and Health.
