Download November 2010

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Human Patient Simulation
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Title: Altered Mental Status
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Target Audience: Resident
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Learning Objectives:
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Primary
– Recognize a septic patient
– Identify etiology of sepsis
 Urosepsis and Sacral Decubitus Ulcer
– Full physical exam to identify infected sacral ulcer
– Appropriate management of sepsis
– Contacting referring facility and/ or family
– Diagnose delirium
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Secondary
– Aggressive resuscitation
– Transfuse Packed Red Blood Cells (PRBC)
– Central Venous Pressure (CVP) by ultrasound
– Vasopressors
– Identify Do Not Intubate (DNI) status and do not intubate the
patient
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Critical Actions Checklist
 2 large bore intravenous access (IV)
 Oxygen
 Monitor
 Blood and Urine Cultures
 Appropriate Labs
 Chest X-ray (CXR)
 Identify Pyelonephritis
 Identify Infected Sacral Decubitus Ulcer
 Antibiotics
 PRBCs transfusion
 Vasopressors
 Patient is a DNI
 Do not intubate patient
 Intensive Care Unit (ICU) consultation
 Surgery Consultation
Environment:
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Environment
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– Rural Emergency Department
Manikin Set Up
– Elderly female
Props
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Sacral decubitus ulcer prop
Foley catheter containing cloudy yellow fluid
Electrocardiogram (EKG)
CXR
DNI Sheet (can be faxed in)
Ultrasound (U/S) video showing Inferior Vena Cava (IVC)
compression
CAM-ICU worksheet
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Actors: (All roles may be played by residents participating)
- Resident Physician
- Nurse
- Intern
- Family Member
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Case Narrative:
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Chief Complaint
– Altered Mental Status
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History
– Patient is an 82 year old female who presents from a nursing home
via EMS for evaluation of altered mental status and fever. Per
paramedics, the nursing home staff noted a fever of 102.2 and the
patient has not been as alert as she was 2 days ago. She has been a
resident there for two months while trying to rehabilitate from a
hip fracture.
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Additional history given only if asked
– If called, the nurse at the nursing home states she usually takes
care of the patient during the week and last Friday she was doing
well, but something happened over the weekend. The nurse at the
nursing home (or the husband)can also tell the team
 She still is not getting out of bed.
 She had a Foley catheter placed recently.
 Her Primary Medical Doctor (PMD) is treating her with
amoxicillin.
 The patient has a son, but he only has been to the nursing
home once or twice to see his mother.
 Patient resuscitation status is DNI.
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The only way to obtain this information is to contact the
referring nursing home or the patient’s husband.
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Past Medical History
– Hypertension (HTN)
– Urinary Tract Infection (UTI)
– Dementia
– Hyperlipidemia
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Social History
– Pt used to live at home with her husband. He was her primary
caretaker until she fell and suffered a hip fracture.
– No alcohol, tobacco, or drug use
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Medications
– Amoxicillin for UTI over the past few days
– Memantine, Atorvastatin, Hydrochlorothiazide, Atenolol, Lantus,
Enoxaparin
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Surgical History
– Hip fracture 2 months ago status-post arthroplasty
– Hysterectomy
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Allergies
– No known drug allergies (NKDA)
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Review of Systems
– Deconditioning, decreasing appetite, fevers,
– No shortness of breath, no cough
– No chest pain or palpitations
– No vomiting, no dysphagia, no abdominal pain, no bloody stools
– No focal weakness or numbness, no headache
– Delirium for the past 48 hours
– No lower extremity edema
– Mild diaphoresis, no rashes or lesions
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Physical Exam
– Heart Rate (HR) 123, Blood Pressure (BP) 82/45, Respiratory Rate
(RR) 31, O2 – 95% on room air, Temperature 39.1
– Accucheck – 52 (only if asked for)
– General – Lethargic, moaning, Glasgow Coma Scale – 11 (eyes 3,
Verbal 4, Movement 4)
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Head, Eyes, Ears, Nose Throat (HEENT) – dry mucous
membranes, no meningismus, pupils equally reactive and
responsive to light and accommodation (PERRLA)
Cardiovascular (CVS) – tachycardic, regular rhythm and rate , no
murmurs, rubs, or gallops, no palpable distal pulses, but palpable
femoral and carotid
Respiratory – tachypnea, clear to auscultation bilaterally with no
wheezes, rales, or rhonchi
Abdominal – wincing and increased moaning with suprapubic
palpation, no rebound or guarding, rectal hemoccult negative
Genitourinary – Foley catheter in place with cloudy urine
Extremities – no edema, no rashes
Skin –no cyanosis
Only if asked for (patient turned)
 Large 10 cm sacral decubitus ulcer stage 4 with
surrounding erythema, yellowish-green base, and foul
sweet smell.
Scenario Branch Points
– The resident participant must identify the septic patient. This will
be evident through her general appearance, physical exam, and
vital signs.
– The etiology of her sepsis is obtained not only by labs (UTI /
pyelonephritis), but also by a thorough physical exam. Only if she
is rolled with they identify the infected decubitus ulcer, suspicious
for pseudomonas.
– Aggressive resuscitation should be initiated with IVF, antibiotics,
and vasopressors.
– Fluid resuscitation can be guided by a CVP through a central
venous line or by evaluating IVC compression with and
ultrasound.
– Antibiotic coverage must be tailored to include methicillin resistant
Staphylococcus aureus, Pseudomonas, and urinary flora.
– The patient will require at least 4 liters of fluid resuscitation, 2
units of PRBCs, and vasopressors before vital signs, urinary
output, or perfusion will improve.
– The patient will appear to need mechanical ventilation, but this
should not be done. The resident needs to obtain the patient’s code
status, and this can only be done by contacting her husband.
– If the patient is intubated, her husband will spontaneously arrive in
the Emergency Department requesting she be taken off the
ventilator.
– The resident should consult both the Medical intensivist and
Surgeon for evaluation and admission.
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Instructors Notes:
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Tips to Keep the Scenario Flowing
– The director should give the paramedic report
– The director should answer questions as if they were the patient
– Make the patient be very vague, altered and toxic appearing
– Do not give tips regarding the presence of a sacral decubitus ulcer.
– The patient must not improve unless the appropriate amounts of
fluids are given.
– The patient’s appearance, vitals and perfusion will not improve
with only 1-2 liters of IVF and vasopressors.
– Allow the resident to intubate the patient if they so choose.
– If intubated, the patient’s husband will arrive in the ER with
disapproval of the decision to intubate and request she be taken off
the ventilator.
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Tips to Direct Actors
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Nurses will be new grads and unfamiliar with management of
sepsis. They will need specific drug dosages and instructions for
what type of IV access, lines, etc…
The Patient’s Husband - You will be very clear regarding the
patient’s DNI status if contacted over the phone. If not contacted
and the patient is intubated, you should let your disappointment be
known once you arrive to the Emergency Department. Request
that your wife’s breathing tube be removed.
Scenario Steps
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Optimal Management Path
 Identify sepsis and likely etiology (UTI, pyelonephritis,
infected sacral decubitus ulcer)
 IV fluid Resuscitation guided by CVP (via central venous
line or IVC using U/S)
 Blood and urine cultures
 Tailored antibiotics
 Contacting family
 Respecting patient’s DNI status
Potential Errors Path
 Not recognizing sepsis
 Not obtaining cultures
 Not rolling the patient and identifying the sacral decubitus
ulcer likely infected with pseudomonas
 Under resuscitation with not enough IV fluids
 Starting vasopressors without completely resuscitating the
patient with IV fluids beforehand
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Imaging and Labs
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Not contacting family members
Intubating the patient
CBC – WBC 18, Hgb 7, Hct 26, Plt 180
Chem 7 – Na 148, K 4.9, Cl 111, CO2 13, BUN 64, Cr 1.9, Glu
180
Lactate – 7.2
U/A – WBC >182, Many Bacteria, + LE, + Nitrates
ABG 7.21 / 29 / 158 / 14 / 95% / - 11
Debriefing Plan:
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Topics to discuss
– Identifying the signs and symptoms of Systemic Inflammatory
Response Syndrome and Sepsis
– The importance of physical exam
– Correct Management of Sepsis
– Management of DNR/DNI patient’s and how to update a patient’s
DNR/DNI status in the Emergent Department
– The importance of contacting referring facility and/ or family.
– Importance and techniques for diagnosing delirium.
Pilot Testing and Revision:
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Number of Participants – 4
Anticipated Management Mistakes
– Under resuscitation
– No antibiotics
– Intubation
– Not identifying sacral decubitus ulcer
- Evaluation form for participants – generic handout
Authors:
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John B. Seymour M.D. University of North Carolina Department of
Emergency Medicine, PGY – 3
Rochelle Chijioke M.D. University of North Carolina Department of
Emergency Medicine.
Kevin Biese M.D. University of North Carolina Department of Emergency
Medicine, Associate Professor and Residency Director
Graham Snyder M.D. Wake Med Health and Hospitals Department of
Emergency Medicine, Assistant Program Director and Simulation Director
Jan Busby-Whitehead M.D. University of North Carolina Division of
Geriatric Medicine/ Institute on Aging, Professor and Chief
Copyright © 2011 The University of North Carolina School of Medicine