Download Infant_with_SVT_F1

CSC Standardized Curriculum
Specialty: Pediatrics
Simulation: Infant with SVT
Submitted by: COL Robert Puntel
Target Audience: Pediatric and Family Medicine Residents, Pediatric and Family
Medicine Staff
ACGME Competencies Addressed:
Medical Knowledge
Patient Care
Communication
Professionalism
RRC Requirements Addressed:
Infant resuscitation, PALS skills, Medication delivery, IV start, IO start, synchronized
cardioversion
Version 1, 4/11/2008
Case Scenarios
Primary:
Emergency Room: 3 month old infant, previously healthy and history of term delivery,
presents to the ED with parents. Chief complaint is fast breathing and poor feeding for
approximately 6 to 8 hours. No history of fever, URI symptoms, cough, diarrhea or
vomiting. No ill contacts. Received 2 month immunizations on time. Has been gaining
weight and developing normally to date. No other medical problems. FHX is not
contributory. No medications or unusual exposures.
Alternate scenario:
Pediatric Clinic: 3 year old, history of several similar episodes in the past, this is first
time to care for this, says “heart is beeping” and has been breathing a bit fast and seems
tired. This has been for about 30 minutes. No fever, cough or URI. No meds. Healthy
with normal growth and development. PMHX, PSHX, ROS, FHX all noncontributory.
Basic Instructions for participants:
Please read the scenario and then enter the room when instructed by your staff.
1. You may ask questions if you have them, and please remember to: Treat the situation
as realistically as possible.
2. Think out loud, vocalize abnormal/critical findings, state the doses of drugs, and
declare differential diagnoses you are considering. Only with this behavior can we
evaluate you and make sure you succeed.
3. If you have questions about the simulation or manikin ask the supervisor
4. If you need further patient information, ask; do not make assumptions; do not declare
the answers/results to physical finding/labs without asking
5. Assume that you can request any resource you would have available in the hospital in
which you are training
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Simulation Setup:
Simulators to be used: SimBaby or child mannequin
Room Setup: SimBaby or child mannequin with monitor on table, crib or warmer,
stethoscope, oxygen mask and infant and pediatric nasal canulae
Additional Equipment needed 24 and 22 gauge IV catheters, IV extension tubing, 500
cc NS, tape, pediatric intraosseus needle, defibrillator/cardioverter, Infant and child size
Zoll pads, monitor leads, 5cc syringe, 3 cc syringe, 1 cc syringe, 3 way stop cock, 23
gauge needle, Adenocard 6 mg vial (sham)
Optional Equipment: Bag-valve mask, ET tubes infant sizes: 3.5 and 4.0, child sizes
4.5 and 5.0, laryngoscope, stylet, tape
Personnel needed: SimBaby trained technician and scenario instructor, can be run
with 1 instructor trained on SimBaby
Basic Scenario Tips: Initial presentation in both scenarios is stable patient with
normal BP. General appearance is moderately tachypneic, but no respiratory
distress, and minimal if any decrease in capillary refill. Learners should progress
through vagal maneuvers, then adenosine administration. If there is delay in
management, patient should become progressively less well perfused and less
interactive, decreasing BP and require synchronized cardioversion to terminate the
arrhythmia.
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Case Flow/Algorithm with branch point and completion criteria:
Primary scenario:
General Appearance: 3 month old, nondysmorphic, mildly fussy, mildly pale, consolable
briefly
Vital signs: Temp: 36.5. Resp rate: 70, no distress. O2 sat: 94%. Pulses: 274. BP (right
arm): 70/54. Weight: 6 kg. Birth Weight: 3.5 kg
Exam: AF flat Mucous membranes moist. Mild nasal flaring. No grunting. Mild
suprasternal and subcostal retractions. Mild tachypnea without significant distress.
Auscultation: Lungs are overall clear, no wheezing
Cor: hyperdynamic, soft nonspecific 1/6 systolic murmur at LUSB
Liver is 2 cm below the right costal margin
Pulses in the brachial and femoral are all equal but mildly, too fast to count
Capillary refill is 3 seconds
Skin is cool without petechiae or rash
Case Flow: Stable infant in SVT
1. Initial assessment: Airway and breathing are stable, O2 can be administered by NC or
blow by Circulation: Stable SVT should be verbalized. Initial interventions: Vagal
maneuvers (Ice bag to face and neck for 10 to 15 seconds, do not occlude airway) should
be attempted. SVT persists, so adenosine is indicated. Secure IV access, preferably in a
larger vein such as antecubital vein. Dose of adenosine should be verified in text or card.
Adenosine 100 mcg/kg (About 0.5 mg) should be given IV push with 3 cc NS IV push
flush following immediately. This will convert rhythm to normal rhythm.
2. Scenario can continue in SVT with no effect from adenosine: Patient vital signs now
change: Pulse 274, patient appears lethargic and not interactive, BP 56/34. Capillary refill
4 to 5 seconds. Synchronized cardioversion must be given. Infant Zoll pads should be
applied over sternum and back. Verify defibrillator is demonstrating EKG. Choose
synchronization on the defibrillator and verify visually. Dial Joules as 0.5 per kg (about 3
Joules or lowest may be 5 Joules) “Clear” patient and press deliver shock button. Patient
is converted to NSR with rate 160.
3. Post resuscitation care should include warming if needed, bedside d-stick, consider 10
to 20cc/kg of IVF if history of many hours of poor feeding, consultation with pediatric
cardiologist.
Alternate scenario:
General Appearance: 3 year old, nondysmorphic, mildly fussy but attends
Vital signs: Resp rate: 30, no distress. O2 sat: 94%. Pulse 230. BP (right arm): 82/54.
Weight: 15 kg.
Exam: Mucous membranes moist. Mild suprasternal and subcostal retractions. Mild
tachypnea without significant distress.
Auscultation: Lungs are overall clear, no wheezing
Cor: hyperdynamic, soft nonspecific 1/6 systolic murmur at LUSB, HR about 200
Liver is 2 cm below the right costal margin
Pulses in the brachial and femoral are all equal but mildly, too fast to count
Version 1, 4/11/2008
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Capillary refill is 3 seconds
Skin is cool without petechiae or rash
Case Flow: Stable child in SVT
1. Initial assessment: Airway and breathing are stable, O2 can be administered by NC or
blow-by
Circulation: Stable SVT should be verbalized. Initial interventions: Vagal maneuvers
(Bearing down, blowing through an occluded straw) should be attempted. SVT persists,
so adenosine is indicated. Secure IV access, preferably in a larger vein such as antecubital
vein. Dose of adenosine should be verified in text or card. Adenosine 100 mcg/kg
(About 1.5 mg) should be given IV push with 5 cc NS IV push flush following
immediately. This will convert rhythm to normal rhythm.
2. Scenario can continue in SVT with no effect from adenosine: Patient vital signs now
change: Pulse 192, patient appears lethargic and not interactive, BP 60/40. Capillary refill
4 to 5 seconds. Synchronized cardioversion must be given. Child Zoll pads should be
applied over sternum and back. Verify defibrillator is demonstrating EKG. Choose
synchronization on the defibrillator and verify visually. Dial Joules as 0.5 per kg About
10 Joules) “Clear” patient and press deliver shock button. Patient is converted to NSR
with rate 120.
3. Post resuscitation care should include warming if needed, bedside d-stick, consider 10
to 20cc/kg of IVF if history of many hours of poor feeding, consultation with pediatric
cardiologist.
Common pitfalls to monitor for: Giving an IV fluid bolus is contraindicated in the
presentation of SVT. Proper administration of adenosine with a rapid NS flush must be
demonstrated.
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Evaluation Form:
Physician # / Name ____________________________
Date
_______________________
Training Site __________________________________
Grader
__________________
Training Level: (Circle One)
Fellow Staff
PGY-1
PGY-2
PGY-3
Completed
Not Completed Indeterminate
History (3 points)
Obtains relevant history (1 point)
Requests full vitals (1 point)
Requests continuous monitoring
(1 point)
Physical Exam (7 points)
Notes general appearance (1 points)
Recognizes tachycardia (2 points)
Recognizes tachypnea (2 points)
Recognizes signs of poor perfusion
(2 points)
Diagnostic evaluation (6 points)
Categorizes as stable or unstable/shock
(3 points)
Appropriately diagnoses rhythm/SVT
(3 points)
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Management (13 points)
Completed
Not completed Indeterminate
Assesses Airway, Breathing
And Circulation (2 points)
IV/IO demonstrated (2 points)
Appropriate vagal maneuvers
discussed/demonstrated (3 points)
Appropriate use of Adensoine and dosage
discussed/demonstrated
(3 points)
Appropriate use of cardioversion
discussed/demonstrated (3 points)
Time goals (11 points)
SVT diagnosed (1:00 minute) (2 points)
Vagal maneuvers (2:00 scenario time)
(3points)
Adenosine used (4:00 scenario time)
(3 points)
Cardioversion discussed/used (6:00 minutes
scenario time (3 points)
Contraindicated Actions and Interventions
Contraindicated
IVF bolus given (-3 points)
Sequence of vagal maneuvers, then adenosine, then
cardioversion if unstable not followed (-3 points)
Defibrillation instead of cardioversion used (-3 points)
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Scenario score: Assign points for all items checked as ‘Completed’ or ‘Contraindicated”.
No points are given for “Not completed” and ‘Indeterminate’ actions.
(Maximum points possible for this scenario = 40)
Correct action points = _____
Contraindicated action points = _____
Total scenario points = _____
Percent scenario score (Total scenario points /40) = _____
Overall scenario performance rating:
 1 (poor)
 2 (fair)
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 3 (good)
 4 (Very good)
 5 (Excellent)
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Please answer the following questions about this provider’s performance:
1. Provider performed airway evaluation in timely fashion
Strongly Disagree
0
1
2
Neither agree
Or disagree
3
4
5
6
Strongly Agree
7
8
9
10
2. Respiratory status exam was accurate and complete
Strongly Disagree
0
1
2
Neither agree
Or disagree
3
4
5
6
Strongly Agree
7
8
9
10
3. Provider initiated appropriate diagnostic evaluation in a timely fashion
Strongly Disagree
0
1
2
Neither agree
Or disagree
3
4
5
6
Strongly Agree
7
8
9
10
4. Provider made appropriate therapeutic decision
Extremely Poor
0
1
Average
2
3
4
5
6
Outstanding
7
8
9
10
4. How prepared do you feel the provider was to manage this scenario?
Not prepared at all
0
1
Reasonably prepared
2
3
4
5
6
Very prepared
7
8
9
10
Perceived competency:
 Not competent to handle a similar scenario on a patient even with supervision*
 Competent to handle a similar scenario on a patient with supervision
 Competent to handle a similar scenario on a patient independently
 Competent to teach others about this scenario
* If student not competent to perform procedure please refer for remedial simulation training
Version 1, 4/11/2008
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Key Teaching Points/Critical Actions to discuss in debriefing:
IVF bolus contraindicated with patient in SVT (similar to CHF patients). Adenosine dose
should be looked up and not determined from memory. Adenosine must be given with a
rapid 3 to 5cc NS flush following. This is best accomplished with a 3 way stopcock.
Learners should demonstrate proper placement of Zoll pads on patient and discuss age
differences. Synchronized cardioversion at low joules/kg (0.5 to 1 J/kg) must be used if
unstable, and not defibrillation. Learners should demonstrate the use of the defibrillator to
appropriately give DC cardioversion that is synchronized and not defibrillation.
Suggested time length for modules: Total time: 20 minutes.
3 minute introduction to Sim Baby if not already known, auscultation and pulse points on
the mannequin,
2 minute introduction to scenario,
3 minute assessment and initial plans for vagal maneuvers, flow is unsuccessful with
maneuvers,
3 minutes discussion of adenosine dose and demonstration of administration with IV
flush with 3 way stopcock.
Zoll pad placement and synchronized cardioversion as case progresses. (5 minutes)
Brief Didactic:
SVT is generally well tolerated by infants and children. Some infants can present after
being in SVT for 1 to 2 days and appear relatively well. IVF boluses, especially usual
20cc/kg are contraindicated in SVT.
Small peripheral vein adenosine administration may not work (hand or scalp IV),
intraosseus administration is very unlikely to work due to diffusion of drug through bone
marrow. ET tube administration is contraindicated. Other drugs can be discussed for use
in SVT such as calcium channel blockers (example: verapamil or diltiazem) but these
have the significant side effect of hypotension in children and are usually avoided.
Synchronized cardioversion means that the joules are delivered to avoid the T wave
which could initiate ventricular fibrillation.
Some vagal maneuvers in children can be coughing, gently pressing on abdomen and
asking them to push back on your hand with their abdomen (valsalva), blowing upn exam
glove (do not leave a child unattended with a glove as the child could choke on a piece of
glove)
Supporting Literature and Suggested Readings:
Moss and Adams, Fifth Edition, pp 1572 to 1584.
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