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Human Patient Simulation
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Title: Chronic Severe Salicylate Toxicity
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Target Audience: Lower and Upper Level Resident
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Learning Objectives:
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Primary
– Recognize a critical patient and begin immediate advanced cardiac
life support (ACLS)
– Recognize severe salicylate toxicity
– Improve care transition by contacting referring facility
Secondary
– Successfully implement ACLS x 3 rounds with proper drug
dosages
– Obtain additional history from referring facility during code
situation
– Treat salicylate toxicity with bicarbonate drip, fluids, vasopressors,
and transfer to higher level of care
Critical Actions Checklist
 ACLS
 Intern performing high quality Cardiopulomonary Resuscitation
(CPR)
 Intubation / Rapid Sequence Intubation (RSI) meds
 get history from assisted living facility
 recognize salicylate toxicity
 Intraosseous (I/O) access
 Bolus intravenous fluids (IVF)
 Bicarbonate drip
 Vasoconstrictive agents
 Transfer to higher level of care
Environment:
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Environment
– Rural 12 bed Emergency Department with hospitalist back up
Manikin Set Up
– I/O lines
– Code cart
– Intubation equipment
– Code drugs
– RSI drugs
Props
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Distractors
– The extremis of the patient can distract from taking a thorough
history and the need to call the referring facility.
Actors: (All roles may be played by residents participating)
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Electrocardiogram (EKG) with sinus tachycardia after successful
ACLS
Chest X-Ray (CXR) with pulmonary edema and successful
intubation
Resident running the case
Nurse to place I/O and obtain additional history
Assisted living facility nurse
Intern/ junior resident who will intubate the patient and perform correct
CPR
Another resident to be the attending or Medical Intensive Care Unit
(MICU) consultant at another hospital (able to give recommendations)
Case Narrative:
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Chief Complaint
– Change in mental status followed by respiratory collapse
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History
– 66 year female is brought to the Emergency Department by
ambulance from local assisted living facility for increased
confusion. EMS brought her in. She was initially confused and
disorientated. She suffered respiratory collapse immediately
before arrival so they began to use bag mask valve to ventilate
patient. If called, the nurse at the nursing home will reveal that the
patient has had chronic knee pain which has increased recently and
has been taking large amounts of aspirin and BC Powder.
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Additional history given only if asked
– The patient has complained to nursing staff about her chronic
arthritis in her backs and knees for several months.
– She takes aspirin daily and sometimes goes through a bottle every
“few days” along with BC powder.
– She has been losing her ability to hear over the past 2 months.
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Past Medical History
– Mild hypertension (HTN). The nurse doesn’t think she has any
history of coronary artery disease (CAD), diabetes mellitus (DM),
or cerebrovascular accident (CVA). She doesn’t see a doctor on a
regular basis. No history of depression.
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Social History
– Long time smoker, no alcohol, lives along in assisted living
facility, husband dies 10 years ago
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Medications
– Aspirin
– BC Powder
– HCTZ
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Surgical History – none
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Allergies – none
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Review of Systems – unable to provide given condition
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Physical Exam
– Glasgow Coma Scale 3, pulseless, ashen, apneic, no signs of
trauma, no deformities
– Head, Eyes, Ears, Nose, Throat (HEENT) – normocephalic
atraumatic, pupils 5mm bilaterally and sluggishly reactive, no
extraocular eye movements, gag reflex intact
– Respiratory – apneic
– Cardiovascular – no central pulses
– Abdomen – soft, non distended
– Extremities – no gross deformities or ecchymosis
– Neurological – GCS 3
– Skin – mottled, pale, cool
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Scenario Branch Points
– On arrival, resident should immediately recognize that ACLS
should be implemented. After three rounds of CPR and code
drugs, a slight pulse will return. Airway should be secured during
resuscitation. As it will be difficult to obtain peripheral IV access,
an I/O needle should be placed for immediate access to give code
drugs. During the course of CPR, additional history from the
referring facility should be obtained by another health care
provider which will lead to clues of chronic salicylate toxicity with
end organ failure. Calling the assisted living facility will reveal
that the patient takes a bottle of aspirin every few days and has
been complaining of hearing loss. This should clue the resident to
search for salicylate toxicity and treat with a sodium bicarbonate
continuous infusion as she is severely acidemic with end organ
failure. A bicarbonate drip should be implemented. Vasopressors
and a large amount of IVF will be required. Patient will need
increasing peak end expiratory pressure for pulmonary edema. If
performed, a computerized tomography scan (CT) of the brain will
be negative. She will need to be transferred to an intensive care
setting..
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Instructors Notes:
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Tips to Keep the Scenario Flowing
– The director should emphasize the critical condition of the patient
on arrival
– Allow 3 rounds of ACLS before return of spontaneous circulation
– Encourage the resident to obtain additional history
– Focus on proper intubation techniques by the intern
– Focus on proper I/O technique by the resident and/or nurse
– Make sure the resident uses proper drug dosages
– Do not let the patient die
– The patient will survive if given IVF and vasopressor medications
 The proctor of the simulation case should act as the MICU
consultant. They should ask the resident why they believe
this patient is coding and help guide the resident through a
differential.
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Tips to Direct Actors
– The nurse at the assisted living facility should inform of the aspirin
use only if called and asked about patient’s medications.
– The director should only give information when acting as a MICU
consultant.
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Scenario Steps
– ACLS
– Intubation
– IVF
– Recognize chronic and severe salicylate toxicity
– Bicarbonate drip
– Vasoactive agents
– Increasing vent requirements
– Transfer to higher level of care.
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Imaging and Labs
– CXR – pulmonary edema
– Labs – high anion gap metabolic acidosis, respiratory acidosis,
renal failure, rhabdomyolysis, hyperkalemia
– Salicylate Level – 61
– Urine Drug Screen – negative
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Debriefing Plan:
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Topics to discuss
– What are the drugs used during ACLS?
– What is the difference between acute and chronic salicylate
toxicity and who is at risk?
– How do you mix and start a bicarbonate drip?
– Should dialysis be a consideration for this patient?
– How can transfer of care and communication be improved?
Pilot Testing and Revision:
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Cardiac Enzymes – negative
CT head negative
Arterial Blood Gas – metabolic acidosis and respiratory acidosis
(because of respiratory collapse)
Lactate – 8
Thyroid Stimulating Hormone – within normal limits
Number of Participants – 5
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, PGY - 2
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