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Download November 2010
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MedEd Portal/ POGOe Human Patient Simulation Title: Chronic Salicylate Toxicity Target Audience: Upper Level Resident Learning Objectives: - - - Primary – Recognize a critical patient and begin immediate advanced cardiac life support (ACLS) – Recognize chronic salicylate toxicity Secondary – Successfully implement ACLS x 3 rounds with proper drug dosages – Obtain additional history from family during code situation – Treat salicylate toxicity with bicarbonate drip, fluids, vasopressors, and transfer to higher level of care for hemodialysis Critical Actions Checklist ACLS Performing high quality Cardiopulomonary Resuscitation (CPR) Intubation / Rapid Sequence Intubation (RSI) meds Obtain history from the rest of her family Recognize salicylate toxicity Intraosseous (I/O) access Bolus intravenous fluids (IVF) Bicarbonate drip Vasoconstrictive medicaitons Transfer to higher level of care for hemodialysis Environment: - - 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 – Aspirin bottle in pocket – Electrocardiogram (EKG) with sinus tachycardia after successful ACLS – Chest X-Ray (CXR) with pulmonary edema - Actors: (All roles may be played by residents participating) - Distractors – The patient’s son wants to leave the room because he can’t bear to watch his mother undergo ACLS and also wants to call his other family members. The resident should either ask him for additional history prior to the son leaving the room or have a nurse obtain additional history. Resident running the case Nurse to place I/O and obtain additional history Family Member – Son Intern 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: - Chief Complaint – Unresponsive - History – 66 year female is brought to the Emergency Department by private vehicle with her son. The front desk technician wheeled her back in a wheelchair unconscious. Her son states she stopped breathing in the car. The patient’s son does not know all of his mother’s medical history. Her son lives an hour away, but over the phone she has been complaining of chronic knee pain for several weeks, decreased appetite, and occasionally vomiting. On arrival to her house this afternoon, she would not answer the door and he had to break in. He found her lying on the floor, altered, moaning, and decided to bring her directly to the ER. - Additional history given only if asked – The patient has complained 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”. – Her son found several empty bottles of aspirin next to her chair in the living room. – She has been losing her ability to hear over the past 2 months. - Past Medical History – He doesn’t think she has any history of coronary artery disease (CAD), diabetes mellitus (DM), hypertension (HTN), cerebrovascular accident (CVA). She doesn’t see a doctor on a regular basis. No history of depression. - Social History – Long time smoker, no alcohol, lives along, husband dies 10 years ago - Medications – Unsure (The resident needs to specifically ask about over the counter meds and will be told there were several empty aspirin bottles on the kitchen counter.) - Surgical History – none - Allergies – unsure - Review of Systems – unable to provide given condition - 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 - 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. An I/O needle should be placed for immediate access to give code drugs. During the course of CPR, additional history should be obtained by another health care provider which will lead to clues of chronic salicylate toxicity with end organ failure. The patient’s son will state that his mother 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 for hemodialysis. Instructors Notes: - 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 pressors 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. - Tips to Direct Actors – The family member should persistently try to leave the room without giving further history. – The director should only give information when acting as a MICU consultant. - Scenario Steps – ACLS – Intubation – IVF – Recognize chronic salicylate toxicity – Bicarbonate drip – Pressors – Increasing vent requirements – Transfer to higher level of care for hemodialysis - Imaging and Labs – CXR – pulmonary edema – Labs – high anion gap metabolic acidosis, respiratory acidosis, renal failure, rhabdomyolysis – Salicylate Level – 61 – Urine Drug Screen – negative – – – – – Debriefing Plan: - 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? Pilot Testing and Revision: - Cardiac Enzymes – negative CT head negative Arterial Blood Gas – metabolic acidosis and respiratory acidosis Lactate – 4 Thyroid Stimulating Hormone – within normal limits Number of Participants – 4 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.
