Scenario: Geriatric Trauma Resuscitation #1

PALMETTO HEALTH RICHLAND

Scenario #6A: Geriatric End-of-Life Issues — #3

Goals & Objectives: 1. Demonstrate recognition and correction of impending respiratory failure 2. Demonstrate proper intubation of geriatric patients 3. Demonstrate knowledge of post-intubation cardiopulmonary management 4. Recognize healthcare-associated pneumonia and institute proper antibiotics 5. Improve communication skills with family members 6. Review principles of DNR orders 7. Learn the definition of decisional capacity

Equipment: 1. SimMan 2. Code cart 3. Live patient relative (son) 4. DNR (valid, signed, dated, and notarized)

Moulage: 1. Heel protectors 2. Depends diaper 3. Dentures

Sim Spec Instructions: 1. Make intubation difficult: stiff jaw/neck, dentures 2. “Rhonchorous,” shallow breath sounds 3. Thready tachycardic pulse

Initial Vignette: 91-year-old male nursing home resident is brought in by EMS. EMS was called for decreased mental status and found him unresponsive. Initial vital signs per EMS: BP 80/60 Pulse 112 RR 24 O sat 88% (2 L nasal cannula) 2

Initial Appearance: Obtunded. Moans in response to painful stimuli but does not move. If checked, rectal temp is 101 If checked, there is no gag reflex If placed on 100% oxygen, pulse ox improves to 90% Over the next 2 minutes, respiratory rate decreases to 0

Nursing Home Documentation: lung cancer, hypertension, diabetes, COPD Meds: albuterol, Norvasc, metformin, ASA, Lipitor Allergies: morphine, penicillin Code status is not listed PALMETTO HEALTH RICHLAND

Scenario Flow (medical management 10 minutes; family stage 5 minutes):  Oxygen, pulse oximetry, cardiac monitor, BP  Intubation for respiratory distress/failure: RSI to relax the jaw and neck (must demonstrate correct dosages). Post-intubation CXR and ABG, and verify position of endotracheal tube.  IVF bolus for hypotension: BP improves to 110/66 and pulse drops to 104  Labs ordered: abnormal WBC, glucose, lytes, CXR: lung cancer, pneumonia  Antibiotics administered for healthcare-associated pneumonia Son arrives any time after intubation done (at tester’s preference):  He is upset because he says his dad requested no heroic interventions  Learnero Introduce must: self to son o Explain what has happened and why his father was intubated o Explain the lack of code status from the nursing home o Ask the son if the father has written down his desires for no heroic intervention o Examine the DHEC DNR order that the son shows for: date, physician signature, patient signature o After validating the DNR order, ask the son if he wants the father off the ventilator  When son asks if his father will die without the ventilator, answer yes. Son will agree. Physician must wait an appropriate time to disconnect the ventilator to allow the paralytic agents to wear off.

Critical Actions Identifies respiratory failure prior to apnea  Demonstrates proper meds and dosages for RSI  Demonstrates proper intubation technique Obtains rectal temp  Initiates proper antibiotics for healthcare-associated pneumonia  Introduces self to son Explains to son what happened  Recognizes valid DNR form  Offers to take father off of ventilator Facilitator Debriefing Points  Review the legal forms one might encounter. DNR, HCPOA, advance directive  Principles of DNR orders  Definition of decisional capacity  Ways to improve communication with family members of patients  Post-resuscitation care of the geriatric patient PALMETTO HEALTH RICHLAND

For Geriatric Scenario #6 (A, B, C)

WBC: 12,300

Polys: 65%

Bands: 4%

Lymph: 28%

Hgb: 11.9

Hct: 34%

Platelets: 220,000 PALMETTO HEALTH RICHLAND

Na: 139

K: 4.6

Cl: 100

HCO: 24

BUN: 26

Creat: 1.6 PALMETTO HEALTH RICHLAND

ABG (100% oxygen, post-intubation) pH: 7.42 pO2: 155 pCO2: 38

O2 Sat: 100% PALMETTO HEALTH RICHLAND

Urinalysis

Specific gravity: 1.022 pH: 7.0

Protein: None

Glucose: None

Blood: None

Ketones: None

WBC: 5–10

RBC: 0–1

Epithelial: 5–10

Bacteria: 1+ PALMETTO HEALTH RICHLAND

Cardiac Enzymes

CPK: 172

CK-MB: 1.2

Troponin: 0.2