APLS Simulation Scenarios

module Simulation Scenarios

This material is made available as part of the professional education programs of the American Academy of Pediatrics and the American College of Emergency Physicians. No endorsement of any product or service should be inferred or is intended. Every effort has been made to ensure that contributors to the APLS materials are knowledgeable authorities in their fields. Readers are nevertheless advised that the statements and opinions expressed are provided as guidelines and should not be construed as official policy of the American Academy of Pediatrics or the American College of Emergency Physicians. The recommendations in these accompanying materials do not indicate an exclusive course of treatment. Variations, taking into account individual circumstances, nature of medical oversight, and local protocols, may be appropriate. The American Academy of Pediatrics, the American College of Emergency Physicians, and the authors here within disclaim any liability or responsibility for the consequences of any actions taken in reliance on these statements, opinions, or contents contained within these materials.

Contents Adrenal Insufficiency 1 Blunt Abdominal Trauma—Hypovolemic Shock 4 Cardiogenic Shock Due to Congenital Heart Disease 8 Altered Mental Status 10 Diabetic Ketoacidosis and Cerebral Edema 12 Hyperthermia 15 Hypothermia—Near Drowning 18 Iron Overdose 22 Myocarditis—Cardiogenic Shock 25 Occult Trauma (Intentional Trauma) 27 Postoperative Cardiac Patient—Ventricular Fibrillation 30 Septic Shock 33 Chest Crisis—Sickle Cell Disease 36 Status Asthmaticus 39 Status Epilepticus 42 Stridor Due to Foreign Body 45 Supraventricular Tachycardia 48 Tricyclic Antidepressant Overdose 50 Metabolic Crisis—Hyperammonemia 54

Learning Objectives • Describe the signs and symptoms of an infant presenting with salt-wasting adrenal crisis associated with congenital adrenal hyperplasia and adrenal insufficiency. • Demonstrate the treatment of a newborn with salt-wasting crisis. – Initial stabilizing steps. – Replacement therapy.

Simulator: Infant Simulator

Scenario Patient Instructor Time, Stage Condition Intervention Debriefing Notes min

STAGE 1 History Take a History: 5 • Three-week-old boy with unremarkable history, referred to • No ill contacts emergency department from physician’s office with a low • No medications serum sodium level (126 mmol/L) • No allergies • Mother’s pregnancy was normal; she recalls no abnormal • Poor feeding over last week, spitting up more in past few test results days • Triage nurse was worried about how ill the child appears • No fever • You arrive to assess the patient • Sleeping through feeding time last few days, slept most of Weight: the last 12 h • 3 kg • Has lost weight since last family physician visit Condition: Airway: • Very unwell, listless • Listen for breath sounds, present Physical Examination Findings: • Apply oxygen via nonrebreather mask at 15 L/min • Temperature 36.2°C (97.2°F), HR 152/min, RR 36/min, oxygen Breathing: saturation 98% in room air, BP 72/58 mm Hg • Apply monitors, including oxygen saturation and blood • CNS: asleep, wakes briefly with painful stimulation pressure • CVS: pulses present centrally, absent peripherally • Auscultate chest and observe respiratory rate • Respiratory: clear Circulation: • Abdomen: no hepatosplenomegaly • Assess pulse, HR, capillary refill, BP • Extremities/skin: capillary refill >4 s • Ask nurse for an IV catheter to be placed • Ask for normal saline or lactated Ringer solution bolus of 20 mL/kg to be given quickly (push) Medical Management: • Order laboratory tests: (CBC, electrolytes, blood cultures, venous blood gas, bedside glucose)

1 Simulation Scenarios Adrenal Insufficiency

STAGE 2 Condition: REASSESSMENT OF THE PATIENT: 5 • HR remains elevated and BP is now low Circulation: • Nurse notes aloud, “His hands are just so cold.” • Reassess HR, pulse, capillary refill, BP after bolus • Blood glucose level is low if bedside testing was performed • Order second bolus, also push • Laboratory results: sodium 124 mmol/L, potassium 7.8 Medical Management: mmol/L, bicarbonate 16 mmol/L, BUN and creatinine normal • Consult endocrinologist for treatment guidance; order tests for age, pH from venous gas 7.26 they might request Physical Examination • Order IV hydrocortisone Findings: • Order D10W IV bolus to correct hypoglycemia • HR 150/min, RR 36/min, oxygen saturation 99% on 100% • Initiate management of hyperkalemia oxygen (if placed), BP 73/60 mm Hg • CNS: cries weakly with painful stimuli • Respiratory: clear • CVS: clamped down and cool extremities. • Abdomen: no hepatosplenomegaly

STAGE 3 Condition: REASSESSMENT OF THE PATIENT: 5 • “He is looking around more now.” Circulation: • Improved perfusion and alertness after second bolus • Reassess HR, pulse, capillary refill, BP Physical Examination Findings: Medical Management: • HR 138/min, RR 36/min, BP 78/48 mm Hg, saturation 98% on • Order recheck of electrolytes after bolus therapy room air Disposition: • Abdomen: no hepatosplenomegaly • Arrange for neonatal or pediatric ICU for monitoring and frequent laboratory work until stabilized or plan for transport to tertiary care facility (depending on presenting facility resources)

Abbreviations: BP, blood pressure; BUN, blood urea nitrogen; CBC, complete blood cell count; CNS, central nervous system; CVS, cardiovascular system; D10W, 10% dextrose in water; HR, heart rate; ICU, intensive care unit; IV, intravenous; RR, respiratory rate.

2 Simulation Scenarios Adrenal Insufficiency

© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians Notes 1. Potassium and sodium derangements usually do not require short-term treatment beyond fluid resuscitation and hydrocortisone.

3 Simulation Scenarios Adrenal Insufficiency

© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians Blunt Abdominal Trauma—Hypovolemic Shock Adam Cheng, MD, FRCPC, FAAP Mark Adler, MD Learning Objectives • Describe the signs and symptoms of a patient with hypovolemic shock. • Demonstrate the management of circulatory failure due to hypovolemic shock. – Demonstrate the approach to pediatric trauma: primary and secondary assessment. – Demonstrate use of fluid resuscitation in patients with profound blood loss. – Identify and manage abdominal injury in a trauma patient. – Demonstrate use of rapid infuser in trauma care.

Simulator: Pediatric Simulator

Scenario Patient Instructor Time, Stage Condition Intervention Debriefing Notes min

STAGE 1 History: TAKE A HISTORY: 2 • Five-year-old boy From Paramedics: • Playing in the driveway • Initially delirious, screaming, GCS score of 15/15 • Found by parents crushed and trapped underneath garage • Extraction took 10 min in total door • IV antecubital one time • Garage door directly over his abdomen • Given normal saline. 20 mL/kg • No witnesses to the incident • Transport time, 15 min • Ambulance arrived within 12 min PRIMARY SURVEY MANAGEMENT: Weight: Airway: • 18 kg • Assess airway, talk to the patient Condition: Breathing: • Moaning in pain • Check oxygen saturation • Temperature 36°C (96.8°F), HR 150/min, RR 30/min, BP 85/50 • Apply monitors mm Hg, oxygen saturation 96% room air • Auscultate chest • Monitor: sinus tachycardia • Check for chest rise • CNS: cervical collar on patient; moaning in pain, answers • Apply 100% oxygen questions, asking for mom, confused at times, GCS score Circulation: of 15. • Apply monitors • H/N: cervical spine not tender, no obvious facial injury • Check pulse, capillary refill, BP • CVS: capillary refill 4 s, pulses palpable but weak • Identify the rhythm • Respiratory: chest clear • Check first IV catheter, asks for second large-bore IV catheter • Abdomen: bruising all over abdomen • Ask for rapid infuser and bolus of IV normal saline • Neurologic: normal • Order trauma blood work, including type and cross. • Musculoskeletal: normal • Activate trauma team/call for help

4 Simulation Scenarios Blunt Abdominal Trauma—Hypovolemic Shock

STAGE 2 Condition: REASSESSMENT OF THE PATIENT: 3 • The patient’s condition has worsened slightly, BP lower, GCS Airway: score unchanged • Maintain cervical spine precautions Physical Examination Findings: Breathing: • Temperature 36°C (96.8°F), HR 170/min, RR 40/min, BP 80/40 • Auscultate chest mm Hg, saturation 100% with oxygen by mask Circulation: • Monitor: sinus tachycardia • Reassess HR, pulses, BP, capillary refill • CNS: cervical spine collar on patient; moaning in pain, • Ask for second bolus of IV normal saline answers questions, asking for mom, confused at times, GCS • Reaffirm need for rapid infuser score of 15 • Order blood • H/N: cervical spine not tender, no obvious facial injury Performs Secondary Survey: • CVS: capillary refill 4 s, pulses palpable but weak • H/N: pupils equal and reactive to light, facial bones not • Respiratory: chest clear tender, neck supple and not tender • Abdomen: bruising all over abdomen • Chest: trachea midline, chest clear. • Neurologic: normal • CVS: profoundly tachycardic, color mottled now, pulses • Musculoskeletal: normal weak, and capillary refill 5 s • Abdomen: soft. Bowel sounds absent, tender all over abdomen (screams in pain) • Pelvis: stable. • Genitalia: no blood at meatus • Musculoskeletal: normal • Back: good rectal tone, no tenderness Medical Management: • Pain control: IV morphine • Immediate consultation: general surgery • Order radiographs: cervical spine, chest, pelvis • Insert nasogastric tube • Insert Foley catheter

5 Simulation Scenarios Blunt Abdominal Trauma—Hypovolemic Shock

STAGE 3 Condition: REASSESSMENT OF PATIENT: 5 • The patient is less responsive, BP is decreasing, eyes still open, Airway: Intubation: GCS score of 13 • Prepare for intubation due to decreasing level of Physical Examination Findings: consciousness • Temperature 36°C (96.8°F), HR 180/min, RR 40/min, BP 70/30 • Preoxygenate mm Hg, saturation 100% with oxygen by mask • Prepare equipment and ETCO2 • Monitor: sinus tachycardia • IV atropine • CNS: cervical spine collar on patient; moaning in pain, • IV ketamine or etomidate intermittently answers questions, confused and delirious at • IV succinylcholine times, GCS score of 13. • Check tube placement after intubation, order chest • H/N: cervical spine not obviously tender, no obvious facial radiograph if intubation is performed injury Breathing: • CVS: capillary refill 5 s, pulses palpable but very weak • Assess chest before and after intubation • Respiratory: chest clear • Monitor oxygen saturation • Abdomen: bruising all over abdomen Circulation: • Neurologic: normal • Identify worsening shock • Musculoskeletal: normal • Order third bolus of IV normal saline and blood (O negative if cross-matched not available) Blood Work: • WBC 15,500/mm3, hemoglobin 7 g/dL, platelets 500,000/ mm3 • Sodium 135 mmol/L, potassium 4.5 mmol/L, urea 4.2 mmol/L, creatinine 46 mmol/L, glucose normal co o • pH 7.20, P 2 40 mm Hg, P 2 80 mm Hg, bicarbonate 15 mmol/L, base excess −11 mmol/L Imaging: • Normal radiographs Medical Management: • General surgeon arrives: discuss need to perform CT of the abdomen vs direct to operating room • Consider focused abdominal sonography for trauma • Discuss need for CT of the H/N and chest.

Abbreviations: BP, blood pressure; CNS, central nervous system; CT, computed tomography; CVS, cardiovascular system; ETCO2, end-tidal carbon dioxide; GCS, Glasgow Coma Scale; H/N, head and neck; HR, heart rate; IV, intravenous; RR, respiratory rate; WBC, white blood cell count.

6 Simulation Scenarios Blunt Abdominal Trauma—Hypovolemic Shock

© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians Notes 1. Makeup can be applied to the mannequin to simulate bruises on the abdomen. 2. Use of a prerecorded focused abdominal sonography for trauma (FAST) video can be projected on a computer screen while FAST is being performed

Common Pitfalls • Failure to stabilize cervical spine during assessment and treatment of patient. • Failure to perform a complete secondary survey (eg, failure to log roll patient or failure to assess neurologic status of lower extremity). • Sedation and/or paralysis of patient before completing neurologic assessment of patient. • Treatment of patient without support of consultants.

7 Simulation Scenarios Blunt Abdominal Trauma—Hypovolemic Shock

Learning Objectives • Describe the signs and symptoms of an infant with cardiogenic shock. • Demonstrate the management of circulatory failure due to cardiogenic shock. – Obtain a chest radiograph to confirm suspected cause of cardiac shock. – Use normal saline to expand circulatory volume in a limited manner. – Obtain consultative services urgently.

Simulator: Infant Simulator

Scenario Patient Instructor Time, Stage Condition Intervention Debriefing Notes min

STAGE 1 History: Take a History: 5 • Five-month-old boy with history of poor feeding and weight • No ill contacts loss for past month • No upper respiratory tract infection symptoms, no diarrhea • Sent from physician’s office for evaluation • Takes a long time to eat and tires out; sweats a lot with feeding • You are called to evaluate patient • Was noted to have a “hole in the heart” on a prenatal Weight: ultrasonogram but had no murmur at birth—no follow-up • 5 kg was performed Condition: • No allergies • Very unwell, gray, with respiratory distress • Reflux medications started for poor feeding Physical Examination Findings: • Approximately 0.5-kg weight lost during last 2 wk • Temperature 37.3°C (99°F), HR 158/min, RR 58/min, oxygen Airway: saturation 91% in room air, BP 72/58 mm Hg • Listen for breath sounds • CNS: cries weakly, lays still in bed • Apply oxygen via nonrebreather mask at 15 L/min • CVS: pulses present centrally, weak peripherally Breathing: • Respiratory: bilateral crackles, retractions • Apply monitors, including oxygen saturation and blood • Abdomen: liver is firm and enlarged to the umbilicus in the pressure midclavicular line • Auscultate chest and observe respiratory rate • Extremities/skin: capillary refill approximately 3 s Circulation: • Assess pulse, HR, capillary refill, BP • Murmur and gallop rhythm heard • Ask nurse to obtain IV access • Ask for normal saline or lactated Ringer solution bolus of 5 or 10 mL/kg • Palpate abdomen for organomegaly as a sign of right heart failure

8 Simulation Scenarios Cardiogenic Shock Due to Congenital Heart Disease

STAGE 1, Medical Management: continued • Order laboratory tests (CBC, electrolytes, venous blood gas, bedside glucose, consider infection laboratory work at this time as diagnosis not clear) • Order ECG and a chest radiograph

STAGE 2 Condition: REASSESSMENT OF THE PATIENT: 7 • Condition is unchanged Circulation: co o • Venous gas reveals acidosis (pH 7.21, P 2 28 mm Hg, P 2 32 • Nurse cannot obtain IV access; intraosseous needle placed mm Hg, base excess −16 mmol/L) by participant • Blood glucose level is normal • Reassess HR, pulse, capillary refill, BP after bolus • Chest radiograph reveals marked cardiomegaly with • Call for cardiologist to consult and perform pulmonary markings consistent with fluid overload echocardiography; if not locally available, begin process of Physical Examination Findings: transferring patient • HR 163/min, RR 60/min, oxygen saturation 98% in 100% • Consider IV furosemide for fluid overload oxygen (if placed), BP 78/53 mm Hg • Consider afterload reduction (eg, milrinone) • Examination findings unchanged Medical Management: • Consider bicarbonate for acidosis

STAGE 3 Condition: REASSESS THE PATIENT: 5 • Patient stabilizes Disposition: Physical Examination Findings: • Arrange for ICU admission or transport to tertiary care • HR 162/min, RR 52/min, BP 78/62 mm Hg, saturation 98% on facility (depending on presenting facility resources) nonrebreather mask • Obtain second IV access other than intraosseous access

Abbreviations: BP, blood pressure; CBC, complete blood cell count; CNS, central nervous system; CVS, cardiovascular system; ECG, electrocardiogram; HR, heart rate; ICU, intensive care unit; IV, intravenous; RR, respiratory rate

Notes 1. Radiography can be performed via a simulator (some models support this) or as a “wet read” result communicated to the team noting the large heart and fluid overload. 2. The quality of cardiac and respiratory sounds varies considerably among simulator models. Comments from the nurse confederate can help clarify findings—“I listened at triage and thought I heard a loud murmur.” Common Pitfalls • Misrecognition of patient as having respiratory distress due to reactive airway disease and administration of albuterol (salbutamol). Patient will get worse with this therapy. • Misrecognition of patient as having sepsis, with excessive fluid delivery, resulting in increasing heart rate and respiratory rate and decreased oxygen saturations. Nurse confederate notes that the child “looks worse after that bolus.” – Both of these problems occur when an inadequate history is obtained—the history provided is a clear indication of a primary cardiac cause. • Treatment of patient without support of consultants. Echocardiography is an important step in management planning, and the initial steps in performing this test should be started as soon as possible. 9 Simulation Scenarios Cardiogenic Shock Due to Congenital Heart Disease

Learning Objectives • Describe the common causes of altered mental status in an infant. • Demonstrate the treatment of an infant with altered mental status. – Assessing for possible ingestion. – Checking glucose at bedside. – Treating hypoglycemia and confirming that treatment was effective.

Simulator: Infant Simulator

Scenario Patient Instructor Time, Stage Condition Intervention Debriefing Notes min

STAGE 1 History: Take a History: 3–4 • Eleven-month-old found unresponsive, was with • No allergies grandmother, who is his usual babysitter • Patient takes no medications • Brought to ED by grandmother • No ill contacts • Unresponsive at triage, brought to resuscitation bay • No idea at all what has happened • You are called to assess patient • No history of trauma or fall Weight: • No other children in home • 9 kg • If asked specifically, grandmother takes oral sulfonylurea Condition: (glyburide), which she keeps in a bedside drawer • Infant is pink and well-perfused but comatose Airway: Physical Examination Findings: • Listen for breath sounds • Temperature 37.2°C (99°F), HR 94/min, RR 28/min, oxygen Breathing: saturation 98% in room air, BP 89/66 mm Hg • Apply monitors, including oxygen saturation and blood • CNS: unresponsive to painful stimulation if given. Pupils 3 pressure mm and reactive bilaterally • Auscultate chest and observe respiratory rate • CVS: pulses intact Circulation: • Respiratory: clear • Assess pulse, HR, capillary refill, BP • Abdomen: soft and without hepatosplenomegaly • Ask nurse to obtain IV access • Extremities/skin: no bruising noted (if asked specifically) Disability: • Quick neurologic assessment (pupils, response to pain)

10 Simulation Scenarios Altered Mental Status

STAGE 2 Condition: Medical Management: 5 • Mental status unchanged • Recognize and treat hypoglycemia (5 mL/kg D10W using the • Blood glucose level is low if measured “rule of 50”—see note below) Physical Examination Findings: • Perform further ingestion laboratory tests (urine toxicology, • Vitals unchanged acetaminophen [paracetamol], salicylates, ethanol, +/– digitalis levels)

STAGE 3 Condition: Medical Management: 5 • Patient is now more awake and cries • Order recheck of glucose level in 15–30 min • HR 125/min, RR 28/min, BP 85/62 mm Hg, saturation 98% on • Recognize need to provide supplementary IV glucose and room air admit due to long-acting oral diabetic agent Disposition: • Hospital or ICU for frequent IV glucose level checks

Abbreviations: BP, blood pressure; CNS, central nervous system; CVS, cardiovascular system; D10W, 10% dextrose in water; ED, emergency department; HR, heart rate; ICU, intensive care unit; IV, intravenous; RR, respiratory rate.

Notes 1. Rule of 50 = to give half of a gram of glucose per kilogram of body weight, the product of the glucose concentration (eg, D10) and the dose in milliliters per kilogram should equal 50. Note that this dosing is different than recommended by the Neonatal Resuscitation Program course, and this can be a source of confusion among participants. CONCENTRATION DOSE PRODUCT

D10 5 mL/kg 50

D25 2 mL/kg 50

D50 Not recommended due to high osmolarity

2. To discourage the use of the term “amp,” our practice is to state that we do not have adult amps available at this time. 3. Specific drug screening practices vary. Although polyingestions are more common in adolescents, most of the listed drugs above are high-risk, treatable entities.

Common Pitfalls • Participants do not ask about medication in the home but only what the child is taking. • Participants check the glucose level and treat the patient according to the glucose level but fail to obtain a follow-up glucose measurement.

11 Simulation Scenarios Altered Mental Status

Learning Objectives • Describe the signs and symptoms of a child presenting with diabetic ketoacidosis (DKA). • Describe the signs and symptoms of moderate dehydration. • Demonstrate the treatment of a child with DKA. – Initial stabilizing steps. – Management of suspected cerebral edema.

Simulator: Pediatric Simulator

Scenario Patient Instructor Time, Stage Condition Intervention Debriefing Notes min

STAGE 1 History: Takes a History: 5 • Six-year-old girl • Excessive drinking, bedwetting, and increasing tiredness • Two-week history of fever and lethargy • “Growing but not gaining weight” • Very unwell in last 24 h: excessively drowsy, very poor • Unwell for 36 h with increasing fatigue, vague abdominal energy, difficulty breathing, abdominal pains pain Weight: • Polyuria, polydipsia, enuresis, 5-kg weight loss • 20 kg • No vomiting Condition: • Becoming progressively lethargic today • Looks unwell; GCS score of 13 (motor response 6, vocal • Medical history: unremarkable response 4, eye response 3) Airway: Physical Examination Findings: • Assess airway • Temperature 37.4°C (99.3°F), HR 160/min, RR 30/min, BP • Provide head tilt, chin lift, jaw thrust as needed 90/50 mm Hg, oxygen saturation 98% on room air Breathing: • Very flushed cheeks • Check oxygen saturation • Monitor: sinus tachycardia • Auscultate chest • CNS: sleepy, pupils normal • Identify Kussmaul respirations • CVS: normal heart sounds, capillary refill 3 s, pulses weak Circulation: • Respiratory: Kussmaul respirations, lung fields clear • Apply monitors • Mucous membranes: mouth/lips very dry, crying a few tears • Check HR, BP, capillary refill • Abdomen: mild diffuse tenderness • Insert IV catheter, keeps patient nothing by mouth • Identify sinus tachycardia

12 Simulation Scenarios Diabetic Ketoacidosis and Cerebral Edema

STAGE 1, Assesses Hydration:

continued • Capillary refill • Skin turgor • Mucous membranes • Urine output • Assign degree of dehydration • Strict monitoring of intake and output CNS: • Establish baseline examination • Express need to monitor for cerebral edema Medical Management: • Order blood work: CBC, differential, electrolytes, renal function, capillary gas, bedside glucose, serum osmolality, and urine dip for glucose/ketones • Bedside glucose: critically high • Urine dip or ketones 4+ • Identify DKA as diagnosis Begin DKA protocol: • Have patient weighed/ask for patient weight • Consider need for IV normal saline bolus (10 mL/kg) • Calculate IV rate assuming need to replace deficit evenly over 48 h • Use appropriate replacement fluid pending laboratory results • Order IV insulin infusion • Use flow sheet to track laboratory results, vital signs

STAGE 2 Condition: REASSESSMENT OF THE PATIENT: 5 • Patient less responsive, GCS score decreasing Airway: Physical Examination Findings: • Suction the airway • GCS score of 8 (motor response 3, vocal response 3, eye • Reposition the head with head tilt, chin lift, jaw thrust response 2) • Reapply oxygen mask • Temperature 37.5°C (99.5°F), HR 120/min, RR 24/min, BP Breathing: 110/60 mm Hg, oxygen saturation 98% on room air • Reassess • Monitor: sinus tachycardia • Prepare for possible intubation: draws up rapid sequence • CNS: grumpy and tired, mumbling, eyes closed intubation medication • CVS: normal HS, capillary refill 2 s, pulses still weak Circulation: • Respiratory: a bit less labored • Reassess HR, BP, capillary refill • Abdomen: seems less tender • Rest of examination results unchanged

13 Simulation Scenarios Diabetic Ketoacidosis and Cerebral Edema

STAGE 2, CNS: continued • Reassess GCS score • Institute frequent neuro checks • Look for Cushing triad, posturing Medical Management: • Laboratory results: glucose critically high (at bedside); urine 4+ ketones, 4+ glucose, urine specific gravity (SG) 1.030 • Continue DKA protocol • Recheck fluid-rate calculations • Consider impending cerebral edema and transtentorial herniation • Call ICU for consultation • Consider management of increased intracranial pressure: IV mannitol or 3% sodium chloride solution (ie, hypertonic saline) • Repeat bedside glucose measurement • Order repeat laboratory tests • Calculate corrected sodium level • Recognize coexisting hypernatremia and need for slow rehydration

Abbreviations: BP, blood pressure; CBC, complete blood cell count; CNS, central nervous system; CVS, cardiovascular system; DKA, diabetic ketoacidosis; GCS, Glasgow Coma Scale; HR, heart rate; ICU, intensive care unit; IV, intravenous; RR, respiratory rate. Notes 1. Management of DKA involves the preparation and administration of various types of medications and fluids. The realism of the scenario can be increased by preparing labeled syringes with the names and concentrations of these medications and preparing an intravenous (IV) catheter with a drain so that the students are able to push fluids through the catheter. 2. Laboratory results should be ready for the students and are best given to them on a slip of paper (as opposed to verbally provided by the instructor).

Common Pitfalls • IV fluid for volume expansion is delivered too aggressively. – If the students do this, the instructor can decide to change the scenario slightly and make the child decompensate by altering his level of consciousness further or have the patient demonstrate signs of increased intracranial pressure. – Failing to check a bedside glucose level. Instead, the students might only order a glucose measurement to be processed by the laboratory. – Failure to recognize signs of cerebral edema and thus not preparing medications for management of increased intracranial pressure.

14 Simulation Scenarios Diabetic Ketoacidosis and Cerebral Edema

Learning Objectives • Recognize the features of environmental hyperthermia. • Demonstrate the steps in the initial treatment of a hyperthermic infant.

Simulator: Infant Simulator

Scenario Patient Instructor Time, Stage Condition Intervention Debriefing Notes min

STAGE 1 History: Take a History: 5 • Eight-month-old infant was unintentionally left in a car for • Previously healthy 2 h; temperature outside was 32.2°C (90°F) • No medications or allergies • Child was apneic, pulseless, and cyanotic • Immunizations up to date • CPR was initiated by paramedics with bag-mask ventilation. • Paramedics have been doing CPR for 5 min • Child brought to ED by paramedics with CPR in progress Airway: Weight: • Continue bag-mask ventilation • 8 kg • Clear or suction the airway Condition: • Prepare for possible intubation (gathers equipment) • Apneic and now with faint pulses (EMS reports pulse return Breathing: at arrival) • Check oxygen saturation • Temperature 42°C (107.6°F), HR 185/min, RR 0/min, BP 62/50 • Apply monitors mm Hg, oxygen saturation 93% (bag-mask) • Auscultate chest • Monitor: sinus tachycardia • Check for adequacy of chest rise with bagging • CNS: obtunded, nonresponsive Circulation: • Cardiovascular: capillary refill 6–7 s, weak pulse centrally • Apply monitors • Respiratory: coarse crackles bilaterally • Check pulse, capillary refill, BP • Abdomen: soft, no organomegaly • Establish IO access (IV attempts fail) • Skin: hot, dry • Give 20-mL/kg normal saline bolus • Order vasopressor (dobutamine vs dopamine, avoids primarily α-agonists) Disability and Exposure: • Check neurologic status • Remove clothes • Active cooling measures: cooling blanket, ice bags, lower room temperature, peritoneal lavage (latter rarely used) • Monitor rectal temperature

15 Simulation Scenarios Hyperthermia

STAGE 1, Medical Management: continued • Order blood work: CPK, electrolytes, BUN, creatinine, CBC, LFTs, bedside glucose • Order ECG

STAGE 2 Condition: REASSESSMENT OF THE PATIENT: 5 • Some cooling has occurred Airway: Physical Examination Findings: • May consider intubation • Temperature 40.5°C (105°F), HR 169/min, RR 20/min • Bagged at rate of 8–10/min (bagged), BP 65/59 mm Hg, oxygen saturation 98% Breathing: • Monitor: sinus tachycardia • Not breathing spontaneously • CNS: obtunded, nonresponsive Circulation: • CVS: weak pulses • Place urinary catheter to assess renal function • Respiratory: clear • Begin dobutamine or dopamine • Abdomen: soft Medical Management: • Skin warm and dry • Send urine sample for myoglobin/UA Laboratory test results: • Glucose level normal • Electrolytes (from laboratory or gas tests if ordered): sodium 148 mmol/L, potassium 4.6 mmol/L, chloride 110 mmol/L, calculated bicarbonate 8 mmol/L, ionized calcium 1.01 mmol/L

STAGE 3 Condition: REASSESS THE PATIENT: 5 • Improvement Airway: Physical Examination Findings: • Reassess airway (considers intubation if not already done) • Temperature 39.6°C (103.3°F), HR 159/min, RR 10/min Breathing: (bagged), BP 63/59 mm Hg, saturation 98% with 100% • Assess breathing oxygen Circulation: • Monitor: sinus tachycardia • Titrate pressors • CNS: unconscious Medical Management: • CVS: capillary refill 4 s, pulses weak • Consider further management for possible rhabdomyolysis • Respiratory: clear (furosemide and/or mannitol) • Skin: warm • Notify critical care personnel Laboratory test results: • CPK, 400 IU/L; UA and hemoglobin

16 Simulation Scenarios Hyperthermia

STAGE 4 Disposition: • Arrange Disposition to ICU 2 Condition: • Stable Physical Examination Findings: • Temperature 39.2°C (102.6°F), HR 155/min, RR 10/min (bagged), BP 63/59 mm Hg, saturation 98% with 100% oxygen • Monitor: sinus tachycardia • CNS: unconscious • CVS: capillary refill 3 s, pulses weak • Respiratory: clear • Skin: warm

Abbreviations: BP, blood pressure; BUN, blood urea nitrogen; CBC, complete blood cell count; CNS, central nervous system; CPK, creatine phosphokinase; CPR, cardiopulmonary resuscitation; CVS, cardiovascular system; ECG, electrocardiogram; ED, emergency department; EMS, emergency medical services; HR, heart rate; ICU, intensive care unit; IO, intraosseous; IV, intravenous; LFTs, liver function tests; RR, respiratory rate; UA, urinalysis.

Common Pitfalls 1. Lack of aggressive active cooling. 2. Failure to consider and look for sequelae of hyperthermia—electrolyte disturbances, hypoglycemia, rhabdomyolysis.

17 Simulation Scenarios Hyperthermia

Learning Objectives • Describe the definition, signs, and symptoms of hypothermia. • Demonstrate the treatment of a patient with submersion injury. – Initial stabilizing steps. – Recognize the importance of airway management and cervical spine protection in submersion injury. – Demonstrate passive and active rewarming techniques for hypothermia.

Simulator: Pediatric Simulator

Scenario Patient Instructor Time, Stage Condition Intervention Debriefing Notes min

STAGE 1 History: Take a History: 3 • Six-year-old boy • Previously healthy • Was boating with his father when the small boat • No medications or allergies inadvertently hit a large wave and flipped over • Immunizations up to date • Child was not wearing a life jacket • Paramedics have been doing CPR for 10 min • Father survived and swam with unconscious child to shore Airway: • CPR initiated on the scene and 911 called • Maintain cervical spine precautions • On arrival, paramedics noted child was apneic, pulseless, • Take over bagging and CPR immediately and cyanotic • Clear or suction the airway • CPR was initiated by paramedics with bag-mask ventilation • Identify needs for immediate intubation and cervical collar applied • Intubate patient without sedation or paralysis • Child brought to ED by paramedics with CPR in progress Breathing: Weight: • Check oxygen saturation • 20 kg • Apply monitors • Auscultate chest • Check for adequacy of chest rise after tube is placed

• Identify that ETCO2 detection not helpful because child is pulseless • Order chest radiograph to confirm tube placement

18 Simulation Scenarios Hypothermia—Near Drowning

Condition: Circulation: • Apneic and pulseless • Apply monitors • Temperature 28°C (82.4°F), HR 40/min, RR 0/min, BP NA, • Check pulse, capillary refill, BP oxygen saturation NA • Identify PEA • Monitor: sinus bradycardia • Insert IV or IO catheter • CNS: obtunded, nonresponsive, GCS score 3, cervical spine • Do not order epinephrine (adrenaline) because core collar on patient, bruises and cuts on face temperature is below 32°C (89.6°F) • CVS: cap refill 6–7 s, no pulse palpable • Give warmed IV fluids through IO catheter and attempt to • Respiratory: coarse crackles bilaterally obtain second IV/IO access • Abdomen: bruising all over abdomen Disability and Exposure: • Rest of examination results normal • Check GCS score and neurologic status • Expose patient completely to conduct a secondary survey • Apply warm blankets Medical Management: • Order blood work: arterial blood gas, lactate, electrolytes, BUN, creatinine, CBC, LFTs, glucose, crossmatch • Consider internal rewarming techniques: gastric lavage, bladder irrigation, and possibly peritoneal irrigation • Activate extracorporeal membrane oxygenation team and PICU team

STAGE 2 Condition: REASSESSMENT OF THE PATIENT: 2 • The patient’s condition has not changed apart from an Airway: increase in the temperature. • Intubate patient Physical Examination Findings: • Bag at rate of 8–10/min • Temperature 33°C (91.4°F), HR 45/min, RR 10/min (bagged), • Maintain cervical spine precautions BP NA, oxygen saturation NA Breathing: • Monitor: sinus bradycardia • Not breathing spontaneously • CNS: obtunded, nonresponsive, GCS score of 3, cervical Circulation: spine collar on patient, bruises and cuts on face • Continue CPR • CVS: cap refill 6–7 s, no pulse palpable • Identify PEA, temperature has increased now to 33°C • Respiratory: coarse crackles bilaterally (91.4°F). • Abdomen: bruising all over abdomen • Deliver defibrillation at 2 J/kg • Rest of examination results normal • Continue CPR and order epinephrine (adrenaline) via IO catheter • Continue CPR • Give IV normal saline fluid bolus

19 Simulation Scenarios Hypothermia—Near Drowning

STAGE 2, Medical Management: continued • Chest radiograph: bilateral hazy lung fields, endotracheal tube in good position

• ABG: pH 6.9, Pco2 15 mm Hg, Po2 60 mm Hg, bicarbonate 3 mmol/L, base excess −27 mmol/L • Lactate 8.0 mmol/L • Glucometer: critical low: corrects this with bolus if IV D10W • Unable to obtain other laboratory tests

STAGE 3 Condition: REASSESS THE PATIENT: 5 • The patient is back to a perfusing rhythm Airway: Physical Examination Findings: • Intubate and sedate • Temperature 35°C (95°F), HR 80/min, RR 10/min (bagged), BP • Maintain cervical spine precautions 60/P mm Hg, saturation 91% with 100% oxygen Breathing: • Monitor: sinus rhythm • Assess breathing • CNS: intubated and unconscious Circulation: • CVS: capillary refill 4 s, pulses weak • Identify hypotension • Respiratory: coarse crackles bilaterally • Identify sinus rhythm • Abdomen: bruising all over the abdomen • Stop chest compressions • Rest of examination results normal • Give IV normal saline fluid bolus • Order inotrope infusion IV (dopamine or epinephrine [adrenaline]) • Arrange transfer to ICU for admission to hospital Medical Management: • Perform CT scan of head, neck, and abdomen • Consult general surgeon • Consult neurosurgeon • Notify parents

Abbreviations: ABG, arterial blood gas; BP, blood pressure; BUN, blood urea nitrogen; CBC, complete blood cell count; CNS, central nervous system; CPR, cardiopulmonary resuscitation; CT, computed tomography; CVS, cardiovascular system;

D10W, 10% dextrose in water; ETCO2, end-tidal carbon dioxide; ED, emergency department; HR, heart rate; ICU, intensive care unit; IO, intraosseous; IV, intravenous; LFTs, liver function tests; NA, not applicable; PEA, pulseless electrical activity; PICU, pediatric intensive care unit; RR, respiratory rate.

20 Simulation Scenarios Hypothermia—Near Drowning

© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians Notes 1. The scenario should begin with two instructors performing cardiopulmonary resuscitation (CPR) on the patient. The history should be taken at the bedside while CPR is performed. 2. The core temperature should not be provided unless the students ask for it. 3. Makeup or moulage should be used to add bruises to the abdomen. 4. The patient should be made wet by adding some water on the top of the mannequin.

Common Pitfalls • Failure to consistently maintain cervical spine protection during the resuscitation. • One common mistake is to aggressively resuscitate the patient with multiple doses of epinephrine (adrenaline) despite the patient being hypothermic (temperature <32°C [89.6°F]). • Failure to dry off the patient with a towel. • Delaying insertion of venous access by attempting multiple intravenous catheter insertions. Ideally, students should start immediately with attempted intraosseous access.

21 Simulation Scenarios Hypothermia—Near Drowning

Learning Objectives • Describe the signs and symptoms of an infant with an iron overdose. • Demonstrate the management of acute iron intoxication.

Simulator: Infant Simulator

Scenario Patient Instructor Time, Stage Condition Intervention Debriefing Notes min

STAGE 1 History: Take a History: 5 • Twelve-month-old boy found at home sleepy • No ill contacts • No preceding illness • No medications • Chaotic home setting with four other children and a single • Patient has vomited at home and had loose stools mother, shares home with another family • If asked, sibling is receiving iron supplementation for anemia Weight: • Mom has large bottle of iron liquid medication at home • 10 kg Airway: Condition: • Listen for breath sounds, present • Ill appearance and tachypnea, sleepy • Apply oxygen via nonrebreather mask at 15 L/min Physical Examination Findings: Breathing: • Temperature 36.6°C (97.9°F), HR 158/min, RR 42/min, oxygen • Apply monitors, including oxygen saturation and blood saturation 97% in room air, BP 68/42 mm Hg pressure • CNS: asleep, wakes briefly with stimulation • Auscultate chest and observe respiratory rate • CVS: pulses present centrally, absent peripherally Circulation: • Respiratory: clear • Assess pulse, HR, capillary refill, BP • Abdomen: no hepatosplenomegaly • Ask nurse to place IV catheter • Extremities/skin: capillary refill approximately 3 s • Ask for normal saline or lactated Ringer solution bolus of 20 mL/kg to be given quickly (push) Medical Management: • Order laboratory tests (CBC, electrolytes, coagulation studies, blood cultures, venous blood gas, bedside glucose)

22 Simulation Scenarios Iron Overdose

STAGE 2 Condition: REASSESSMENT OF THE PATIENT: 5 • HR remains elevated and BP is now 68/52 mm Hg Airway/Breathing: • Blood glucose level is slightly elevated if bedside glucose • Reassess airway patency, RR, and saturations was measured Circulation: co o • Venous gas: pH 7.06, P 2 28 mm Hg, P 2 39 mm Hg, base • Reassess HR, pulse, capillary refill, BP after bolus excess −20 mmol/L • Order second bolus, also push • Patient vomits again • Order vasopressor (dopamine) to bedside (“That will take • Iron overdose exceeds 60 mg/kg body weight (provided if about 10–15 minutes to get from the pharmacy”) in team asks dose) anticipation of need later Physical Examination Findings: Medical Management: • HR 163/min, RR 36/min, oxygen saturation 98% in 100% • If team fails to suspect overdose, can prompt with statement oxygen (if placed), BP 63/52 mm Hg “Someone has called to inform the mom that a bottle of • CNS: barely responds to any stimuli sibling medication labeled ferrous sulfate is open and empty • Respiratory: clear on the floor.” • CVS: clamped down and cool extremities • Orders additional tests • Abdomen: no hepatosplenomegaly - Venous gas to assess pH - Iron, salicylate, and acetaminophen (paracetamol) levels - Abdominal radiograph for pill fragments (given history of liquid ingestion) • Consult poison control for recommendations

STAGE 3 Condition: REASSESSMENT OF THE PATIENT: 5 • “He doesn’t seem much better.” Circulation: • Remains tachycardic after second bolus • Reassess HR, pulse, capillary refill, BP • Poison control recommends treatment with IV deferoxamine Medical Management: Physical Examination Findings: • Order third bolus of IV saline push • Unchanged from stage 2 except that HR is now 150/min and • Begin administration of dopamine as it arrives, titrates to BP is 66/52 mm Hg improve BP (this happens when dopamine is running at 10 • Abdomen: no hepatosplenomegaly mcg/kg/min) • Consult intensive care service for admission • Order deferoxamine as recommended

STAGE 4 Condition: REASSESS THE PATIENT: 5 • Patient improves with vasopressor support Disposition: Physical Examination Findings: • Arrange for ICU admission or transport to tertiary care • HR 148/min, BP 78/62 mm Hg, saturation 98% on facility (depending on presenting facility resources) nonrebreather mask • Extremities feel warmer • Child is somewhat more alert

Abbreviations: BP, blood pressure; CBC, complete blood cell count; CNS, central nervous system; CVS, cardiovascular system; HR, heart rate; ICU, intensive care unit; IV, intravenous; RR, respiratory rate

23 Simulation Scenarios Iron Overdose

© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians Notes 1. Time course of case precludes availability of full electrolyte panel, which would reveal an anion gap acidosis. This could be reported if a rapid electrolyte test is available. 2. Deferoxamine therapy is not without risks (hypotension), and poison control consultation is recommended even if the team were to come up with this treatment on its own.

Common Pitfalls • Intravenous (IV) fluid for volume expansion is not delivered in a rapid and/or controlled manner. –IV “wide open” fluid administration can lead to very rapid infusion of a whole liter of fluid OR can result in underresuscitation if there is significant resis- tance to flow (small IV gauge). Infants and small children should always receive resuscitation fluids using either a pump or push to allow for observation and control of fluid delivery. Pressure bags can increase the likelihood of excessive fluid overload. – Pushing fluid is accomplished by attaching a three-way stopcock in line with the IV catheter and pulling fluid directly from the bag (step 1) and then switching the stopcock and pushing the fluid into the patient. • Failing to consider ingestion as a cause of a septic shock–like picture. Metabolic derangements, both inborn errors and those due to ingestions, can mimic sepsis. The sudden onset and absence of fever are clues, as is the history of lead toxic effects (suggesting pica) and the chaotic home setting. • Waiting until the third bolus is started or finished to order pressors. Participants should recognize and anticipate that infant and pediatric pressor drips must be prepared individually for a patient’s weight and are not stock items because these items are for adults. Depending on the institution, there might be a significant delay in preparation and delivery of pressor drips.

24 Simulation Scenarios Iron Overdose

Learning Objectives • Describe the signs and symptoms of cardiogenic shock. • Demonstrate the treatment of a child in cardiogenic shock. – Initial stabilizing steps. – Order the appropriate investigations. – Select the appropriate inotrope.

Simulator: Pediatric Simulator

Scenario Patient Instructor Time, Stage Condition Intervention Debriefing Notes min

STAGE 1 History: Take a History: 3 • Five-year-old boy • Previously healthy • Cough, runny nose, and fever for 5 d • Other kids at school sick with similar cough, cold symptoms • Diaphoretic and chills today • Unwell today, slept most of the day • Short of breath and felling unwell • Woke up, vomited five times • Taken to the emergency department for assessment • Diaphoretic and chills • Given acetaminophen (paracetamol) only Weight: • 20 kg Airway: • Talk to the patient Condition: • Optimize airway position: head tilt, chin lift, jaw thrust • Looks very unwell, toxic Breathing: Physical Examination Findings: • Check oxygen saturation • Temperature 39°C (102.2°F), HR 170/min, RR 40/min, BP 95/P • Give 100% oxygen mm Hg, oxygen saturation 88% on room air • Auscultate chest • Monitor: sinus tachycardia Circulation: • CNS: awake, GCS score of 15 • Ask for monitors • CVS: gallop rhythm, soft murmur, cap refill 3 s, pulses weak • Check pulse, capillary refill, BP • Respiratory: crackles bilaterally • Identify the rhythm (sinus tachycardia) and recognizes • Abdomen: liver edge palpable uncompensated shock • Rest of examination results normal • Insert IV catheter two times (large bore) • Order IV normal saline bolus Medical Management: • Order blood work: CBC, differential, blood culture, electrolytes, BUN, creatinine, glucose, blood gas, LFTs, PTT, and INR • Order IV antibiotics

25 Simulation Scenarios Myocarditis—Cardiogenic Shock

STAGE 2 Condition: REASSESSMENT OF THE PATIENT: 2 • The patient’s condition deteriorates as the BP decreases and Airway: perfusion worsens after the first bolus of normal saline • Reassess airway Physical Examination Findings: • Suction airway as needed • Temperature 39°C (102.2°F), HR 180/min, RR 45/min, BP 70/P Breathing: mm Hg, oxygen saturation 90% on 100% oxygen • Consider assisting ventilations with anesthesia bag/self- • Monitor: sinus tachycardia inflating bag • CNS: drowsy but arousable, GCS score of 12 Circulation: • CVS: gallop rhythm, soft murmur, cap refill 4 s, pulses weak • Identify worsening shock • Respiratory: crackles • Order second bolus of IV normal saline • Abdomen: liver edge palpable • Insert second IV catheter (if not done already) • Rest of examination results normal Medical Management: • Order chest radiograph to evaluate for cardiogenic shock • Order ECG

STAGE 3 Condition: REASSESSMENT OF THE PATIENT: 5 • The patient’s perfusion is getting worse with the second Airway: fluid bolus • Reassess airway Physical Examination Findings: • Suction airway as needed • Temperature 39°C (102.2°F), HR 180/min, RR 45/min, BP • Prepare for rapid sequence intubation 65/P mm Hg, oxygen saturation 92% on 100% oxygen with Breathing: assisted ventilations • Assist ventilations with anesthesia bag/self-inflating bag • Monitor: sinus tachycardia Circulation: • CNS: drowsy but arousable, GCS score of 12 • Identify worsening shock • CVS: gallop rhythm, soft murmur, cap refill 5 s, pulses weak • Order IV inotrope infusion for suspected cardiogenic shock • Respiratory: crackles (dopamine/milrinone/epinephrine [adrenaline]). • Abdomen: liver edge palpable Medical Management: • Rest of examination results normal • Chest radiograph: bilateral hazy, wet lung fields with an enlarged heart

Abbreviations: BP, blood pressure; BUN, blood urea nitrogen; CBC, complete blood cell count; CNS, central nervous system; CVS, cardiovascular system; ECG, electrocardiogram; GCS, Glasgow Coma Scale; HR, heart rate; INR, international normalized ratio; IV, intravenous; LFTs, liver function tests; PTT, partial thromboplastin time; RR, respiratory rate

Notes 1. An actor or confederate nurse can be used to report a palpable enlarged liver and prolonged capillary refill.

Common Pitfalls • Overly aggressive fluid resuscitation and failure to consider cardiogenic shock in the differential diagnosis. • Delay in ordering antibiotics. • Ordering a chest radiograph or electrocardiogram are not considered as part of the workup for this patient.

26 Simulation Scenarios Myocarditis—Cardiogenic Shock

Learning Objectives • Describe the “red flags” in a history that raise concern for non-accidental trauma (and recognize these might or might not be present in all cases). • Describe the signs and symptoms of an infant with nonoccult multisystem trauma. • Demonstrate the management of multisystem trauma. – Conduct a trauma evaluation (primary and secondary survey). – Consider stabilizing the cervical spine. – Control airway due to depressed level of consciousness, using appropriate medication. – Recognize and treat signs of elevated intracranial pressure. – Consider and evaluate for clinical significant injuries other than head injuries.

Simulator: Infant Simulator IMPORTANT REMINDER: If required, change the lens of the simulator to simulate dilated pupil on the LEFT.

Scenario Patient Instructor Time, Stage Condition Intervention Debriefing Notes min

STAGE 1 History: Take a History: 3–4 • Six-month-old child found by parent in crib, unarousable • No allergies after nap • No medications • Babysitter put him down a few hours ago, thought he • No ill contacts was fine • No idea at all what has happened • Child was completely well when parent left this morning • No history of trauma or fall • Triage nurse has rushed patient back to resuscitation room • No other children in home because he is barely responsive at triage • Babysitter has been with them approximately 1 month • You arrive to assess the patient Airway: Weight: • Listen for breath sounds, present but slow • 7 kg • Apply oxygen via nonrebreather mask at 15 L/min Condition: Breathing: • Infant is pink and well perfused but comatose • Apply monitors, including oxygen saturation and BP Physical Examination Findings: • Auscultate chest and observe respiratory rate • Temperature 37.2°C (99°F), HR 104/min, RR 12/min, oxygen Circulation: saturation 97% in room air, BP 89/66 mm Hg • Assess pulse, HR, capillary refill, BP • CNS: unresponsive, if painful stimulation is given (nailbed • Ask nurse to obtain IV access, ideally two larger IV catheters pressure or sternal rub, demonstrate EXTENSOR posturing: “The child did this [demonstrate] when you did that?”)

27 Simulation Scenarios Occult Trauma (Non-accidental Trauma)

STAGE 1, – If examined, the left pupil is dilated maximally and fixed; Disability: continued right is 2–3 mm and barely reactive • Quick neurologic assessment (pupils, response to pain) • CVS: pulses intact • Assessment of GCS score • Respiratory: clear and slow Environment and Exposure: • Abdomen: soft and without hepatosplenomegaly • Remove patient clothing, examine completely • Extremities/skin: no bruising noted (if asked) • Keep patient euthermic (blanket or warming equipment)

STAGE 2 Condition: REASSESSMENT OF THE PATIENT: 3 • Mental status unchanged Airway/Breathing: • Blood glucose level is normal if obtained • Prepare for intubation due to poor mental status • BP is increasing and HR is slowing steadily • Gather necessary materials (SOAP mnemonic) Physical Examination Findings: – Suction • HR 94/min, RR 6–8/min (irregular if this is a supported – Oxygen equipment (bag-mask, endotracheal tube, feature), BP 106/88 mm Hg (if simulator supports, this trend qualitative ETCO2 detector, or ETCO2 monitor) can be set to progress over the first 4–5 min) – Airway equipment (laryngoscope and blade) • CNS: unchanged – Pharmacy: rapid sequence medication • Respiratory: clear, rate is now slower Circulation: • CVS: unchanged • Consider fluid management in light of signs of intracranial • Abdomen: somewhat more full than before, no pressure organomegaly Disability: • May elevate head of bed • Consult neurosurgery Medical Management: • Order laboratory tests (LFTs with or without pancreatic enzymes to screen for abdominal trauma, type and cross) • Order CT scan of head and abdomen, notify scanner of arrival as soon as patient is intubated

STAGE 3 Condition: INTUBATION: 5 • Unchanged except for continuing trend (HR 82/min, BP Airway/Breathing: 110/92 mm Hg) • Complete rapid sequence intubation – Ordering a chest radiograph – Consider lidocaine (lignocaine) premedication • Secure tube (can be done by nurse confederate) – Sedation medication – Paralytic medication – Tube placed with optional cricoid pressure • Tube placement confirmed by: – Auscultation – Direct visualization of chest movement

– ETCO2 detector

28 Simulation Scenarios Occult Trauma (Non-accidental Trauma)

STAGE 3, Circulation: continued • Reassess HR, pulse, capillary refill, BP Disability: • Avoid excessive hyperventilation for elevated ICP (see note below) • Consider IV mannitol (or other similar agents) Medical Management: • Review ordered laboratory test results

STAGE 4 Condition: REASSESS THE PATIENT: 5 • Stable (see note) Disposition: • Arrange for transport for CT scan with appropriate staff (someone who could reintubate if airway is lost) • Notify surgeon of abdominal findings • Notify parents • Plan social work consult and report of suspected child abuse

Abbreviations: BP, blood pressure; CNS, central nervous system; CT, computed tomography; CVS, cardiovascular system; ETCO2, end-tidal carbon dioxide; GCS, Glasgow Coma Scale; HR, heart rate; ICP, intracranial pressure; IV, intravenous; LFTs, liver function tests; RR, respiratory rate.

Notes 1. This is an important topic for which some specific management steps vary among institutions. This case content reflects the Advanced Pediatric Life Support recommended management. The case can be tailored to your institutional practice, as it pertains to rapid sequence drug choices, endotracheal tube type (cuffed or not), use of mannitol or other osmotic agents, or short-term mild hyperventilation. 2. This case can incorporate intraosseous needle insertion if the simulator permits this procedure—have the nurse confederate report he or she cannot obtain access. 3. This case is written to be only mildly suggestive of non-accidental trauma to prevent immediate identification of the problem to the exclusion of all other causes. It is our experience that pediatric health care workers are sensitized to the more obvious “red flags” (eg, mom’s boyfriend at home alone with child). Similarly, a bulging fontanelle (which might be present in a patient) is often so obvious on some simulators as to be a distractor and should be used at the instructor’s discretion after evaluating this functionality on the simulator device to be used. 4. The role of sonography for trauma is not yet broadly established in pediatrics at this time and is not discussed here.

Common Pitfalls • Participants do not recognize the severity of the medical condition, with an extended history obtained before resuscitation. • Focus on the intracranial process to the exclusion of other injuries. This patient has a grade 5 liver laceration that is currently not causing hemodynamic issues. If the patient were to go to the operating room (OR) with this injury not identified, the personnel present in the OR (neurosurgeon) would not be the personnel best prepared to deal with intra-abdominal bleeding. • The team considers sending the patient for computed tomography (CT) without airway control. The confederate nurse states, “This patient seems too ill to go to CT like this.” • Team does not know the correct intubation medications. In this case, treatment can be stopped before intubation, and this material can be reviewed as discussed in the text. • The team intubates the patient without any medications. Allow the case to proceed and discuss afterward the likely impact on intracranial pressure of this approach.

29 Simulation Scenarios Occult Trauma (Non-accidental Trauma)

Learning Objectives • Describe the signs and symptoms of a child presenting with unstable ventricular tachycardia. • Describe the signs and symptoms of a child presenting with ventricular fibrillation and cardiac arrest. • Demonstrate the treatment of a child with unstable ventricular tachycardia. – Demonstrates knowledge of the Pediatric Advanced Life Support (PALS) unstable ventricular tachycardia algorithm. • Demonstrate the treatment of a child with ventricular fibrillation. – Recognize ventricular fibrillation. – Recognize the importance of high-quality chest compressions and early defibrillation. – Demonstrates proper use of the defibrillator. – Demonstrates knowledge of the PALS ventricular fibrillation algorithm.

Simulator: Pediatric Simulator

Scenario Patient Instructor Time, Stage Condition Intervention Debriefing Notes min

STAGE 1 History: Take a History: 5 • Four-year-old boy • Unwell today, slept most of the day • Recent cardiac surgery for congenital heart disease 4 d ago • Difficult to awaken this afternoon, brought to ED • Vomited three times today Airway: • Feeling unwell, lightheaded • Talk to the patient • Taken to the ED for assessment • Open airway Weight: • Head tilt, chin lift, jaw thrust • 20 kg • Prepare for rapid sequence intubation Condition: Breathing: • Looks very unwell, toxic • Check oxygen saturation Physical Examination Findings: • Apply 100% oxygen by mask • Temperature 37.4°C (99.3°F), HR 170/min, RR 35/min, BP • Auscultate chest 60/P mm Hg, oxygen saturation 88% in room air Circulation: • Monitor: ventricular tachycardia • Apply monitors • CNS: drowsy and difficult to arouse, GCS score of 10 • Check pulse, capillary refill, BP • CVS: gallop rhythm, loud murmur, cap refill 4 s, pulses weak • Identify unstable ventricular tachycardia • Respiratory: clear • Insert IV catheter 2 times • Rest of examination results normal

30 Simulation Scenarios Postoperative Cardiac Patient—Ventricular Fibrillation

STAGE 1, • Order IV sedative (eg, ketamine) and prepares for continued synchronized cardioversion (this particular point is controversial and would be a good discussion point because the patient might be too unstable to tolerate a sedative) Medical Management: • Synchronize cardioversion as per PALS protocol • Order blood work: CBC, differential, blood culture, electrolytes, BUN, creatinine, glucose, blood gas, LFTs, PTT, and INR

STAGE 2 Condition: REASSESSMENT OF PATIENT: 3 • The patient is unconscious, GCS score of 3 Airway: • Rhythm: ventricular fibrillation • Recheck airway Physical Examination Findings: • Intubate patient now without sedation or paralysis • Temperature 37.4°C (99.3°F), HR NA, RR 0/min, BP NA, Breathing: oxygen saturation NA • Reassess breathing • Monitor: ventricular fibrillation • Manually provide the patient with ventilatory assistance • CNS: GCS score of 3 Circulation: • CVS: capillary refill 8 s, pulses not palpable • Identify ventricular fibrillation • Respiratory: clear • Start CPR immediately with backboard in place • Rest of examination results normal • Defibrillation at 2 J/kg then CPR as per PALS protocol • Continue CPR and then defibrillates again at 4 J/kg • Give IV/IO epinephrine (adrenaline) • Reassess pulse and rhythm

STAGE 3 Condition: REASSESSMENT OF PATIENT: 2 • Looks very unwell, toxic, rhythm changes to normal sinus Airway: rhythm • Recheck airway and tube Physical Examination Findings: Breathing: • Temperature 37.4°C (99.3°F), HR 80/min, RR 6/min, BP 70/P • Reassess breathing mm Hg, oxygen saturation 90% with bagging • Continue to bag ventilate the patient • Monitor: sinus rhythm Circulation: • CNS: unresponsive, intubated, GCS score of 3 • Identify change to sinus rhythm, checks for pulse • Stop CPR • Administer normal saline bolus • Start inotrope infusion: dopamine or epinephrine (adrenaline)

31 Simulation Scenarios Postoperative Cardiac Patient—Ventricular Fibrillation

STAGE 3, • CVS: gallop rhythm, soft murmur, capillary refill 5 s, pulses Medical Management: continued very weak • Consult ICU and cardiology personnel • Respiratory: bilateral crackles • Order ECG and chest radiograph

Abbreviations: BP, blood pressure; BUN, blood urea nitrogen; CBC, complete blood cell count; CNS, central nervous system; CPR, cardiopulmonary resuscitation; CVS, cardiovascular system; ECG, electrocardiogram; ED, emergency department; GCS, Glasgow Coma Scale; HR, heart rate; ICU, intensive care unit; INR, international normalized ratio; IV, intravenous; IO, intraosseous; LFTs, liver function tests; NA, not applicable; PALS, Pediatric Advanced Life Support; PTT, partial thromboplastin time; RR, respiratory rate

Notes 1. A dressing or bandage should be applied to the chest to mimic recent cardiac surgery or sternotomy scar. 2. An orientation to the defibrillator should be provided before starting this scenario—ensure the students are aware of how to safely operate the defibrillator.

Common Pitfalls • Defibrillation of unstable ventricular tachycardia (instead of synchronized cardioversion). • Management of unstable ventricular tachycardia with medication only. • Delayed defibrillation after recognition of ventricular fibrillation. • Delayed initiation of chest compressions after recognition of ventricular fibrillation. • Management of airway (intubation) before defibrillation or chest compressions while the patient is in ventricular fibrillation. • e Failur to adequately prepare medications for ventricular fibrillation. Instructors should encourage students to prepare epinephrine (adrenaline), amiodarone, and lidocaine (lignocaine) immediately on recognition of the rhythm.

32 Simulation Scenarios Postoperative Cardiac Patient—Ventricular Fibrillation

Learning Objectives • Describe the signs and symptoms of an infant with septic shock. • Demonstrate the management of circulatory failure due to sepsis. – Use of normal saline or lactated Ringer solution to expand circulatory volume. – Order and deliver a pressor to support blood pressure in a timely manner. – Recognize the need for hydrocortisone stress dosing for specific pediatric populations (those taking steroid medications).

Simulator: Infant Simulator

Scenario Patient Instructor Time, Stage Condition Intervention Debriefing Notes min

STAGE 1 History: Take a History: 3–4 • Seven-month-old boy, in treatment for acute lymphocytic • No ill contacts leukemia presents with temperatures to 39.6°C (103.3°F) • Has a double-lumen port (temporal) • Has had one previous admission for fever and neutropenia • Decreased activity since yesterday at 1 month age • Chemotherapy last given 4 d ago, don’t know what drugs • Vomited once en route to the ED were given • Takes trimethoprim-sulfamethoxazole 3 d per week, got • Triage nurse was worried how little he responded to her ibuprofen at triage; is taking prednisone as part of his examination chemotherapy • You arrive to assess the patient • Allergic to vancomycin (red man syndrome) Weight: Airway: • 7 kg • Listen for breath sounds, present Condition: • Apply oxygen via nonrebreather mask at 15 L/min • Very unwell, listless, feels warm over core but hands are cool Breathing: Physical Examination Findings: • Apply monitors, including oxygen saturation and blood • Temperature 39.6°C (103.3°F), HR 158/min, RR 36/min, pressure oxygen saturation 96% in room air, BP 72/58 mm Hg • Auscultate chest and observe respiratory rate • CNS: asleep, wakes briefly with painful stimulation Circulation: • CVS: pulses present centrally, absent peripherally • Assess pulse, HR, capillary refill, BP • Respiratory: clear • Ask nurse to access port • Abdomen: no hepatosplenomegaly • Ask for normal saline or lactated Ringer solution bolus of 20 • Extremities/skin: capillary refill >4 s, scattered petechiae mL/kg to be given quickly (push) Medical Management: • Order laboratory tests (CBC, electrolytes, coagulation studies, blood cultures, venous blood gas, bedside glucose)

33 Simulation Scenarios Septic Shock

STAGE 2 Condition: REASSESSMENT OF THE PATIENT: 3 • HR remains elevated and BP is now 63/52 mm Hg Circulation: • Nurse notes aloud, “His hands are just so cold.” • Reassess HR, pulse, capillary refill, BP after bolus • Blood glucose level is normal if bedside glucose test was • Order second bolus, also push performed • Order vasopressor (dopamine) to bedside (“That will Physical Examination Findings: take about 10–15 minutes to get from the pharmacy.”) in • HR 163/min, RR 36/min, oxygen saturation 98% in 100% anticipation of need later oxygen (if placed), BP 63/52 mm Hg Medical Management: • CNS: barely responds to any stimuli • Order antibiotics (broad spectrum to include coverage for • Respiratory: clear pseudomonas, eg, ceftazidime or meropenem/imipenem) • CVS: clamped down and cool extremities • Abdomen: no hepatosplenomegaly

STAGE 3 Condition: REASSESSMENT OF THE PATIENT: 5 • “He doesn’t seem much better.” Circulation: • Remains tachycardic after second bolus • Reassess HR, pulse, capillary refill, BP Physical Examination Findings: Medical Management: • Unchanged from stage 2 except that HR is now 150/min and • Order third bolus of normal saline IV push BP is 66/52 mm Hg • Begin dopamine as it arrives, titrates to improve BP (this • Abdomen: no hepatosplenomegaly happens when dopamine is running at 10 mcg/kg/min) • Order hydrocortisone stress dose given patient’s daily prednisone (can ask for help with dosing) • Consult intensive care service

STAGE 4 Condition: REASSESS THE PATIENT: 5 • Patient improves Disposition: Physical Examination Findings: • Arrange for ICU admission or transport to tertiary care • HR 148/min, BP 78/62/min, saturation 98% on 100% oxygen facility (depending on presenting facility resources) • Extremities feel warmer • Child is somewhat more alert

Abbreviations: BP, blood pressure; CBC, complete blood cell count; CNS, central nervous system; CVS, cardiovascular system; ED, emergency department; HR, heart rate; ICU, intensive care unit; IV, intravenous; RR, respiratory rate

34 Simulation Scenarios Septic Shock

© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians Common Pitfalls • Intravenous (IV) fluid for volume expansion is not delivered in a rapid and/or controlled manner. – IV “wide open” fluid administration can lead to very rapid infusion of a whole liter of fluid OR can result in underresuscitation if there is significant resis- tance to flow (small IV gauge). Infants and small children should always receive resuscitation fluids using either a pump or push to allow for observation and control of fluid delivery. Pressure bags can increase the likelihood of excessive fluid overload. – Pushing fluid is accomplished by attaching a three-way stopcock in line with the IV catheter and pulling fluid directly from the bag (step 1) and then switching the stopcock and pushing the fluid into the patient. • Withholding antibiotics until either the patient improves or cultures and/or testing is complete. This infant is critically ill and antibiotics should be given as early as is practical. • Failing to check a bedside glucose level. Hypoglycemia is a treatable cause of altered mental status, and ill infants with poor glycogen stores and a poor recent oral intake due to illness are prone to this condition. • Waiting until the third bolus is started or finished to order pressors. Participants should recognize and anticipate that infant and pediatric pressor drips must be prepared individually for a patient’s weight and are not stock items because these items are for adults. Depending on the institution, there might be a significant delay in preparation and delivery of pressor drips.

35 Simulation Scenarios Septic Shock

Learning Objectives • Describe the signs and symptoms of a child presenting with chest crisis and sickle cell disease. • Demonstrate the treatment for a child with a sickle cell chest crisis. – Initial stabilizing steps. – Perform fluid management and resuscitation. – Understand the importance of repeat assessment in children with chest crisis. – Demonstrate knowledge of appropriate antibiotic therapy.

Simulator: Pediatric Simulator

Scenario Patient Instructor Time, Stage Condition Intervention Debriefing Notes min

STAGE 1 History: Take a History: 2 • Seven-year-old boy • Multiple previous admissions • Known homozygous sickle cell disease. • History of chest crisis two times with admission to ICU for • Fever this afternoon exchange transfusion • Coughing 2 times per day • Sepsis one time, dactylitis one time, bony (vaso-occlusive) • Feeling unwell and brought to the hospital crisis five times • Initial oxygen saturation at triage is 88% in room air • Taking prophylactic antibiotics Weight: • Immunizations up to date • 22 kg Airway: Condition: • Open the airway • Very unwell, listless, feels warm over core but hands are cool • Head tilt, chin lift, jaw thrust Physical Examination Findings: Breathing: • Temperature 39.5°C (103°F), HR 130/min, RR 30/min, oxygen • Apply monitors saturation 88% in room air, BP 95/P mm Hg • Auscultate chest and observes respiratory rate • CNS: awake and alert • Oxygen saturation • Respiratory: diffuse crackles bilaterally with poor air entry to • Apply oxygen (100%) right • Get self-inflating bag ready • CVS: pulses strong, capillary refill 2 s Circulation: • Musculoskeletal: no bony tenderness or pain • Assess pulse, HR, capillary refill, BP • Rest of examination results normal • Obtain IV access

36 Simulation Scenarios Chest Crisis—Sickle Cell Disease

STAGE 1, Medical Management: continued • Blood work: CBC, differential, blood culture, gas, electrolytes, BUN, creatinine, glucose • IV ceftriaxone and erythromycin • Chest radiograph • IV fluids (D5NS) at half to one times maintenance

STAGE 2 Condition: REASSESSMENT OF THE PATIENT: 5 • Looks unwell, moderate-severe distress, not oxygenating Airway: well with face mask oxygen, blood pressure decreasing, and • Suction the airway perfusion worsening • Reposition the head with head tilt, chin lift, jaw thrust Physical Examination Findings: • Reapply oxygen mask • Temperature 39.5°C (103°F), HR 130/min, RR 38/min, Intubation: saturation 88% with 100% oxygen, BP 70/P mm Hg • Preparation/equipment • CNS: becoming more drowsy • Preoxygenation; RR 12–15./min • Respiratory: diffuse crackles bilaterally with poor air entry to • Cricoid pressure right • Premedication: IV atropine • CVS: pulses weak, capillary refill 4 s • Sedation: IV ketamine • Rest of examination results normal • Paralysis: IV succinylcholine or rocuronium • Intubate with ETT • Check tube placement with end-tidal carbon dioxide, auscultation and chest radiograph Breathing: • Reassess breathing and RR • Call for help • Consider using high-flow oxygen or anesthesia bag to provide some CPAP • Support ventilation: bag-mask ventilation Circulation: • Reassess HR, pulse, capillary refill, BP • IV access obtained by now • Give normal saline bolus then repeats as necessary • Perform ABG measurement

37 Simulation Scenarios Chest Crisis—Sickle Cell Disease

STAGE 3 Condition: REASSESS THE PATIENT: 3 • Looks unwell, oxygenation and BP improved slightly Airway: Physical Examination Findings: • Suction the ETT: some thin mucus or secretions • Temperature 39.5°C (103°F), HR 130/min, RR 30/min, oxygen Breathing: saturation 94% intubated and ventilated, BP 80/P mm Hg • Auscultate the chest • CNS: paralyzed and sedated • Check chest movement and symmetry • Respiratory: diffuse crackles bilaterally with poor air entry to Circulation: right • Check pulse and BP • CVS: pulses weak, capillary refill 4 s • Consider repeat IV fluid bolus for hypotension • Order inotrope infusion and titrates infusion to increase the BP Medical Management: • Call ICU consultant for help • Prepare for transport • Follow up on chest radiograph • Consider adding vancomycin

Abbreviations: ABG, arterial blood gas; BP, blood pressure; BUN, blood urea nitrogen; CBC, complete blood cell count; CNS, nervous system; CPAP, continuous positive airway pressure; CVS, cardiovascular system; D5NS, 5% dextrose in normal saline; ETT, endotracheal tube; HR, heart rate; ICU, intensive care unit; IV, intravenous; RR, respiratory rate

Common Pitfalls • Overly aggressive fluid resuscitation, leading to pulmonary edema and respiratory failure. • Delayed administration of antibiotics. • Failure to reassess patient and delayed recognition of respiratory decompensation.

38 Simulation Scenarios Chest Crisis—Sickle Cell Disease

Learning Objectives • Describe the signs and symptoms of a child presenting in status asthmaticus. • Recognize the signs and symptoms of respiratory failure. • Demonstrate the treatment of a child with status asthmaticus. – Initial stabilizing steps. – Demonstrate knowledge of medical management of status asthmaticus. – Understand dangers of intubating a sick asthmatic patient.

Simulator: Pediatric Simulator

Scenario Patient Instructor Time, Stage Condition Intervention Debriefing Notes min

STAGE 1 History: Take a History: 2 • Five-year-old boy • Recent contact with younger sibling with URI symptoms • Known to have asthma • Four previous admissions and once to the ICU, never • Taking albuterol (salbutamol) and fluticasone puffers at intubated home • Vomited once at home • Increasing cough and shortness of breath at home today • Took albuterol (salbutamol), two puffs six times at home • Febrile with no improvement, then came to the ED • Initial oxygen saturation at triage is 88% in room air Airway: • Treated by ED nursing staff right away and given albuterol • Talk to the patient (salbutamol) and ipratropium bromide • Suction secretions • You arrive to assess the patient. • Call for help: respiratory therapy Weight: Breathing: • 20 kg • Apply monitors, including oxygen saturation Condition: • Auscultate chest and observe respiratory rate • Very unwell, severe distress • Apply oxygen via nonrebreather (100%) OR move directly to Physical Examination Findings: second nebulization • Temperature 38°C (100.4°F), HR 130/min, RR 36/min, oxygen • Consider albuterol (salbutamol) and ipratropium bromide saturation 88% in room air, BP 110/50 mm Hg back to back three times in total • CNS: awake and alert • Get anesthesia bag or self-inflating bag ready. • CVS: pulses strong, capillary refill 2 s • Give oral steroid (dexamethasone or prednisolone or • Respiratory: scattered, diffuse wheezes bilaterally, prednisone) or parenteral steroid retractions Circulation: • Rest of examination results normal • Assess pulse, HR, capillary refill, BP

39 Simulation Scenarios Status Asthmaticus

STAGE 2 Condition: REASSESSMENT OF THE PATIENT: 3 • After the back to back albuterol (salbutamol) and Airway: ipratropium, patient is still unwell • Suction the airway • Coughing persistently • Reposition the head with head tilt, chin lift, jaw thrust • Persistent respiratory distress (recognizing this child is distressed and vomiting, might be • Child suddenly vomits profusely better to have him on his side as well) Physical Examination Findings: • Reapply oxygen mask • Temperature 38°C (100.4°F), HR 150/min, RR 40/min, oxygen Breathing: saturation 92% in 100% oxygen, BP 100/55 mm Hg • Reassess breathing and RR • CNS: gagging, irritable, coughing persistently • Call for help from respiratory therapy (if not done already) • Respiratory: diffuse wheezes bilaterally with indrawing, • Give continuous albuterol (salbutamol) via nebulization tracheal tug, and worsening retractions Circulation: • CVS: pulses strong, capillary refill 2 s • Reassess HR, pulse, capillary refill, BP • Rest of examination results normal • IV access • Give steroids (IV) because he might have vomited oral steroids • Give magnesium sulfate (IV) Medical Management: • Perform blood work with IV start: CBC, differential, culture, electrolytes, gas • Get immediate chest radiograph and give antibiotics if signs of focal consolidation

STAGE 3 Condition: REASSESSMENT OF THE PATIENT: 5 • Your patient seems to be working harder to breath Airway: • Severe respiratory distress • Suction the airway • No longer responding to verbal commands • Reposition the head with head tilt, chin lift, jaw thrust Physical Examination Findings: • Reapply oxygen mask • Temperature 39°C (102.2°F), HR 160/min, RR 40/min, BP • Consider towel roll at this point 110/55 mm Hg, oxygen saturation 84% in 100% oxygen. If learner proceeds with intubation: • CNS: drowsy • Preparation/equipment • Respiratory: diffuse wheezes, retractions • Preoxygenation; RR, 8–12/min with prolonged expiratory phase • CVS: well perfused, capillary refill 2 s • Cricoid pressure • Rest of examination results unchanged from above • Premedication: IV atropine • Sedation: ketamine IV. • Paralysis: IV succinylcholine • Intubate with ETT 5.0 cuffed

• Check tube placement with ETCO2, auscultation, chest radiograph • Nasogastric tube placement

40 Simulation Scenarios Status Asthmaticus

STAGE 3, Breathing: continued • Reassess breathing and RR • Obtain chest radiograph if not already done by now Circulation: • Reassess HR, pulse, capillary refill, BP Medical Management: • Call ICU for help • Consider IV aminophylline or IV b-agonist. • Consider BiPAP or CPAP

STAGE 4 Condition: REASSESS THE PATIENT: 5 • Patient condition deteriorates after intubation Airway: Physical Examination Findings: • Suction the ETT: some thin mucus or secretions • Very difficult to provide ventilation • Consider direct visualization of the tube with laryngoscope • Poor chest rise bilaterally Breathing: • Temperature 38°C (100.4°F), HR 80/min, RR bagging, • Auscultate the chest saturation 78% in 100% oxygen, BP 80/50 mm Hg • Check for signs of tension pneumothorax (trachea midline, • CNS: sedated/paralyzed blood pressure, percussion of chest, jugular venous • Respiratory: poor chest rise and air entry bilaterally with pressure) wheezing • Give continuous nebulized in-line albuterol (salbutamol) • CVS: pulses weak, capillary refill 4 s • Check oxygen/equipment • Bag-mask ventilates at a slower rate with a prolonged expiratory phase Circulation: • Insert second IV catheter • Give IV bolus of normal saline

Abbreviations: BiPAP, bilevel positive airway pressure; BP, blood pressure; CBC, complete blood cell count; CNS, central nervous system; CPAP, continuous positive airway pressure; CVS, cardiovascular system; ED, emergency department;

ETCO2, end-tidal carbon dioxide; ETT, endotracheal tube; HR, heart rate; ICU, intensive care unit; IV, intravenous; RR, respiratory rate; URI, upper respiratory tract infection.

Notes 1. “Albuterol” is the drug name in the United States. In many other countries the drug name is “salbutamol.” 2. Albuterol (salbutamol) and ipratropium bromide should ideally be administered via metered-dose inhaler.

Common Pitfalls • Overventilation of the patient—leads to breath stacking and potential for pneumothorax or depressed cardiac return and eventual cardiac arrest. • Early intubation attempt without consideration of other possible management options (eg, magnesium sulfate, noninvasive ventilation).

41 Simulation Scenarios Status Asthmaticus

Learning Objectives • Describe the signs and symptoms of a child presenting in status epilepticus. • Demonstrate the treatment of a child with status epilepticus. – Initial stabilizing steps. – Understand complications associated with the treatment of status epilepticus. – Demonstrate knowledge of rapid sequence intubation for a seizing patient.

Simulator: Pediatric Simulator

Scenario Patient Instructor Time, Stage Condition Intervention Debriefing Notes min

STAGE 1 History: Take a History: 2 • Four-year-old boy • Previously healthy, no prior seizures • High fever for 3 d • Unimmunized • Headache and neck pain for 2 d Airway: • Irritable today • Open airway • Found drowsy and unresponsive at home on the floor • Head tilt, chin lift, jaw thrust • Paramedics bringing child to the ED • Suction • Seizing en route for 5 min • Assign someone to attend to airway • Call respiratory therapy for help Weight: • 15 kg Breathing: • Check oxygen saturation Condition: • Apply monitors • Actively seizing patient on arrival • Apply oxygen by mask Physical Examination Findings: • Auscultate chest • Temperature 39.5°C (103°F), HR 160/min, RR 25/min, BP Circulation: 110/P mm Hg, oxygen saturation 92% in room air • Apply monitors • Monitor: sinus tachycardia • Check pulse, capillary refill, BP • CNS: seizing (generalized) • IV access not obtainable initially • CVS: normal heart sounds, capillary refill 2 s, pulses strong Medical Management: • Respiratory: clear, poor air entry bilaterally • Check glucose level: 5.0 mmol/L (90 mg/dL) (normal) • Rest of examination results normal • Give lorazepam or diazepam PR, then IV lorazepam two times • Order phenytoin/fosphenytoin • Order blood work: CBC, electrolytes, blood gas, lactate, renal function, blood culture • Order antibiotics: ceftriaxone, vancomycin, acyclovir

42 Simulation Scenarios Status Epilepticus

STAGE 2 Condition: REASSESSMENT OF THE PATIENT: 3 • Actively seizing patient, child vomiting profusely and Airway: frothing at the mouth, then desaturates • Maintain the airway: jaw thrust, chin lift, head tilt Physical Examination Findings: • Suction vigorously • Temperature 39.5°C (103°F), HR 160/min, RR 25/min, BP • Consider intubation and prepares equipment 110/P mm Hg, saturation 85% in room air Breathing: • Monitor: sinus tachycardia • Increase oxygen delivery to 100% by using nonrebreather • CNS: seizing still mask • CVS: normal heart sounds, capillary refill 2 s, pulses strong • Prepare self-inflating bag • Respiratory: poor air entry bilaterally Circulation: • Rest of examination results normal • IV access two times • Check HR, BP, capillary refill, pulses • Cycle BP every 3–5 min Medical Management: • Laboratory test results come back: – Sodium 130 mmol/L, potassium 3.5 mmol/L, glucose normal

co o – ABG: pH 7.15, P 2 60 mm Hg, P 2 90 mm Hg, bicarbonate 20 mmol/L, base excess −7 mmol/L

STAGE 3 Condition: REASSESSMENT OF PATIENT: 5 • Actively seizing patient, blood pressure and respiratory rate Airway: Intubation: start to decrease • Preoxygenation Physical Examination Findings: • Premedication: IV atropine IV optional • Temperature 39.5°C (103°F), HR 160/min, RR 12/min, BP 70/P • Cricoid pressure mm Hg, saturation 89% in room air • Sedation: IV ketamine, IV midazolam, IV thiopental, or IV • Monitor: sinus tachycardia propofol • CNS: seizing • Paralysis: IV succinylcholine • CVS: normal heart sounds, capillary refill 3–4 s, pulses weak • Check tube placement with ETCO2 detector, auscultation of • Respiratory: poor air entry bilaterally chest, observation of chest rise and order chest radiograph • Rest of examination results normal Breathing: • Reassess breathing • Start to provide ventilatory assistance to the patient Circulation: • Identify hypoxia and worsening hypotension • Reassess blood pressure, pulse, capillary refill • Give IV normal saline bolus

43 Simulation Scenarios Status Epilepticus

STAGE 3, Medical Management: continued • Call ICU • Start infusion of other anticonvulsants (good discussion point); options include levetiracetam (often given first line instead of fosphenytoin) and phenobarbital • IV antibiotics (cefotaxime/vancomycin or similar and acyclovir) to cover the possibilities of bacterial meningitis and herpes encephalitis

STAGE 4 Condition: REASSESSMENT OF PATIENT: 5 • Actively seizing patient, blood pressure still low, but oxygen Airway: saturations improved after intubation • Secure endotracheal tube Physical Examination Findings: Breathing: • Temperature 39.5°C (103°F), HR 160/min, RR 12/min, BP 70/P • Reassess breathing mm Hg, saturation 95% with oxygen • Continue to provide manual ventilation to the patient • Monitor: sinus tachycardia Circulation: • CNS: generalized, tonic-clonic seizure • Identify worsening hypotension • CVS: normal heart sounds, capillary refill 2 s, pulses strong • Reassess blood pressure, pulse, capillary refill • Respiratory: shallow air entry bilaterally • Give another IV normal saline bolus • Rest of examination results normal Medical Management: • Call intensive care specialist for consultation • Consider rectal paraldehyde (not available in the United States but might be available in other countries) • Consider IV midazolam infusion or an additional dose of phenytoin/fosphenytoin/phenobarbital/levetiracetam

Abbreviations: ABG, arterial blood gas; BP, blood pressure; CBC, complete blood cell count; CNS, central nervous system; CVS, cardiovascular system; ED, emergency department; ETCO2, end-tidal carbon dioxide; HR, heart rate; ICU, intensive care unit; IV, intravenous; PR, per rectum; RR, respiratory rate

Notes 1. Playing a video of a seizing child helps to add realism to the simulation. 2. Medications ordered will be institution specific. If your institution uses fosphenytoin, consider having the patient be normotensive and instead focus on airway management of the seizing patient.

Common Pitfalls • Failure to insert multiple intravenous catheters, thus delaying adjunct therapies (eg, antibiotics or fluids). • Delay in checking bedside glucose level. • Assumption that seizures have “stopped” after paralytic is given for intubation

44 Simulation Scenarios Status Epilepticus

Learning Objectives • Describe the possible causes of stridor in an infant. • Demonstrate the management of upper airway obstruction due to a foreign body.

Simulator: Infant Simulator NOTE: Simulator should be placed in a sitting position at the beginning of case and a small object placed in the hypopharynx as the foreign body (eg, toy, pen cap, rolled-up piece of medical tape).

Scenario Patient Instructor Time, Stage Condition Intervention Debriefing Notes min

STAGE 1 History: Take a History: 3–4 • Twelve-month-old with sudden onset of stridor and • No ill contacts respiratory distress • Has been well • Parents rushed him to the ED for evaluation • No medications • You are called to see the patient • No allergies Weight: • Was playing unsupervised in playroom and mom heard • 10 kg coughing and then noticed the trouble breathing when she Condition: entered room • Alert and anxious, sitting upright in bed Airway: Physical Examination Findings: • Listen for breath sounds, stridor easily noted, child is sitting • Temperature 37.2°C (99°F), HR 153/min, RR 40/min, oxygen and does not wish to be moved from sitting position saturation 88% in room air, BP 85/68 mm Hg • Ask for bag-mask, suction, laryngoscope, ETT, and Magill • CNS: alert forceps to bedside • CVS: pulses present Breathing: • Respiratory: clear • Apply monitors, including oxygen saturation and blood • Extremities/skin: capillary refill <2 s pressure • Auscultate chest and observe respiratory rate • If health care worker attempts to place mask or inspect mouth, state “child becomes more anxious and pushes you away—do you want me to hold the child?” Circulation: • Assess pulse, HR, capillary refill, BP Medical Management: • Request ENT or anesthesia consultation • Minimize stimuli: no painful procedures

45 Simulation Scenarios Stridor Due to Foreign Body

STAGE 2 Condition: REASSESSMENT OF THE PATIENT: 5 • Airway obstruction (complete) Airway (ENT/anesthesia consultant not present yet): • Occurs at 4 min regardless of actions OR if the health care • Lay child flat workers look in mouth with tongue blade, force oxygen • Attempt to bag-mask patient with neck properly positioned mask on to child, or place IV catheter and using two-person technique Physical Examination Findings: • When this fails to work, perform direct laryngoscopy and • Immediately: respiratory effort without stridor; rapidly remove small foreign body lapses until unconsciousness Circulation: • RR: initially 40/min but then decreases to 0/min in 30 s • Monitor decreasing vital signs, prepare to start • HR: increases to 170/min in first minute then decreases to compressions if HR decreases below 60/min 65/min in next 90 s • BP: 70/58 mm Hg • Saturation: decreases from 88% to 30% in 30 s

STAGE 3 Recovery: REASSESSMENT OF THE PATIENT: 3–5 • Patient is now easily bagged Airway: Physical Examination Findings: • Continue to bag patient • HR and saturation return to normal • Place nasogastric tube to avoid stomach distension • RR remains zero as bagging continues • May choose to intubate (can stop case before this is complete for time constraints) • Chest radiograph to assess for other possible foreign bodies (if radio-opaque) Disposition: • ICU for observation

Abbreviations: BP, blood pressure; CNS, central nervous system; CVS, cardiovascular system; ED, emergency department; ENT, ear, nose, throat; ETT, endotracheal tube; HR, heart rate; ICU, intensive care unit; IV, intravenous; RR, respiratory rate.

46 Simulation Scenarios Stridor Due to Foreign Body

© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians Notes 1. It is easier to decrease and leave the respiratory rate at zero to both observe the quality of bagging and to avoid the participants being confused by the simulator’s breathing effort. 2. This case can be changed to have foreign body below the vocal cords and having the participants intubate and push the foreign body into the right mainstem bronchus. The point of having the removable foreign body is to reinforce the Magill forceps as a useful tool. 3. For simulators that support obstructing air entry into the lungs, simulators should be turned on when obstruction occurs to stop chest movement. This can be a tangible visual cue that improves the case realism.

Common Pitfalls • Beginning to treat for croup rather than aspiration. • Trigger obstruction by stimulating child. This child should be taken to the operating room by an ear, nose, and throat surgeon and/or anesthesia personnel where a controlled evaluation and removal can be performed. Ideally, the child is placed in a parent’s lap awaiting this event. • Once complete obstruction occurs, failing to attempt airway evaluation and removal of obstruction or attempting intubation. The child now has an emergent condition that cannot await airway expertise.

47 Simulation Scenarios Stridor Due to Foreign Body

Learning Objectives • Describe the signs and symptoms of an infant with supraventricular tachycardia. • Demonstrate the management of stable supraventricular tachycardia using chemical cardioversion with appropriate monitoring.

Simulator: Infant Simulator

Scenario Patient Instructor Time, Stage Condition Intervention Debriefing Notes min

STAGE 1 History: Take a History: 3–4 • Seven-month-old girl with fussiness and poor feeding for • No ill contacts approximately 1 day • No family history of heart problems • No upper respiratory tract symptoms or fever • Given ibuprofen without relief but no cold medications • Sent from physician’s office because of fast heart rate • No allergies Weight: Airway: • 7 kg • Listen for breath sounds, present Condition: Breathing: • Alert but cranky, pale • Apply monitors. Including oxygen saturation and blood Physical Examination Findings: pressure • Temperature 36.9°C (98.4°F), HR 226/min, RR 36/min, oxygen • Apply oxygen mask saturation 98% in room air, BP 79/65 mm Hg • Auscultate chest and observe respiratory rate • CNS: alert Circulation: • CVS: pulses present • Assess pulse, HR, capillary refill, BP • Respiratory: clear • Ask nurse to obtain IV access • Abdomen: liver edge approximately 2 cm below costal Medical Management: margin • Order an ECG • Extremities/skin: capillary refill approximately 2 s • Attempt vagal maneuvers

STAGE 2 Condition: REASSESSMENT OF THE PATIENT: 3 • HR remains elevated Circulation: Physical Examination Findings: • Reassess HR, pulse, capillary refill, BP after bolus • HR 226/min, RR 36/min, oxygen saturation 100% in 100% • Order adenosine oxygen (if placed), BP 81/68 mm Hg • Describe to nurse confederate how to deliver medication when asked (“I am not sure how to give this medication.”) • Prepare for conversion by: – Ensuring availability of defibrillator (might or might not connect pads)

48 Simulation Scenarios Supraventricular Tachycardia

STAGE 2, – Having ECG machine connected and running during continued conversion attempt • Deliver first adenosine bolus (no or brief effect) after considering contacting cardiology or intensive care support personnel

STAGE 3 Condition: REASSESSMENT OF THE PATIENT: 5 • Infant cries when medication given Circulation: • HR remains elevated • Reassess HR, pulse, capillary refill, BP Physical Examination Findings: Medical Management: • Unchanged from stage 2 • Order a repeat dose of adenosine

STAGE 4 Condition: REASSESS THE PATIENT: 5 • Patient improves (HR 145/min and sinus) • Disposition: Physical Examination Findings: • Arrange for ICU or cardiology admission or transport to • HR 148/min, BP 78/62/min, saturation 98% on tertiary care facility (depending on presenting facility nonrebreather mask resources) • Child is more comfortable

Abbreviations: BP, blood pressure; CNS, central nervous system; CVS, cardiovascular system; ECG, electrocardiogram; HR, heart rate; ICU, intensive care unit; IV, intravenous; RR, respiratory rate.

Notes 1. Some institutions have specific guidelines about the presence of cardiology personnel at chemical cardioversion. If this is required, anticipation of this need should be discussed (calling as early as practical). 2. Simulating the patient monitor changes typically seen with cardioversion requires some practice and might not be an ideal representation of the clinical experience (eg, longer pause, delay in rhythm change on monitor). Testing of this effect on the planned device is recommended.

Common Pitfalls • Problems with delivering the adenosine in a rapid push/rapid flush manner. • Electrical cardioversion in this stable patient (less common).

49 Simulation Scenarios Supraventricular Tachycardia

Learning Objectives • Describe the signs and symptoms of the anticholinergic toxidrome. • Demonstrate the treatment of a child with tricyclic antidepressant (TCA) intoxication. – Initial stabilizing steps. – Identify tachyarrhythmia secondary to TCA intoxication. – Manage TCA intoxication with appropriate supportive and therapeutic interventions.

Simulator: Pediatric Simulator

Scenario Patient Instructor Time, Stage Condition Intervention Debriefing Notes min

STAGE 1 History: Take a History: 2 • Four-year-old boy, brought in by parents • No sick contacts • Found extremely sleepy after dinner, slumped over on • No prior history of seizures couch, minimally responsive • No history of trauma • No fever or antecedent illness • No allergies • Previously well • No medications Weight: • Supervised by mother all day • 15 kg • Grandparents arrived from England just before dinner Physical Examination Findings: • Not sure if there are prescription medications in the home • Temperature 37.5°C (99.5°F), HR 150/min, RR 24/min, oxygen Airway: saturation 98% in room air, BP 85/50 mm Hg • Talk to the patient • CNS: eyes closed intermittently, no spontaneous movement, • Optimize airway position: head tilt, chin lift, jaw thrust intermittent verbalization Breathing: • Respiratory: spontaneous respirations, no abnormal breath • Check oxygen saturation sounds, air entry is normal • Apply monitors • CVS: palpable pulses, slightly cool extremities, normal heart • Provide oxygen sounds, tachycardia • Auscultate chest • Abdomen: no bowel sounds, palpable full bladder Circulation: • Apply monitors • Check pulse, capillary refill, BP—skin feels warm and dry • Start IV access

50 Simulation Scenarios Tricyclic Antidepressant Overdose

STAGE 1, Disability: continued • Eyes closed intermittently, opens eyes with stimulation • Moans and vocalizes with stimuli. • Localizes to painful stimuli, otherwise no movement • Pupils 5 mm, sluggish reaction symmetrically Expose the Patient: • Warm, dry skin • No rash, no petechiae • Identify abnormality on cardiac tracing (sinus tachycardia with wide QRS) • Identify need for 12-lead ECG • Order blood work: CBC, differential, electrolytes, glucose, creatinine, BUN, serum osmolality, blood gas, serum acetaminophen and aspirin levels, urine toxicology screen

STAGE 2 Condition: Parent calls on telephone—grandmother has 20–30 missing 3 • The patient’s condition evolves—worsening level of antidepressant pills from her medication cabinet consciousness. REASSESSMENT OF THE PATIENT: Physical Examination Findings: Airway: • Temperature 37.5°C (99.5°F) orally, HR 150/min, RR 24/min, • Prepare equipment for intubation saturation 98% with 100% oxygen, BP 85/50 mm Hg • Prepare medication for rapid sequence intubation • CNS: eyes closed, no spontaneous movement, moaning, Intubation: infrequent verbalization • Preparation/equipment • Chest: spontaneous respirations, no abnormal air entry or • Preoxygenation. breath sounds • Cricoid pressure • CVS: palpable pulses, slightly cool extremities, normal heart • Premedication: IV atropine sounds, tachycardia • Sedation: IV ketamine • Abdomen: no bowel sounds, palpable full bladder • Paralysis: IV succinylcholine • Intubate with ETT

• Check tube placement with ETCO2, auscultation, and chest radiograph Breathing: • Reassessment of breathing, auscultation—no change • Apply 100% oxygen—no change in clinical appearance Circulation: • Reassess HR, pulse, BP • Consider giving IV bolus of normal saline

51 Simulation Scenarios Tricyclic Antidepressant Overdose

STAGE 2, Medical Management: continued • IV sodium bicarbonate bolus • Glucometer: normal results • Continuous ECG monitoring • Call for ICU consultation • Call for toxicology consultation/poison control

STAGE 3 Condition: REASSESSMENT OF PATIENT: 5 • The patient’s condition evolves: ventricular tachycardia Airway: Physical Examination Findings: • Position airway • Temperature 37.5°C (99.5°F) orally, HR 180/min, RR 10/min, • Oropharyngeal airway—still in place saturation 98%, BP 85/50 mm Hg Breathing: • CNS: eyes closed, no spontaneous movement—paralyzed • Reassess auscultation, breathing and sedated • Manual ventilation—patient intubated • Respiratory: air entry equal Circulation: • CVS: palpable pulses, slightly cool extremities, capillary refill • Reassess HR, pulse, BP, capillary refill 2 s • Gives IV normal saline bolus • Abdomen: no bowel sounds, palpable full bladder • ECG: ventricular tachycardia Medical Management: • Follow PALS protocol • Prepare for synchronized cardioversion • Consult cardiologist

STAGE 4 Condition: REASSESS THE PATIENT: 5 • Patient condition deteriorates after intubation Airway: Physical Examination Findings: • Suction the ETT: some thin mucus or secretions • Very difficult to ventilate • Consider direct visualization of the tube with laryngoscope • Poor chest rise bilaterally Breathing: • Temperature 38°C (100.4°F), HR 80/min, RR bagging, • Auscultate the chest saturation 78% in 100% oxygen, BP 80/50 mm Hg • Check for signs of tension pneumothorax (trachea midline, • CNS: sedated/paralyzed blood pressure, percussion of chest, jugular venous pressure) • Respiratory: poor chest rise and air entry bilaterally with • Give continuous nebulized inline albuterol (salbutamol) wheezing • Check oxygen/equipment • CVS: pulses weak, capillary refill 4 s • Bag-mask ventilate at a slower rate with a prolonged expiratory phase Circulation: • Insert second IV catheter • Give IV bolus of normal saline

Abbreviations: BP, blood pressure; BUN, blood urea nitrogen; CBC, complete blood cell count; CNS, central nervous system; CVS, cardiovascular system; ECG, electrocardiogram; ETCO2, end-tidal carbon dioxide; ETT, endotracheal tube; HR, heart rate; ICU, intensive care unit; IV, intravenous; PALS, Pediatric Advanced Life Support; RR, respiratory rate.

52 Simulation Scenarios Tricyclic Antidepressant Overdose

© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians Notes 1. Have someone serve as poison control personnel and provide advice to the medical team over the telephone. 2. “Albuterol” is the drug name in the United States. In many other countries the drug name is “salbutamol.”

Common Pitfalls • Delay in eliciting further history, thus leading to delay in making the diagnosis. • Failure to recognize and anticipate the potential cardiac complications of TCA overdose.

53 Simulation Scenarios Tricyclic Antidepressant Overdose

Learning Objectives • Describe the common causes of vomiting and lethargy in a neonate. • Demonstrate the treatment of a neonate with altered mental status and suspected metabolic crisis. – Manage airway, breathing, and circulation. – Check appropriate laboratory test results—glucose at bedside, blood gas, and serum ammonia. – Treat hypoglycemia and confirm that treatment was effective. – Treat acidosis. – Arrange for treatment of hyperammonemia.

Scenario Patient Instructor Time, Stage Condition Intervention Debriefing Notes min

STAGE 1 History: Take a History: 3–4 • One-week-old with progressive poor feeding, vomiting, and • Term, birth weight 3.3 kg, uncomplicated pregnancy, lethargy for the past 3 d delivery • Brought to ED by parents • No medications or no allergies • Looks very unwell at triage, brought to resuscitation room • Spitting up first few days of life, during last 3 d increased • You are called to assess patient frequency and amount, today four times Weight: • Weight currently 10% less than birth weight • 3 kg • No fever, diarrhea, rash Condition: • No sick contacts or travel • Infant is pale and lethargic, looks unwell Airway: Physical Examination Findings: • Listen for breath sounds • Temperature 36.2°C (97.2°F), HR 165/min, RR 46/min, oxygen Breathing: saturation 98% in room air, BP 75/40 mm Hg • Apply monitors, including oxygen saturation and blood • CNS: eyes open spontaneously, pupils 3 mm and reactive pressure bilaterally • Auscultate chest and observe respiratory rate • CVS: pulses intact but weak Capillary refill 3 s Circulation: • Respiratory: clear • Assess pulse, HR, capillary refill, BP • Abdomen: soft and without hepatosplenomegaly • Ask nurse to obtain IV access • Extremities/skin: loose skinfolds, no bruising noted Disability: • Quick neurologic assessment (pupils, response to pain)

54 Simulation Scenarios Metabolic Crisis—Hyperammonemia

STAGE 1, Medical Management: continued • Order a bedside glucose, electrolytes, BUN, creatinine, LFTs, ammonia, blood gas, CBC, blood culture, urine, urine culture tests, blood to hold for possible additional studies • Orders IV fluid bolus of 10 mL/kg of normal saline

STAGE 2 Condition: REASSESSMENT OF THE PATIENT: 5 • Infant minimally responsive to painful stimulus. Does not Airway: open eyes spontaneously, no verbalization/cooing • Maintain the airway: jaw thrust, chin lift, head tilt Physical Examination Findings: • Suction vigorously • Temperature 36.2°C (97.2°F), HR 175/min, RR 52/min, oxygen • Prepare intubation equipment saturation 94% in 100% oxygen, BP 70/30 mm Hg Breathing: • CNS: unresponsive, unconscious, pupils 3 mm and reactive • Increase oxygen delivery to 100% by using nonrebreather bilaterally • Assist ventilations as required • CVS: pulses intact but weak, capillary refill 4 s Circulation: • Respiratory: clear • Ensure IV access two times • Abdomen: soft and without hepatosplenomegaly • Recheck HR, BP, capillary refill, pulses • Extremities/skin: no bruising noted • Cycle BP every 3–5 min Medical Management: • Laboratory test results come back: – Sodium 135 mmol/L, potassium 3.5 mmol/L, glucose 35 mg/dL (low) • Administer D10W, 0.5 g/kg IV co o • ABG: pH 7.05, P 2 30 mm Hg, P 2 90 mm Hg, bicarbonate 8 mmol/L, base excess −20 mmol/L • Ammonia, 350 µg/dL (205 µmol/L). • WBC and hemoglobin level normal • Metabolic or genetics consultation

STAGE 3 Condition: REASSESSMENT OF PATIENT: 5 • Neonate still unresponsive, does not open eyes Airway: Intubation: spontaneously or to painful stimuli, no verbalization/ • Preoxygenation cooing, intermittent jittering movements of both arms and • Premedication: IV atropine optional stiffening suspicious for seizures • Cricoid pressure Physical Examination Findings: • Sedation: discussion: etomidate vs other options: midazolam • Temperature 36.2°C (97.2°F), HR 175/min, RR 52/min, oxygen plus IV fentanyl saturation 94% in 100% oxygen, BP 70/30 mm Hg • Paralysis: IV rocuronium or IV succinylcholine • CNS: unresponsive, unconscious, pupils 3 mm and reactive • Check tube placement with ETCO2 detector, auscultation of bilaterally chest, observation of chest rise, and order chest radiograph • CVS: pulses intact but weak, capillary refill 4 s

55 Simulation Scenarios Metabolic Crisis—Hyperammonemia

STAGE 3, • Respiratory: clear Breathing: continued • Abdomen: soft and without hepatosplenomegaly • Reassess breathing • Extremities/skin: no bruising noted • Start to provide manual ventilation to the patient Circulation: • Reassess blood pressure, pulse, capillary refill • Give IV normal saline bolus Medical Management: • Call for ICU consultation • Order dose of lorazepam for suspected seizure • Call for metabolism consultation if not already done • Administer bicarbonate • Arrange for hemodialysis, give sodium phenylacetate, sodium benzoate if hemodialysis will be delayed

Abbreviations: ABG, arterial blood gas; BP, blood pressure; BUN, blood urea nitrogen; CBC, complete blood cell count; CNS, central nervous system; CVS, cardiovascular system; D10W, 10% dextrose in water; ED, emergency department;

ETCO2, end-tidal carbon dioxide; HR, heart rate; ICU, intensive care unit; IV, intravenous; LFTs, liver function tests; RR, respiratory rate; WBC, white blood cell count. Notes 1. Consider inborn error of metabolism (IEM) with, not after, other potential diagnoses. History and laboratory findings (hypoglycemia, acidosis, hyperammonemia, neutropenia, anemia) are most suggestive of organic acidemia. Other IEMs most likely to present with catastrophic decompensation in a neonate include aminoacidopathies, urea cycle defects, fatty acid oxidation defects, and mitochondrial disorders. 2. Recognize that results of a newborn screen might not be available at 1 week of age or that child might not have had a newborn screen. 3. Normal pregnancy, delivery, and examination findings are not uncommon with IEM. 4. Family history might be negative given autosomal recessive inheritance of most IEMs. 5. Physical examination findings usually normal except for acute manifestations of illness. 6. Manifestations of seizure in neonates might be subtle. For seizures unresponsive to conventional treatment, consider pyridoxine, folate, and/or biotin. 7. Perform laboratory tests to evaluate for IEMs before any treatment, including glucose or fluids. Initial laboratory tests include bedside glucose, electrolytes, blood urea nitrogen, creatinine, glucose, blood gas, complete blood cell count, blood culture, liver function tests, ammonia, urine, and urine culture. If hypoglycemia, acidosis, and/or hyperammonemia are present, send serum samples for amino acids, acylcarnitine profile, and ketones measurement and urine samples for organic acids and urine acylglycine measurement. Consider taking lactate and pyruvate samples. Blood samples for IEM studies can be sent on newborn screen filter paper. Lactate and pyruvate samples require special tubes. 8. Consultation with metabolism specialist recommended if laboratory test results support suspicion of IEM. 9. Bicarbonate to correct acidosis. No consensus on pH for which to give or dose; consider for pH less than 7.0 to 7.2. 10. Hemodialysis for hyperammonemia. Extracorporeal membrane oxygenation hemodialysis is faster than conventional dialysis but has increased risks in neonates. Sodium phenylacetate or sodium benzoate should be administered per package insert directions if there will be a delay in hemodialysis.

56 Simulation Scenarios Metabolic Crisis—Hyperammonemia

© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians Common Pitfalls • Potential diagnosis of IEM is not considered until late, which increases the risk of long-term disease and/or death. • Participants check and treat the glucose level but fail to obtain a follow-up glucose measurement. A high concentration of glucose is not always maintained with maintenance fluids. • Acidosis is not treated. • Ammonia is not checked. • Failure to recognize and treat seizure.

57 Simulation Scenarios Metabolic Crisis—Hyperammonemia