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. © 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians MODULE Simulation Scenarios 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 © 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians Adrenal Insufficiency Adam Cheng, MD, FRCPC, FAAP Mark Adler, MD 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 © 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians Scenario Patient Instructor Time, Stage Condition Intervention Debriefing Notes min 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. 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 re- sistance to flow (small IV gauge). Infants and small children should always receive resuscitation fluids using 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 check a bedside glucose level. Hypoglycemia is not always present in patients with congenital adrenal hyperplasia and salt-wasting crisis, but it can occur. • Delaying treatment with hydrocortisone to obtain diagnostic tests. 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 © 2015 by the American Academy of Pediatrics and the American College of Emergency