Tyler Stephen; 38 12/23/19 76 Author: Corey Heitz Reviewer: Sharon Griswold Case Title: Allergic Reaction with Angioedema Target Audience: med students, residents Primary Learning Objectives: key learning objectives of the scenario Critical Actions: 1. Manage a patient with a difficult airway 2. Identify and initiate treatment for an allergic reaction 3. Describe management of difficult airway 4. Describe indications for surgical airway management Secondary Objectives: detailed technical goals, behavioral goals, didactic points 1. Identify findings consistent with progressive airway obstruction 2. Initiate treatment for acute allergic reaction. 3. Prepare for a difficult intubation including a call for help/backup when indicated 4. Recognize inability to ventilate patient 5. Perform (or describe procedure) cricothryotomy, if indicated Assessment Options: objectives during the case 1. Obtains history of progressive difficulty swallowing, tongue swelling, and voice changes 2. Recognizes stridorous breath sounds 3. Initiates treatment with steroids, antihistamines, and epinephrine 4. Verbalizes need for early intubation 5. Prepares for difficult airway by requesting alternative airway rescue devices, surgical airway materials, “double setup” 6. Begins airway management by bag-valve-mask ventilation. 1
Transcript
Tyler Stephen; 38 12/23/1976
Author: Corey Heitz Reviewer: Sharon Griswold
Case Title: Allergic Reaction with Angioedema
Target Audience: med students, residents
Primary Learning Objectives: key learning objectives of the scenario
Critical Actions:
1. Manage a patient with a difficult airway2. Identify and initiate treatment for an allergic reaction3. Describe management of difficult airway4. Describe indications for surgical airway management
Secondary Objectives: detailed technical goals, behavioral goals, didactic points1. Identify findings consistent with progressive airway obstruction2. Initiate treatment for acute allergic reaction.3. Prepare for a difficult intubation including a call for help/backup when indicated4. Recognize inability to ventilate patient5. Perform (or describe procedure) cricothryotomy, if indicated
Assessment Options: objectives during the case1. Obtains history of progressive difficulty swallowing, tongue swelling, and
voice changes2. Recognizes stridorous breath sounds3. Initiates treatment with steroids, antihistamines, and epinephrine4. Verbalizes need for early intubation5. Prepares for difficult airway by requesting alternative airway rescue devices,
surgical airway materials, “double setup” 6. Begins airway management by bag-valve-mask ventilation.7. Attempts to improve ventilation by nasal/oral airways, repositioning.8. Verbally states inability to ventilate patient9. Attempts direct laryngoscopy10.Verbally recognizes inability to visualize cords and intubate11.Elects to surgically manage airway with cricothyroidotomy12.Delegates items to team members13.Makes commands clear, and directly identifies who will be performing them14. Is receptive to input from team members
Debriefing Discussion Options:1. Describes the approach to a patient with respiratory distress2. Formulates a differential diagnosis for a patient with stridor3. Formulates a plan for the potential difficult airway4. Describes failed airway algorithm
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5. Describes technique of surgical airway management
Environment (if using as a simulation case)
1. Lab Set Up – The scenario is to take place in an Emergency Department setting.
2. Manikin Set Up – A Laerdal ® SimMan will be used to run the scenario. It will be placed on a stretchis and dressed in a gown. Initially, thise will be no oxygen in place, and no IV or cardiac monitoring.
3. Props – A cardiac monitor with leads, blood pressure cuff, and pulse oximeter will be available, as well as supplemental oxygen by nasal cannula and non-rebreather. A full complement of vasoactive agents, ACLS medications, and medicines necessary for sedation, rapid sequence intubation, and analgesia. In addition, a fully stocked code cart with defibrillator will be available for use, along with a selection of direct laryngoscopy and intubation supplies as well as “difficult intubation” supplies (GlideScope, LMAs, bougies, King airways, cricothyroidotomy kit).
4. Audiovisual – An adult chest xray will be available for viewing showing a normal post-intubation films, as well as a right mainstem intubation film (Appendix A). No laboratory studies will be available.
5. Distractors – As written, this is the only case to be taken care of. However, at the instructors discretion, any distractors may be added, to include but not limited to othis cases to be cared for simultaneously, distraught family members, etc.
Actors1. Roles – Necessary roles include a treating physician and one nurse, as well as
the instructor who will control the scenario and act as the historian and any consulting physicians. Other participants may serve as additional staff to be directed by the treating physician.
2. Who may play them – The resident physicians will play all of the roles. If desired, team training can be performed, in which nurses may be played by nurses-in-training.
Action Role1. Treating physician – to be played by the resident who is being evaluated. The
role is to coordinate the team, obtain a history and perform a physical exam, order studies and treatments, and perform any advanced procedures.
2. Nurse(s) – to be played by the remaining participants. The role is to assist the physician in any requested fashion. This may include minor procedures (IV access), placing the patient on monitoring equipment, performing CPR, and giving medications.
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For Examiner Only
Author: Corey Heitz Reviewer: Sharon Griswold
CASE SUMMARY
CORE CONTENT AREA
Airway; allergy
SYNOPSIS OF HISTORY/ Scenario Background Chief complaint: throat swelling
The participants will be provided with a triage note stating that the patient is a 38 year old male who was brought in by EMS due to throat and tongue swelling for approximately 20 minutes.
Vital Signs en route: Blood pressure 176/89, HR 113, SpO2 96%, RR 23, T 98.4F
Past medical history: Must be requested. The patient has a history of diabetes, hypertension, and arthritis.
Meds and allergies: Must be requested; is taking no medicines and has no allergies except to shellfish.
Family/social history: Must be requested. Patient is a nonsmoker, does not use illicit substances. He is married with no children.
SYNOPSIS OF PHYSICALWhen the learners first encounter the patient, they see the following:
Initial Vital Signs: BP 176/89, HR 113, SpO2 96%, RR 23, T 98.4F
General Appearance: The patient is a well-developed, well-nourished male who appears to be working hard to breathe. He speaks in short sentences and coughs frequently.
After the initial history and physical is performed, the patient begins developing worsening difficulty breathing and stridor develops. After a few minutes longer, the patient can no longer breathe adequately.
A repeat pulse oximetry at this time shows oxygen saturations of 85%.
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If intubation is not performed at this point, the patient's mental status will decline and the stridor will get worse.
A repeat pulse oximetry at this time shows 60%.
At this point, the patient will be unable to be intubated, and BVM will be unsucessful; therefore, a surgical airway is indicated. If this is not performed or is unsuccessful, the patient will go into a bradycardic arrest, at which point ACLS algorithms should be performed.
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For Examiner Only
CRITICAL ACTIONSSCENARIO BRANCH POINTS/ PLAY OF CASE GUIDELINES
Key teaching points or branch points that result in changes in patients’ condition
1. Critical Action
Identifies stridorous breath sounds.
Cueing Guideline: The patient should mention that his breathing is getting more labored, and ask "do you hear that high-pitched sound coming from my throat?"
2. Critical Action
Initiates treatment with epinephrine, steroids and diphenhydramine
Cueing Guideline: If no treatment is given after breathing worsens, the nurse should ask "Doctor, are we going to give this guy anything to make him better?"
(note: for more advanced learners, appropriate dosing is expected)
3. Critical Action
Recognizes the need and prepares for early intubation.
Cueing Guideline: If no preparations are being made as the patients condition worsens, the nurse or another confederate should ask if the doctor thinks that the patient might need to be intubated at some point, and if there's anything he/he can do to help.
4. Critical Action
Prepares for a "double setup" when attempting intubation.
Cueing Guideline: If the learner begins intubation without preparing for a possible cricothyrotomy, the nurse or another confederate should ask how difficult the doctor thinks the airway might be.
5. Critical Action
Recognizes inability to ventilate.
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Cueing Guideline: Once patient is induced and an attempt at intubation is made (and failed), learner should note that attempts to BVM are unsuccessful (saturations do not improve).
6. Critical Action
Chooses surgical airway management.
Cueing Guideline: Once the intubation fails, and the learner cannot ventilate the patient, if the decision is not made to perform a surgical airway, the nurse or other confederate can ask “Doctor, what other options are there for this patient’s airway?”
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For Examiner Only
OPTIMAL MANAGEMENT PATHWAY AND DESIRED OUTCOMESChanges in clinical condition: Shortly after the initial history and physical, the patient will begin coughing more and the stridor will become louder. He will state that he is having worsening difficulty breathing. If this continues for 2 minutes without intervention, his pulse oximetry will begin decreasing over 2 minutes. The patient will begin severe coughing vomiting, and exhibiting persistent, loud stridor. When the oxygen saturations reach 85%, the patient will stop breathing and become unresponsive.
Response to therapy- Oxygen: The patient may initially be placed on nasal cannula oxygen, which
will transiently increase his oxygen saturations to 98%. - Inhaled bronchodilators: These are a treatment option which may be used.
The patients wheezing will resolve.- Steroids: IV steroids can be given, but will have no effect on the patient’s
status.- diphenhydramine and/or ranitidine: These can be given, but will have no
effect on the patient’s status.- Subcutaneous epinephrine: If given, will not have any effect on the patient’s
airway, but will increase the heart rate and blood pressure by 15%.- Bag-Valve-Mask: Application will be insufficient for ventilation.
Progression:The patient’s rapid progression should be identified, and need for prophylactic airway management should be recognized. Treatment should be initiated with steroids, antihistamines, and potentially epinephrine. The patient should be awake at the time intubation is considered, and therefore an induction agent should be given, but a paralytic should be avoided. Bag-valve-masking should be attempted, repositioning and oral/nasal airways should be placed, and failed ventilation should be recognized. Direct laryngoscopy should be attempted, and when the recognition of failure is made, the decision to cric should be verbalized.
Potential complications: No complications of treatment are included in the scenario as written.
Potential errors: The majority of errors will be in failure to appropriate identify and manage the patient’s respiratory status, resulting in worsening hypoxia and eventual respiratory failure, and PEA arrest. Failure to identify impending airway obstruction, and prophylactic intubation, will result in a rapidly decompensating patient who may arrest due to hypoxemic respiratory failure. Only with surgical airway intervention will the patient be able to be resuscitated.
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SCORING GUIDELINES(Critical Action No.)1. Identifies stridor: the learner should recognize stridor. If this is not done verbally, the patient or a confederate should ask for identification of the abnormal sound. Score down if identified incorrectly. 2. Initiates treatment with epinephrine, steroids and diphenhydramine: Score down if, after identification of airway obstruction and possible causes, the learner does not initiate management including the above medications; the most important is epinephrine, and must be included in the treatment to achieve this critical action.
3. Prepares for early intubation: If the learner does not ask for an intubation setup/equipment, or does not verbally mention the possibility, after the initial H/P, score down. The critical action is met if the possibility is discussed with the patient or nurse, or if equipment is requested.
4. Prepares a double setup: If the learner proceeds with intubation attempts prior to preparing for potential cricothyrotomy, score down. If a cric tray is requested, or the learner states that a double setup is requested, then the action is achieved.
5. Recognizes inability to ventilate: If the learner, after a failed intubation attempt, does not realize that BVM ventilation is unsuccessful and does not pursue a “can’t intubate, can’t ventilate” strategy, they should be scored down.
6. Elects surgical management: If the learner performs further intubation attempts and does not choose surgical management when the patient is unable to be ventilated or intubated, score down.
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For Examiner Only HISTORY
Onset of Symptoms: When asked, he will state that he was at lunch today, and began developing an “itching” in his throat. This progressed to the feeling of swelling and difficulty swallowing, and when he went to the bathroom, he thought his lips and tongue appeared swollen, so he called an ambulance. During the ride, his symptoms worsened.
- If asked, the patient will state that the symptoms started one hour ago, and that the swelling did not begin until about 20 minutes ago.
- If asked, the patient will state that he has an allergy to shellfish, and was afraid that his salad may have had shrimp on it.
- If asked, he will state his voice sounds deeper and muffled.
Background Info: The patient is a 38 year old male presenting with throat and tongue swelling after eating lunch.
Recognizes stridor Treats with epinephrine, Benadryl, steroids Prepares for intubation Prepares double setup Identifies inability to ventilate Elects surgical management
Dangerous Actions: (Performance of one dangerous action results in failure of the case)
Attempts intubation prior to double setup/ or calling for help Paralyzes for intubation attempt prior to visualizing cords Attempts intubation after failed intubation and ventilation
Scoring: In accordance with the Standardized Direct Observational Tool (SDOT)
The learner should be scored (based on level of training) for each item above with one of the following:
NI = Needs ImprovementME = Meets ExpectationsAE = Above ExpectationsNA= Not Assessed
**an example of critical actions for a case
Critical Actions NI ME AE NA CategoryRecognizes stridor PC, MKAdministers epinephrine, diphenhydramine, steroids
PC, MK
Prepares for intubation PC, MK, SBPPrepares double setup/ calls for help
PC, MK, SBP
Identifies inability to ventilate PCElects surgical management when indicated
PC, SBP
Effectively communicates with team to manage difficult airway
IPS, SBP
The score sheet may be used for a variety of learners. For example, in using the case for 4th year medical students, the key teaching points of the case may be the recognition of shock and treatment with appropriate fluid resuscitation. Othis items may be marked N/A= not assessed.
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Category: One or more of the ACGME Core Competencies as defined in the SDOTPC = Patient Care
Compassionate, appropriate, and effective for the treatment of health problems and the promotion of health
MK = Medical KnowledgeResidents are expected to formulate an appropriate differential diagnosis with special attention to life-threatening conditions, demonstrate the ability to utilize available medical resources effectively, and apply this knowledge to clinical decision making.
PBL = Practice Based Learning & ImprovementInvolves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care
ICS = Interpersonal Communication SkillsResults in effective information exchange and teaming with patients, their families, and othis health professionals
P = ProfessionalismManifested through a commitment to carrying out professional responsibilities, adhisence to ethical principles, and sensitivity to a diverse patient population
SBP = Systems Based PracticeManifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value
Debriefing for this scenario should focus on the thought processes that occurred as the scenario progressed. The case should move rapidly, and decisions will need to be made quickly and with little information. Ideally, the learner will have a basic understanding of the management of an anaphylaxis reaction and also of the difficult and failed airway algorithms. If there are errors made, the thinking behind them should be uncovered during the debriefing. Questions to ask after the case, with variation based on the strengths/weaknesses of the particular learner, may include:
-How would you describe this patient’s initial assessment?
-Based on your initial information, what was your immediate working differential diagnosis?
-What was your sequence of events upon approaching the patient, and why?
-When your initial treatments were not successful, and the patient’s condition began to deteriorate, what steps did you take? Why?
-At what point did you definitively decide the patient needed airway management, i.e., intubation?
-Describe your approach to this patient’s airway.-What was your initial choice of airway management, and why?-Discuss your plan for oral intubation, including medication choice (and why), your thoughts about steps to take if unsuccessful the first time, and your backup plan(s).
-What options might be available if the patient was able to be ventilated, but not intubated?
(this answer should include blind insertion devices for temporary management, intubating LMA, video laryngoscopy)
-Once the patient was unable to be ventilated after the initial intubation attempt, describe your thought process
(the learner should clearly discuss the “can’t intubate/can’t ventilate” scenario; if they are unfamiliar with this terminology or scenario, this can be explained further)
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-If a cricothyrotomy was not performed (or performed incorrectly), ask the learner to describe the procedure, including equipment needed.
-If the learner did not elect to intubate when the patient was initially decompensating, then the thought process at that time should be explored.
For further reading, direct the learner to:Walls RM, Murphy MF. Manual of emergency airway management. Lippincott Williams & Wilkins; 2008.
Optional: Simulation Equipment Checklist
ENVIRONMENTThis scenario requires
SimulatorType:Mannequin or Standardized patientNon-Invasive BP CuffPulse OximeterTemperature ProbeResp Rate MonitorETTLMALaryngoscopeFiberoptic scopeGum BougieCricothyrotomy kitCrash Cart
