simulation scenario template

Simulation Scenario Template

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Section 1: Case Summary

Scenario Title: Resequenced Date of Development: 22 August 2018

Scenario Developer(s): Andrew Petrosoniak Affiliations/Institutions(s): St. Michael’s Hospital

Contact E-mail: [email protected] Revision Date (If applicable):

Revised By:

Learning Goals & Objectives Target Learners: Medical Students Junior Residents Senior Residents

Staff Physicians Inter-professional Other Target Number of

Learners: 6-12

Location: Sim Lab In Situ Other Approximate Timing: Set-Up:30 minutes Scenario:15 minutes Debrief: 45 minutes Facilitators Required: Instructors: 2

Confederates: TBD Sim Techs: 1

Goals and Objectives Educational Goal: Engage learners in a complex immersive scenario to stimulate discussion and reflection

on how trauma management is prioritized and how actions should be sequenced Objectives: 1. Demonstrate prioritization and coordination of trauma responses to a patient

with multiple injuries with competing requirements 2. Demonstrate management of traumatic injuries including:

a. Pneumothorax b. Haemorrhagic shock c. Neurogenic shock

3. Demonstrate effective teamwork (leadership and followership) and communication in a crisis.



Case Summary: Brief Summary of Case Progression and Major Events Mechanism

• 71M, high speed MVC roll over. Hypotensive with EMS, responded to fluid. GCS 12 on arrival. sBP 103/45, HR 103bpm, Hypoxic (85% on NRB), identification of pneumothorax and decompression improves O2. BP drops in ED. MTP activated, intubated. Initially negative FAST that becomes positive. Stable pelvis. Initial FAST negative. Concern about concomitant neurogenic shock. .

Injuries • Mild-moderate TBI (but ultimately no bleed) • Tension Pneumothorax • Liver laceration, eventually positive FAST • Neurogenic shock (T4 injury)

Expected progression • Primary survery should identify left pneumothorax, negative abdo FAST • Initial physiologic priority is hypoxia. Improves with NRB to 90%. Airway protected but obtunded

o Requires intubation but team should recognize shock state (obstructive and potential hemorrhagic) o Decompression of left pneumothorax identified on US

• Hemodynamics o Drops BP slightly if not intubated, more profoundly if intubated without blood transfusions o Prior to intubation à BP 93/40, prompt blood administration, improves to 98/43, HR unchanged o Repeat FAST will result in +FAST in RUQ o Negative pelvis x-ray

• MTP o FFP/PRBCs/plts/TXA/cryo

• Intubation o If done without resuscitation, then BP drops significantly (62/30) or if ketamine >40mg

(0.5mg/kg, 80kg pt) o Post intubation ongoing hypotension despite MTP

• Neurogenic shock o BP improves once NE started

Decision making for OR vs CT. depends on stability but likely requires OR given ongoing hemodynamic instability Airway personnel will be instructed to be adamant that intubation needs to occur immediately. Slightly disruptive and also asking directly to RNs for phenylephrine. Administration of phenylephrine makes patient profoundly bradycardic



Section 2: Scenario Requirements

A. Patient Mannequin Standardized Patient Task Trainer Hybrid

B. Confederates Role Description of role, any script required for confederate (including conveying patient information if patient is

unable) C. Special Equipment Required iPad and iPhone with ‘Awesome Ultrasound Simulator’app and dummy ultrasound probe Pelvic binder Airway cart/ equipment, intercostal catheter equipment, “massive transfusion” equipment

D. Required Medications Massive transfusion (Packed RBCs, FFP, platelets, cryoprecipitate, Tranexamic acid) Resuscitation drugs (epinephrine, calcium, phenylephrine) Intubation drugs (Propofol, ketamine, fentanyl, midazolam, etomidate, rocuronium, suxamethonium) Analgesia (morphine, fentanyl, ketamine) E. Moulage Abrasions/ minor contusions to face, torso (especially left chest)



Section 3: Baseline State Section4:ScenarioProgression

A. Clinical Vignette: To Read Aloud at Beginning of Case Paramedics provide the following handover regarding this patient, Robert Kite: A- 71y M, T- 30 minutes ago, M – high-speed MVC roll over on the highway. I – possible head injury (decr GCS), chest wall trauma, maybe pelvis so we bound it. S - P-103/min R-25/min BP-103/45 SpO2- 85% on NRB; GCS 11 (E3V4M4 in arms); T- C-spine collar, high flow oxygen via NRB; PIVC x 2x 16G, 5mg morphine IV. We haven’t seen him move his legs The paramedics leave as your team is starting to assess the patient.

B. Patient Profile and History Patient Name: Robert Kite Age: 73 year Weight: 80kg Gender: M F Code Status: Full Resuscitation Chief Complaint: Multi-trauma History of Presenting Illness: 71M, high speed MVC roll over. Hypotensive with EMS, responded to fluid. GCS 12 on arrival. sBP 103/45, HR 80 bpm, Hypoxic (85% on NRB), Past Medical History: Nil Medications: Morphine 5mg IV stat Unknown tetanus status Oxygen 15 L/min via NRB Allergies: NKA Social History: unknown Patient personality/background (thoughts, feelings, perspective):

C. Baseline Simulator State and Physical Exam No Monitor Display Monitor On, no data displayed Monitor on Standard Display

HR: 80 /min BP: 103/45 mmHg RR: 25/min O2SAT: 85% T: 36oC Rhythm: SR Glucose: 6 mmol/L GCS: (E 4 V4 M6) Pupils: PEARL 3 mm General Status: Unconscious, moaning CNS: GCS 11, no movement of legs HEENT: nil CVS: Mild cool peripheries RESP: 85% O2 via NRB; decr a/e left side, -ve lung slide on left ABDO: Guarding GU: None MSK: None SKIN: Superficial abrasions to face, torso, and limbs

Scenario States, Modifiers and Triggers



Patient State Patient Status Learner Actions, Modifiers & Triggers to Move to Next State 1. Baseline State BP 103/45, 80bpm, 85% NRB

Altered No movement of legs Resp distress

Learner Actions - O2 - “Hands off” team leader - Primary survey - consider pelvic binder - Confirm 2 x large bore IV access - Secondary survey - Send bloods - FAST scan: left PTX - Trauma series XR

Modifiers Changes to patient condition based on learner action - progressively more hypoxic if no chest decompression - if decision to intubate first then drop BP to 62/30 Triggers For progression to next state -

2. Progressively hypotensive

BP drops to 93/50 but improved O2 requirements HR remains 80 No neuro change

Learner Actions - Call for pRBC - TXA - Fluid warmer - Prepare intubation - Consider repeat FAST

Modifiers - if intubation then drop BP - requires blood before intubation (at least 1U), if not BP drops to 60/40 - airway person wants to intubation right away. Consistently requesting and also requests phenylephrine

3. Ongoing hypotension

Consistent hypotension requiring pRBC

Learner Actions - repeat FAST if not done already - Continue pRBC - Intubation with decr dose of induction agent - reassess causes for shock

Modifiers - EMS will return with further info that patient not moving legs -

4. Neurogenic shock

BP drops to 80/50 despite pRBC. +FAST and also neurogenic shock as HR drops.

Learner Actions - start norepi - arterial line/central line - plan for definitive management/next steps Discuss with trauma surgeon.

Learner Actions -



Section 5: Facilitator Cheat Sheet

Section 6: References

LITFL Trauma! Initial assessment and management https://lifeinthefastlane.com/trauma-initial-assessment-management/ Airway - Airway in neck trauma https://lifeinthefastlane.com/ccc/airway-in-neck-trauma/ - Airway management in major trauma https://lifeinthefastlane.com/ccc/airway-management-major-trauma/ - Airway and cervical spine injury https://lifeinthefastlane.com/ccc/airway-cervical-spine-injury/ Extremity injury - Extremity injuries https://lifeinthefastlane.com/ccc/extremity-injuries/ - Extremity arterial injury https://lifeinthefastlane.com/ccc/extremity-arterial-injury/ - Crush injury - Thoracic trauma https://lifeinthefastlane.com/ccc/thoracic-trauma/ - Pneumothorax ultrasound https://lifeinthefastlane.com/ccc/pneumothorax-ultrasound/ - Major haemorrhage in trauma https://lifeinthefastlane.com/ccc/major-haemorrhage-in-trauma/ - Haemostatic resuscitation https://lifeinthefastlane.com/ccc/haemostatic-resuscitation/ Pelvic trauma - Pelvic trauma https://lifeinthefastlane.com/ccc/pelvic-trauma/ - Pelvic arterial injury https://lifeinthefastlane.com/ccc/pelvic-arterial-injury/ - AngiographyandEmbolisationinPelvicTrauma https://lifeinthefastlane.com/ccc/angiography-and-embolisation-in-pelvic-trauma/ - Pre-peritoneal packing https://lifeinthefastlane.com/ccc/pre-peritoneal-packing/



Section 7: Laboratory Results



Section 8: ECGs, X-rays, and Ultrasounds

Paste in any auxiliary files required for running the session. Don’t forget to include their source so you can find them later! ECG - normal ECG – SR 150/min (taken while in pain) https://lifeinthefastlane.com/ecg-library/sinus-tachycardia/ Need x-rays - left pneumothorax if done - normal pelvis xray Need Awesome Ultrasound Simulator on iPad and iPhone and dummy ultrasound probe - left sided pneumothorax - normal echo - initially negative then positive FAST

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