SimulationScenarioTemplate

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Section1:CaseSummary

ScenarioTitle: Keywords: CHF,Pneumothorax,lungPOCUS

BriefDescriptionofCase: CHFpulmonaryedema,PneumothoraxwhileonBiPAP

GoalsandObjectivesEducationalGoal: ClinicalapplicationoflungPOCUSinterpretation

Objectives:(MedicalandCRM)

AcutedyspneaassessmentusinglungultrasoundRe-evaluateclinicalchangeusinglungultrasoundNon-InvasiveventilationindicationsandcontraindicationsIdentifycomplicationsofnon-invasiveventilationie.pneumothorax

EPAsAssessed:

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Section2A:InitialPatientInformation

A. PatientChartPatientName:TheresaHo Age:74 Gender:F Weight:64kgPresentingcomplaint:ShortnessofBreathTemp:36.5 HR:100 BP:130/74 RR:34 O2Sat:86% FiO2:6LNRBCapglucose:8 GCS:15(E4V5M6)Triagenote:4daysofworseningshortnessofbreath.Unabletowalkfromthebedroomtothebathroomtodaysoherpartnercalled911.BroughtinbyEHSonNRB.Significantincreasedworkofbreathing.Abletospeakintwowordanswers.Allergies:nonePastMedicalHistory:CAD–LADstent2016COPD–40packyearsmokinghistoryProvokedPEposthipreplacement2019Type2DiabetesHypothyroidismHypertension

CurrentMedications:ASA81mgPOdailyBisoprolol5mgPOdailyLasix40mgPOBIDLevothyroxine75mcgPOdailyAmlodipine10mgPOdaily

Section2B:ExtraPatientInformation

A.FurtherHistoryIncludeanyrelevanthistorynotincludedintriagenoteabove.Whatinformationwillonlybegiventolearnersiftheyask?Whowillprovidethisinformation(mannequin’svoice,confederate,SP,etc.)?Medicationsnotinblisterpack.Patientmentionsmissingdosesofhermedicationsforaboutaweekincludingthewaterpills.

B.PhysicalExamListanypertinentpositiveandnegativefindingsCardio:regularrhythm,noextraheartsounds Neuro:GCS15,notdrowsyResp:diffusecrackles,mildexpiratorywheeze,indrawing,dyspneic

Head&Neck:nilacute

Abdo:benign MSK/skin:nilacuteOther:pittingedematoherknees,shesaysshealwayshassomedegreeofswelling,mightbemorenow,notsure

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Section3:TechnicalRequirements/RoomVision

A.Patient�Mannequin(specifytypeandwhetherinfant/child/adult)-ADULT�StandardizedPatient�TaskTrainer�Hybrid

B.SpecialEquipmentRequiredPOCUSmachine,Computer/TablettodisplayPOCUSimages

C.RequiredMedicationsLasix,ASA,Salbutamol,Ipratropium,Methylprednisone,Prednisone,Nitroglycerin,Ketamine,Fentanyl,Lorazepam

D.MoulageN/A

E.MonitorsatCaseOnset�Patientonmonitorwithvitalsdisplayed�Patientnotyetonmonitor

F.PatientReactionsandExamIncludeanyrelevantphysicalexamfindingsthatrequiremannequinprogrammingorcuesfrompatient(e.g.–abnormalbreathsounds,moaningwhenRUQpalpated,etc.)MaybehelpfultoframeinABCDEformat.Ifavailable–coarsecracklesandwheeze,increasedrespiratoryrate,short2wordsentencesasanswers.

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Section5:ScenarioProgression

ScenarioStates,ModifiersandTriggers

PatientState/Vitals

PatientStatus

LearnerActions,Modifiers&TriggerstoMovetoNextState

FacilitatorNotes

1.BaselineStateRhythm:Sinus

HR:100

BP:160/74

RR:34

O2SAT:86%6LNRB

T:36.5oC

GCS:15

Tachypnea,2

worddyspnea,

interactiveand

alertbut

workinghardtobreathe

ExpectedLearnerActions

ApplyMonitors

ConsiderDDxfordyspnea

EmpiricMedications

Modifiers-Baselineclinicalstatus

unchanged

-pCXRoccupiedinICU

(unavailablefor10min)

Triggers-Empiricmedicationsgiven

withoutimprovement

EmpiricMedications

-Learnertodecideetiologyof

dyspneaandadministerCHFor

COPDmedications

-ShouldusePOCUS,donotneedto

promptiftheydon’tyet

-Nomedicationwillhelp

significantly

2.HR:120sinus

BP190/74

RR:34

O2Sat:84%6LNRB

T:36.5

GCS15

Stillalert

Ongoing

tachypneaand

dyspnea

unchangedwith

meds

ExpectedLearnerActions

IdentifyneedforNIPPV

LearnersshouldPOCUS

BiPAPapplied

Targetedmedication(Lasix,

ASA,nitrospray

Modifiers

-Baselineclinicalstatus

unchanged

-POCUSavailable

-NIPPVavailable

Triggers

-BiPAPapplied,patientwill

initiallyimprove

POCUSFindings:DiffuseBlinesto

apex,bilateralsimplepleural

effusions.(Clips:1and2)

POCUSFindings:decreasedLV

systolicfunction(Clips:3and4)

Note:advancedlearnerwill

commentBlinesatapexrulesout

pneumothoraxasetiologyof

dyspnea

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3.HR:100

BP155/72

RR:24onBiPAP

O2Sat:92%BiPAP

T:36.5

GCS:15

Stillalert

Tachypnea

significantly

improveson

BiPAP

ExpectedLearnerActions

LearnersMUSTPOCUS

(promptifnot)

Modifiers

-BiPAPisnowon

Triggers

-Suddensevererightchestpain,

tachypneaworsens,O2satsdrop

Prompt:iflearnerappliedBiPAP

beforePOCUS,promptthemto

scanlungsnowbyasking“whatis

theetiologyofthispatients

shortnessofbreath?”

-stillNOCXRavailable

4.HR:124

BP:80/50

RR:44

GCS15:

Stillalert

SEVEREleft

sidedchestpain

Tachypnea

worsens

ExpectedLearnerActions

ImmediatelyremoveBiPAP

PlaceonNRB

POCUSforpneumothorax

Modifiers

-POCUStodiagnose

pneumothorax

Triggers

-STOPcasewhenidentify

pneumothorax

POCUSFinding:pneumothoraxon

anteriorrightchest(Clip5)

Prompt:learnertodescribehowto

treattensionpneumothorax

(fingerdecompressionthen

surgicalchesttube)

ENDCASE

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AppendixB:ECGs,X-rays,UltrasoundsandPictures

Video1-BlinesVideo2–pleuraleffusionsVideo3–DecreasedLVsystolicfunctionLongAxisviewVideo4–DecreasedLVsystolicfunctionshortaxisviewVideo5–DecreasedLVsystolicfunctionApical4ChamberImage6–CXRVideo7–LeftanteriorchestlungslideVideo8–Rightanteriorchestnolungslide

1. 2.

3. 4.

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5. 6.

7.

8.

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AppendixC:FacilitatorCheatSheet&DebriefingTips

Includekeyerrorstowatchforandcommonchallengeswiththecase.Listissuesexpectedtobepartofthedebriefingdiscussion.Supplementalinformationregardinganyrelevantpathophysiology,guidelines,ormanagementinformationthatmaybereviewedduringdebriefingshouldbeprovidedforfacilitatorstohaveasareference.

Explainrationaleanddifferentialforacutedyspnea.

Identifycriticaldecisionmakingpointsandhow/ifPOCUSwasused

EducationalResource:WesternSono

1. Image Acquisition https://westernsono.ca/screencasts/lung-ultrasound/lung-ultrasound-acquisition-tutorial-2/

2.ImageInterpretationhttps://westernsono.ca/screencasts/lung-ultrasound/lung-ultrasound-image-interpretation-tutorial/

References

1.WesternSonowesternsono.ca