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
1 Simulation Scenarios Adrenal Insufficiency
Adrenal Insufficiency
Adam Cheng, MD, FRCPC, FAAPMark Adler, MD
Learning Objectives
• Describethesignsandsymptomsofaninfantpresentingwithsalt-wastingadrenalcrisisassociatedwithcongenitaladrenalhyperplasia and adrenal insufficiency.
• Demonstratethetreatmentofanewbornwithsalt-wastingcrisis.– Initial stabilizing steps.– Replacement therapy.
Simulator: Infant Simulator
Scenario Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 1 History• Three-week-oldboywithunremarkablehistory,referredto
emergencydepartmentfromphysician’sofficewithalowserumsodiumlevel(126mmol/L)
• Mother’spregnancywasnormal;sherecallsnoabnormaltestresults
• Triagenursewasworriedabouthowillthechildappears• Youarrivetoassessthepatient
Weight: • 3kg
Condition: • Veryunwell,listless
Physical Examination Findings:• Temperature36.2°C(97.2°F),HR152/min,RR36/min,oxygen
saturation98%inroomair,BP72/58mmHg• CNS:asleep,wakesbrieflywithpainfulstimulation• CVS:pulsespresentcentrally,absentperipherally• Respiratory:clear• Abdomen:nohepatosplenomegaly• Extremities/skin:capillaryrefill>4s
Take a History: • Noillcontacts• Nomedications• Noallergies• Poorfeedingoverlastweek,spittingupmoreinpastfew
days• Nofever• Sleepingthroughfeedingtimelastfewdays,sleptmostof
thelast12h• Haslostweightsincelastfamilyphysicianvisit
Airway:• Listenforbreathsounds,present• Applyoxygenvianonrebreathermaskat15L/min
Breathing: • Applymonitors,includingoxygensaturationandblood
pressure• Auscultatechestandobserverespiratoryrate
Circulation:• Assesspulse,HR,capillaryrefill,BP• AsknurseforanIVcathetertobeplaced• AskfornormalsalineorlactatedRingersolutionbolusof20
mL/kgtobegivenquickly(push)
Medical Management:• Orderlaboratorytests:(CBC,electrolytes,bloodcultures,
venousbloodgas,bedsideglucose)
5
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
2 Simulation Scenarios Adrenal Insufficiency
Scenario Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 2 Condition:• HRremainselevatedandBPisnowlow• Nursenotesaloud,“Hishandsarejustsocold.”• Bloodglucoselevelislowifbedsidetestingwasperformed• Laboratoryresults:sodium124mmol/L,potassium7.8
mmol/L,bicarbonate16mmol/L,BUNandcreatininenormalforage,pHfromvenousgas7.26
Physical Examination Findings:
• HR150/min,RR36/min,oxygensaturation99%on100%oxygen(ifplaced),BP73/60mmHg
• CNS:criesweaklywithpainfulstimuli• Respiratory:clear• CVS:clampeddownandcoolextremities.• Abdomen:nohepatosplenomegaly
REASSESSMENT OF THE PATIENT:Circulation:
• ReassessHR,pulse,capillaryrefill,BPafterbolus• Ordersecondbolus,alsopush
Medical Management:• Consultendocrinologistfortreatmentguidance;ordertests
theymightrequest• OrderIVhydrocortisone• OrderD10WIVbolustocorrecthypoglycemia• Initiatemanagementofhyperkalemia
5
STAGE 3 Condition:• “Heislookingaroundmorenow.”• Improvedperfusionandalertnessaftersecondbolus
Physical Examination Findings:• HR138/min,RR36/min,BP78/48mmHg,saturation98%on
roomair• Abdomen:nohepatosplenomegaly
REASSESSMENT OF THE PATIENT:
Circulation:• ReassessHR,pulse,capillaryrefill,BP
Medical Management:• Orderrecheckofelectrolytesafterbolustherapy
Disposition:• ArrangeforneonatalorpediatricICUformonitoring
andfrequentlaboratoryworkuntilstabilizedorplanfortransporttotertiarycarefacility(dependingonpresentingfacilityresources)
5
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.
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
3 Simulation Scenarios Adrenal Insufficiency
Notes
1.Potassiumandsodiumderangementsusuallydonotrequireshort-termtreatmentbeyondfluidresuscitationandhydrocortisone.
Common Pitfalls
• Intravenous(IV)fluidforvolumeexpansionisnotdeliveredinarapidand/orcontrolledmanner.– IV“wideopen”fluidadministrationcanleadtoveryrapidinfusionofawholeliteroffluidORcanresultinunderresuscitationifthereissignificantre-
sistancetoflow(smallIVgauge).Infantsandsmallchildrenshouldalwaysreceiveresuscitationfluidsusingapumporpushtoallowforobservationandcontroloffluiddelivery.Pressurebagscanincreasethelikelihoodofexcessivefluidoverload.
– Pushingfluidisaccomplishedbyattachingathree-waystopcockinlinewiththeIVcatheterandpullingfluiddirectlyfromthebag(step1)andthenswitchingthestopcockandpushingthefluidintothepatient.
• Failingtocheckabedsideglucoselevel.Hypoglycemiaisnotalwayspresentinpatientswithcongenitaladrenalhyperplasiaandsalt-wastingcrisis,butitcanoccur.
• Delayingtreatmentwithhydrocortisonetoobtaindiagnostictests.
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
4 Simulation Scenarios Blunt Abdominal Trauma—Hypovolemic Shock
Blunt Abdominal Trauma—Hypovolemic Shock
Adam Cheng, MD, FRCPC, FAAPMark Adler, MD
Learning Objectives
• Describethesignsandsymptomsofapatientwithhypovolemicshock.• Demonstratethemanagementofcirculatoryfailureduetohypovolemicshock.
– Demonstrate the approach to pediatric trauma: primary and secondary assessment.– Demonstrateuseoffluidresuscitationinpatientswithprofoundbloodloss.– Identify and manage abdominal injury in a trauma patient.– Demonstrate use of rapid infuser in trauma care.
Simulator: Pediatric Simulator
Scenario Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 1 History: • Five-year-oldboy• Playinginthedriveway• Foundbyparentscrushedandtrappedunderneathgarage
door• Garagedoordirectlyoverhisabdomen• Nowitnessestotheincident• Ambulancearrivedwithin12min
Weight:• 18kg
Condition:• Moaninginpain• Temperature36°C(96.8°F),HR150/min,RR30/min,BP85/50
mmHg,oxygensaturation96%roomair• Monitor:sinustachycardia• CNS:cervicalcollaronpatient;moaninginpain,answers
questions,askingformom,confusedattimes,GCSscoreof15.
• H/N:cervicalspinenottender,noobviousfacialinjury• CVS:capillaryrefill4s,pulsespalpablebutweak• Respiratory:chestclear• Abdomen:bruisingalloverabdomen• Neurologic:normal• Musculoskeletal:normal
TAKE A HISTORY:
From Paramedics:• Initiallydelirious,screaming,GCSscoreof15/15• Extractiontook10minintotal• IVantecubitalonetime• Givennormalsaline.20mL/kg• Transporttime,15min
PRIMARY SURVEY MANAGEMENT:
Airway:• Assessairway,talktothepatient
Breathing:• Checkoxygensaturation• Applymonitors• Auscultatechest• Checkforchestrise• Apply100%oxygen
Circulation:• Applymonitors• Checkpulse,capillaryrefill,BP• Identifytherhythm• CheckfirstIVcatheter,asksforsecondlarge-boreIVcatheter• AskforrapidinfuserandbolusofIVnormalsaline• Ordertraumabloodwork,includingtypeandcross.• Activatetraumateam/callforhelp
2
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
5 Simulation Scenarios Blunt Abdominal Trauma—Hypovolemic Shock
Scenario Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 2 Condition:• Thepatient’sconditionhasworsenedslightly,BPlower,GCS
scoreunchanged
Physical Examination Findings:• Temperature36°C(96.8°F),HR170/min,RR40/min,BP80/40
mmHg,saturation100%withoxygenbymask• Monitor:sinustachycardia• CNS:cervicalspinecollaronpatient;moaninginpain,
answersquestions,askingformom,confusedattimes,GCSscoreof15
• H/N:cervicalspinenottender,noobviousfacialinjury• CVS:capillaryrefill4s,pulsespalpablebutweak• Respiratory:chestclear• Abdomen:bruisingalloverabdomen• Neurologic:normal• Musculoskeletal:normal
REASSESSMENT OF THE PATIENT:
Airway:• Maintaincervicalspineprecautions
Breathing:• Auscultatechest
Circulation:• ReassessHR,pulses,BP,capillaryrefill• AskforsecondbolusofIVnormalsaline• Reaffirmneedforrapidinfuser• Orderblood
Performs Secondary Survey:• H/N:pupilsequalandreactivetolight,facialbonesnot
tender,necksuppleandnottender• Chest:tracheamidline,chestclear.• CVS:profoundlytachycardic,colormottlednow,pulses
weak,andcapillaryrefill5s• Abdomen:soft.Bowelsoundsabsent,tenderallover
abdomen(screamsinpain)• Pelvis:stable.• Genitalia:nobloodatmeatus• Musculoskeletal:normal• Back:goodrectaltone,notenderness
Medical Management:• Paincontrol:IVmorphine• Immediateconsultation:generalsurgery• Orderradiographs:cervicalspine,chest,pelvis• Insertnasogastrictube• InsertFoleycatheter
3
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
6 Simulation Scenarios Blunt Abdominal Trauma—Hypovolemic Shock
Scenario Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 3 Condition:• Thepatientislessresponsive,BPisdecreasing,eyesstillopen,
GCSscoreof13
Physical Examination Findings:• Temperature36°C(96.8°F),HR180/min,RR40/min,BP70/30
mmHg,saturation100%withoxygenbymask• Monitor:sinustachycardia• CNS:cervicalspinecollaronpatient;moaninginpain,
intermittentlyanswersquestions,confusedanddeliriousattimes,GCSscoreof13.
• H/N:cervicalspinenotobviouslytender,noobviousfacialinjury
• CVS:capillaryrefill5s,pulsespalpablebutveryweak• Respiratory:chestclear• Abdomen:bruisingalloverabdomen• Neurologic:normal• Musculoskeletal:normal
REASSESSMENT OF PATIENT:
Airway: Intubation:• Prepareforintubationduetodecreasinglevelof
consciousness• Preoxygenate• PrepareequipmentandETCO2
• IVatropine• IVketamineoretomidate• IVsuccinylcholine• Checktubeplacementafterintubation,orderchest
radiographifintubationisperformed
Breathing:• Assesschestbeforeandafterintubation• Monitoroxygensaturation
Circulation:• Identifyworseningshock• OrderthirdbolusofIVnormalsalineandblood(Onegative
ifcross-matchednotavailable)
Blood Work:• WBC15,500/mm3,hemoglobin7g/dL,platelets500,000/
mm3
• Sodium135mmol/L,potassium4.5mmol/L,urea4.2mmol/L,creatinine46mmol/L,glucosenormal
• pH7.20,Pco240mmHg,Po280mmHg,bicarbonate15mmol/L,baseexcess−11mmol/L
Imaging:• Normalradiographs
Medical Management:• Generalsurgeonarrives:discussneedtoperformCTofthe
abdomenvsdirecttooperatingroom• Considerfocusedabdominalsonographyfortrauma• DiscussneedforCToftheH/Nandchest.
5
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.
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
7 Simulation Scenarios Blunt Abdominal Trauma—Hypovolemic Shock
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
• Failuretostabilizecervicalspineduringassessmentandtreatmentofpatient.• Failuretoperformacompletesecondarysurvey(eg,failuretologrollpatientorfailuretoassessneurologicstatusoflowerextremity).• Sedationand/orparalysisofpatientbeforecompletingneurologicassessmentofpatient.• Treatmentofpatientwithoutsupportofconsultants.
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
8 Simulation Scenarios Cardiogenic Shock Due to Congenital Heart Disease
Cardiogenic Shock Due to Congenital Heart Disease
Adam Cheng, MD, FRCPC, FAAPMark Adler, MD
Learning Objectives
• Describethesignsandsymptomsofaninfantwithcardiogenicshock.• Demonstratethemanagementofcirculatoryfailureduetocardiogenicshock.
– 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 Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 1 History:• Five-month-oldboywithhistoryofpoorfeedingandweight
lossforpastmonth• Sentfromphysician’sofficeforevaluation• Youarecalledtoevaluatepatient
Weight: • 5kg
Condition: • Veryunwell,gray,withrespiratorydistress
Physical Examination Findings:• Temperature37.3°C(99°F),HR158/min,RR58/min,oxygen
saturation91%inroomair,BP72/58mmHg• CNS:criesweakly,laysstillinbed• CVS:pulsespresentcentrally,weakperipherally• Respiratory:bilateralcrackles,retractions• Abdomen:liverisfirmandenlargedtotheumbilicusinthe
midclavicularline• Extremities/skin:capillaryrefillapproximately3s
Take a History: • Noillcontacts• Noupperrespiratorytractinfectionsymptoms,nodiarrhea• Takesalongtimetoeatandtiresout;sweatsalotwithfeeding• Wasnotedtohavea“holeintheheart”onaprenatal
ultrasonogrambuthadnomurmuratbirth—nofollow-upwasperformed
• Noallergies• Refluxmedicationsstartedforpoorfeeding• Approximately0.5-kgweightlostduringlast2wk
Airway:• Listenforbreathsounds• Applyoxygenvianonrebreathermaskat15L/min
Breathing:• Applymonitors,includingoxygensaturationandblood
pressure• Auscultatechestandobserverespiratoryrate
Circulation:• Assesspulse,HR,capillaryrefill,BP• Murmurandgalloprhythmheard• AsknursetoobtainIVaccess• AskfornormalsalineorlactatedRingersolutionbolusof5
or10mL/kg• Palpateabdomenfororganomegalyasasignofrightheart
failure
5
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
9 Simulation Scenarios Cardiogenic Shock Due to Congenital Heart Disease
Scenario Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 1, continued
Medical Management:• Orderlaboratorytests(CBC,electrolytes,venousbloodgas,
bedsideglucose,considerinfectionlaboratoryworkatthistimeasdiagnosisnotclear)
• OrderECGandachestradiograph
STAGE 2 Condition:• Conditionisunchanged• Venousgasrevealsacidosis(pH7.21,Pco228mmHg,Po232
mmHg,baseexcess−16mmol/L)• Bloodglucoselevelisnormal• Chestradiographrevealsmarkedcardiomegalywith
pulmonarymarkingsconsistentwithfluidoverload
Physical Examination Findings:• HR163/min,RR60/min,oxygensaturation98%in100%
oxygen(ifplaced),BP78/53mmHg• Examinationfindingsunchanged
REASSESSMENT OF THE PATIENT:
Circulation:• NursecannotobtainIVaccess;intraosseousneedleplaced
byparticipant• ReassessHR,pulse,capillaryrefill,BPafterbolus• Callforcardiologisttoconsultandperform
echocardiography;ifnotlocallyavailable,beginprocessoftransferringpatient
• ConsiderIVfurosemideforfluidoverload• Considerafterloadreduction(eg,milrinone)
Medical Management:• Considerbicarbonateforacidosis
7
STAGE 3 Condition:• Patientstabilizes
Physical Examination Findings:• HR162/min,RR52/min,BP78/62mmHg,saturation98%on
nonrebreathermask
REASSESS THE PATIENT:
Disposition: • ArrangeforICUadmissionortransporttotertiarycare
facility(dependingonpresentingfacilityresources)• ObtainsecondIVaccessotherthanintraosseousaccess
5
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
Notes1. 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
fluidoverload.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• Misrecognitionofpatientashavingrespiratorydistressduetoreactiveairwaydiseaseandadministrationofalbuterol(salbutamol).Patientwillgetworse
with this therapy.• Misrecognitionofpatientashavingsepsis,withexcessivefluiddelivery,resultinginincreasingheartrateandrespiratoryrateanddecreasedoxygen
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.
• Treatmentofpatientwithoutsupportofconsultants.Echocardiographyisanimportantstepinmanagementplanning,andtheinitialstepsinperformingthis test should be started as soon as possible.
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
10 Simulation Scenarios Altered Mental Status
Altered Mental Status
Adam Cheng, MD, FRCPC, FAAPMark Adler, MD
Learning Objectives
• Describethecommoncausesofalteredmentalstatusinaninfant.• Demonstratethetreatmentofaninfantwithalteredmentalstatus.
– Assessing for possible ingestion.– Checking glucose at bedside.– Treating hypoglycemia and confirming that treatment was effective.
Simulator: Infant Simulator
Scenario Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 1 History:• Eleven-month-oldfoundunresponsive,waswith
grandmother,whoishisusualbabysitter• BroughttoEDbygrandmother• Unresponsiveattriage,broughttoresuscitationbay• Youarecalledtoassesspatient
Weight: • 9kg
Condition:• Infantispinkandwell-perfusedbutcomatose
Physical Examination Findings:• Temperature37.2°C(99°F),HR94/min,RR28/min,oxygen
saturation98%inroomair,BP89/66mmHg• CNS:unresponsivetopainfulstimulationifgiven.Pupils3
mmandreactivebilaterally• CVS:pulsesintact• Respiratory:clear• Abdomen:softandwithouthepatosplenomegaly• Extremities/skin:nobruisingnoted(ifaskedspecifically)
Take a History: • Noallergies• Patienttakesnomedications• Noillcontacts• Noideaatallwhathashappened• Nohistoryoftraumaorfall• Nootherchildreninhome• Ifaskedspecifically,grandmothertakesoralsulfonylurea
(glyburide),whichshekeepsinabedsidedrawer
Airway:• Listenforbreathsounds
Breathing: • Applymonitors,includingoxygensaturationandblood
pressure• Auscultatechestandobserverespiratoryrate
Circulation:• Assesspulse,HR,capillaryrefill,BP• AsknursetoobtainIVaccess
Disability:• Quickneurologicassessment(pupils,responsetopain)
3–4
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
11 Simulation Scenarios Altered Mental Status
Scenario Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 2 Condition:• Mentalstatusunchanged• Bloodglucoselevelislowifmeasured
Physical Examination Findings:• Vitalsunchanged
Medical Management:• Recognizeandtreathypoglycemia(5mL/kgD10Wusingthe
“ruleof50”—seenotebelow)• Performfurtheringestionlaboratorytests(urinetoxicology,
acetaminophen[paracetamol],salicylates,ethanol,+/–digitalislevels)
5
STAGE 3 Condition:• Patientisnowmoreawakeandcries• HR125/min,RR28/min,BP85/62mmHg,saturation98%on
roomair
Medical Management:• Orderrecheckofglucoselevelin15–30min• RecognizeneedtoprovidesupplementaryIVglucoseand
admitduetolong-actingoraldiabeticagent
Disposition:• HospitalorICUforfrequentIVglucoselevelchecks
5
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 5mL/kg 50
D25 2mL/kg 50
D50 Notrecommendedduetohighosmolarity
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.Specificdrugscreeningpracticesvary.Althoughpolyingestionsaremorecommoninadolescents,mostofthelisteddrugsabovearehigh-risk,treatable
entities.
Common Pitfalls
• Participantsdonotaskaboutmedicationinthehomebutonlywhatthechildistaking.• Participantschecktheglucoselevelandtreatthepatientaccordingtotheglucoselevelbutfailtoobtainafollow-upglucosemeasurement.
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
12 Simulation Scenarios Diabetic Ketoacidosis and Cerebral Edema
Diabetic Ketoacidosis and Cerebral Edema
Adam Cheng, MD, FRCPC, FAAPMark Adler, MD
Learning Objectives
• Describethesignsandsymptomsofachildpresentingwithdiabeticketoacidosis(DKA).• Describethesignsandsymptomsofmoderatedehydration.• DemonstratethetreatmentofachildwithDKA.
– Initial stabilizing steps.– Management of suspected cerebral edema.
Simulator: Pediatric Simulator
Scenario Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 1 History: • Six-year-oldgirl• Two-weekhistoryoffeverandlethargy• Veryunwellinlast24h:excessivelydrowsy,verypoor
energy,difficultybreathing,abdominalpains
Weight: • 20kg
Condition: • Looksunwell;GCSscoreof13(motorresponse6,vocal
response4,eyeresponse3)
Physical Examination Findings:• Temperature37.4°C(99.3°F),HR160/min,RR30/min,BP
90/50mmHg,oxygensaturation98%onroomair• Veryflushedcheeks• Monitor:sinustachycardia• CNS:sleepy,pupilsnormal• CVS:normalheartsounds,capillaryrefill3s,pulsesweak• Respiratory:Kussmaulrespirations,lungfieldsclear• Mucousmembranes:mouth/lipsverydry,cryingafewtears• Abdomen:milddiffusetenderness
Takes a History:• Excessivedrinking,bedwetting,andincreasingtiredness• “Growingbutnotgainingweight”• Unwellfor36hwithincreasingfatigue,vagueabdominal
pain• Polyuria,polydipsia,enuresis,5-kgweightloss• Novomiting• Becomingprogressivelylethargictoday• Medicalhistory:unremarkable
Airway:• Assessairway• Provideheadtilt,chinlift,jawthrustasneeded
Breathing:• Checkoxygensaturation• Auscultatechest• IdentifyKussmaulrespirations
Circulation:• Applymonitors• CheckHR,BP,capillaryrefill• InsertIVcatheter,keepspatientnothingbymouth• Identifysinustachycardia
5
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
13 Simulation Scenarios Diabetic Ketoacidosis and Cerebral Edema
Scenario Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 1,continued
Assesses Hydration:• Capillaryrefill• Skinturgor• Mucousmembranes• Urineoutput• Assigndegreeofdehydration• Strictmonitoringofintakeandoutput
CNS:• Establishbaselineexamination• Expressneedtomonitorforcerebraledema
Medical Management:• Orderbloodwork:CBC,differential,electrolytes,renal
function,capillarygas,bedsideglucose,serumosmolality,andurinedipforglucose/ketones
• Bedsideglucose:criticallyhigh• Urinediporketones4+• IdentifyDKAasdiagnosis
Begin DKA protocol:• Havepatientweighed/askforpatientweight• ConsiderneedforIVnormalsalinebolus(10mL/kg)• CalculateIVrateassumingneedtoreplacedeficitevenly
over48h• Useappropriatereplacementfluidpendinglaboratory
results• OrderIVinsulininfusion• Useflowsheettotracklaboratoryresults,vitalsigns
STAGE 2 Condition: • Patientlessresponsive,GCSscoredecreasing
Physical Examination Findings:• GCSscoreof8(motorresponse3,vocalresponse3,eye
response2)• Temperature37.5°C(99.5°F),HR120/min,RR24/min,BP
110/60mmHg,oxygensaturation98%onroomair• Monitor:sinustachycardia• CNS:grumpyandtired,mumbling,eyesclosed• CVS:normalHS,capillaryrefill2s,pulsesstillweak• Respiratory:abitlesslabored• Abdomen:seemslesstender• Restofexaminationresultsunchanged
REASSESSMENT OF THE PATIENT:Airway:
• Suctiontheairway• Repositiontheheadwithheadtilt,chinlift,jawthrust• Reapplyoxygenmask
Breathing:• Reassess• Prepareforpossibleintubation:drawsuprapidsequence
intubationmedication
Circulation:• ReassessHR,BP,capillaryrefill
5
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
14 Simulation Scenarios Diabetic Ketoacidosis and Cerebral Edema
Scenario Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 2, continued
CNS:• ReassessGCSscore• Institutefrequentneurochecks• LookforCushingtriad,posturing
Medical Management:• Laboratoryresults:glucosecriticallyhigh(atbedside);urine4+
ketones,4+glucose,urinespecificgravity(SG)1.030• ContinueDKAprotocol• Recheckfluid-ratecalculations• Considerimpendingcerebraledemaandtranstentorial
herniation• CallICUforconsultation• Considermanagementofincreasedintracranialpressure:
IVmannitolor3%sodiumchloridesolution(ie,hypertonicsaline)
• Repeatbedsideglucosemeasurement• Orderrepeatlaboratorytests• Calculatecorrectedsodiumlevel• Recognizecoexistinghypernatremiaandneedforslow
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.ManagementofDKAinvolvesthepreparationandadministrationofvarioustypesofmedicationsandfluids.Therealismofthescenariocanbeincreasedby preparing labeled syringes with the names and concentrations of these medications and preparing an intravenous (IV) catheter with a drain so that the studentsareabletopushfluidsthroughthecatheter.
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
• IVfluidforvolumeexpansionisdeliveredtooaggressively.– 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.
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
15 Simulation Scenarios Hyperthermia
Hyperthermia
Adam Cheng, MD, FRCPC, FAAPMark Adler, MD
Learning Objectives
• Recognizethefeaturesofenvironmentalhyperthermia.• Demonstratethestepsintheinitialtreatmentofahyperthermicinfant.
Simulator: Infant Simulator
Scenario Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 1 History: • Eight-month-oldinfantwasunintentionallyleftinacarfor
2h;temperatureoutsidewas32.2°C(90°F)• Childwasapneic,pulseless,andcyanotic• CPRwasinitiatedbyparamedicswithbag-maskventilation.• ChildbroughttoEDbyparamedicswithCPRinprogress
Weight: • 8kg
Condition: • Apneicandnowwithfaintpulses(EMSreportspulsereturn
atarrival)• Temperature42°C(107.6°F),HR185/min,RR0/min,BP62/50
mmHg,oxygensaturation93%(bag-mask)• Monitor:sinustachycardia• CNS:obtunded,nonresponsive• Cardiovascular:capillaryrefill6–7s,weakpulsecentrally• Respiratory:coarsecracklesbilaterally• Abdomen:soft,noorganomegaly• Skin:hot,dry
Take a History: • Previouslyhealthy• Nomedicationsorallergies• Immunizationsuptodate• ParamedicshavebeendoingCPRfor5min
Airway:• Continuebag-maskventilation• Clearorsuctiontheairway• Prepareforpossibleintubation(gathersequipment)
Breathing: • Checkoxygensaturation• Applymonitors• Auscultatechest• Checkforadequacyofchestrisewithbagging
Circulation:• Applymonitors• Checkpulse,capillaryrefill,BP• EstablishIOaccess(IVattemptsfail)• Give20-mL/kgnormalsalinebolus• Ordervasopressor(dobutaminevsdopamine,avoids
primarilyα-agonists)
Disability and Exposure:• Checkneurologicstatus• Removeclothes• Activecoolingmeasures:coolingblanket,icebags,lower
roomtemperature,peritoneallavage(latterrarelyused)• Monitorrectaltemperature
5
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
16 Simulation Scenarios Hyperthermia
Scenario Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 1, continued
Medical Management: • Orderbloodwork:CPK,electrolytes,BUN,creatinine,CBC,
LFTs,bedsideglucose• OrderECG
STAGE 2 Condition: • Somecoolinghasoccurred
Physical Examination Findings:• Temperature40.5°C(105°F),HR169/min,RR20/min
(bagged),BP65/59mmHg,oxygensaturation98%• Monitor:sinustachycardia• CNS:obtunded,nonresponsive• CVS:weakpulses• Respiratory:clear• Abdomen:soft• Skinwarmanddry
Laboratory test results: • Glucoselevelnormal• Electrolytes(fromlaboratoryorgastestsifordered):sodium
148mmol/L,potassium4.6mmol/L,chloride110mmol/L,calculatedbicarbonate8mmol/L,ionizedcalcium1.01mmol/L
REASSESSMENT OF THE PATIENT:Airway:
• Mayconsiderintubation• Baggedatrateof8–10/min
Breathing:• Notbreathingspontaneously
Circulation:• Placeurinarycathetertoassessrenalfunction• Begindobutamineordopamine
Medical Management:• Sendurinesampleformyoglobin/UA
5
STAGE 3 Condition:• Improvement
Physical Examination Findings:• Temperature39.6°C(103.3°F),HR159/min,RR10/min
(bagged),BP63/59mmHg,saturation98%with100%oxygen
• Monitor:sinustachycardia• CNS:unconscious• CVS:capillaryrefill4s,pulsesweak• Respiratory:clear• Skin:warm
Laboratory test results: • CPK,400IU/L;UAandhemoglobin
REASSESS THE PATIENT:Airway:
• Reassessairway(considersintubationifnotalreadydone)
Breathing:• Assessbreathing
Circulation:• Titratepressors
Medical Management:• Considerfurthermanagementforpossiblerhabdomyolysis
(furosemideand/ormannitol)• Notifycriticalcarepersonnel
5
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
17 Simulation Scenarios Hyperthermia
Scenario Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 4 Disposition:Condition:
• Stable
Physical Examination Findings:• Temperature39.2°C(102.6°F),HR155/min,RR10/min
(bagged),BP63/59mmHg,saturation98%with100%oxygen
• Monitor:sinustachycardia• CNS:unconscious• CVS:capillaryrefill3s,pulsesweak• Respiratory:clear• Skin:warm
• ArrangeDispositiontoICU 2
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.
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
18 Simulation Scenarios Hypothermia—Near Drowning
Hypothermia—Near Drowning
Adam Cheng, MD, FRCPC, FAAPMark Adler, MD
Learning Objectives
• Describethedefinition,signs,andsymptomsofhypothermia.• Demonstratethetreatmentofapatientwithsubmersioninjury.
– 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 Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 1 History:• Six-year-oldboy• Wasboatingwithhisfatherwhenthesmallboat
inadvertentlyhitalargewaveandflippedover• Childwasnotwearingalifejacket• Fathersurvivedandswamwithunconsciouschildtoshore• CPRinitiatedonthesceneand911called• Onarrival,paramedicsnotedchildwasapneic,pulseless,
andcyanotic• CPRwasinitiatedbyparamedicswithbag-maskventilation
andcervicalcollarapplied• ChildbroughttoEDbyparamedicswithCPRinprogress
Weight: • 20kg
Take a History: • Previouslyhealthy• Nomedicationsorallergies• Immunizationsuptodate• ParamedicshavebeendoingCPRfor10min
Airway:• Maintaincervicalspineprecautions• TakeoverbaggingandCPRimmediately• Clearorsuctiontheairway• Identifyneedsforimmediateintubation• Intubatepatientwithoutsedationorparalysis
Breathing: • Checkoxygensaturation• Applymonitors• Auscultatechest• Checkforadequacyofchestriseaftertubeisplaced• IdentifythatETCO2detectionnothelpfulbecausechildis
pulseless• Orderchestradiographtoconfirmtubeplacement
3
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
19 Simulation Scenarios Hypothermia—Near Drowning
Scenario Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
Condition: • Apneicandpulseless• Temperature28°C(82.4°F),HR40/min,RR0/min,BPNA,
oxygensaturationNA• Monitor:sinusbradycardia• CNS:obtunded,nonresponsive,GCSscore3,cervicalspine
collaronpatient,bruisesandcutsonface• CVS:caprefill6–7s,nopulsepalpable• Respiratory:coarsecracklesbilaterally• Abdomen:bruisingalloverabdomen• Restofexaminationresultsnormal
Circulation:• Applymonitors• Checkpulse,capillaryrefill,BP• IdentifyPEA• InsertIVorIOcatheter• Donotorderepinephrine(adrenaline)becausecore
temperatureisbelow32°C(89.6°F)• GivewarmedIVfluidsthroughIOcatheterandattemptto
obtainsecondIV/IOaccess
Disability and Exposure:• CheckGCSscoreandneurologicstatus• Exposepatientcompletelytoconductasecondarysurvey• Applywarmblankets
Medical Management: • Orderbloodwork:arterialbloodgas,lactate,electrolytes,
BUN,creatinine,CBC,LFTs,glucose,crossmatch• Considerinternalrewarmingtechniques:gastriclavage,
bladderirrigation,andpossiblyperitonealirrigation• Activateextracorporealmembraneoxygenationteamand
PICUteam
STAGE 2 Condition:• Thepatient’sconditionhasnotchangedapartfroman
increaseinthetemperature.
Physical Examination Findings:• Temperature33°C(91.4°F),HR45/min,RR10/min(bagged),
BPNA,oxygensaturationNA• Monitor:sinusbradycardia• CNS:obtunded,nonresponsive,GCSscoreof3,cervical
spinecollaronpatient,bruisesandcutsonface• CVS:caprefill6–7s,nopulsepalpable• Respiratory:coarsecracklesbilaterally• Abdomen:bruisingalloverabdomen• Restofexaminationresultsnormal
REASSESSMENT OF THE PATIENT:Airway:
• Intubatepatient• Bagatrateof8–10/min• Maintaincervicalspineprecautions
Breathing:• Notbreathingspontaneously
Circulation:• ContinueCPR• IdentifyPEA,temperaturehasincreasednowto33°C
(91.4°F).• Deliverdefibrillationat2J/kg• ContinueCPRandorderepinephrine(adrenaline)viaIO
catheter• ContinueCPR• GiveIVnormalsalinefluidbolus
2
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
20 Simulation Scenarios Hypothermia—Near Drowning
Scenario Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 2, continued
Medical Management:• Chestradiograph:bilateralhazylungfields,endotracheal
tubeingoodposition• ABG:pH6.9,Pco215mmHg,Po260mmHg,bicarbonate3
mmol/L,baseexcess−27mmol/L• Lactate8.0mmol/L• Glucometer:criticallow:correctsthiswithbolusifIVD10W• Unabletoobtainotherlaboratorytests
STAGE 3 Condition:• Thepatientisbacktoaperfusingrhythm
Physical Examination Findings:• Temperature35°C(95°F),HR80/min,RR10/min(bagged),BP
60/PmmHg,saturation91%with100%oxygen• Monitor:sinusrhythm• CNS:intubatedandunconscious• CVS:capillaryrefill4s,pulsesweak• Respiratory:coarsecracklesbilaterally• Abdomen:bruisingallovertheabdomen• Restofexaminationresultsnormal
REASSESS THE PATIENT:
Airway:• Intubateandsedate• Maintaincervicalspineprecautions
Breathing:• Assessbreathing
Circulation:• Identifyhypotension• Identifysinusrhythm• Stopchestcompressions• GiveIVnormalsalinefluidbolus• OrderinotropeinfusionIV(dopamineorepinephrine
[adrenaline])• ArrangetransfertoICUforadmissiontohospital
Medical Management:• PerformCTscanofhead,neck,andabdomen• Consultgeneralsurgeon• Consultneurosurgeon• Notifyparents
5
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.
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
21 Simulation Scenarios Hypothermia—Near Drowning
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
• Failuretoconsistentlymaintaincervicalspineprotectionduringtheresuscitation.• Onecommonmistakeistoaggressivelyresuscitatethepatientwithmultipledosesofepinephrine(adrenaline)despitethepatientbeinghypothermic
(temperature <32°C [89.6°F]).• Failuretodryoffthepatientwithatowel.• Delayinginsertionofvenousaccessbyattemptingmultipleintravenouscatheterinsertions.Ideally,studentsshouldstartimmediatelywithattempted
intraosseous access.
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
22 Simulation Scenarios Iron Overdose
Iron Overdose
Adam Cheng, MD, FRCPC, FAAPMark Adler, MD
Learning Objectives
• Describethesignsandsymptomsofaninfantwithanironoverdose.• Demonstratethemanagementofacuteironintoxication.
Simulator: Infant Simulator
Scenario Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 1 History: • Twelve-month-oldboyfoundathomesleepy• Noprecedingillness• Chaotichomesettingwithfourotherchildrenandasingle
mother,shareshomewithanotherfamily
Weight: • 10kg
Condition: • Illappearanceandtachypnea,sleepy
Physical Examination Findings:• Temperature36.6°C(97.9°F),HR158/min,RR42/min,oxygen
saturation97%inroomair,BP68/42mmHg• CNS:asleep,wakesbrieflywithstimulation• CVS:pulsespresentcentrally,absentperipherally• Respiratory:clear• Abdomen:nohepatosplenomegaly• Extremities/skin:capillaryrefillapproximately3s
Take a History: • Noillcontacts• Nomedications• Patienthasvomitedathomeandhadloosestools• Ifasked,siblingisreceivingironsupplementationforanemia• Momhaslargebottleofironliquidmedicationathome
Airway:• Listenforbreathsounds,present• Applyoxygenvianonrebreathermaskat15L/min
Breathing: • Applymonitors,includingoxygensaturationandblood
pressure• Auscultatechestandobserverespiratoryrate
Circulation:• Assesspulse,HR,capillaryrefill,BP• AsknursetoplaceIVcatheter• AskfornormalsalineorlactatedRingersolutionbolusof20
mL/kgtobegivenquickly(push)
Medical Management:• Orderlaboratorytests(CBC,electrolytes,coagulation
studies,bloodcultures,venousbloodgas,bedsideglucose)
5
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
23 Simulation Scenarios Iron Overdose
Scenario Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 2 Condition:• HRremainselevatedandBPisnow68/52mmHg• Bloodglucoselevelisslightlyelevatedifbedsideglucose
wasmeasured• Venousgas:pH7.06,Pco228mmHg,Po239mmHg,base
excess−20mmol/L• Patientvomitsagain• Ironoverdoseexceeds60mg/kgbodyweight(providedif
teamasksdose)
Physical Examination Findings:• HR163/min,RR36/min,oxygensaturation98%in100%
oxygen(ifplaced),BP63/52mmHg• CNS:barelyrespondstoanystimuli• Respiratory:clear• CVS:clampeddownandcoolextremities• Abdomen:nohepatosplenomegaly
REASSESSMENT OF THE PATIENT:Airway/Breathing:
• Reassessairwaypatency,RR,andsaturations
Circulation:• ReassessHR,pulse,capillaryrefill,BPafterbolus• Ordersecondbolus,alsopush• Ordervasopressor(dopamine)tobedside(“Thatwilltake
about10–15minutestogetfromthepharmacy”)inanticipationofneedlater
Medical Management:• Ifteamfailstosuspectoverdose,canpromptwithstatement
“Someonehascalledtoinformthemomthatabottleofsiblingmedicationlabeledferroussulfateisopenandemptyonthefloor.”
• Ordersadditionaltests- VenousgastoassesspH
- Iron,salicylate,andacetaminophen(paracetamol)levels
- Abdominalradiographforpillfragments(givenhistoryofliquidingestion)
• Consultpoisoncontrolforrecommendations
5
STAGE 3 Condition:• “Hedoesn’tseemmuchbetter.”• Remainstachycardicaftersecondbolus• PoisoncontrolrecommendstreatmentwithIVdeferoxamine
Physical Examination Findings:• Unchangedfromstage2exceptthatHRisnow150/minand
BPis66/52mmHg• Abdomen:nohepatosplenomegaly
REASSESSMENT OF THE PATIENT:Circulation:
• ReassessHR,pulse,capillaryrefill,BP
Medical Management:• OrderthirdbolusofIVsalinepush• Beginadministrationofdopamineasitarrives,titratesto
improveBP(thishappenswhendopamineisrunningat10mcg/kg/min)
• Consultintensivecareserviceforadmission• Orderdeferoxamineasrecommended
5
STAGE 4 Condition:• Patientimproveswithvasopressorsupport
Physical Examination Findings:• HR148/min,BP78/62mmHg,saturation98%on
nonrebreathermask• Extremitiesfeelwarmer• Childissomewhatmorealert
REASSESS THE PATIENT:Disposition:
• ArrangeforICUadmissionortransporttotertiarycarefacility(dependingonpresentingfacilityresources)
5
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
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
24 Simulation Scenarios Iron Overdose
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)fluidforvolumeexpansionisnotdeliveredinarapidand/orcontrolledmanner.–IV“wideopen”fluidadministrationcanleadtoveryrapidinfusionofawholeliteroffluidORcanresultinunderresuscitationifthereissignificantresis-
tancetoflow(smallIVgauge).Infantsandsmallchildrenshouldalwaysreceiveresuscitationfluidsusingeitherapumporpushtoallowforobservationandcontroloffluiddelivery.Pressurebagscanincreasethelikelihoodofexcessivefluidoverload.
–Pushingfluidisaccomplishedbyattachingathree-waystopcockinlinewiththeIVcatheterandpullingfluiddirectlyfromthebag(step1)andthenswitchingthestopcockandpushingthefluidintothepatient.
• Failingtoconsideringestionasacauseofasepticshock–likepicture.Metabolicderangements,bothinbornerrorsandthoseduetoingestions,canmimicsepsis. The sudden onset and absence of fever are clues, as is the history of lead toxic effects (suggesting pica) and the chaotic home setting.
• Waitinguntilthethirdbolusisstartedorfinishedtoorderpressors.Participantsshouldrecognizeandanticipatethatinfantandpediatricpressordripsmust 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.
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
25 Simulation Scenarios Myocarditis—Cardiogenic Shock
Myocarditis—Cardiogenic Shock
Adam Cheng, MD, FRCPC, FAAPMark Adler, MD
Learning Objectives
• Describethesignsandsymptomsofcardiogenicshock.• Demonstratethetreatmentofachildincardiogenicshock.
– Initial stabilizing steps.– Order the appropriate investigations.– Select the appropriate inotrope.
Simulator: Pediatric Simulator
Scenario Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 1 History:• Five-year-oldboy• Cough,runnynose,andfeverfor5d• Diaphoreticandchillstoday• Shortofbreathandfellingunwell• Takentotheemergencydepartmentforassessment
Weight: • 20kg
Condition: • Looksveryunwell,toxic
Physical Examination Findings:• Temperature39°C(102.2°F),HR170/min,RR40/min,BP95/P
mmHg,oxygensaturation88%onroomair• Monitor:sinustachycardia• CNS:awake,GCSscoreof15• CVS:galloprhythm,softmurmur,caprefill3s,pulsesweak• Respiratory:cracklesbilaterally• Abdomen:liveredgepalpable• Restofexaminationresultsnormal
Take a History: • Previouslyhealthy• Otherkidsatschoolsickwithsimilarcough,coldsymptoms• Unwelltoday,sleptmostoftheday• Wokeup,vomitedfivetimes• Diaphoreticandchills• Givenacetaminophen(paracetamol)only
Airway:• Talktothepatient• Optimizeairwayposition:headtilt,chinlift,jawthrust
Breathing: • Checkoxygensaturation• Give100%oxygen• Auscultatechest
Circulation:• Askformonitors• Checkpulse,capillaryrefill,BP• Identifytherhythm(sinustachycardia)andrecognizes
uncompensatedshock• InsertIVcathetertwotimes(largebore)• OrderIVnormalsalinebolus
Medical Management:• Orderbloodwork:CBC,differential,bloodculture,
electrolytes,BUN,creatinine,glucose,bloodgas,LFTs,PTT,andINR
• OrderIVantibiotics
3
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
26 Simulation Scenarios Myocarditis—Cardiogenic Shock
Scenario Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 2 Condition:• Thepatient’sconditiondeterioratesastheBPdecreasesand
perfusionworsensafterthefirstbolusofnormalsaline
Physical Examination Findings:• Temperature39°C(102.2°F),HR180/min,RR45/min,BP70/P
mmHg,oxygensaturation90%on100%oxygen• Monitor:sinustachycardia• CNS:drowsybutarousable,GCSscoreof12• CVS:galloprhythm,softmurmur,caprefill4s,pulsesweak• Respiratory:crackles• Abdomen:liveredgepalpable• Restofexaminationresultsnormal
REASSESSMENT OF THE PATIENT:Airway:
• Reassessairway• Suctionairwayasneeded
Breathing:• Considerassistingventilationswithanesthesiabag/self-
inflatingbag
Circulation:• Identifyworseningshock• OrdersecondbolusofIVnormalsaline• InsertsecondIVcatheter(ifnotdonealready)
Medical Management:• Orderchestradiographtoevaluateforcardiogenicshock• OrderECG
2
STAGE 3 Condition:• Thepatient’sperfusionisgettingworsewiththesecond
fluidbolus
Physical Examination Findings:• Temperature39°C(102.2°F),HR180/min,RR45/min,BP
65/PmmHg,oxygensaturation92%on100%oxygenwithassistedventilations
• Monitor:sinustachycardia• CNS:drowsybutarousable,GCSscoreof12• CVS:galloprhythm,softmurmur,caprefill5s,pulsesweak• Respiratory:crackles• Abdomen:liveredgepalpable• Restofexaminationresultsnormal
REASSESSMENT OF THE PATIENT:Airway:
• Reassessairway• Suctionairwayasneeded• Prepareforrapidsequenceintubation
Breathing:• Assistventilationswithanesthesiabag/self-inflatingbag
Circulation:• Identifyworseningshock• OrderIVinotropeinfusionforsuspectedcardiogenicshock
(dopamine/milrinone/epinephrine[adrenaline]).
Medical Management:• Chestradiograph:bilateralhazy,wetlungfieldswithan
enlargedheart
5
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
• Overlyaggressivefluidresuscitationandfailuretoconsidercardiogenicshockinthedifferentialdiagnosis.• Delayinorderingantibiotics.• Orderingachestradiographorelectrocardiogramarenotconsideredaspartoftheworkupforthispatient.
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
27 Simulation Scenarios Occult Trauma (Non-accidental Trauma)
Occult Trauma (Non-accidental Trauma)
Adam Cheng, MD, FRCPC, FAAPMark Adler, MD
Learning Objectives
• Describethe“redflags”inahistorythatraiseconcernfornon-accidentaltrauma(andrecognizethesemightormightnotbepresentinallcases).• Describethesignsandsymptomsofaninfantwithnonoccultmultisystemtrauma.• Demonstratethemanagementofmultisystemtrauma.
– 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 Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 1 History: • Six-month-oldchildfoundbyparentincrib,unarousable
afternap• Babysitterputhimdownafewhoursago,thoughthe
wasfine• Childwascompletelywellwhenparentleftthismorning• Triagenursehasrushedpatientbacktoresuscitationroom
becauseheisbarelyresponsiveattriage• Youarrivetoassessthepatient
Weight: • 7kg
Condition: • Infantispinkandwellperfusedbutcomatose
Physical Examination Findings:• Temperature37.2°C(99°F),HR104/min,RR12/min,oxygen
saturation97%inroomair,BP89/66mmHg• CNS:unresponsive,ifpainfulstimulationisgiven(nailbed
pressureorsternalrub,demonstrateEXTENSORposturing:“Thechilddidthis[demonstrate]whenyoudidthat?”)
Take a History:• Noallergies• Nomedications• Noillcontacts• Noideaatallwhathashappened• Nohistoryoftraumaorfall• Nootherchildreninhome• Babysitterhasbeenwiththemapproximately1month
Airway:• Listenforbreathsounds,presentbutslow• Applyoxygenvianonrebreathermaskat15L/min
Breathing: • Applymonitors,includingoxygensaturationandBP• Auscultatechestandobserverespiratoryrate
Circulation:• Assesspulse,HR,capillaryrefill,BP• AsknursetoobtainIVaccess,ideallytwolargerIVcatheters
3–4
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
28 Simulation Scenarios Occult Trauma (Non-accidental Trauma)
Scenario Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 1, continued
–Ifexamined,theleftpupilisdilatedmaximallyandfixed;rightis2–3mmandbarelyreactive
• CVS:pulsesintact• Respiratory:clearandslow• Abdomen:softandwithouthepatosplenomegaly• Extremities/skin:nobruisingnoted(ifasked)
Disability:• Quickneurologicassessment(pupils,responsetopain)• AssessmentofGCSscore
Environment and Exposure:• Removepatientclothing,examinecompletely• Keeppatienteuthermic(blanketorwarmingequipment)
STAGE 2 Condition:• Mentalstatusunchanged• Bloodglucoselevelisnormalifobtained• BPisincreasingandHRisslowingsteadily
Physical Examination Findings:• HR94/min,RR6–8/min(irregularifthisisasupported
feature),BP106/88mmHg(ifsimulatorsupports,thistrendcanbesettoprogressoverthefirst4–5min)
• CNS:unchanged• Respiratory:clear,rateisnowslower• CVS:unchanged• Abdomen:somewhatmorefullthanbefore,no
organomegaly
REASSESSMENT OF THE PATIENT:
Airway/Breathing:• Prepareforintubationduetopoormentalstatus• Gathernecessarymaterials(SOAPmnemonic)
–Suction
–Oxygenequipment(bag-mask,endotrachealtube,qualitativeETCO2detector,orETCO2monitor)
–Airwayequipment(laryngoscopeandblade)
–Pharmacy:rapidsequencemedication
Circulation:• Considerfluidmanagementinlightofsignsofintracranial
pressure
Disability:• Mayelevateheadofbed• Consultneurosurgery
Medical Management:• Orderlaboratorytests(LFTswithorwithoutpancreatic
enzymestoscreenforabdominaltrauma,typeandcross)• OrderCTscanofheadandabdomen,notifyscannerof
arrivalassoonaspatientisintubated
3
STAGE 3 Condition:• Unchangedexceptforcontinuingtrend(HR82/min,BP
110/92mmHg)–Orderingachestradiograph
• Securetube(canbedonebynurseconfederate)
INTUBATION:
Airway/Breathing:• Completerapidsequenceintubation
–Considerlidocaine(lignocaine)premedication
–Sedationmedication
–Paralyticmedication
–Tubeplacedwithoptionalcricoidpressure
• Tubeplacementconfirmedby:–Auscultation
–Directvisualizationofchestmovement
–ETCO2detector
5
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
29 Simulation Scenarios Occult Trauma (Non-accidental Trauma)
Scenario Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 3, continued
Circulation:• ReassessHR,pulse,capillaryrefill,BP
Disability:• AvoidexcessivehyperventilationforelevatedICP(seenote
below)• ConsiderIVmannitol(orothersimilaragents)
Medical Management:• Revieworderedlaboratorytestresults
STAGE 4 Condition:• Stable(seenote)
REASSESS THE PATIENT:Disposition:
• ArrangefortransportforCTscanwithappropriatestaff(someonewhocouldreintubateifairwayislost)
• Notifysurgeonofabdominalfindings• Notifyparents• Plansocialworkconsultandreportofsuspectedchildabuse
5
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.
Notes1. Thisisanimportanttopicforwhichsomespecificmanagementstepsvaryamonginstitutions.ThiscasecontentreflectstheAdvancedPediatricLifeSupportrecommended
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
otherosmoticagents,orshort-termmildhyperventilation.
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. Thiscaseiswrittentobeonlymildlysuggestiveofnon-accidentaltraumatopreventimmediateidentificationoftheproblemtotheexclusionofallothercauses.Itisour
experiencethatpediatrichealthcareworkersaresensitizedtothemoreobvious“redflags”(eg,mom’sboyfriendathomealonewithchild).Similarly,abulgingfontanelle(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.
• Focusontheintracranialprocesstotheexclusionofotherinjuries.Thispatienthasagrade5liverlacerationthatiscurrentlynotcausinghemodynamicissues.Ifthepatient
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-abdominalbleeding.
• Theteamconsiderssendingthepatientforcomputedtomography(CT)withoutairwaycontrol.Theconfederatenursestates,“ThispatientseemstooilltogotoCTlikethis.”
• Teamdoesnotknowthecorrectintubationmedications.Inthiscase,treatmentcanbestoppedbeforeintubation,andthismaterialcanbereviewedasdiscussedinthetext.
• Theteamintubatesthepatientwithoutanymedications.Allowthecasetoproceedanddiscussafterwardthelikelyimpactonintracranialpressureofthisapproach.
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
30 Simulation Scenarios Postoperative Cardiac Patient—Ventricular Fibrillation
Postoperative Cardiac Patient—Ventricular Fibrillation
Adam Cheng, MD, FRCPC, FAAPMark Adler, MD
Learning Objectives
• Describethesignsandsymptomsofachildpresentingwithunstableventriculartachycardia.• Describethesignsandsymptomsofachildpresentingwithventricularfibrillationandcardiacarrest.• Demonstratethetreatmentofachildwithunstableventriculartachycardia.
– Demonstrates knowledge of the Pediatric Advanced Life Support (PALS) unstable ventricular tachycardia algorithm.• Demonstratethetreatmentofachildwithventricularfibrillation.
– Recognize ventricular fibrillation.– Recognizetheimportanceofhigh-qualitychestcompressionsandearlydefibrillation.– Demonstrates proper use of the defibrillator.– Demonstrates knowledge of the PALS ventricular fibrillation algorithm.
Simulator: Pediatric Simulator
Scenario Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 1 History:• Four-year-oldboy• Recentcardiacsurgeryforcongenitalheartdisease4dago• Vomitedthreetimestoday• Feelingunwell,lightheaded• TakentotheEDforassessment
Weight: • 20kg
Condition:• Looksveryunwell,toxic
Physical Examination Findings:• Temperature37.4°C(99.3°F),HR170/min,RR35/min,BP
60/PmmHg,oxygensaturation88%inroomair• Monitor:ventriculartachycardia• CNS:drowsyanddifficulttoarouse,GCSscoreof10• CVS:galloprhythm,loudmurmur,caprefill4s,pulsesweak• Respiratory:clear• Restofexaminationresultsnormal
Take a History: • Unwelltoday,sleptmostoftheday• Difficulttoawakenthisafternoon,broughttoED
Airway:• Talktothepatient• Openairway• Headtilt,chinlift,jawthrust• Prepareforrapidsequenceintubation
Breathing: • Checkoxygensaturation• Apply100%oxygenbymask• Auscultatechest
Circulation:• Applymonitors• Checkpulse,capillaryrefill,BP• Identifyunstableventriculartachycardia• InsertIVcatheter2times
5
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
31 Simulation Scenarios Postoperative Cardiac Patient—Ventricular Fibrillation
Scenario Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 1, continued
• OrderIVsedative(eg,ketamine)andpreparesforsynchronizedcardioversion(thisparticularpointiscontroversialandwouldbeagooddiscussionpointbecausethepatientmightbetoounstabletotolerateasedative)
Medical Management:• SynchronizecardioversionasperPALSprotocol• Orderbloodwork:CBC,differential,bloodculture,
electrolytes,BUN,creatinine,glucose,bloodgas,LFTs,PTT,andINR
STAGE 2 Condition:• Thepatientisunconscious,GCSscoreof3• Rhythm:ventricularfibrillation
Physical Examination Findings:• Temperature37.4°C(99.3°F),HRNA,RR0/min,BPNA,
oxygensaturationNA• Monitor:ventricularfibrillation• CNS:GCSscoreof3• CVS:capillaryrefill8s,pulsesnotpalpable• Respiratory:clear• Restofexaminationresultsnormal
REASSESSMENT OF PATIENT:
Airway:• Recheckairway• Intubatepatientnowwithoutsedationorparalysis
Breathing:• Reassessbreathing• Manuallyprovidethepatientwithventilatoryassistance
Circulation:• Identifyventricularfibrillation• StartCPRimmediatelywithbackboardinplace• Defibrillationat2J/kgthenCPRasperPALSprotocol• ContinueCPRandthendefibrillatesagainat4J/kg• GiveIV/IOepinephrine(adrenaline)• Reassesspulseandrhythm
3
STAGE 3 Condition: • Looksveryunwell,toxic,rhythmchangestonormalsinus
rhythm
Physical Examination Findings:• Temperature37.4°C(99.3°F),HR80/min,RR6/min,BP70/P
mmHg,oxygensaturation90%withbagging• Monitor:sinusrhythm• CNS:unresponsive,intubated,GCSscoreof3
REASSESSMENT OF PATIENT:
Airway:• Recheckairwayandtube
Breathing:• Reassessbreathing• Continuetobagventilatethepatient
Circulation:• Identifychangetosinusrhythm,checksforpulse• StopCPR• Administernormalsalinebolus• Startinotropeinfusion:dopamineorepinephrine
(adrenaline)
2
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
32 Simulation Scenarios Postoperative Cardiac Patient—Ventricular Fibrillation
Scenario Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 3, continued
• CVS:galloprhythm,softmurmur,capillaryrefill5s,pulsesveryweak
• Respiratory:bilateralcrackles
Medical Management:• ConsultICUandcardiologypersonnel• OrderECGandchestradiograph
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
• Defibrillationofunstableventriculartachycardia(insteadofsynchronizedcardioversion).• Managementofunstableventriculartachycardiawithmedicationonly.• Delayeddefibrillationafterrecognitionofventricularfibrillation.• Delayedinitiationofchestcompressionsafterrecognitionofventricularfibrillation.• Managementofairway(intubation)beforedefibrillationorchestcompressionswhilethepatientisinventricularfibrillation.• Failuretoadequatelypreparemedicationsforventricularfibrillation.Instructorsshouldencouragestudentstoprepareepinephrine(adrenaline),amiodarone,
and lidocaine (lignocaine) immediately on recognition of the rhythm.
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
33 Simulation Scenarios Septic Shock
Septic Shock
Adam Cheng, MD, FRCPC, FAAPMark Adler, MD
Learning Objectives
• Describethesignsandsymptomsofaninfantwithsepticshock.• Demonstratethemanagementofcirculatoryfailureduetosepsis.
– 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 Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 1 History:• Seven-month-oldboy,intreatmentforacutelymphocytic
leukemiapresentswithtemperaturesto39.6°C(103.3°F)(temporal)
• Decreasedactivitysinceyesterday• Chemotherapylastgiven4dago,don’tknowwhatdrugs
weregiven• Triagenursewasworriedhowlittleherespondedtoher
examination• Youarrivetoassessthepatient
Weight:• 7kg
Condition: • Veryunwell,listless,feelswarmovercorebuthandsarecool
Physical Examination Findings:• Temperature39.6°C(103.3°F),HR158/min,RR36/min,
oxygensaturation96%inroomair,BP72/58mmHg• CNS:asleep,wakesbrieflywithpainfulstimulation• CVS:pulsespresentcentrally,absentperipherally• Respiratory:clear• Abdomen:nohepatosplenomegaly• Extremities/skin:capillaryrefill>4s,scatteredpetechiae
Take a History:• Noillcontacts• Hasadouble-lumenport• Hashadonepreviousadmissionforfeverandneutropenia
at1monthage• VomitedonceenroutetotheED• Takestrimethoprim-sulfamethoxazole3dperweek,got
ibuprofenattriage;istakingprednisoneaspartofhischemotherapy
• Allergictovancomycin(redmansyndrome)
Airway:• Listenforbreathsounds,present• Applyoxygenvianonrebreathermaskat15L/min
Breathing: • Applymonitors,includingoxygensaturationandblood
pressure• Auscultatechestandobserverespiratoryrate
Circulation:• Assesspulse,HR,capillaryrefill,BP• Asknursetoaccessport• AskfornormalsalineorlactatedRingersolutionbolusof20
mL/kgtobegivenquickly(push)
Medical Management:• Orderlaboratorytests(CBC,electrolytes,coagulation
studies,bloodcultures,venousbloodgas,bedsideglucose)
3–4
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
34 Simulation Scenarios Septic Shock
Scenario Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 2 Condition:• HRremainselevatedandBPisnow63/52mmHg• Nursenotesaloud,“Hishandsarejustsocold.”• Bloodglucoselevelisnormalifbedsideglucosetestwas
performed
Physical Examination Findings:• HR163/min,RR36/min,oxygensaturation98%in100%
oxygen(ifplaced),BP63/52mmHg• CNS:barelyrespondstoanystimuli• Respiratory:clear• CVS:clampeddownandcoolextremities• Abdomen:nohepatosplenomegaly
REASSESSMENT OF THE PATIENT:
Circulation:• ReassessHR,pulse,capillaryrefill,BPafterbolus• Ordersecondbolus,alsopush• Ordervasopressor(dopamine)tobedside(“Thatwill
takeabout10–15minutestogetfromthepharmacy.”)inanticipationofneedlater
Medical Management:• Orderantibiotics(broadspectrumtoincludecoveragefor
pseudomonas,eg,ceftazidimeormeropenem/imipenem)
3
STAGE 3 Condition:• “Hedoesn’tseemmuchbetter.”• Remainstachycardicaftersecondbolus
Physical Examination Findings:• Unchangedfromstage2exceptthatHRisnow150/minand
BPis66/52mmHg• Abdomen:nohepatosplenomegaly
REASSESSMENT OF THE PATIENT:
Circulation:• ReassessHR,pulse,capillaryrefill,BP
Medical Management:• OrderthirdbolusofnormalsalineIVpush• Begindopamineasitarrives,titratestoimproveBP(this
happenswhendopamineisrunningat10mcg/kg/min)• Orderhydrocortisonestressdosegivenpatient’sdaily
prednisone(canaskforhelpwithdosing)• Consultintensivecareservice
5
STAGE 4 Condition:• Patientimproves
Physical Examination Findings:• HR148/min,BP78/62/min,saturation98%on100%oxygen• Extremitiesfeelwarmer• Childissomewhatmorealert
REASSESS THE PATIENT:
Disposition:• ArrangeforICUadmissionortransporttotertiarycare
facility(dependingonpresentingfacilityresources)
5
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
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
35 Simulation Scenarios Septic Shock
Common Pitfalls
• Intravenous(IV)fluidforvolumeexpansionisnotdeliveredinarapidand/orcontrolledmanner.– IV“wideopen”fluidadministrationcanleadtoveryrapidinfusionofawholeliteroffluidORcanresultinunderresuscitationifthereissignificantresis-
tancetoflow(smallIVgauge).Infantsandsmallchildrenshouldalwaysreceiveresuscitationfluidsusingeitherapumporpushtoallowforobservationandcontroloffluiddelivery.Pressurebagscanincreasethelikelihoodofexcessivefluidoverload.
– Pushingfluidisaccomplishedbyattachingathree-waystopcockinlinewiththeIVcatheterandpullingfluiddirectlyfromthebag(step1)andthenswitchingthestopcockandpushingthefluidintothepatient.
• Withholdingantibioticsuntileitherthepatientimprovesorculturesand/ortestingiscomplete.Thisinfantiscriticallyillandantibioticsshouldbegivenasearly as is practical.
• Failingtocheckabedsideglucoselevel.Hypoglycemiaisatreatablecauseofalteredmentalstatus,andillinfantswithpoorglycogenstoresandapoorrecentoral intake due to illness are prone to this condition.
• Waitinguntilthethirdbolusisstartedorfinishedtoorderpressors.Participantsshouldrecognizeandanticipatethatinfantandpediatricpressordripsmustbe 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.
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
36 Simulation Scenarios Chest Crisis—Sickle Cell Disease
Chest Crisis—Sickle Cell Disease
Adam Cheng, MD, FRCPC, FAAPMark Adler, MD
Learning Objectives
• Describethesignsandsymptomsofachildpresentingwithchestcrisisandsicklecelldisease.• Demonstratethetreatmentforachildwithasicklecellchestcrisis.
– Initial stabilizing steps.– Performfluidmanagementandresuscitation.– Understand the importance of repeat assessment in children with chest crisis.– Demonstrate knowledge of appropriate antibiotic therapy.
Simulator: Pediatric Simulator
Scenario Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 1 History:• Seven-year-oldboy• Knownhomozygoussicklecelldisease.• Feverthisafternoon• Coughing2timesperday• Feelingunwellandbroughttothehospital• Initialoxygensaturationattriageis88%inroomair
Weight:• 22kg
Condition: • Veryunwell,listless,feelswarmovercorebuthandsarecool
Physical Examination Findings:• Temperature39.5°C(103°F),HR130/min,RR30/min,oxygen
saturation88%inroomair,BP95/PmmHg• CNS:awakeandalert• Respiratory:diffusecracklesbilaterallywithpoorairentryto
right• CVS:pulsesstrong,capillaryrefill2s• Musculoskeletal:nobonytendernessorpain• Restofexaminationresultsnormal
Take a History:• Multiplepreviousadmissions• HistoryofchestcrisistwotimeswithadmissiontoICUfor
exchangetransfusion• Sepsisonetime,dactylitisonetime,bony(vaso-occlusive)
crisisfivetimes• Takingprophylacticantibiotics• Immunizationsuptodate
Airway:• Opentheairway• Headtilt,chinlift,jawthrust
Breathing: • Applymonitors• Auscultatechestandobservesrespiratoryrate• Oxygensaturation• Applyoxygen(100%)• Getself-inflatingbagready
Circulation:• Assesspulse,HR,capillaryrefill,BP• ObtainIVaccess
2
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
37 Simulation Scenarios Chest Crisis—Sickle Cell Disease
Scenario Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 1, continued
Medical Management:• Bloodwork:CBC,differential,bloodculture,gas,electrolytes,
BUN,creatinine,glucose• IVceftriaxoneanderythromycin• Chestradiograph• IVfluids(D5NS)athalftoonetimesmaintenance
STAGE 2 Condition:• Looksunwell,moderate-severedistress,notoxygenating
wellwithfacemaskoxygen,bloodpressuredecreasing,andperfusionworsening
Physical Examination Findings:• Temperature39.5°C(103°F),HR130/min,RR38/min,
saturation88%with100%oxygen,BP70/PmmHg• CNS:becomingmoredrowsy• Respiratory:diffusecracklesbilaterallywithpoorairentryto
right• CVS:pulsesweak,capillaryrefill4s• Restofexaminationresultsnormal
REASSESSMENT OF THE PATIENT:Airway:
• Suctiontheairway• Repositiontheheadwithheadtilt,chinlift,jawthrust• Reapplyoxygenmask
Intubation:• Preparation/equipment• Preoxygenation;RR12–15./min• Cricoidpressure• Premedication:IVatropine• Sedation:IVketamine• Paralysis:IVsuccinylcholineorrocuronium• IntubatewithETT• Checktubeplacementwithend-tidalcarbondioxide,
auscultationandchestradiograph
Breathing:• ReassessbreathingandRR• Callforhelp• Considerusinghigh-flowoxygenoranesthesiabagto
providesomeCPAP• Supportventilation:bag-maskventilation
Circulation:• ReassessHR,pulse,capillaryrefill,BP• IVaccessobtainedbynow• Givenormalsalinebolusthenrepeatsasnecessary• PerformABGmeasurement
5
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
38 Simulation Scenarios Chest Crisis—Sickle Cell Disease
Scenario Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 3 Condition: • Looksunwell,oxygenationandBPimprovedslightly
Physical Examination Findings:• Temperature39.5°C(103°F),HR130/min,RR30/min,oxygen
saturation94%intubatedandventilated,BP80/PmmHg• CNS:paralyzedandsedated• Respiratory:diffusecracklesbilaterallywithpoorairentryto
right• CVS:pulsesweak,capillaryrefill4s
REASSESS THE PATIENT:Airway:
• SuctiontheETT:somethinmucusorsecretions
Breathing:• Auscultatethechest• Checkchestmovementandsymmetry
Circulation:• CheckpulseandBP• ConsiderrepeatIVfluidbolusforhypotension• Orderinotropeinfusionandtitratesinfusiontoincreasethe
BP
Medical Management:• CallICUconsultantforhelp• Preparefortransport• Followuponchestradiograph• Consideraddingvancomycin
3
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
• Overlyaggressivefluidresuscitation,leadingtopulmonaryedemaandrespiratoryfailure.• Delayedadministrationofantibiotics.• Failuretoreassesspatientanddelayedrecognitionofrespiratorydecompensation.
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
39 Simulation Scenarios Status Asthmaticus
Status Asthmaticus
Adam Cheng, MD, FRCPC, FAAPMark Adler, MD
Learning Objectives
• Describethesignsandsymptomsofachildpresentinginstatusasthmaticus.• Recognizethesignsandsymptomsofrespiratoryfailure.• Demonstratethetreatmentofachildwithstatusasthmaticus.
– Initial stabilizing steps.– Demonstrate knowledge of medical management of status asthmaticus.– Understand dangers of intubating a sick asthmatic patient.
Simulator: Pediatric Simulator
Scenario Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 1 History: • Five-year-oldboy• Knowntohaveasthma• Takingalbuterol(salbutamol)andfluticasonepuffersat
home• Increasingcoughandshortnessofbreathathometoday• Febrile• Initialoxygensaturationattriageis88%inroomair• TreatedbyEDnursingstaffrightawayandgivenalbuterol
(salbutamol)andipratropiumbromide• Youarrivetoassessthepatient.
Weight: • 20kg
Condition: • Veryunwell,severedistress
Physical Examination Findings:• Temperature38°C(100.4°F),HR130/min,RR36/min,oxygen
saturation88%inroomair,BP110/50mmHg• CNS:awakeandalert• CVS:pulsesstrong,capillaryrefill2s• Respiratory:scattered,diffusewheezesbilaterally,
retractions• Restofexaminationresultsnormal
Take a History: • RecentcontactwithyoungersiblingwithURIsymptoms• FourpreviousadmissionsandoncetotheICU,never
intubated• Vomitedonceathome• Tookalbuterol(salbutamol),twopuffssixtimesathome
withnoimprovement,thencametotheED
Airway:• Talktothepatient• Suctionsecretions• Callforhelp:respiratorytherapy
Breathing: • Applymonitors,includingoxygensaturation• Auscultatechestandobserverespiratoryrate• Applyoxygenvianonrebreather(100%)ORmovedirectlyto
secondnebulization• Consideralbuterol(salbutamol)andipratropiumbromide
backtobackthreetimesintotal• Getanesthesiabagorself-inflatingbagready.• Giveoralsteroid(dexamethasoneorprednisoloneor
prednisone)orparenteralsteroid
Circulation:• Assesspulse,HR,capillaryrefill,BP
2
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
40 Simulation Scenarios Status Asthmaticus
Scenario Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 2 Condition:• Afterthebacktobackalbuterol(salbutamol)and
ipratropium,patientisstillunwell• Coughingpersistently• Persistentrespiratorydistress• Childsuddenlyvomitsprofusely
Physical Examination Findings:• Temperature38°C(100.4°F),HR150/min,RR40/min,oxygen
saturation92%in100%oxygen,BP100/55mmHg• CNS:gagging,irritable,coughingpersistently• Respiratory:diffusewheezesbilaterallywithindrawing,
trachealtug,andworseningretractions• CVS:pulsesstrong,capillaryrefill2s• Restofexaminationresultsnormal
REASSESSMENT OF THE PATIENT:Airway:
• Suctiontheairway• Repositiontheheadwithheadtilt,chinlift,jawthrust
(recognizingthischildisdistressedandvomiting,mightbebettertohavehimonhissideaswell)
• Reapplyoxygenmask
Breathing:• ReassessbreathingandRR• Callforhelpfromrespiratorytherapy(ifnotdonealready)• Givecontinuousalbuterol(salbutamol)vianebulization
Circulation:• ReassessHR,pulse,capillaryrefill,BP• IVaccess• Givesteroids(IV)becausehemighthavevomitedoral
steroids• Givemagnesiumsulfate(IV)
Medical Management:• PerformbloodworkwithIVstart:CBC,differential,culture,
electrolytes,gas• Getimmediatechestradiographandgiveantibioticsifsigns
offocalconsolidation
3
STAGE 3 Condition:• Yourpatientseemstobeworkinghardertobreath• Severerespiratorydistress• Nolongerrespondingtoverbalcommands
Physical Examination Findings:• Temperature39°C(102.2°F),HR160/min,RR40/min,BP
110/55mmHg,oxygensaturation84%in100%oxygen.• CNS:drowsy• Respiratory:diffusewheezes,retractions• CVS:wellperfused,capillaryrefill2s• Restofexaminationresultsunchangedfromabove
REASSESSMENT OF THE PATIENT:Airway:
• Suctiontheairway• Repositiontheheadwithheadtilt,chinlift,jawthrust• Reapplyoxygenmask• Considertowelrollatthispoint
If learner proceeds with intubation:• Preparation/equipment• Preoxygenation;RR,8–12/minwithprolongedexpiratory
phase• Cricoidpressure• Premedication:IVatropine• Sedation:ketamineIV.• Paralysis:IVsuccinylcholine• IntubatewithETT5.0cuffed• ChecktubeplacementwithETCO2,auscultation,chest
radiograph• Nasogastrictubeplacement
5
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
41 Simulation Scenarios Status Asthmaticus
Scenario Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 3, continued
Breathing:• ReassessbreathingandRR• Obtainchestradiographifnotalreadydonebynow
Circulation:• ReassessHR,pulse,capillaryrefill,BP
Medical Management:• CallICUforhelp• ConsiderIVaminophyllineorIVb-agonist.• ConsiderBiPAPorCPAP
STAGE 4 Condition:• Patientconditiondeterioratesafterintubation
Physical Examination Findings:• Verydifficulttoprovideventilation• Poorchestrisebilaterally• Temperature38°C(100.4°F),HR80/min,RRbagging,
saturation78%in100%oxygen,BP80/50mmHg• CNS:sedated/paralyzed• Respiratory:poorchestriseandairentrybilaterallywith
wheezing• CVS:pulsesweak,capillaryrefill4s
REASSESS THE PATIENT:Airway:
• SuctiontheETT:somethinmucusorsecretions• Considerdirectvisualizationofthetubewithlaryngoscope
Breathing:• Auscultatethechest• Checkforsignsoftensionpneumothorax(tracheamidline,
bloodpressure,percussionofchest,jugularvenouspressure)
• Givecontinuousnebulizedin-linealbuterol(salbutamol)• Checkoxygen/equipment• Bag-maskventilatesataslowerratewithaprolonged
expiratoryphase
Circulation:• InsertsecondIVcatheter• GiveIVbolusofnormalsaline
5
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)andipratropiumbromideshouldideallybeadministeredviametered-doseinhaler.
Common Pitfalls
• Overventilationofthepatient—leadstobreathstackingandpotentialforpneumothoraxordepressedcardiacreturnandeventualcardiacarrest.• Earlyintubationattemptwithoutconsiderationofotherpossiblemanagementoptions(eg,magnesiumsulfate,noninvasiveventilation).
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
42 Simulation Scenarios Status Epilepticus
Status Epilepticus
Adam Cheng, MD, FRCPC, FAAPMark Adler, MD
Learning Objectives
• Describethesignsandsymptomsofachildpresentinginstatusepilepticus.• Demonstratethetreatmentofachildwithstatusepilepticus.
– 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 Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 1 History: • Four-year-oldboy• Highfeverfor3d• Headacheandneckpainfor2d• Irritabletoday• Founddrowsyandunresponsiveathomeonthefloor• ParamedicsbringingchildtotheED• Seizingenroutefor5min
Weight: • 15kg
Condition: • Activelyseizingpatientonarrival
Physical Examination Findings:• Temperature39.5°C(103°F),HR160/min,RR25/min,BP
110/PmmHg,oxygensaturation92%inroomair• Monitor:sinustachycardia• CNS:seizing(generalized)• CVS:normalheartsounds,capillaryrefill2s,pulsesstrong• Respiratory:clear,poorairentrybilaterally• Restofexaminationresultsnormal
Take a History: • Previouslyhealthy,nopriorseizures• Unimmunized
Airway:• Openairway• Headtilt,chinlift,jawthrust• Suction• Assignsomeonetoattendtoairway• Callrespiratorytherapyforhelp
Breathing: • Checkoxygensaturation• Applymonitors• Applyoxygenbymask• Auscultatechest
Circulation:• Applymonitors• Checkpulse,capillaryrefill,BP• IVaccessnotobtainableinitially
Medical Management:• Checkglucoselevel:5.0mmol/L(90mg/dL)(normal)• GivelorazepamordiazepamPR,thenIVlorazepamtwotimes• Orderphenytoin/fosphenytoin• Orderbloodwork:CBC,electrolytes,bloodgas,lactate,renal
function,bloodculture• Orderantibiotics:ceftriaxone,vancomycin,acyclovir
2
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
43 Simulation Scenarios Status Epilepticus
Scenario Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 2 Condition: • Activelyseizingpatient,childvomitingprofuselyand
frothingatthemouth,thendesaturates
Physical Examination Findings:• Temperature39.5°C(103°F),HR160/min,RR25/min,BP
110/PmmHg,saturation85%inroomair• Monitor:sinustachycardia• CNS:seizingstill• CVS:normalheartsounds,capillaryrefill2s,pulsesstrong• Respiratory:poorairentrybilaterally• Restofexaminationresultsnormal
REASSESSMENT OF THE PATIENT:Airway:
• Maintaintheairway:jawthrust,chinlift,headtilt• Suctionvigorously• Considerintubationandpreparesequipment
Breathing:• Increaseoxygendeliveryto100%byusingnonrebreather
mask• Prepareself-inflatingbag
Circulation:• IVaccesstwotimes• CheckHR,BP,capillaryrefill,pulses• CycleBPevery3–5min
Medical Management:• Laboratorytestresultscomeback:
–Sodium130mmol/L,potassium3.5mmol/L,glucosenormal
–ABG:pH7.15,Pco260mmHg,Po290mmHg,bicarbonate20mmol/L,baseexcess−7mmol/L
3
STAGE 3 Condition: • Activelyseizingpatient,bloodpressureandrespiratoryrate
starttodecrease
Physical Examination Findings:• Temperature39.5°C(103°F),HR160/min,RR12/min,BP70/P
mmHg,saturation89%inroomair• Monitor:sinustachycardia• CNS:seizing• CVS:normalheartsounds,capillaryrefill3–4s,pulsesweak• Respiratory:poorairentrybilaterally• Restofexaminationresultsnormal
REASSESSMENT OF PATIENT:Airway: Intubation:
• Preoxygenation• Premedication:IVatropineIVoptional• Cricoidpressure• Sedation:IVketamine,IVmidazolam,IVthiopental,orIV
propofol• Paralysis:IVsuccinylcholine• ChecktubeplacementwithETCO2detector,auscultationof
chest,observationofchestriseandorderchestradiograph
Breathing:• Reassessbreathing• Starttoprovideventilatoryassistancetothepatient
Circulation:• Identifyhypoxiaandworseninghypotension• Reassessbloodpressure,pulse,capillaryrefill• GiveIVnormalsalinebolus
5
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
44 Simulation Scenarios Status Epilepticus
Scenario Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 3, continued
Medical Management:• CallICU• Startinfusionofotheranticonvulsants(gooddiscussion
point);optionsincludelevetiracetam(oftengivenfirstlineinsteadoffosphenytoin)andphenobarbital
• IVantibiotics(cefotaxime/vancomycinorsimilarandacyclovir)tocoverthepossibilitiesofbacterialmeningitisandherpesencephalitis
STAGE 4 Condition: • Activelyseizingpatient,bloodpressurestilllow,butoxygen
saturationsimprovedafterintubation
Physical Examination Findings:• Temperature39.5°C(103°F),HR160/min,RR12/min,BP70/P
mmHg,saturation95%withoxygen• Monitor:sinustachycardia• CNS:generalized,tonic-clonicseizure• CVS:normalheartsounds,capillaryrefill2s,pulsesstrong• Respiratory:shallowairentrybilaterally• Restofexaminationresultsnormal
REASSESSMENT OF PATIENT:Airway:
• Secureendotrachealtube
Breathing:• Reassessbreathing• Continuetoprovidemanualventilationtothepatient
Circulation:• Identifyworseninghypotension• Reassessbloodpressure,pulse,capillaryrefill• GiveanotherIVnormalsalinebolus
Medical Management:• Callintensivecarespecialistforconsultation• Considerrectalparaldehyde(notavailableintheUnited
Statesbutmightbeavailableinothercountries)• ConsiderIVmidazolaminfusionoranadditionaldoseof
phenytoin/fosphenytoin/phenobarbital/levetiracetam
5
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
• Failuretoinsertmultipleintravenouscatheters,thusdelayingadjuncttherapies(eg,antibioticsorfluids).• Delayincheckingbedsideglucoselevel.• Assumptionthatseizureshave“stopped”afterparalyticisgivenforintubation
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
45 Simulation Scenarios Stridor Due to Foreign Body
Stridor Due to Foreign Body
Adam Cheng, MD, FRCPC, FAAPMark Adler, MD
Learning Objectives
• Describethepossiblecausesofstridorinaninfant.• Demonstratethemanagementofupperairwayobstructionduetoaforeignbody.
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,pencap,rolled-uppieceofmedicaltape).
Scenario Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 1 History:• Twelve-month-oldwithsuddenonsetofstridorand
respiratorydistress• ParentsrushedhimtotheEDforevaluation• Youarecalledtoseethepatient
Weight: • 10kg
Condition: • Alertandanxious,sittinguprightinbed
Physical Examination Findings:• Temperature37.2°C(99°F),HR153/min,RR40/min,oxygen
saturation88%inroomair,BP85/68mmHg• CNS:alert• CVS:pulsespresent• Respiratory:clear• Extremities/skin:capillaryrefill<2s
Take a History: • Noillcontacts• Hasbeenwell• Nomedications• Noallergies• Wasplayingunsupervisedinplayroomandmomheard
coughingandthennoticedthetroublebreathingwhensheenteredroom
Airway:• Listenforbreathsounds,stridoreasilynoted,childissitting
anddoesnotwishtobemovedfromsittingposition• Askforbag-mask,suction,laryngoscope,ETT,andMagill
forcepstobedside
Breathing: • Applymonitors,includingoxygensaturationandblood
pressure• Auscultatechestandobserverespiratoryrate• Ifhealthcareworkerattemptstoplacemaskorinspect
mouth,state“childbecomesmoreanxiousandpushesyouaway—doyouwantmetoholdthechild?”
Circulation:• Assesspulse,HR,capillaryrefill,BP
Medical Management:• RequestENToranesthesiaconsultation• Minimizestimuli:nopainfulprocedures
3–4
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
46 Simulation Scenarios Stridor Due to Foreign Body
Scenario Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 2 Condition:• Airwayobstruction(complete)• Occursat4minregardlessofactionsORifthehealthcare
workerslookinmouthwithtongueblade,forceoxygenmaskontochild,orplaceIVcatheter
Physical Examination Findings:• Immediately:respiratoryeffortwithoutstridor;rapidly
lapsesuntilunconsciousness• RR:initially40/minbutthendecreasesto0/minin30s• HR:increasesto170/mininfirstminutethendecreasesto
65/mininnext90s• BP:70/58mmHg• Saturation:decreasesfrom88%to30%in30s
REASSESSMENT OF THE PATIENT:Airway (ENT/anesthesia consultant not present yet):
• Laychildflat• Attempttobag-maskpatientwithneckproperlypositioned
andusingtwo-persontechnique• Whenthisfailstowork,performdirectlaryngoscopyand
removesmallforeignbody
Circulation:• Monitordecreasingvitalsigns,preparetostart
compressionsifHRdecreasesbelow60/min
5
STAGE 3 Recovery:• Patientisnoweasilybagged
Physical Examination Findings:• HRandsaturationreturntonormal• RRremainszeroasbaggingcontinues
REASSESSMENT OF THE PATIENT:
Airway:• Continuetobagpatient• Placenasogastrictubetoavoidstomachdistension• Maychoosetointubate(canstopcasebeforethisis
completefortimeconstraints)• Chestradiographtoassessforotherpossibleforeignbodies
(ifradio-opaque)
Disposition:• ICUforobservation
3–5
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.
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
47 Simulation Scenarios Stridor Due to Foreign Body
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
• Beginningtotreatforcroupratherthanaspiration.• Triggerobstructionbystimulatingchild.Thischildshouldbetakentotheoperatingroombyanear,nose,andthroatsurgeonand/oranesthesiapersonnel
where a controlled evaluation and removal can be performed. Ideally, the child is placed in a parent’s lap awaiting this event. • Oncecompleteobstructionoccurs,failingtoattemptairwayevaluationandremovalofobstructionorattemptingintubation.Thechildnowhasanemergent
condition that cannot await airway expertise.
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
48 Simulation Scenarios Supraventricular Tachycardia
Supraventricular Tachycardia
Adam Cheng, MD, FRCPC, FAAPMark Adler, MD
Learning Objectives
• Describethesignsandsymptomsofaninfantwithsupraventriculartachycardia.• Demonstratethemanagementofstablesupraventriculartachycardiausingchemicalcardioversionwithappropriatemonitoring.
Simulator: Infant Simulator
Scenario Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 1 History:• Seven-month-oldgirlwithfussinessandpoorfeedingfor
approximately1day• Noupperrespiratorytractsymptomsorfever• Sentfromphysician’sofficebecauseoffastheartrate
Weight: • 7kg
Condition: • Alertbutcranky,pale
Physical Examination Findings:• Temperature36.9°C(98.4°F),HR226/min,RR36/min,oxygen
saturation98%inroomair,BP79/65mmHg• CNS:alert• CVS:pulsespresent• Respiratory:clear• Abdomen:liveredgeapproximately2cmbelowcostal
margin• Extremities/skin:capillaryrefillapproximately2s
Take a History: • Noillcontacts• Nofamilyhistoryofheartproblems• Givenibuprofenwithoutreliefbutnocoldmedications• Noallergies
Airway:• Listenforbreathsounds,present
Breathing: • Applymonitors.Includingoxygensaturationandblood
pressure• Applyoxygenmask• Auscultatechestandobserverespiratoryrate
Circulation:• Assesspulse,HR,capillaryrefill,BP• AsknursetoobtainIVaccess
Medical Management:• OrderanECG• Attemptvagalmaneuvers
3–4
STAGE 2 Condition:• HRremainselevated
Physical Examination Findings:• HR226/min,RR36/min,oxygensaturation100%in100%
oxygen(ifplaced),BP81/68mmHg
REASSESSMENT OF THE PATIENT:
Circulation:• ReassessHR,pulse,capillaryrefill,BPafterbolus• Orderadenosine• Describetonurseconfederatehowtodelivermedication
whenasked(“Iamnotsurehowtogivethismedication.”)• Prepareforconversionby:
–Ensuringavailabilityofdefibrillator(mightormightnotconnectpads)
3
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
49 Simulation Scenarios Supraventricular Tachycardia
Scenario Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 2, continued
–HavingECGmachineconnectedandrunningduringconversionattempt
• Deliverfirstadenosinebolus(noorbriefeffect)afterconsideringcontactingcardiologyorintensivecaresupportpersonnel
STAGE 3 Condition:• Infantcrieswhenmedicationgiven• HRremainselevated
Physical Examination Findings:• Unchangedfromstage2
REASSESSMENT OF THE PATIENT:
Circulation:• ReassessHR,pulse,capillaryrefill,BP
Medical Management:• Orderarepeatdoseofadenosine
5
STAGE 4 Condition:• Patientimproves(HR145/minandsinus)
Physical Examination Findings:• HR148/min,BP78/62/min,saturation98%on
nonrebreathermask• Childismorecomfortable
REASSESS THE PATIENT:• Disposition:• ArrangeforICUorcardiologyadmissionortransportto
tertiarycarefacility(dependingonpresentingfacilityresources)
5
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
• Problemswithdeliveringtheadenosineinarapidpush/rapidflushmanner.• Electricalcardioversioninthisstablepatient(lesscommon).
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
50 Simulation Scenarios Tricyclic Antidepressant Overdose
Tricyclic Antidepressant Overdose
LinaAl-Bakry,MDAdam Cheng, MD, FRCPC, FAAPMark Adler, MD
Learning Objectives
• Describethesignsandsymptomsoftheanticholinergictoxidrome.• Demonstratethetreatmentofachildwithtricyclicantidepressant(TCA)intoxication.
– Initial stabilizing steps.– Identify tachyarrhythmia secondary to TCA intoxication.– Manage TCA intoxication with appropriate supportive and therapeutic interventions.
Simulator: Pediatric Simulator
Scenario Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 1 History:• Four-year-oldboy,broughtinbyparents• Foundextremelysleepyafterdinner,slumpedoveron
couch,minimallyresponsive• Nofeverorantecedentillness• Previouslywell
Weight: • 15kg
Physical Examination Findings:• Temperature37.5°C(99.5°F),HR150/min,RR24/min,oxygen
saturation98%inroomair,BP85/50mmHg• CNS:eyesclosedintermittently,nospontaneousmovement,
intermittentverbalization• Respiratory:spontaneousrespirations,noabnormalbreath
sounds,airentryisnormal• CVS:palpablepulses,slightlycoolextremities,normalheart
sounds,tachycardia• Abdomen:nobowelsounds,palpablefullbladder
Take a History:• Nosickcontacts• Nopriorhistoryofseizures• Nohistoryoftrauma• Noallergies• Nomedications• Supervisedbymotherallday• GrandparentsarrivedfromEnglandjustbeforedinner• Notsureifthereareprescriptionmedicationsinthehome
Airway:• Talktothepatient• Optimizeairwayposition:headtilt,chinlift,jawthrust
Breathing: • Checkoxygensaturation• Applymonitors• Provideoxygen• Auscultatechest
Circulation:• Applymonitors• Checkpulse,capillaryrefill,BP—skinfeelswarmanddry• StartIVaccess
2
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
51 Simulation Scenarios Tricyclic Antidepressant Overdose
Scenario Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 1, continued
Disability:• Eyesclosedintermittently,openseyeswithstimulation• Moansandvocalizeswithstimuli.• Localizestopainfulstimuli,otherwisenomovement• Pupils5mm,sluggishreactionsymmetrically
Expose the Patient:• Warm,dryskin• Norash,nopetechiae• Identifyabnormalityoncardiactracing(sinustachycardia
withwideQRS)• Identifyneedfor12-leadECG• Orderbloodwork:CBC,differential,electrolytes,glucose,
creatinine,BUN,serumosmolality,bloodgas,serumacetaminophenandaspirinlevels,urinetoxicologyscreen
STAGE 2 Condition:• Thepatient’sconditionevolves—worseninglevelof
consciousness.
Physical Examination Findings:• Temperature37.5°C(99.5°F)orally,HR150/min,RR24/min,
saturation98%with100%oxygen,BP85/50mmHg• CNS:eyesclosed,nospontaneousmovement,moaning,
infrequentverbalization• Chest:spontaneousrespirations,noabnormalairentryor
breathsounds• CVS:palpablepulses,slightlycoolextremities,normalheart
sounds,tachycardia• Abdomen:nobowelsounds,palpablefullbladder
Parentcallsontelephone—grandmotherhas20–30missingantidepressantpillsfromhermedicationcabinet
REASSESSMENT OF THE PATIENT:Airway:
• Prepareequipmentforintubation• Preparemedicationforrapidsequenceintubation
Intubation:• Preparation/equipment• Preoxygenation.• Cricoidpressure• Premedication:IVatropine• Sedation:IVketamine• Paralysis:IVsuccinylcholine• IntubatewithETT• ChecktubeplacementwithETCO2,auscultation,andchest
radiograph
Breathing:• Reassessmentofbreathing,auscultation—nochange• Apply100%oxygen—nochangeinclinicalappearance
Circulation:• ReassessHR,pulse,BP• ConsidergivingIVbolusofnormalsaline
3
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
52 Simulation Scenarios Tricyclic Antidepressant Overdose
Scenario Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 2, continued
Medical Management:• IVsodiumbicarbonatebolus• Glucometer:normalresults• ContinuousECGmonitoring• CallforICUconsultation• Callfortoxicologyconsultation/poisoncontrol
STAGE 3 Condition:• Thepatient’sconditionevolves:ventriculartachycardia
Physical Examination Findings:• Temperature37.5°C(99.5°F)orally,HR180/min,RR10/min,
saturation98%,BP85/50mmHg• CNS:eyesclosed,nospontaneousmovement—paralyzed
andsedated• Respiratory:airentryequal• CVS:palpablepulses,slightlycoolextremities,capillaryrefill
2s• Abdomen:nobowelsounds,palpablefullbladder
REASSESSMENT OF PATIENT:Airway:
• Positionairway• Oropharyngealairway—stillinplace
Breathing:• Reassessauscultation,breathing• Manualventilation—patientintubated
Circulation:• ReassessHR,pulse,BP,capillaryrefill• GivesIVnormalsalinebolus• ECG:ventriculartachycardia
Medical Management:• FollowPALSprotocol• Prepareforsynchronizedcardioversion• Consultcardiologist
5
STAGE 4 Condition:• Patientconditiondeterioratesafterintubation
Physical Examination Findings:• Verydifficulttoventilate• Poorchestrisebilaterally• Temperature38°C(100.4°F),HR80/min,RRbagging,
saturation78%in100%oxygen,BP80/50mmHg• CNS:sedated/paralyzed• Respiratory:poorchestriseandairentrybilaterallywith
wheezing• CVS:pulsesweak,capillaryrefill4s
REASSESS THE PATIENT:Airway:
• SuctiontheETT:somethinmucusorsecretions• Considerdirectvisualizationofthetubewithlaryngoscope
Breathing:• Auscultatethechest• Checkforsignsoftensionpneumothorax(tracheamidline,
bloodpressure,percussionofchest,jugularvenouspressure)• Givecontinuousnebulizedinlinealbuterol(salbutamol)• Checkoxygen/equipment• Bag-maskventilateataslowerratewithaprolonged
expiratoryphase
Circulation:• InsertsecondIVcatheter• GiveIVbolusofnormalsaline
5
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.
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
53 Simulation Scenarios Tricyclic Antidepressant Overdose
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
• Delayinelicitingfurtherhistory,thusleadingtodelayinmakingthediagnosis.• FailuretorecognizeandanticipatethepotentialcardiaccomplicationsofTCAoverdose.
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
54 Simulation Scenarios Metabolic Crisis—Hyperammonemia
Metabolic Crisis—Hyperammonemia
Adam Cheng, MD, FRCPC, FAAP Mark Adler, MDDebraWeiner,MD
Learning Objectives
• Describethecommoncausesofvomitingandlethargyinaneonate.• Demonstratethetreatmentofaneonatewithalteredmentalstatusandsuspectedmetaboliccrisis.
– 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 Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 1 History:• One-week-oldwithprogressivepoorfeeding,vomiting,and
lethargyforthepast3d• BroughttoEDbyparents• Looksveryunwellattriage,broughttoresuscitationroom• Youarecalledtoassesspatient
Weight: • 3kg
Condition: • Infantispaleandlethargic,looksunwell
Physical Examination Findings:• Temperature36.2°C(97.2°F),HR165/min,RR46/min,oxygen
saturation98%inroomair,BP75/40mmHg• CNS:eyesopenspontaneously,pupils3mmandreactive
bilaterally• CVS:pulsesintactbutweakCapillaryrefill3s• Respiratory:clear• Abdomen:softandwithouthepatosplenomegaly• Extremities/skin:looseskinfolds,nobruisingnoted
Take a History: • Term,birthweight3.3kg,uncomplicatedpregnancy,
delivery• Nomedicationsornoallergies• Spittingupfirstfewdaysoflife,duringlast3dincreased
frequencyandamount,todayfourtimes• Weightcurrently10%lessthanbirthweight• Nofever,diarrhea,rash• Nosickcontactsortravel
Airway:• Listenforbreathsounds
Breathing: • Applymonitors,includingoxygensaturationandblood
pressure• Auscultatechestandobserverespiratoryrate
Circulation:• Assesspulse,HR,capillaryrefill,BP• AsknursetoobtainIVaccess
Disability:• Quickneurologicassessment(pupils,responsetopain)
3–4
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
55 Simulation Scenarios Metabolic Crisis—Hyperammonemia
Scenario Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 1, continued
Medical Management:• Orderabedsideglucose,electrolytes,BUN,creatinine,LFTs,
ammonia,bloodgas,CBC,bloodculture,urine,urineculturetests,bloodtoholdforpossibleadditionalstudies
• OrdersIVfluidbolusof10mL/kgofnormalsaline
STAGE 2 Condition: • Infantminimallyresponsivetopainfulstimulus.Doesnot
openeyesspontaneously,noverbalization/cooing
Physical Examination Findings:• Temperature36.2°C(97.2°F),HR175/min,RR52/min,oxygen
saturation94%in100%oxygen,BP70/30mmHg• CNS:unresponsive,unconscious,pupils3mmandreactive
bilaterally• CVS:pulsesintactbutweak,capillaryrefill4s• Respiratory:clear• Abdomen:softandwithouthepatosplenomegaly• Extremities/skin:nobruisingnoted
REASSESSMENT OF THE PATIENT:Airway:
• Maintaintheairway:jawthrust,chinlift,headtilt• Suctionvigorously• Prepareintubationequipment
Breathing:• Increaseoxygendeliveryto100%byusingnonrebreather• Assistventilationsasrequired
Circulation:• EnsureIVaccesstwotimes• RecheckHR,BP,capillaryrefill,pulses• CycleBPevery3–5min
Medical Management:• Laboratorytestresultscomeback:
–Sodium135mmol/L,potassium3.5mmol/L,glucose35mg/dL(low)
• AdministerD10W,0.5g/kgIV• ABG:pH7.05,Pco230mmHg,Po290mmHg,bicarbonate8
mmol/L,baseexcess−20mmol/L• Ammonia,350µg/dL(205µmol/L).• WBCandhemoglobinlevelnormal• Metabolicorgeneticsconsultation
5
STAGE 3 Condition: • Neonatestillunresponsive,doesnotopeneyes
spontaneouslyortopainfulstimuli,noverbalization/cooing,intermittentjitteringmovementsofbotharmsandstiffeningsuspiciousforseizures
Physical Examination Findings:• Temperature36.2°C(97.2°F),HR175/min,RR52/min,oxygen
saturation94%in100%oxygen,BP70/30mmHg• CNS:unresponsive,unconscious,pupils3mmandreactive
bilaterally• CVS:pulsesintactbutweak,capillaryrefill4s
REASSESSMENT OF PATIENT:
Airway: Intubation:• Preoxygenation• Premedication:IVatropineoptional• Cricoidpressure• Sedation:discussion:etomidatevsotheroptions:midazolam
plusIVfentanyl• Paralysis:IVrocuroniumorIVsuccinylcholine• ChecktubeplacementwithETCO2detector,auscultationof
chest,observationofchestrise,andorderchestradiograph
5
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
56 Simulation Scenarios Metabolic Crisis—Hyperammonemia
Scenario Stage
Patient Condition Intervention
Instructor Debriefing Notes
Time, min
STAGE 3, continued
• Respiratory:clear• Abdomen:softandwithouthepatosplenomegaly• Extremities/skin:nobruisingnoted
Breathing:• Reassessbreathing• Starttoprovidemanualventilationtothepatient
Circulation:• Reassessbloodpressure,pulse,capillaryrefill• GiveIVnormalsalinebolus
Medical Management:• CallforICUconsultation• Orderdoseoflorazepamforsuspectedseizure• Callformetabolismconsultationifnotalreadydone• Administerbicarbonate• Arrangeforhemodialysis,givesodiumphenylacetate,
sodiumbenzoateifhemodialysiswillbedelayed
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. Manifestationsofseizureinneonatesmightbesubtle.Forseizuresunresponsivetoconventionaltreatment,considerpyridoxine,folate,and/orbiotin. 7. PerformlaboratoryteststoevaluateforIEMsbeforeanytreatment,includingglucoseorfluids.Initiallaboratorytestsincludebedsideglucose,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/orhyperammonemiaarepresent,sendserumsamplesforaminoacids,acylcarnitineprofile,andketonesmeasurementandurinesamples 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.
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
57 Simulation Scenarios Metabolic Crisis—Hyperammonemia
Common Pitfalls
• PotentialdiagnosisofIEMisnotconsidereduntillate,whichincreasestheriskoflong-termdiseaseand/ordeath.• Participantscheckandtreattheglucoselevelbutfailtoobtainafollow-upglucosemeasurement.Ahighconcentrationofglucoseisnotalwaysmaintained
withmaintenancefluids.• Acidosisisnottreated.• Ammoniaisnotchecked.• Failuretorecognizeandtreatseizure.
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians