Emergency Medicine ST4 Simulation Course
Patients Name: Jane West
Patients Age / DOB: 26
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Major Problem |
Medical Thyroid Storm |
CRM Communicate effectively Using all available information Prevent and manage fixation errors Re-evaluate repeatedly
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Learning Goal
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Medical Diagnosis and treatment of thyroid storm. Contraindications in pregnancy. |
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Narrative Description
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A 26 year old female in her first pregnancy, currently 8/40 gestation, has attended A & E with her husband. Previously well. She has been tearful and anxious since finding out that she was pregnant 2 weeks ago. Two days ago she started vomiting; she was seen by the GP and given antiemetics. Today, she woke up feeling feverish, vomiting and confused. Her husband is concerned. |
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Staffing
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Faculty Control Room: 1 x Sim man controls 1 x Pt voice Faculty Role Players: 1 x Nurse 1 x Husband |
Candidates X1 ST4 |
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Case Briefing
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To All Candidates A 26 year old pregnant woman has been brought to the ED by her husband. She has been vomiting for 2 days but woke up today feverish, vomiting and confused.
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To Role Players Husband: You are very concerned about your wife and the baby. This is her first pregnancy and she has been really anxious, tearful and having problems sleeping over the last few weeks, but you have both put this down to the pregnancy. She started vomiting 2 days ago but the GP was not concerned and gave her anti-sickness tablets. Today she seems sleepy and vague. She has continued to vomit and feels hot. |
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Manikin preparation
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Female wig. Fine mist spray to replicate sweating. |
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Room set up
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ED Resus room |
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Simulator operation
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Mild confusion, drowsy voice Breath sounds=equal breath sounds, mild wheeze Cardiac rhythm= AF |
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Props needed |
Vomit bowl next to manikin. Defibrillator/resus trolley. Urinary catheter / trolley. BNF. IV line. CXR. NG tube. |
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Observations:
Initial
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Par score |
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HR |
140 |
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O2 sats |
94% |
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BP |
165/95 |
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Temp |
40 |
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RR |
28 |
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GCS |
E=3 V=4 M=6 Total= 13/15 |
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Total Par Score |
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With Oxygen
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Par score |
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HR |
144 |
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O2 sats |
96% |
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BP |
170/100 |
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Temp |
40 |
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RR |
30 |
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GCS |
E=3 V=4 M=6 Total = 13/15 |
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Total Par Score |
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With Fluids
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Par score |
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HR |
160 |
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O2 sats |
96% |
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BP |
180/110 |
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Temp |
40 |
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RR |
32 |
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GCS |
E=3 V=4 M=6 Total= 13/15 |
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Total Par Score |
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Post Propranolol
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Par score |
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HR |
90 |
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O2 sats |
97% |
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BP |
140/75 |
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Temp |
38 |
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RR |
24 |
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GCS |
E= 3 V=4 M=6 Total=13/15 |
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Total Par Score |
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Nurse Role
Scenario
A 26 year old female in her first pregnancy, currently 8/40 gestation, has attended A & E with her husband. Previously well. She has been tearful and anxious since finding out that she was pregnant 2 weeks ago. Two days ago she started vomiting; she was seen by the GP and given antiemetics. Today, she woke up feeling feverish, vomiting and was confused. Her husband is concerned.
Underlying diagnosis
Thyroid storm in pregnancy
Instructions
You follow instructions and are competent
Patient Role
Scenario
You are a 26 year old female in your first pregnancy, currently 8/40 gestation, who has attended A & E with your husband. Previously well. You have been tearful and anxious since finding out that you were pregnant 2 weeks ago. Two days ago you started vomiting; you were seen by the GP and given antiemetics. Today, you woke up feeling feverish, vomiting and confused. Your husband is concerned.
Underlying diagnosis
Thyroid storm in pregnancy
Patient Instructions
Anxious, drowsy and slightly confused to time but oriented to place and person. Otherwise, neurologically normal. Not sleeping well. Vomiting for 2 days. Mild generalised abdominal pain. No previous illnesses or operations, no allergies. No eye signs, small goitre.
Husband role
Scenario
Your wife is 26 years old in her first pregnancy, currently 8/40 gestation, who has attended A & E with you. Previously well. She has been tearful and anxious since finding out that she was pregnant 2 weeks ago. Two days ago she started vomiting; she was seen by the GP and given antiemetics. Today, she woke up feeling feverish, vomiting and confused. You are concerned for her.
Underlying diagnosis
Thyroid storm in pregnancy
Instructions
You are very concerned about your wife and the baby. This is her first pregnancy and she has been really anxious, tearful and having problems sleeping over the last few weeks, but you have both put this down to the pregnancy. She started vomiting 2 days ago but the GP was not concerned and gave her anti-sickness tablets. Today she seems sleepy and vague. She has continued to vomit and feels hot. Wants to know how things will affect the baby.
Blood results - Not available
Test results - Urinalysis: ket 3+, otherwise NAD. BhCG +ve. Toxicology screen negative.
X-rays - Upper lobe diversion, slightly enlarged heart
ECG - Fast AF
Background
- Problem: Thyroid storm in pregnancy. No obvious focus for infection. Not hyperemesis. Not drug induced.
- Patient has fast AF and will develop congestive cardiac failure/ increasing respiratory distress if only oxygen and fluids are given.
- Bloods sent should include TFTs, Free T3 and Free T4. Cardiac panel negative. ABGs show mild decrease in mild respiratory alkalosis with pO2 of 9 on air
- BNF in the room provides a reminder of the medications needed for the treatment of thyroid storm.
- Will require IV propranolol for rate and symptom control.
- Will also require hydrocortisone/dexamethasone and propylthiouracil (safer in pregnancy; must be given down NG tube) with Lugol’s iodine 1 hour following for the treatment of thyroid storm.
- Cooling with cool fluids and ice packs if necessary.
- Radioactive iodine contraindicated. Aspirin contraindicated.
- Needs admission to HDU/ITU.
