Emergency medicine ST4 Simulation Course
Patients Name: John Jarvis
Patients Age / DOB: 92 yrs old
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Major Problem |
Medical Head injury; SVT |
CRM
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Learning Goal
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Medical Criteria for trauma call/ Senior Help Recognition of Narrow Complex Tachycardia (NCT) & management Informed consent & capacity assessment Radiological investigations and disposal |
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Narrative Description
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Priority call: A 92 year old man fallen down a flight of stairs. Sustained cut on his forehead; bruises over left shoulder and left leg but no actual deformity or injury. His obs at scene: HR 190, Sat 95% RA, BP 97/59, RR 21. GCS 13, Temp 37 ETA 2 minutes. On arrival, the patient is on a spinal board and C spine immobilised. ECG reveals SVT. If 6mg Adenosine IV administered then a very brief effect -sinus rhythm and then back to SVT. If cardiology registrar called then DC cardioversion advised. The anaesthetist should prepare for endotracheal intubation. If attempt made to obtain consent, patient fails his capacity assessment (not able to retain information). Cardioversion with 3 synchronised shocks at 50J, 100J, 150J will not convert the patient into sinus. Repeat consultation with the Cardiology registrar: IV Amiodarone 300 mg infusion advised. Post secondary survey, if patient goes to CT scan without contrast, the CT head revealed 2 subdural haematomas without midline shift. |
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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 Cardiology Reg |
Possible Candidates 1 x FY2 1 x ED Consultant 1 x Trauma team 1 x Anaesthetics Reg 1 x Medical registrar |
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Case Briefing
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To All Candidates You are the Resus Registrar and designated Trauma Team Leader Priority call: A 92 years old man fell down a flight of stairs Sustained cut on his forehead, with bruises to left shoulder and Left leg. ETA 6 min His obs at scene: HR 190, sat 95% RA, BP 97/59, temp 37C, RR21, GCS 13 E=3 V=4 M=6 |
To Role Players Nurse: follow instruction from team leader Cardiology registrar: advise on the phone |
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Manikin preparation |
Forehead cut; bruises over left shoulder & left leg. But no actual deformity or injuries. Spinal board and c-spine immobilised. Patient as 1 x IV access from ambulance. |
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Room set up |
A Resus room |
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Simulator operation |
Patient is in SVT; transient conversion with adenosine. Failed DC cardioversion. Needs Amiodarone to convert into sinus rhythm. |
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Props needed |
Cardiac monitor and defibrillator, airway & IV access trays, O2 and suction, fluids and fluid giving sets, scissors, drugs (Adenosine, Amiodarone, Magnesium sulphate) & a pc screen to view CT images |
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Observations:
Initial at scene
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Par score |
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HR |
190 SVT |
3 |
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O2 sats |
95%on air |
0 |
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BP |
97/59 |
1 |
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Temp |
37 |
0 |
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RR |
21 |
0 |
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GCS |
E=3 V=4 M= 6 Total 13 |
1 |
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Total Par Score |
4 |
On arrival to ED
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Par score |
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HR |
195 SVT |
3 |
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O2 sats |
97% on 10L O2 |
1 |
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BP |
90/59 |
1 |
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Temp |
37 |
0 |
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RR |
26 |
0 |
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GCS |
E=3 V=4 M= 6 Total 13 |
1 |
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Total Par Score |
6 |
Post Amiodarone Mg Sulphate
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Par score |
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HR |
150 |
2 |
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O2 % |
97% on 10L O2 |
1 |
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BP |
110/70 |
0 |
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Temp |
37 |
0 |
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RR |
20 |
0 |
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GCS |
E=4 V=5 M= 6 Total 14 |
0 |
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Total Par Score |
3 |
Pre transfer to ward
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Par score |
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HR |
115 |
1 |
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O2 % |
97% on 10L O2 |
1 |
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BP |
115/70 |
0 |
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Temp |
37 |
0 |
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RR |
18 |
0 |
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GCS |
E=4 V=5 M= 6 Total 14 |
0 |
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Total Par Score |
2 |
Nurse Role
Scenario
Priority call: A 92 year old man fell down a flight of stairs Sustained cut on his forehead and bruises to left shoulder and left leg but no deformity.
His obs at scene: HR 190, Sat 95% RA, BP 97/59, RR 21. GCS 13, Temp 37
Underlying diagnosis:
SVT
2 subdural haemorrhages
Instructions
Assist and follow instructions from the team leader. You are competent and able to do anything you asked to do within normal limitations. You do not make suggestions / assist unless the candidate is really struggling.
Patient Role
Scenario
You are a 92 years old man who fell down a flight of stairs. You have sustained a cut on your forehead, and have pain in your left shoulder and left leg due to bruises but no deformity.
Your observations at scene were HR 190, Sat 95% RA, BP 97/59, RR 21. GCS 13, Temp 37
Underlying diagnosis
SVT
2 subdural haemorrhages
Patient Instructions
You are an elderly male on a spinal board, in pain & confused. You respond to verbal command, but are pale and tachypnoeic.
You are unable to provide any information on your past medical history, medications or allergies.
You have no capacity to consent as you are unable to retain any information that is given to you.
Cardiology Registrar – on phone
Scenario
Priority call: A 92 year old man fell down a flight of stairs Sustained cut on his forehead with bruises to the left shoulder and left leg but no deformity.
His obs at scene: HR 190, Sat 95% RA, BP 97/59, RR 21. GCS 13, Temp 37
Underlying diagnosis
SVT
2 subdural haemorrhages
Instructions
You advice to treat the patient initially with adenosine if this hasn’t already been tried. You then advise a trial of DC cardioversion.
Both the above will be unsuccessful so they should call you back and you then suggest 300mg Amiodarone IV (with monitoring etc).
Blood results: not available
Arterial blood gas: available
Radiology: CT scan of head
ECG: available
Summary of dilemmas in scenario
Dilemma 1: Activation of trauma team - criteria
Dilemma 2: SVT treatment algorhythm
Dilemma 3: Consent & capacity assessment
Dilemma 4: CT Brain - HI NICE guidelines
Measurement Report
Serial Number 7643
Instrument ID A&E Department
Operator ID: St Thomas’ Hospital
Patient ID: Bed 1
Last Name
First Name
Temperature 37.0 oC
FIO2 0.60
R 0.84
Sample type Blood
Blood Type Arterial
pH 7.349 (7.350 - 7.450)
PCO2 3.07 kPa ( 4.67 - 6.00 )
PO2 20.07 kPa ( 10.67 - 13.33)
pH 7.349
PCO2 3.07 kPa
PO2 20.07 kPa
Na 140 mmol/L ( 135.0 - 148.0)
K+ 3.55 mmol/L ( 3.50 - 4.50 )
Cl- 99.3 mmol/L ( 98.0 - 107.0)
Ca2+ not activated ( 1.120 - 1.320)
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Hct 46.5% ( 35.0 - 50.0)
Glu 6.0 mmol/L ( 3.3 - 6.1 )
Lac 5.5 mmol/L (++) (0.4 - 2.2 )
tHb 13.4 g/dL ( 11.5 - 17.4 )
02Hb 96.1 % ( 95.0 - 99.0 )
COHb 1.3 % ( 0.5 - 2.5 )
HHb 1.4 % ( 1.0 - 5.0 )
MetHb 0.5 % ( 0.4 - 1.5 )
BE -4.1 mmol/L
cHCO2 22.1 mmol/L
AaDO2 0.0 mmHg
SO2 96.1 % ( 75.0 - 99.0)
cHCO3st 22.1 mmol/L
P50 23.7 mmHg
ctO2 16.7 vol%
ECG on arrival: John Jarvis
ECG Post cardioversion: John Jarvis
CT scan: John Jarvis
