Emergency Medicine Simulation Session

Shortness of Breath Module

Ingham Clinical Skills and Simulation Centre

Introductions

Admin Matters

• Toilets • Mobile phones to silent and wi-fi off!• Fire Exits• Post course evaluations please

Learning Outcomes• Introduction to simulation and understand

the basic ground rules in simulation

• Be able to do an A-E assessment on an critically ill patient

• To improve your skills in emergency management of various presentations of shortness of breath

• Gain confidence using ISBAR handover

The ABCDE assessment (primary assessment)

Airway

Breathing

Circulation

Disability

Exposure

NB If no patient response – open airway, if no normal breathing/central pulse = cardiac arrest – start CPR!!

ABCDE approachUnderlying principles• Complete initial assessment (get to E)

• Treat life-threatening problems

• Reassessment after any treatment or if any change in condition of patient

• Call for senior help early!!

ABCDE approachAirway

Causes of airway obstruction:

• CNS depression• Blood • Vomit • Foreign body • Trauma

• Infection • Inflammation • Laryngospasm • Bronchospasm

ABCDE approachAirway

Recognition of partial airway obstruction:

•Talking? Quality of Voice?•Difficulty breathing, distressed, choking•Shortness of breath•Noisy breathing•Stridor, wheeze, gurgling •See-saw respiratory pattern, accessory muscles

ABCDE approachAirway

Treatment of airway obstruction:

• Airway opening– Head tilt, chin lift, jaw thrust

• Simple adjuncts• Advanced techniques– e.g. LMA, tracheal tube

• Oxygen

ABCDE approachBreathing

Treatment of breathing problems:• Sit the patient up !!• Airway

• Oxygen (if sats low)

• Treat underlying cause

• Support breathing only if needed–e.g. ventilate with bag-mask

ABCDE approachBreathing

• Decreased respiratory drive/ CNS depression

- drugs

- raised ICP

•Decreased respiratory effort– Muscle weakness – Nerve damage– Restrictive chest defect

– Pain from fractured ribs

• Lung disorders – Pneumothorax– Haemothorax – Infection– Acute exacerbation

COPD– Asthma– Pulmonary embolus– ARDS

Causes of breathing problems:

ABCDE approachBreathing

Recognition of breathing problems:• Look– Respiratory distress, accessory muscles,

cyanosis, resp rate, conscious level etc

• Listen – Noisy breathing, breath sounds

• Feel – Expansion, percussion, tracheal position

ABCDE approachCirculation

Recognition of circulation problems:• Look at the patient• Pulse - tachycardia, bradycardia• Peripheral perfusion - capillary refill time (normal

< 2 secs)• Blood pressure• Organ perfusion– Chest pain, mental state, urine output

• Bleeding, fluid losses

ABCDE approachCirculation

Treatment of circulation problems:

• Airway, Breathing• Oxygen• IV/IO access, take bloods• Treat cause• Fluid challenge• Haemodynamic monitoring• Inotropes/vasopressors

ABCDE approachDisability

Recognition

• AVPU or GCS• Pupils• Blood sugar • Check drug

chart/med hx

Treatment

•ABC

•Treat underlying cause

•Blood glucose•If < 4 mmol l-1

give glucose

•Consider lateral position

ABCDE approachExposure

• Remove clothes to enable examination– e.g. injuries, bleeding, rashes

• Check all of patient: – surface, orifice, extremity and cavity

• Avoid excessive heat loss

• Maintain dignity

Sim Ground Rules

• Respectfulness• Confidentiality – faculty and students

(performance and scenarios)• Fiction contract – try to suspend

disbelief• No assessments!• Try to relax, have fun learning as a

team!

The Basic Assumption

We all believe that everyone in this room is:•Intelligent•Capable•Cares about doing their best •Wants to improve

Centre for Medical Simulation, Harvard, Boston USA.

Fiction Contract• The scenarios are not real life but are based on

real cases & are the next best thing

• We accept you may act differently from real life

• And that the manikins/sim cases have their limitation but….simulations allow us to train as a team and practice our skills

• If you act as yourself, take it seriously & commit to being part of the sim you will gain much more from the experience…. Are we all agreed?

Sim Cases• 3 teams– 1 sim case case per team then swap

around• Each case 20 mins – different patient &

presentation• Faculty will be inside room with you• ‘Pause & discuss’ scenarios, followed by a debrief• We will call a ‘timeout’ when good time for

discussion (not because you are doing poorly!)• Those of you not directly involved with each case

will be inside sim room - will still be involved with the discussions and the debrief

The Debrief

• We all come back to debrief room afterwards to discuss the case

• Sim team to sit together in semicircle with instructor• Time for reflection & constructive feedback • Allows lessons learned within the case to be

generalised and transferred to real clinical practice• Possible questions: How did you feel? What

happened? How did the team function? What did you learn? What would you change? Take home messages?

Tips for the Sim Cases• Decide upon a team leader before the case• TL to stand at end of bed - hands off the patient• T/L to delegate roles to team members• But team members must help the T/L out & help make

suggestions• Andrea will be the nurse in the room to help• Communicate loudly & clearly with each other • Start each case with an A-E assessment & take a focused

history to help work out the problem• If there is any change in patient status go back to start with

Airway

• TL must give ISBAR handover to consultant

ISBAR Handover

Introduction - Identify yourself, your role & location

Situation - State the pt diagnosis or current problem

Background - What is the clinical background/context?

Assessment – What are the pts current obs?

- What do you think the problem is?

Recommend - What do you recommend ?

- What do you want the person you have called to do?

Sim Demo

Any questions?

Lets see the sim room & meet our patient!