Emergency Medicine Simulation
Session
Shortness of Breath Module
Ingham Clinical Skills and Simulation
Centre
Introductions
Admin Matters
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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)
NB If no patient
response – open
airway, if no normal
breathing/central
pulse = cardiac
arrest – start CPR!!
Airway
Breathing
Circulation
Disability
Exposure
ABCDE approach
Underlying 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 approach
Airway
Causes of airway obstruction:
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CNS depression
Blood
Vomit
Foreign body
Trauma
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Infection
Inflammation
Laryngospasm
Bronchospasm
ABCDE approach
Airway
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 approach
Airway
Treatment of airway obstruction:
• Airway opening
– Head tilt, chin lift, jaw thrust
• Simple adjuncts
• Advanced techniques
– e.g. LMA, tracheal tube
• Oxygen
ABCDE approach
Breathing
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 approach
Breathing
Causes of breathing problems:
• Lung disorders
Pneumothorax
Haemothorax
Infection
Acute exacerbation
COPD
– Asthma
– Pulmonary embolus
– ARDS
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• Decreased respiratory
drive/ CNS depression
- drugs
- raised ICP
• Decreased respiratory
effort
– Muscle weakness
– Nerve damage
– Restrictive chest defect
– Pain from fractured ribs
ABCDE approach
Breathing
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 approach
Circulation
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 approach
Circulation
Treatment of circulation problems:
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Airway, Breathing
Oxygen
IV/IO access, take bloods
Treat cause
Fluid challenge
Haemodynamic monitoring
Inotropes/vasopressors
ABCDE approach
Disability
Recognition
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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 approach
Exposure
• 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
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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!