Scenario Details for Perioperative Emergency Simulation Training
ANAPHYLAXIS SUMMARY: Patient is 48 y/o M undergoing a fistula repair for an
enterocutaneous fistula likely due to a GSW to the Abdomen 2 years prior.
Participant has been called into the OR where the anesthetic confederate reports he
is concerned about increasing airway pressures near the beginning of the case.
Participant is to recognize signs and cause of anaphylactic reaction. Critical Steps
include: removing offending agent and correct does epinephrine.
Assessment Instruments:
NOTTS framework
1. Situation awareness
 Monitors ongoing physiology
 Recognizes Problem- reflects and discusses significance of
information
 Shows evidence of having a contingency plan
2. Decision making
 Recognizes and articulates problem
 Asks surgeon and scrub team for help/opinion
3. Communication and Teamwork
 Keeps team informed about situation
 Seeks and listens to advice of team members
 Clearly communicates plan
4. Leadership
 Makes appropriate decisions
 Emphasizes the urgency of the situation
 Delegates tasks and coordinates team appropriately
Room Setup:
X
Anesthesia Machine
X
X
X
ETT
X Non-Invasive BP Cuff
Infusion Pumps
LMA
X Arterial Line
Bronchoscope
Laryngoscope
Defibrillator
Hotline
PA Catheter
X 5 Lead ECG
Nerve Stimulator
Temperature Probe
Echo Machine and Probe
X Pulse Oximeter
CPB Machine + Circuit
X Capnograph
Orpheus Simulator
X
CVP
SIM Man
BIS
X Urinary Catheter
Other equipment required:
Antibiotic infusion (inciting agent)
Albuterol
Airway kit
Anesthesia drugs
“Code resuscitation” drug box
Epinephrine infusion
Hydrocortisone
Diphenhydramine and Cimetidine
Supporting Files (CXR, ECG, echocardiogram, assessment, handouts, etc)
1.
2.
3.
4.
CXR – normal, male
ABG (ANAPH EARLY and LATE)
BMP, CBC
Photo of chest with rash
STATE 1: 00:00
Starts in NSR 82 bpm, SaO2: 98%, RR: 16, BP: 110/70. Immediate down trend
begins rapidly increasing HR (+90 over 6.5 minutes) and RR (+17 over 6.5 minutes),
and decreasing SaO2 (-45 over 6.5 minutes) and BP (-90 over 6.5 minutes).
Wheezing and difficult airway
INTERVENTIONS (with physiological trends):
-
-
Fluids Wide Open: HR -10; BP +15/10 over 5 minutes
Epinephrine Bolus (100 mcg): Wheezing Resolves; Lung Compliance
Resolves; BP +25/25; HR +15 over 15 seconds, Net +0 over 3 minutes;
RR -6 over 1 minutes, net +0 over 3 minutes; SaO2 + 15 over 1 minute,
net +0 over 3 minutes.
Epinephrine Infusion (0.5 mcg/kg/min): Wheezing Resolves; Lung
Compliance Resolves; BP +15/10; RR +6; SaO2 +3
Critical Steps Push to State 2: Removal of antigen, Epinephrine Bolus (100
mcg IV), Epinephrine Infusion (0.5 mcg/kg/min)
STATE 2: (Recovery)
Normalizing of wheezing or lung resistance
Trigger: Critical Interventions from state 1
INTERVENTION: Continuing interventions from state one will lower HR and
Increase BP. Defervesce if epinephrine infusion is not started (BP – 15/10, HR +15)
CONCLUSION:
Transfer of care to ICU (phone call to Simulation specialist)
CEREBRAL VASCULAR ACCIDENT (CVA) SUMMARY: 68 y/o F underwent left
total hip arthroplasty preformed under epidural. In recovery the patient
demonstrates altered mental status (becomes non-responsive). Cranial nerve and
gross motor exam consistent with left MCA stroke distribution. Participant is to
recognize the signs of CVA and management. Critical steps include: state CVA
diagnosis, request STAT neurology consult, intubate patient, STAT noncontrast
head CT, notify neuro-interventional radiology
Assessment Instruments:
NOTTS framework
2. Situation awareness
 Monitors ongoing physiology
 Recognizes Problem- reflects and discusses significance of
information
 Shows evidence of having a contingency plan
3. Decision making
 Recognizes and articulates problem
 Asks surgeon and scrub team for help/opinion
4. Communication and Teamwork
 Keeps team informed about situation
 Seeks and listens to advice of team members
 Clearly communicates plan
5. Leadership
 Makes appropriate decisions
 Emphasizes the urgency of the situation
 Delegates tasks and coordinates team appropriately
Room Setup:
Anesthesia Machine
X
Infusion Pumps
Bronchoscope
X
X ETT
LMA
X Non-Invasive BP Cuff
Arterial Line
X Laryngoscope
CVP
Defibrillator
Hotline
PA Catheter
X 5 Lead ECG
X Nerve Stimulator
X Temperature Probe
Echo Machine and Probe
X Pulse Oximeter
CPB Machine + Circuit
X Capnograph
Orpheus Simulator
X
SIM Man
BIS
X Urinary Catheter
Other equipment required:
Airway kit
“Code resuscitation” drug box
Altepase
Central line kit
Supporting Files (CXR, ECG, echocardiogram, assessment, handouts, etc)
5.
6.
7.
8.
9.
CXR – normal, female
ANGIOGRAM –occluded flow L MCA
ABG (CVA)
BMP, CBC
Images for cranial nerve exam (if performed on mannequin)
STATE 1: 00:00
Starts in NSR 95 bpm, SaO2: 95%, RR: 20, BP: 135/85. Immediate downward trend
in BP, begins rapidly changing RR Cheyne-stokes (over 3m minutes). If no
treatment over first 3 minutes decrease in HR (-45 bpm over 3 minutes), BP (-10
over 3 minutes), SaO2 (-45 over 3 minutes)
If Neurology is “consulted”, conversation will allow participant to describe symptoms
and onset, request test, and discuss immediacy of interventions. If asked about
administration of thrombolytics, the confederate will indicate the neuro-interventional
suite is immediately available but leave decision to participant.
State 2: 01:30-03:30: Cheyne-Stokes breathing pattern. Continue until intubated
State 3: 3:30-06:00: SaO2 -40 over 1 minute; BP -15/10 over 45 seconds; HR -45
over 2.5 minutes
Critical Steps: Stated CVA DDX, Intubation, Notified Neuro-interventional, STAT
Neuro Consult, STAT non-contrast head CT
HYPERKALEMIC ARREST SUMMARY: Patient is 65 y/o M with diabetes,
hypertension, coronary artery disease and chronic renal insufficiency undergoing left
total knee replacement. Upon release of the tourniquet from the operative leg, the
patient will demonstrate instability and ECG changes consistent with hyperkalemia.
Based on management and timing, patient may become pulseless and require ACLS
in addition to treatment of hyperkalemia. Critical steps include: patient assessment,
ECG monitoring, administration of calcium, adherence to pulseless treatment
algorithm (if pulseless state is reached).
Assessment Instruments:
NOTTS framework
3. Situation awareness
 Monitors ongoing physiology
 Recognizes Problem- reflects and discusses significance of
information
 Shows evidence of having a contingency plan
4. Decision making
 Recognizes and articulates problem
 Asks surgeon and scrub team for help/opinion
5. Communication and Teamwork
 Keeps team informed about situation
 Seeks and listens to advice of team members
 Clearly communicates plan
6. Leadership
 Makes appropriate decisions
 Emphasizes the urgency of the situation
 Delegates tasks and coordinates team appropriately
Room Setup:
X
Anesthesia Machine
X
Infusion Pumps
LMA
Bronchoscope
Laryngoscope
X
X ETT
Defibrillator
X Arterial Line
CVP
PA Catheter
Hotline
X 5 Lead ECG
Nerve Stimulator
Porcine heart lung block
Temperature Probe
Echo Machine and Probe
X Pulse Oximeter
CPB Machine + Circuit
X Capnograph
Orpheus Simulator
X
X Non-Invasive BP Cuff
SIM Man
BIS
X Urinary Catheter
Other equipment required:
1.
2.
3.
4.
5.
6.
7.
8.
Orthopedic surgery supplies including tourniquet
Albuterol
Anesthesia drugs
“Code resuscitation” drug box
Calcium chloride
Insulin and D50 ampules
Sodium Bicarbonate ampules
Defibrillator and pads
Supporting Files (CXR, ECG, echocardiogram, assessment, handouts, etc)
10. CXR – normal, male
11. ABG (Hyperkalemia early and late)
12. BMP (CRI) and CBC (normal)
STATE 1: 00:00
Starts in NSR 78 bpm (with increasing amplitude of T-wave and PVCs over first 2
minutes), SaO2: 100%, RR: 12(ventilator), BP: 127/76. Initial downtrend begins:
increase in HR (+85 over 4 minutes), Decrease in SaO2 (-32 over 4.5 minutes), BP
(-60 over 4 minutes, CO2 (-22 over 4.5 minutes)
Critical Steps Pushes to State 4 if with first 3 minutes: Ca+ Supplementation +1
x ; Hyperventilation, Sodium Bicarbonate administration.
STATE 2: VTach 3:00
Critical Steps Pushes to State 4: Initial Critical Steps; CPR, Epinephrine 1 mg,
CPR if pulseless
STATE 3: Asystole 5:00
Critical Steps Pushes to State 4: Initial Critical Steps (exception hyperventilation);
CPR, Epinephrine 1 mg
STATE 4 (Recovery):
Sinus with peaked T-waves 111 bpm, BP 11/1 to 160/80 over 1 minute
CONCLUSION:
Participant should transfer to ICU, consider renal consult.
MALIGNANT HYPERTHERMIA SUMMARY: Patient is 30 y/o M undergoing
laparoscopic appendectomy. Participant has been called into the OR to give a break.
The end tidal carbon dioxide and temperature are rising. Participant is to recognize
signs of malignant hyperthermia. Critical Steps include: order ABG, administer
adequate dose of Dantrolene (2.5mg/kg), hyperventilation, fluid bolus, and initiation
of cooling measures.
Assessment Instruments:
NOTTS framework
4. Situation awareness
 Monitors ongoing physiology
 Recognizes Problem- reflects and discusses significance of
information
 Shows evidence of having a contingency plan
5. Decision making
 Recognizes and articulates problem
 Asks surgeon and scrub team for help/opinion
6. Communication and Teamwork
 Keeps team informed about situation
 Seeks and listens to advice of team members
 Clearly communicates plan
7. Leadership
 Makes appropriate decisions
 Emphasizes the urgency of the situation
 Delegates tasks and coordinates team appropriately
Room Setup:
X
Anesthesia Machine
X
X
X
ETT
X Non-Invasive BP Cuff
Infusion Pumps
LMA
X Arterial Line
Bronchoscope
Laryngoscope
Defibrillator
Hotline
Nerve Stimulator
PA Catheter
X 5 Lead ECG
Temperature Probe
Echo Machine and Probe
X Pulse Oximeter
CPB Machine + Circuit
X Capnograph
Orpheus Simulator
X
CVP
SIM Man
BIS
X Urinary Catheter
Other equipment required:
Anesthesia drugs
“Code resuscitation” drug box
Dantrolene (MH Kit)
Ice packs and cooled IVF
Supporting Files (CXR, ECG, echocardiogram, assessment, handouts, etc)
13. CXR – normal, male
14. ABG (Hyperkalemia early and late)
STATE 1: 00:00
Starts in NSR 124 bpm, SaO2: 97%, RR: 12 (ventilator) , BP: 152/96, etCO2 56,
temp 38.1C
STATE 2: 02:000-6:00:
HR to 150 over 4 minutes, SaO2: 97% RR 12 (ventilator), BP 152/96, etCO2 64
unless interventions already occurred, Temp to 39.0 over 4 minutes.
Increase HR, peaked T waves, and PVCs
INTERVENTIONS (with physiological trends):
-
-
Initial Dantrolene 2.5 mg/kg: EtCO2, HR, and Blood Temp start to
normalize but
return to previous elevated states without continuous
dosing
Second Dose of Dantrolene: EtCO2 -20; Temp -1.1 degrees, HR -20 bpm;
SaO2 +7
Bicarb 1-2mEq/kg: HR -6 bpm; SaO2 +4; BP +10/5;EtCO2 -2; Temp -0.6
Vasopressors: HR +4 bpm; SaO2 -2; BP +15/10; EtCO2 -2
Critical Steps: Initial Dantrolene 2.5 mg/kg, Second Dose of Dantrolene or infusion
started, Stop Triggering Agents
STATE 3: 06:00:
HR VTach 192, SaO2 94%, RR 12 (ventilator), BP 80/32 (if VT), etCO2 (dependent
on interventions), Temp 39
Critical steps: cooling mechanism, fluid bolus, and hyperventilation
STATE 4 (Recovery):
Stabilizes to NSR with mild Hyperkalemia. Other vitals trend toward initial as
scenario concludes
ST ELEVATION MYOCARDIAL INFARCTION SUMMARY: Patient is 58 y/o M
awaiting urgent repair of a femur fracture. He has history of hypertension and
hyperlipidemia and broke his femur falling from a ladder. He complained of
shortness of breath upon arrival to preop holding bay. Critical Steps include:
assessment of medical history, physical exam, order 12-lead ECG and chest
radiograph, discussion of sildenafil (listed outpatient medication PRN), acute
coronary syndrome care (O2, beta blocker, nitroglycerine, aspirin) and transfer to
cardiac catheterization lab.
Assessment Instruments:
NOTTS framework
5. Situation awareness
 Monitors ongoing physiology
 Recognizes Problem- reflects and discusses significance of
information
 Shows evidence of having a contingency plan
6. Decision making
 Recognizes and articulates problem
 Asks surgeon and scrub team for help/opinion
7. Communication and Teamwork
 Keeps team informed about situation
 Seeks and listens to advice of team members
 Clearly communicates plan
8. Leadership
 Makes appropriate decisions
 Emphasizes the urgency of the situation
 Delegates tasks and coordinates team appropriately
Room Setup:
X
X
Anesthesia Machine
ETT
Infusion Pumps
LMA
Arterial Line
Bronchoscope
Laryngoscope
CVP
Defibrillator
Hotline
Nerve Stimulator
Echo Machine and Probe
X
X Non-Invasive BP Cuff
PA Catheter
X 5 Lead ECG
Temperature Probe
X Pulse Oximeter
CPB Machine + Circuit
Capnograph
Orpheus Simulator
BIS
SIM Man
X Urinary Catheter
Other equipment required:
12-lead ECG machine
“Code resuscitation” drug box
Clopedigrel
Heparin
Supporting Files (CXR, ECG, echocardiogram, assessment, handouts, etc)
15. CXR – normal, male
16. ABG (normal)
17. BMP, CBC
18. Troponin (POC)
19. ECG showing STEMI
STATE 1: 00:00
Starts in sinus rhythm with anterior MI, ST elevation 110 bpm , SaO2: 95%, BP:
160/90, etCO2 34. Initial downtrend begins: Increase of HR (+30 over 4 minutes),
RR (+12 over 4 minutes), Decrease in SaO2 (-11 over 4 minutes), BP (- 19/11)
INTERVENTIONS (with physiological trends):
-
Orders Beta Blocker IV: HR -10 bpm; -5/5
Nitroglycerin SL Paste or GTT: RR -5; SaO2 +10; BP -15/15: HR -6 bpm
Critical: Order STAT Cards consult, Activate Cath Lab, Orders Beta Blocker IV for
HR control, Nitroglycerin SL Paste or GTT, ASA 325mg PO
STATE 2 (Recovery) :
Decrease in HR (-31 over 4 minutes if beta blockers administered), RR (-4 over 4
minutes), SaO2 (+18 over 4 minutes), BP (+22/20)
Prepare for phone consultation as cardiologist. Confederate may endorse being
ready for patient but must allow participant to decide about anticoagulation.