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“Simwars” Case Template
Scenario overview
Critical actions
 (List 3-5 Critical Actions)
Teaching Objectives
 Clinical and medical management

Communication and Teamwork
Supplies & Moulage

Images
 (CXR, EKG, CT)
Actors and roles
 (Nurse, EMS, Family member)
Case Flow/Timeline
Key Action Items – Related to teaching points.
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Scenario Overview
36-year-old-male, BIBA, s/p jumping off of a 3-story fire escape to get away from DEA. As per
DEA, they were notified about drug activity in a building. When they responded and broke down
the door, they found the patient swallowing something wrapped in a clear bag. They chased the
patient onto the fire escape when the patient jumped off from the third floor onto the concrete
sidewalk. Witnesses saw the patient hit his head. Patient is agitated and uncooperative
screaming about his right chest that hurts.
Critical Actions
 CT head
 Chest tube placement
 Control environment, i.e. police
 Intubation
 Benzodiazepine
Teaching Objectives
 Clinical and Medical Mangement
o Recognition and management of Traumatic Brain Injury
o Recognition of and management of Sympathomemetic overdose – stuffer
o Illustrate proper sedation and management in an agitated patient
o Recognition and management of pneumothorax
 Communication and Teamwork
o Identify team roles and leader
o Conflict resolution with police
Supplies & Moulage
 Handcuffs
 Simulator clothes
 C collar
 Head injury with blood and gauze
Images
 CXR – Pneumothorax
 EKG – Sinus Tachycardia
 CT head – Normal CT
Actors and roles
 DEA/Police: Police is in the trauma bay trying to get information from the patient. They
are being obstructive to care. Refusing to leave. (States patient has had multiple priors
and “I’m gotta find out who his dealer is!!!”)
 EMS: EMS states, they found patient in handcuffs with police. Patient was AxOx2,
uncooperative and cursing. + Head trauma. Moving all extremities symmetrically.
Trying to get out of the cuffs.
 Patient: Agitated, swearing, refusing to cooperate with EMS and police.
 ER Tech: Facilitates management of case with key exam findings and physical exam
items not reproducible on simulator.
 Surgery
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Case Flow/Timeline
TIME 0 NOTIFICATION: 36-year-old fall from 2-3 stories. BP 185/110 HR 145 RR 22
Sat 100% on NRB
What does the pt. look like?
Pt is agitated and uncooperative, blood on occiput
Vitals:
BP 185/110 P 155 RR 24 T 100.1 F Sat 100% on NRB
IV : none
Monitor: ST at 145
Physical exam:
Gen: AxOx2 (person, place, 2004 July), agitated and uncooperative, swearing
Heent: 6 mm and reactive
Neck: Collar – no stepoff
Chest: Decreased BS on right, + crepitus, normal BS on left
Heart: Tachy rate without M/R/G
Abdomen: NT, ND, no R/G/R, hyperactive bowel sounds
Rectal: guaic neg if done, normal tone
Skin: sweaty
Ext: no C/C/E
Neuro: AxOx2, moving all extremities symmetrically, CN2-12 grossly intact
FAST: Normal if done
TIME 1MIN-2 MIN (Initial State – Pneumothorax & Agitation & Police)
Vitals - BP 185/110 P 155 RR 24 T 100.1 F Sat 100% on NRB
Pneumothorax -> if no chest tube will desaturate to 85% rapidly -> if intubated
without chest tube will desaturate rapidly
Right sided chest tube
Pain medicine (rib fracture) -> no pain meds, unable to get chest tube
Agitation -> if not sedation, more agitated, unable to do exam
Ativan for sedation (2-4mg)
Scene control (Police) -> cannot proceed until police removed from bedside
Remove Police from the bedside
TIME 2 MIN- 4 MIN (Trauma management)
Trauma management
Two large bore IV
Disability
Exposure
Labs (type and cross)
Trauma team – Wants to wait till he drinks contrast
CXR, Pelvis, C spine
CT head/Chest/Abd/Pelvis
Exam
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TIME 4-5 MIN (Herniation and Intubation)
Patient becomes increasingly lethargic unresponsive
Starts to brady down with irregular breathing pattern
VS BP 205/120 HR 55 RR 6-12 Sat 93% on NRB
Intubation with RSI and brain protection
BP management
Labs:
SMA-7 (nl) ,
CBC (nl) ,
PT/PTT/INR (nl),
Etoh level 140
Other tox negative
CT results:
Head CT (+ epidural and subdural bleed);
C-Spine: normal
CT – chest/abd/pelvis - negative
TIME 6-7 MIN (Head bleed)
Elevated ICP management
Neurosurgery
ICP monitoring
Elevate head
Hyperventilate
Mannitol
Maintain BP and Sat
Sedation/Ativan
Key Action Items
 Actions for Trauma
o (1 Min) ABC – recognition of pneumothorax
o (2-4 Min) ATLS
o (5-6 Min) CT of Head and C-spine; give results
o Trauma Surgery consult
o Control environment – Get police away from patient

Actions for Airway Management
o Chest tube
o RSI with in-line stabilization

Actions for increased ICP/Bleed
o Maintain MAP
o Elevate head
o Sedation
o Hyperventilate
o Mannitol
o Surgery
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o
ICP monitoring

Actions for Cocaine overdose
o Sedation with benzos
o R/O other overdose
o EKG
o CT head

Final Actions:
o Neurosurgery
o NSICU
o Ventriculostomy
Critical Actions
 CT head
 Chest tube placement
 Control environment, i.e. police
 Intubation
 Benzodiazepine