Template for Simulation Patient Design
Developed by Jeffrey M. Taekman, M.D.
Duke University
Made available through a Creative Commons License
http://simcenter.duke.edu/support.html
Case Information
Section 1: Demographics
Case Title: Local Anesthetic Toxicity in Patient with Small Bowel Obstruction/Volvulus
Patient Name: Baby Packard
Scenario Name: Local Anesthetic Toxicity in Infant
Simulation Developer(s): Ellen Wang, Anita Honkanen, Michael Chen
Date(s) of Development: 8 – 2011 through 10 - 2011
Appropriate for following learning groups (circle all that apply)
Faculty:
CME
Residents:(PGY)
Specialties:
Medical Students (yr):
Nurse Anesthesia Faculty:
Nursing Students (yr):
Other:
1
2
3
4
5
Anesthesiology Nurse Anesthesia
Critical Care Emergency Medicine
1
2
3
4
CEU
1
2
_____________________
6
7
Surgery
Obstetrics
Template for Simulation Patient Design
Developed by Jeffrey M. Taekman, M.D.
Duke University
Made available through a Creative Commons License
http://simcenter.duke.edu/support.html
Section 2: Curricular Information
Educational Rationale:
Learning Objectives: (ACGME Core Competencies: Medical knowledge (mk), Patient care (pc), Practice-based learning
and improvement (pli), Interpersonal and communication skills (cs), Professionalism (pr), Systems-based practice (sbp))





objective 1: Review of Local Anesthetic Toxicity manifestations and treatments (mk, pc)
objective 2: Review Guidelines and regulations for drugs that nurses/surgeons use intraoperatively
and medication errors (sbp)
objective 3: Review of ischemic bowel and likely repercussions (mk)
objective 4: Review resources available for cardiopulmonary support (sbp)
objective 5: Understand critical behaviors for effective team performance in ACRM, leadership and
communication in a crisis situation (pr, cs)
Guided Study Questions:
 question 1
 question 2
 etc
References used (included PubMed ID when possible):
 reference 1
 reference 2
 etc
Didactics:
 powerpoint slide set
 web site
 etc
Assessment Instruments:
 Instrument name
Template for Simulation Patient Design
Developed by Jeffrey M. Taekman, M.D.
Duke University
Made available through a Creative Commons License
http://simcenter.duke.edu/support.html
Section 3: Preparation
Monitors Required:
X
X
X
X
X
Non-Invasive BP Cuff
Arterial Line
CVP
PA Catheter
3 lead EKG
Temperature Probe
Pulse Oximeter
Capnograph
BIS
Other equipment required:
SimBaby, Anesthesia Machine, IV poles/sets, IV materials/supplies, syringes and needles for sim meds
(including emergency drugs, intralipids), airway equipment (mask, ambu, LMA and ETT, laryngoscope
blades/handles, stylets), suction, defibrillator, stethoscopes, drapes/surgical instruments, patient’s chart
and anesthesia record
X
X
Anesthesia Machine
Pumps
Brochoscope
Defibrillator
Hotline
Nerve Stimulator
Echo Machine and Probe
X
X
ETT
LMA
Laryngoscope
Supporting Files (cxr, ekg echo, assessment, handouts, etc)
1. CXR and KUB of abdomen
Time Duration
Set-up
Preparation
Simulation
Debrief
20 minutes
10 minutes
20 minutes
40 minutes
Template for Simulation Patient Design
Developed by Jeffrey M. Taekman, M.D.
Duke University
Made available through a Creative Commons License
http://simcenter.duke.edu/support.html
Case Stem
Case Stem (one to two paragraphs on pertinent patient and scenario information-this should be the stem for the
learner and should include location, physician/help availability, family present, etc.):
You are taking over the intraop management of a 13 month old boy, scheduled for urgent ex-lap for volvulus
with possible dead bowel.
He is a full-term infant, otherwise healthy, with no previous surgeries or procedures, no family history of
problems with anesthetics. Not currently taking any medications. No allergies.
He had a 2 day history of poor intake, fussiness, with vomiting starting today with abdominal guarding noted
on exam with presentation at physicians office. Sent to ED for evaluation; plain films revealed largely
distended loop of bowel with proximal bowel distension, but no air in colon. Attempt at reduction in
radiology earlier today unsuccessful, with subsequent film revealing free air under the diaphragm.
Came to OR with 22 G PIV placed in ED in situ in the left hand. This IV used for RSI with an easy intubation, but
relatively poor flow noted after induction. Unable to place second IV after multiple attempts, so surgeons
placing central venous line for access.
Meds given on induction included etomidate (6 mg), rocuronium (10 mg), fentanyl (25 mcg); 10 mcg
phenylephrine given after induction for BP 60/30 with HR 170, 100 mls of NS pushed in with resistance using
syringe, IV barely flowing at this time. Cefoxitin, 480mg given.
Primary anesthesiologist must leave for family emergency – child involved in MVA while riding bicycle.
Background and briefing information for Facilitator/coordinator’s eyes only:
Patient in the OR, at beginning of the case, when "hot seat" participant comes in to take over care - original
anesthesiologist must leave due to a family emergency. The patient is stable at the time of handoff,
intubated, surgeon in the process of finishing line placement. The original anesthesiologist will tell the “hot
seat” participant that the original PIV is not working and difficult to place, so the surgeon has just placed a
central line. Allowing some time for the “hot seat” participant to get settled, the surgeon will continue with
line placement. Once line is secured, the surgeon will flush the line with what should be saline, but is actually
bupivacaine and hand off line under drape to anesthesiologist. Will follow quickly with incision. Ectopy will
appear on ECG within 30 seconds of line flush, followed by more ECG changes – sinus bradycardia, conduction
blocks (prolonged QT, widened QRS), hypotension. Confusion as to reason for dysrhythmias – electrolyte
abnormalities second to the dead bowel vs local anesthetic toxicity. At some point (if “hot seat” participant
needs prompting), the scrub tech will ask the surgeon what happened to the basin of local anesthetic, which is
empty. Recognition of local anesthetic toxicity should prompt a call for intralipids and amiodarone. ECG will
progress to ventricular fibrillation with loss of pulses, and CPR should be initiated. Cardiopulmonary bypass
should be considered, and perfusion services and cardiothoracic surgery should be called for.
Template for Simulation Patient Design
Developed by Jeffrey M. Taekman, M.D.
Duke University
Made available through a Creative Commons License
http://simcenter.duke.edu/support.html
Patient Data Background and Baseline State
Patient History (should follow standard H and P format):
Review of Systems:
CNS: normal
Cardiovascular: normal
Pulmonary: normal
Renal / Hepatic: normal
Endocrine: normal
Heme/Coag: normal
Current Medications and Allergies:
No meds, no allergies
Physical Examination:
General: mildly obtunded, easily aroused to responsiveness but ill appearing
Weight, Height: 12 kg, 79 cm
Vital Signs: HR – 155, BP – 75/30, RR – 28, Temp – 38, SpO2 - 98
Airway: WNL
Lungs: CTA, shallow respirations
Heart: Regular, 2/6 flow murmur, normal heart tones
Laboratory, Radiology, and other relevant studies:
HCT: 37, WBC: 10, Plts: 122,000, INR: 1.3, Na: 143, K: 3.8, Cl: 106, HCO3: 26
CXR/KUB: clear lung fields, slightly elevated diaphragms, free air under in around bowel loops, distended
EKG: not available
Template for Simulation Patient Design
Developed by Jeffrey M. Taekman, M.D.
Duke University
Made available through a Creative Commons License
http://simcenter.duke.edu/support.html
Baseline Simulator State:
Vitals: HR: 135, BP: 65/35, PC: 15/4 with TV 90 to 100, RR: 16, ETCO2: 34, Temp: 36
Neuro: anesthetized
Respiratory: intubated, ventilated
Cardiovascular: SR
Gastrointestinal: abodomen prepped/draped, ready for incision
Genitourinary: foley catheter in place, less than 5 ml urine output noted
Metabolic: afebrile
Environmental: OR with circulating nurse, scrub tech, surgeon all present, primary anesthesiologist about
to leave after giving hand-off report
Template for Simulation Patient Design
Developed by Jeffrey M. Taekman, M.D.
Duke University
Made available through a Creative Commons License
http://simcenter.duke.edu/support.html
State
Patient Status
1. BASELINE:
Anesthetized:
immediately
at handoff
Relatively stable after
induction and
resuscitation with
phenylephrine/volume,
awaiting central line
from surgeon
2. Local
anesthetic is
injected into
central line by
surgeon as flush
(syringe not
labeled, mistaken
as flush syringe
while tech and
circulator
completing initial
instrument and
sponge count)
3. Non perfusing
rhythm noted by
team
Patient stable until LA
hits heart, progressive
ECG changes – ectopy,
morphology changes,
runs of V-tach
4. Scrub Tech
Student learning outcomes or actions desired and trigger to move to next state
Learner Actions:
o become familiarized with environment,
review patient chart, review patient
history, introduce self to team, review
plan with surgeon
Learner Actions:
o note ECG changes, initiate discussion
with surgeon, ask to hold on
incision/manipulation of bowel if already
open abdomen
Operator:
o maintain VS’s within 10% of baseline
Teaching Points:
o get complete handoff, communicate with team to develop baseline shared mental model
of plan
Trigger: handoff complete
Operator:
o add dysrhythmias, BP changes
Teaching Points:
o situational awareness – note ECG changes and course of surgery, develop
Trigger: surgeon tells anesthesiologist that handing off line under the drapes
ECG VFib, no SpO2
ithout effective
compressions, no
ETCO2 without
effective compressions
and decreased with
compressions
Return to perfusing
Learner Actions:
o initiate code response, call for help, direct
team members in appropriate actions,
ask for input from team on etiologies –
develop differential list
Learner Actions:
Operator:
o VFib, no other vitals unless managed properly, see below
Teaching Points:
o Manage code, manage OR team
Trigger: time from injection at 1 minute, VS’s (ETCO2, SpO2) based on effective chest
compressions
Operator:
Template for Simulation Patient Design
Developed by Jeffrey M. Taekman, M.D.
Duke University
Made available through a Creative Commons License
http://simcenter.duke.edu/support.html
notes missing
syringe of local
anesthetic on
back table, asks
surgeon about
why missing,
confers with
circulator
rhythm if appropriate
actions taken
o
o
Moves LA toxicity to head of differential if
notes communication from rest of OR
team
Initiates intralipid treatment, calls for
backup support/ICU/cardiac for bypass if
required
o
Return to perfusing rhythm
Teaching Points:
o Communication within team, understanding of LA toxicity and treatments, use of
environmental cues (cognitive aids?)
Trigger: administration of effective dose of intralipid and continued effective chest
compressions for at least 2 minute