MedEd Portal
Human Patient Simulation
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Title: Aortic Aneurysm
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Target Audience: Medical Students, Interns, Residents
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Learning Objectives:
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Primary:
– Timely diagnosis of a ruptured abdominal aortic aneurysm
Secondary:
– Recognize an acute abdomen
– Create a thorough differential for abdominal pain in the elderly
population
– Use of ultrasound to assist in speedy diagnosis
– Discuss with family the prognosis regarding diagnosis while
coordinating care
Critical Actions Checklist
 Intravenous access (IV)
 Oxygen (O2)
 Monitor
 Recognize b blocker suppressed tachycardia
 Focused Abdominal Sonography in Trauma + (FAST)
 Call for immediate blood – emergent O- and type and cross
multiple units
 Stat portable Chest X-ray (CXR)
 Show correct technique for ultrasounding and measuring aorta
 Transfuse and bolus for goal Systolic Blood Pressure (SBP) 90100
 Call for surgeon
 Discuss risks and benefits with family while managing patient, if
possible appoint a person to keep the family updated while you run
the code
 Overall timely diagnosis and efficient coordination of care
Environment:
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Environment – General Tertiary Care Center
Manikin Set Up – IV’s, Monitor, Code Cart
Props – Ultrasound Machine, Ultrasound imaging handouts,
Electrocardiogram (EKG), CXR
Distractors – Multiple family members appropriately wishing to be
updated and decide on care
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Actors: (All roles may be played by residents participating)
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Resident Leader
2 Nurses (one be designated to help care for family)
2 family members who deliberate over care and diagnosis
On call surgeon
Case Narrative:
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Chief Complaint – Flank and abdominal pain
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History
– Patient is a 72 year old male who presents to the Emergency
Department (ED) with his son from the golf course for evaluation
of left flank and abdominal pain. He thinks he may have a kidney
stone again or pulled a muscle swinging his golf club, but the pain
is more severe, getting worse, and he feels like he is going to pass
out.
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Additional history given only if asked
– He has had similar pain over the past few weeks, but it was not this
intense and did not last this long. He has not followed up with his
regular doctor in a year
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Past Medical History
– Hypertension (HTN), Hyperlipidemia (HLP), Diabetes Mellitus
(DM)
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Social History
– He played golf 2-3 times a week and is a retired banker. He has 23 drinks per day and quit smoker 10 years ago
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Meds
– Metoprolol, Clonidine, Lisinopril, Atorvastatin, Docusate (Colace),
Metformin, Insulin
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Surgical History
– No prior surgeries
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Allergies
– No known drug allergies
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ROS
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Intermittent abdominal pain for the past few weeks
No diarrhea, dark or bloody stools
No difficulty urinating
No chest pain or shortness of breath
No weight loss
No itching
No chronic back pain
No focal weakness or numbness
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Pertinent Physical Exam Findings
– Heart Rate 88, Blood Pressure 78/52, Oxygen – 98%, Respiratory
Rate – 28, Temperature 98.2 F, Glucose - 117
– General - Elderly male who appears in distress, moaning and in
moderate to severe pain while grabbing his abdomen.
– Cardiac – regular rhythm and rate with no murmurs, rubs, or
gallops. Symmetric, but weak, femoral and lower extremity pulses.
– Respiratory - tachypnea, but clear to auscultation bilaterally
– Abdominal – diffuse tenderness to palpation, but most in the
periumbilcal region. There is a palpable pulsatile abdominal mass.
(The participant must specifically ask if there is a pulsatile mass.)
– Back - Mild right costovertebral angle tenderness to palpation
– Skin - pale and diaphoretic
– Musculoskeletal – no gross deformities
– Neurologically intact
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Scenario Branch Points
– The patient presents to the Emergency Department with increasing
abdominal pain, hypotension and a regular heart rate. The resident
should quickly recognize abnormal vital signs and intervene with
IV, O2, monitor, and intravenous fluids (IVF) resuscitations. The
resident needs to do a focused exam to quickly suspect abdominal
aortic aneurysm (AAA) with rupture. The resident may use
ultrasound to diagnose an enlarged aneurysm with free fluid in
Morrison's Pouch. The resident should make immediate
interventions including calling the vascular surgeon, blood bank
(need to specify type O non cross matched blood initially or there
will be a delay in obtaining blood), and alerting the operating room
(OR). The resident will need to perform the above tasks while
notifying the patient and family of the prognosis and would do
well to assign a nurse to take care of family while the resident runs
the medical situation.
– If the above tasks are not performed within approximately 15
minutes of the case, the patient will decompensate in the ED. The
patient will become hypotense, lose consciousness, need to be
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intubated, given large volume unmatched blood, and vasopressors
initiated to titrate for SBP 90-100.
The patient will not die in the case, but instead will survive long
enough to make it to the OR.
Instructors Notes:
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Tips to Keep the Scenario Flowing
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Tips to Direct Actors
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The goal of the case is early intervention of a rupturing AAA. The
resident will facilitate this process through timely diagnosis and
coordination of care. The simulation should only take
approximately 10 minutes.
The patient needs to be in so much pain that he is unable to give a
full and thorough history.
Encourage the resident to properly use staff to coordinate care.
 Grab the ultrasound machine that will be out of the
simulation room.
 Someone to call the blood bank, surgeon, and OR
 Have nurse recruit help for IV’s
 Have the intern place the central venous line.
 Have a nurse talk with family through the case after the
resident gets initial information from them.
After 10-15 minutes, make the patient decompensate if the critical
actions have not been met to transport the patient to the OR
Allow one round of ACLS
The patient will respond to vasopressors with an increasing SBP
and return of spontaneous circulation (ROSC).
The family members should be persistent regarding wanting to
know the diagnosis. The resident needs to not only manage the
patient’s stressful diagnosis, but also very concerned family
members.
Nurses will be new graduates and need specific instructions on
interventions (drug dosages, IVF on pressure bags instead of
pumps, large bore IV’s, how to attach the defibrillator monitor,
etc..)
Scenario Steps
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Optimal Management Path
 Early treatment of ruptured AAA
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Imaging and Labs
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CXR – within normal limits (wnl), no widened mediastinum
CBC 16>7/23<332
Chem 10 – metabolic acidosis
ABG – ph 7.3, metabolic acidosis w/ compensatory respiratory
alkalosis, lactate 6
FAST – 8 cm AAA w/ free fluid
EKG – sinus tachycardia
Debriefing Plan:
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Topics to discuss
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 Complete critical actions and patient goes to the OR
 Facilitate excellent communication with the family
Potential Complications Path
 No timely diagnosis
 Patient becomes hypotensive and lose pulses
 Patient needs ACLS x 1 round
Potential Errors Path
 Surgery not consulted immediately
 Patient sent to computerized tomography (CT) scan
o Patient will have cardiac arrest if this occurs
 Incorrect diagnosis and patient will have cardiac arrest
Morbidity and mortality of ruptured AAA
 Key to mortality reduction is early diagnosis and treatment
Differential diagnosis of acute abdomen in the elderly
Clinical signs and symptoms of AAA
Risk factors for AAA
 Smoking, family history, male gender (most important)
Recognizing hypovolemic shock in the setting of a normal heart
rate secondary to beta-blockers
Optimal patient/ family communication strategies in peri-code
situations
Timely management of the critically ill
 Include key step in your department
o Calling blood bank, operating room (OR), surgery,
etc…
Pilot Testing and Revision:
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Number of participants – 5
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Physician - director
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Anticipated Management Mistakes
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3 – Nurses perform orders, communication with family
Intern - procedures
Untimely diagnosis
Do not call the blood bank
Do not use U/S
Send pt to CT
Pt does not get to the OR in 15 minutes
Does not create plan for family communications
Evaluation form for participants – generic handout
Authors:
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John B. Seymour M.D. University of North Carolina Department of
Emergency Medicine, PGY – 3
Rochelle Chijioke M.D. University of North Carolina Department of
Emergency Medicine, PGY – 2
Kevin Biese M.D. University of North Carolina Department of Emergency
Medicine, Associate Professor and Residency Director
Graham Snyder M.D. Wake Med Health and Hospitals Department of
Emergency Medicine, Assistant Program Director and Simulation Director
Jan Busby-Whitehead M.D. University of North Carolina Division of
Geriatric Medicine/ Institute on Aging, Professor and Chief
Copyright © 2011 The University of North Carolina School of Medicine