Simulation Scenario Template –VRR Pediatric Seizure

SimulationScenarioTemplate–VRR–PediatricSeizure

©2019EMSIMCASES.COMandtheEmergencyMedicineSimulationEducationResearchersofCanada(EM-SERC) Page1

ThisworkislicensedunderaCreativeCommonsAttribution-ShareAlike4.0InternationalLicense.

Section1:CaseSummary

ScenarioTitle: Keywords: PediatricVirtualSimulation5–PediatricSeizure

BriefDescriptionofCase:

*ThiscaseisdesignedtoaccompanytheVirtualResuscitationRoom©FOAMED

foundat:

A6-year-oldboywithaknownseizuredisorderpresentstoacommunityGeneral

EmergencyDepartmentwithageneraltonic-clonicseizureinstatusepilepticus.

Thechildisrefractorytobenzodiazepinesandsecondlinemedications.Theteamis

ultimatelyrequiredtostartacontinuousantiepilepticinfusionandintubatethe

childforprogressiverespiratoryfailure.Thereisanoptionforthesimulations

facilitatortoprogressthechildtosubclinicalstatusepilepticusin-betweensecond

linemedicationsandcontinuousantiepilepticinfusionbasedlearnerneed.

GoalsandObjectivesEducationalGoal:

Objectives:

(Expertknowledgeand

CRM)

Bytheendofthiscaseparticipantswillbeableto:

Expertknowledge:

1. Developandimplementapathwayformanagingrefractorystatusepilepticusmanagementinacommunitygeneralhospitalsetting

2. Recognizeindicationsforsecuringairwayinchildrenwithrefractorystatusepilepticus.

3. Consideranoperationaldifferentialdiagnosisforseizureinachild4. Optional:Recognizesignsandsymptomsof“subclinical”status

epilepticusinchildren

CRM:

1. Effectiveclosedloopcommunicationtoteammembers2. Developmentofasharedmentalmodel3. Demonstrateinterprofessionalcollaboration:roleclarification,

conflictmanagement,inclusiveleadership,communication,conflict

resolution.

EPAsAssessed: N/A

Learners,SettingandPersonnel

TargetLearners:

�JuniorLearners �SeniorLearners �Staff(Continuing

education)

�Physicians �Nurses �RTs �Inter-professional

�OtherLearners:

Location: �SimLab �InSitu �Other:VirtualResus

Room©-SettingofcommunityEDresuscitationroom

RecommendedNumber Instructors:1-2




ofFacilitators: Confederates:

SimTechs:1

ScenarioDevelopmentDateofDevelopment: September22,2020

ScenarioDeveloper(s): Dr.JamesLeung

Affiliations/Institutions(s): McMasterUniversity

ContactE-mail: [email protected]

LastRevisionDate: September22,2020

RevisedBy: Dr.SarahFoohey,MarcAuerbach

VersionNumber: 1




Section2A:InitialPatientInformation

A. PatientChartPatientName:MichaelB Age:6 Gender:M Weight:25kg

Presentingcomplaint:Seizure/StatusEpilepticus

Temp:37oC/

98.6oF

HR:160 BP:98/55 RR:30(Seizing) O2Sat:90% FiO2:21%(RA)

Capglucose:8.5mmol/L(153mg/dL) GCS:3(E1V1M1)-seizing

Triagenote:

TransportedfromhomebyEMS.Immediatelymovedtoresuscitationforongoinggeneraltonicclonicseizure

(GTC)forlast45minutes.Seeresuscitationrecord.Momisenroute.

Allergies:Nonelisted

PastMedicalHistory:

Knownseizuredisorderfollowedbyneurologyatthe

localchildren’shospital

CurrentMedications:

Carbamazepine80mgPOTID(~10mg/kg/day)

(NB*effectivedosewouldbe20-30mg/kg/day)

Section2B:ExtraPatientInformation

A.FurtherHistoryIncludeanyrelevanthistorynotincludedintriagenoteabove.Whatinformationwillonlybegiventolearnersifthey

ask?Whowillprovidethisinformation(mannequin’svoice,confederate,SP,etc.)?

PerEMSconfederate:

Hehasbeenseizingcontinuouslyforthelast45minutes.Hehasknownepilepsy,onhome

carbamazepine.Nootherco-morbiddiagnoses,andhasbeendoingwellrecentlywithabiggrowth

spurt.Therehasbeennorecentfever,orinfectioussymptoms.Theirregularneurologyappointments

havebeendelayedbecauseofCOVID-19andmomthinkshehasoutgrownhismedication.Heusually

has1seizuresevery3-4months,allGTClikethisseizure.Patientusuallystopsspontaneously,but

thisseizureislongerthannormal.HeusuallyrespondstoPRNlorazepam,buthadonetimewherehe

wasairliftedtochildren’shospitalforaPICUstay.Parentalreadygavehomelorazepam(2mg)x2

doseswithnoeffect.Becauseofthis,EMSwascalled,asrecommendedbytheirneurologist.

EMShasprovidedmidazolam5mgIN,approximately10minutesagowithnochange.

B.PhysicalExamListanypertinentpositiveandnegativefindings

Cardio:Nil Neuro:GTC

Resp:Nil Head&Neck:NOneckstiffness

Abdo:Nil MSK/skin:NOrash




Other:Nil

Section3:TechnicalRequirements/RoomVision

A.Patient�Mannequin(specifytypeandwhetherinfant/child/adult)–Virtualchild

�StandardizedPatient

�TaskTrainer

�Hybrid

B.SpecialEquipmentRequiredThissimulationisdesignedtobeconductedinavirtualenvironment.

- Zoom™orsimilarvideoconferencingaccount

- Computeraccess

- Internetaccess–institutionalfirewallsthatpermitaccesstoGooglesuites

- Quietroomtoconductsimulationvirtually

C.RequiredMedicationsN/A–builtintovirtualsimulationroom.Additionalantiepilepticstoconsider:

o Antiepileptics

• Midazolam(IV/PO/PR/IM/IN)

• Lorazepam(IV/PO/PR/IM)

• Phenytoin(IV)

• Phenobarbitol(IV)

• Phosphenytoin(IV)

• Levetiracettam(IV)

• Propofol(IV)

D.MoulageN/A–VirtualCase

E.MonitorsatCaseOnset�Patientonmonitorwithvitalsdisplayed�Patientnotyetonmonitor

F.PatientReactionsandExamIncludeanyrelevantphysicalexamfindingsthatrequiremannequinprogrammingorcuesfrompatient

(e.g.–abnormalbreathsounds,moaningwhenRUQpalpated,etc.)MaybehelpfultoframeinABCDEformat.

N/A–VirtualResuscitationRoomshouldbeinanunusedcasestate.




Section4:ConfederatesandStandardizedPatients

ConfederateandStandardizedPatientRolesandScriptsRole Descriptionofrole,expectedbehavior,andkeymomentstointervene/promptlearners.Includeanyscript

required(includingconveyingpatientinformationifpatientisunable)

EMS Simulationfacilitator.EMShandsoverpatientandifpromptedwillprovidebackgroundstoryas

listedabove.EMSwillthenleaveafterpatienthandover,andwillnolongerbeabletoparticipate

inthecase.

PICU

consultant

Simulationfacilitatorcanfillinthisroleiflearnersrequireassistanceearlyinthecase.ThePICU

consultantbasedatthelocalchildren’shospital45minutesawaybycar.Thepatientiscurrently

inacommunitygeneralED.Theconsultantpediatricintensivistissupportive,andwillanswer

questionsasaskedbytheteam.TheconsultantPICUwillneedtobeconsultedatsomepointin

thecasetoreceivehandover,accept,andarrangecriticaltransport.

SimulationScenarioTemplate

©2019EMSIMCASES.COMandtheCanadianEMSimulationEducatorsCollaborative(CESEC) Page6


Section5:ScenarioProgression

ScenarioStates,ModifiersandTriggersPatientState/Vitals PatientStatus LearnerActions,Modifiers&TriggerstoMovetoNextState FacilitatorNotes

1.StatusepilepticusRhythm:sinustachy

HR:162

BP:110/76

RR:30(seizing)

O2SAT:90%

T:37oC(98.6oF)

GCS:3

Generaltonic

clonicseizure.

A-trismus.Unable

toopenmouth.

Obstructing.

B-transmitted

upperairway

sounds

C-CRT2-3s

D–Pupils3mm

reactiveL=R

E-No

bruises/extremity

injury.Norash.

Notoxidrome

findings.

ExpectedLearnerActions

HandoverreceivedfromEMS

Jawthrustpatient

Placesmonitors

Weightobtained(inkg)

Primarysurveydone

Capillarybloodglucosemeasured

(BG8.5mmol/L(153mg/dL))

ObtainvascularaccessbyIO–

unabletogetIVx2attempts

Bloodworkobtained

Benzodiazepine(1stline

medication)administered

ModifiersChangestopatientconditionbasedonlearneraction-Deceasegraduallyto85%ifnojaw

thrustdone.

-IncreaseSpO2to95%ifO2applied

TriggersForprogressiontonextstate-Afteradministrationof

benzodiazepine

-IOaccessobtained

*localinstitutionsmayhavevarying

doseranges.

1stLINEANTI-EPILEPTICS:

• Midazolam:

(IV/IO)0.1mg/kg(max10mg)

(IN)0.2mg/kg(max10mg,with

5mgmaxpernare)

(Buccal)0.5mg/kg(max10mg)

• Lorazepam:(IV/IO)0.1mg/kg(max4mg/dose)

• Diazepam:(IV/IO)0.2mg/kg(max10mg)

(PR)0.5mg/kg(max20mg)

2.Continuedseizure*Nochangewithbenzodiazepine

Vitals:unchanged

HR:162

BP:110/76

RR:30(seizing)

O2SAT:90%ifRA,95%

ifO2

T:37oC(98.6oF)

GCS:3

Generaltonic

clonicseizure.

A-patientwith

jawthrust

B/C/D/E–

unchanged

Pupilsstill3mm


Reassesspatient

Considerboluscrystalloid

CriticalVBGwillreturn–reviewresults

Considerreversiblecausesof

seizure(hypoGlu,hypoCa,

Secondlineantiepilepticordered

Secondlineantiepileptic

delivered

Intubation/RSIpreparation

begins

Modifiers

-Facilitatorscanpromptteamto

consultPICU(offsite)

-

Triggers

-Afteradministrationofsecondline

antiepileptic

ADVANCETOEITHERPHASE3aor3b

*Becauseantiepilepticstaketime(10-20min),facilitatortofastforwardtimetokeepsimulationbrief.

2NDLINEANTI-EPILEPTICS:

• Phenytoin20mg/kgIV/IO(max

1500mg)over20minutes.Filter

requiredformedication.

• Phenobarbital20mg/kgIV/IO

(max1000mg)over20minutes.

Filterrequiredformedication.

• Fosphenytoin20mg/kgIV/IO

(max1000mg)over10minutes.

Nofilterrequired.

• Levetriacetam60mg/kgIV/IO

(max3000mg)over15min




3a.Progressiverespiratorydepression+ContinuedseizureHR:150

BP:115/76

RR:15(seizing)

O2SAT:83%(02)

T:37oC(98.6oF)

GCS:3

Generaltonic

clonicseizure

continues.

A-patientwith

jawthrust

B-decreasing

respiratoryeffort.

Intermittant

snoring

C-CRT3-4s

D-GCS3–seizing.

Pupils3mmL=R

E-nochange


Recognizerespiratorydepression

Prepareforintubation

RSIdrugsdrawnup

Patientintubated–considertime

out

Orderalternativesecondline

medicationorthirdlineantiepileptic

ConsiderPICUconsult

Modifiers

-Ifrespiratorydepressionnot

recognized,makeSpO2decreaseto

70%over5min


recognizedafter5min,makepatient

PEAarrest

Triggers

-Successfulintubation

-Administrationofalternativesecond

linemedication,orinitiationofthird

lineanti-epileptic

-PICUconsultedfortransport

ADVANCETOPHASE4(not3b)


RSIMedications:

• 1)KetamineIV1-2mg/kg(100mg

max)|2)PropofolIV0.5-2mg/kg

(100mgmax)+Fentanyl1mcg/kg

(100mcgmax)|3)MidazolamIV

0.1-0.25mg/kg(10mgmax)+

Fentanyl1mcg/kg(100mcgmax)

• Succinylcholine1-2mg/kg(150mg

max)ORrocuoronium1-2mg/kg

(100mgmax)

3rdLINEANTI-EPILEPTICS

• Midazolaminfusion:0.15mg/kg

bolusthenstartinfusionat

120mcg/kg/hr(2mcg/kg/min).

Increaseby120mg/kg/hrq5

minutesasneeded.Maxinfusion

rate1440mcg/kg/hr

(24mcg/kg/min)

• Propofolinfusion:2-5mg/kgbolus,

theninfusionat2-5mg/kg/hr***

lesspreferredthanmidazolam***

3b.(optional)Subclinicalstatusandrespiratorydepression

HR:150

BP:94/52

RR:10(snoring)

O2SAT:83%(02)

T:37oC(98.6oF)

GCS:3

Nomovement.

GCS3.No

responseto

touch/pain.

A-patientwith

jawthrust

B-decreasing

respiratoryeffort.

Intermittant

snoring

C-CRT3-4s

D-GCS3–seizing.

Pupils3mmL=R

E-nochange


Recognizerespiratorydepression

Prepareforintubation

RSIdrugsdrawnup

RecognizepatientisstillseizingPatientintubated–considertime

out

Orderalternativesecondline

medicationorthirdlineantiepileptic

ConsiderPICUconsult

Modifiers


recognized,makeSpO2decreaseto

70%over5min


recognizedafter5min,makepatient

PEAarrest

Triggers

-Facilitatorscanpromptthatpatient

isinsubclinicalstatusafter3-5min

-Administrationofalternativesecond

linemedication,orinitiationofthird

lineanti-epileptic

-PICUconsultedfortransport

ADVANCETOPHASE4

Seeaboveformedication

recommendations

Takingthisalternativepathwaywill

resultinthesamefinalphase4

(below)





4.StabilizationHR:115

BP:98/55

RR:paralyzed/apneic

(dependingonparalytic

usedforRSI)

O2SAT:97%(02)

T:37oC(98.6oF)

GCS:3

Nomovement

(eitherbecause

seizurestopped

orparalyzed)–

postictal


PICUconsultedifnotalready

done

Thirdlineantiepilepticstartedif

notalreadystarted

Transportarranged

Considerantibiotics

PostintubationX-ray

Modifiers

-Endsimulationatanytime

Triggers

-Endsimulationatanytime


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AppendixA:LaboratoryResults

LABORATORY SERVICES COLLECTION SITE: NAME: PATIENT ID: PHYSICIAN: RESULT REFERENCE RANGE (SI Units) COMPLETE BLOOD COUNT Hemoglobin 125 120-160 g/L Hematocrit 0.40 0.36-0.48 RBC 4 4.0-5.6 MCV 88 82-100 MCHC 340 320-360 RDW 12 11.0-16.0 Platelet Count 440 H 150-400 WBC 13 H 4.0-11.0

Neutrophils 11 H 2.0-9.0 Lymphocytes 0.5 0.5-3.3 Monocytes 0.5 0.0-1.0 Eosinophils 0.5 0.0-0.7 Basophils 0.2 0.0-0.2

GENERAL CHEMISTRY Na 140 133-145 K 4 3.5-5 Cl 110 98-111 CO2 24 21-31 Urea 5 2.0-7.0 Creatinine 40 20.0-60.0 Glucose 3.6-11.1 Osmolality 300 280-300 Calcium (serum) 2.2 2.1-2.5 Magnesium 0.85 0.65-1.05 Phosphate 1.6 1.3-2.3 BLOOD GAS (VENOUS) pH 7.40 7.35-7.45 pCO2 54 H 35-45 pO2 36 35-45 cHCO3 28 H 18-26



AppendixB:ECGs,X-rays,UltrasoundsandPictures

Pasteinanyauxiliaryfilesrequiredforrunningthesession.Don’tforgettoincludetheirsourcesoyoucanfindthemlater!



AppendixC:FacilitatorCheatSheet&DebriefingTips

Includekeyerrorstowatchforandcommonchallengeswiththecase.Listissuesexpectedtobepartofthedebriefingdiscussion.Supplementalinformationregardinganyrelevantpathophysiology,guidelines,ormanagementinformationthatmaybereviewedduringdebriefingshouldbeprovidedforfacilitatorstohaveasareference.Keydebriefingpoints:

1. Antiepilepticchoices2. RSIchoices3. Toparalyseornot?4. Drugdosereferencesused?5. Approach1vs2vs3rdlineapproachtostatusepilepticus6. Comfortofteamaspatientfailstoimprovewithsuccessivetherapies7. Recognitionofrespiratoryfailure8. Preparationforintubationanddecisionthresholdstointubate9. SYSTEMSISSUES:Ifyougeneralizetoyourregularclinicalenvironment,whatequipmentdoyouhaveor

don’thave?Whatprocessesdoyouhaveordon’thave?

References

1.TREKKSeizurePedsPacfoundat:https://trekk.ca/resources?tag_id=D0132262.VirtualResusRoomfoundat:https://virtualresusroom.com/

Simulation Scenario Template –VRR Pediatric Seizure

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