SOB - PNEUMONIA PARAMEDIC SIM

Shortness of Breath - PneumoniaScenario Information

Title: Pneumonia Date Created: 3 February 2016Target Audience: PCP I PCP II PCP ACP CCPScenario Author: William Johnston Author Contact: C_johnston37@fanshaweonline.ca

Scenario OverviewParamedics are called to a 75 year old male at home who is experiencing shortness of breath. The patient has a history of CHF and previous cardiac history. Further examination will reveal coarse crackles in the L lower lobe only and a fever. The patient should be treated as a potential pneumonia. CHF interventions should be withheld and the patient should be transferred to hospital for further evaluation.

Scenario Objectives, Summary, NOCPS, and ExpectationsLearning Objectives:

Apply information to come to a differential diagnosis Adapt to the patient’s physical presentation Consider differential diagnoses for shortness of breath

Associated NOCPs 4.3.c – Conduct cardiac assessment and interpret findings 4.3.e – Conduct respiratory assessment and interpret findings 6.1.c – Provide care for a patient experiencing signs and symptoms

involving the respiratory system 6.3.a – Conduct ongoing assessments based on patient presentation

and interpret findings 6.3.b – Redirect priorities based on assessment findings

Paramedic GRS1 Expectations: Situational Awareness: consider alternative differentials to congestive

heart failure History Gathering: gather a thorough patient history not limited to

cardiac conditions Patient Assessment:: conduct assessment of the patient including

respiratory causes Decision Making: consider non-CHF causes of patient’s current

distress Resource Utilization: utilize patient’s family for history of infection as

well Communication: effectively communicate findings to family Procedural Skill: proper respiratory assessment

1. Tavares W, Boet S, Theriault R, Mallette T, Eva KW. Global rating scale for the assessment of paramedic clinical competence. Prehospital emergency care. 2012 Dec 5;17(1):57-67.

SOB - PNEUMONIA PARAMEDIC SIM

Scenario PreparationPatient Requirements

Moulage Patient Instructions Patient should be made to look

diaphoretic (spray bottle is acceptable) Patient should be made to look cyanotic

by adding a blue tinge to the patient’s lips

Patient is speaking in one word sentences Patient is taking shallow breaths Patient should be confused and unable to

effectively answer questions

Additional Equipment and PropsProps Equipment

Lounge chair Side table

BLS Bag Monitor with Rhythm generator Oxygen bag

Scene Set-Up The patient should be seated In the lounge chair with the lounge chair not completely reclined Wife should be standing at the door to great the Paramedics

Bystander Wife is able to give entire patient history Wife is extremely agitated and upset, needs to be reassured to be able to give a full patient

history

Dispatch Information Code 4 for a 75 year old male complaining of shortness of breath history of congestive heart failure,

negative for trael but does have a cough.

SOB - PNEUMONIA PARAMEDIC SIM

Patient Information Patient Name: Jerome Stevens Age: 75 Weight: 220Lb Gender: MaleChief Complaint: Shortness of BreathHistory of Present: Patient has been increasingly short of breath for past week, had a visit with family physician and had Lasix prescription increased. Patient became acutely short of breath this afternoon prompting call for Paramedics. Patient also seems increasingly confused compared to normal mentationSAMPLE History:

Allergies NoneMedications Lasix, Nitro, ASA, Metoprolol, Amlodipine, Valsartan Past History Congestive Heart Failure, Past MI, Angina, HTNOral Intake Had breakfast earlier that morning

OPRST (If Applicable)

Onset Wife states “got really bad about an hour ago” Provocation Wife states “normally he has to sit up when he cant breathe” Palliation Wife states “nothing is helping” Quality Wife states “I don’t know but he can’t breathe”Radiation Not applicableSeverity 1 word dyspnea, Wife states “It’s never been this bad”Time Wife states “has been really bad for the past hour”

Additional Information

Patient is able to mumble responses to questions like “are you having trouble breathing” or “do you have any chest pain

Wife states that the patient visited family doctor approximately 1 week prior

Physical FindingsPrimary Survey:

Airway Airway is patentBreathing Laboured and shallow breathingCirculation Rapid central pulsesAuscultation Crackles noted in L Lower lobeDistal Pulses Weak distal pulses Shock Diaphoretic, hot to touch

Secondary Survey :

Head UnremarkableNeck UnremarkableChest UnremarkableBack UnremarkablePelvis UnremarkableLegs Unremarkable Extremities No edema noted

SOB - PNEUMONIA PARAMEDIC SIM

Vital Signs, Expected Actions, and ModifiersPatient states change throughout the scenarios. Generally, a scenario will include 3 patient states. You may have states if you have a very dynamic scenario or if there are a number of potential patient modifiers. Patient State 1:

State: Baseline TRIGGER: Start of Scenario Vital Signs Expected ActionsHR 95 Thorough cardiac assessment

Thorough Respiratory assessment Oxygen administration Communicate situation to wife Ventilations assisted IV access obtained

SPO2 79 (84) (92)BP 160/98CO2 55 (44) RR 36 (18)Temp 39.6Skin Diaph, HotGCS E2,V3,M5Pupils ++BGL 6.2ECG NSR+ PVC 12 Lead NSR+ PVCModifiers Patient saturations improve to 84% with oxygen administration

If patient’s respiratory rate decreases with ventilation increase saturations to 92%

If patient’s ventilations are assisted, decrease end-tidal to 44 If Nitro is administered proceed to State 3 If patient is treated with Salbutamol proceed to State 4

Trigger Nitro or Salbutamol administered (State 3 or 4) 12 minutes scenario ends

Patient State 2: State: Nitro Administered TRIGGER: Nitro is administered to the patient Vital Signs Expected ActionsHR 140 Patient should be ventilated, effectiveness of ventilations

determined by the evaluator IV access should be obtained

SPO2 79 (84) (92)BP 120/60CO2 20RR 6Temp 39.6Skin Hot, DiaphGCS E2,V2,M4Pupils ++BGL 6.2ECG Sinus Tach12 Lead Sinus TachModifiers If ventilations are effective, increase saturations to 92%

If ventilations are ineffective saturations should stay at 84% If ventilations are not provided, saturations decrease to 79%

Trigger 12 minuets Scenario ends

SOB - PNEUMONIA PARAMEDIC SIM

Patient State 4: State: Salbutamol Admin TRIGGER: WHAT CAUSES THIS STATE TO OCCUR Vital Signs Expected ActionsHR 150 Supportive care

Oxygen Patch into hospital

SPO2 79 (84) (92)BP 160/98CO2 20RR 25Temp 39.6Skin Hot, DiaphGCS E2,V2,M4Pupils ++BGL 6.2ECG Sinus Tach12 Lead Sinus TachModifiers NoneTrigger 12 Minutes Scenario Ends