emergency medicine simulation session shortness of breath module ingham clinical skills and...
TRANSCRIPT
Emergency Medicine Simulation Session
Shortness of Breath Module
Ingham Clinical Skills and Simulation Centre
Admin Matters
• Toilets • Mobile phones to silent and wi-fi off!• Fire Exits• Post course evaluations please
Learning Outcomes• Introduction to simulation and understand
the basic ground rules in simulation
• Be able to do an A-E assessment on an critically ill patient
• To improve your skills in emergency management of various presentations of shortness of breath
• Gain confidence using ISBAR handover
The ABCDE assessment (primary assessment)
Airway
Breathing
Circulation
Disability
Exposure
NB If no patient response – open airway, if no normal breathing/central pulse = cardiac arrest – start CPR!!
ABCDE approachUnderlying principles• Complete initial assessment (get to E)
• Treat life-threatening problems
• Reassessment after any treatment or if any change in condition of patient
• Call for senior help early!!
ABCDE approachAirway
Causes of airway obstruction:
• CNS depression• Blood • Vomit • Foreign body • Trauma
• Infection • Inflammation • Laryngospasm • Bronchospasm
ABCDE approachAirway
Recognition of partial airway obstruction:
•Talking? Quality of Voice?•Difficulty breathing, distressed, choking•Shortness of breath•Noisy breathing•Stridor, wheeze, gurgling •See-saw respiratory pattern, accessory muscles
ABCDE approachAirway
Treatment of airway obstruction:
• Airway opening– Head tilt, chin lift, jaw thrust
• Simple adjuncts• Advanced techniques– e.g. LMA, tracheal tube
• Oxygen
ABCDE approachBreathing
Treatment of breathing problems:• Sit the patient up !!• Airway
• Oxygen (if sats low)
• Treat underlying cause
• Support breathing only if needed–e.g. ventilate with bag-mask
ABCDE approachBreathing
• Decreased respiratory drive/ CNS depression
- drugs
- raised ICP
•Decreased respiratory effort– Muscle weakness – Nerve damage– Restrictive chest defect
– Pain from fractured ribs
• Lung disorders – Pneumothorax– Haemothorax – Infection– Acute exacerbation
COPD– Asthma– Pulmonary embolus– ARDS
Causes of breathing problems:
ABCDE approachBreathing
Recognition of breathing problems:• Look– Respiratory distress, accessory muscles,
cyanosis, resp rate, conscious level etc
• Listen – Noisy breathing, breath sounds
• Feel – Expansion, percussion, tracheal position
ABCDE approachCirculation
Recognition of circulation problems:• Look at the patient• Pulse - tachycardia, bradycardia• Peripheral perfusion - capillary refill time (normal
< 2 secs)• Blood pressure• Organ perfusion– Chest pain, mental state, urine output
• Bleeding, fluid losses
ABCDE approachCirculation
Treatment of circulation problems:
• Airway, Breathing• Oxygen• IV/IO access, take bloods• Treat cause• Fluid challenge• Haemodynamic monitoring• Inotropes/vasopressors
ABCDE approachDisability
Recognition
• AVPU or GCS• Pupils• Blood sugar • Check drug
chart/med hx
Treatment
•ABC
•Treat underlying cause
•Blood glucose•If < 4 mmol l-1
give glucose
•Consider lateral position
ABCDE approachExposure
• Remove clothes to enable examination– e.g. injuries, bleeding, rashes
• Check all of patient: – surface, orifice, extremity and cavity
• Avoid excessive heat loss
• Maintain dignity
Sim Ground Rules
• Respectfulness• Confidentiality – faculty and students
(performance and scenarios)• Fiction contract – try to suspend
disbelief• No assessments!• Try to relax, have fun learning as a
team!
The Basic Assumption
We all believe that everyone in this room is:•Intelligent•Capable•Cares about doing their best •Wants to improve
Centre for Medical Simulation, Harvard, Boston USA.
Fiction Contract• The scenarios are not real life but are based on
real cases & are the next best thing
• We accept you may act differently from real life
• And that the manikins/sim cases have their limitation but….simulations allow us to train as a team and practice our skills
• If you act as yourself, take it seriously & commit to being part of the sim you will gain much more from the experience…. Are we all agreed?
Sim Cases• 3 teams– 1 sim case case per team then swap
around• Each case 20 mins – different patient &
presentation• Faculty will be inside room with you• ‘Pause & discuss’ scenarios, followed by a debrief• We will call a ‘timeout’ when good time for
discussion (not because you are doing poorly!)• Those of you not directly involved with each case
will be inside sim room - will still be involved with the discussions and the debrief
The Debrief
• We all come back to debrief room afterwards to discuss the case
• Sim team to sit together in semicircle with instructor• Time for reflection & constructive feedback • Allows lessons learned within the case to be
generalised and transferred to real clinical practice• Possible questions: How did you feel? What
happened? How did the team function? What did you learn? What would you change? Take home messages?
Tips for the Sim Cases• Decide upon a team leader before the case• TL to stand at end of bed - hands off the patient• T/L to delegate roles to team members• But team members must help the T/L out & help make
suggestions• Andrea will be the nurse in the room to help• Communicate loudly & clearly with each other • Start each case with an A-E assessment & take a focused
history to help work out the problem• If there is any change in patient status go back to start with
Airway
• TL must give ISBAR handover to consultant
ISBAR Handover
Introduction - Identify yourself, your role & location
Situation - State the pt diagnosis or current problem
Background - What is the clinical background/context?
Assessment – What are the pts current obs?
- What do you think the problem is?
Recommend - What do you recommend ?
- What do you want the person you have called to do?