Get documents about "198.204.66.129_-8589069956464886708Pediatric Upper Airway FOB with Resp_Cardiac Arrest NMMC
Document Sample
Pediatric Foreign Body Aspiration with Subsequent Respiratory and Cardiac
Arrest Simulation Case
I. Title: Pediatric Foreign Body Aspiration with Subsequent Respiratory and
Cardiac Arrest
II. Target Audience: EM Residents, EM Staff Physicians
III. Learning Objectives or Assessment Objectives
A. Primary
1. Develop an approach to delineating the etiology of respiratory distress
2. Demonstrate an algorithmic approach to managing a child with an
upper airway foreign body
3. Demonstrate the ability to perform a pediatric resuscitation based on
APLS / PALS algorithms
4. Demonstrate the ability to re-assess the ABCs each time the patient‟s
status changes (ie. check the pulse when patient becomes apneic)
5. Demonstrate the skills & equipment required to remove an upper
airway foreign body in a child
B. Secondary
1. Understand the difference between stridor and wheezing and the
differential diagnosis of each
2. Understand that in children, a cardiac arrest is usually secondary to a
respiratory arrest
3. Demonstrate the use of the Magill forceps
4. Understand the importance of consulting ENT early for upper airway
foreign bodies
5. Demonstrate the use of a rapid pediatric dosing resource during the
resuscitation (such as the broslow tape, Dr. Tsai‟s book, or other)
C. Critical actions checklist – a list to ensure the educational /assessment
goals are met.
1. Obtain vital signs & place the child on continuous
cardiopulmonary monitoring, including pulse oximetry
2. Auscultate the patient‟s lungs
3. Recognize stridor and the potential for an upper airway foreign
body
4. Keep the child in a comfortable position and do not force her to
wear a face mask
5. Consult ENT for the possible need for rigid bronchoscopy in the
OR for removal
6. Ask for a soft tissue lateral neck XR
7. Plan to take an „awake look‟ with DL or fiberoptic laryngoscopy
with sedation
8. After the respiratory / cardiac arrest, remove the foreign body with
the Magill forceps
9. Recognize that the patient is in PEA by checking a pulse when
patient becomes apneic
10. Start BVM ventilation after removal of the FOB
11. Start chest compressions
12. Administer epinephrine as recommended in APLS
13. Admit the patient to the PICU after resuscitation is complete
IV. Environment
A. Lab Set Up – ED
B. Manikin Set Up
1. High Fidelity Simulator
2. Moulage: Street clothes for small child
3. Lines: 20g, 22g, 24g PIVs
4. IVFs: NS
5. Drugs Needed
a. Basic code medications assumed
b. Ketamine, Etomidate, Propofol, Succinylcholine, Vecuronium,
Rocuronium, Fentanyl, Versed, Ativan, Atropine,
Glycopyrrolate
6. Airway Equipment Needed
a. Basic airway equipment assumed
b. Multiple ETT sizes: 4.0, 4.5, 5.0, 5.5, 6.0, 6.5
c. Bougie
d. Magill Forceps
e. Suction tubing and suction tip
f. Meconium aspirator
g. ETT with tip and murphy‟s eye cut off (or scissors to do this)
h. Transtracheal jet ventilation needle
C. Props
1. EKGs – not required
2. XRays – None obtained until after resuscitation (the nurse can tell the
participants that the ETT „looks like it‟s in good position‟ if they
intubated the patient, „can‟t see it,‟ and ask about it). Soft tissue lateral
of the neck: radiology does not arrive in time prior to the patient‟s
respiratory and cardiac arrest.
3. US images - none
4. Lab results
Labs:
14
11.5 247
42
137 110 23
98
4.5 25 1.0
VBG: 7.32 / 40 / 70 / 24
5. Triage Note – None
6. Other Props
a. Spray bottle for diaphoresis
b. Upper airway foreign body (with a mechanism so that it is not
able to be pushed into the trachea of the mannequin)
D. Distractors – Hysterical mother (optional)
V. Actors
A. Roles – paramedic, nurse, consultant
1. Nurse (required)
2. Paramedic (optional, nurse can relay medic report also)
3. Mother (optional)
4. Consultants (ENT via phone, PICU via phone) (required)
B. Who may play them – other residents, other students, actors
1. Nurse: It is best if this role is played by an ED or ICU nurse or an
actor experienced with playing this role.
2. Paramedic: Can be played by resident, nurse, medic, student, actor
3. Mother: Can be played by anyone who wants to act
4. Consultants: Should be played by attending physician or senior
resident
C. Action Role – what role do they serve in the scenario
1. Nurse: Experienced ED nurse, helpful, does what the participants ask,
clarifies medications and dosages before meds are given
2. Paramedic: Gives report and then leaves
3. Mother (optional): Recurrently is answering “I don‟t know” when
asked questions about whether there were any small objects that they
child could have put in her mouth. (OPTIONAL) Mother can be
hysterical if a „distractor‟ is needed / wanted.
4. Consultants
a. PICU Attending (on phone): accepts patient, pleasant, very
busy with a code in the PICU that he must get back to quickly
b. ENT Attending (on phone): is in the middle of an OR case at a
neighboring institution, can come to your hospital in 1-2 hours.
Non-negotiable, no residents are available either.
VI. Case Narrative
A. Scenario Background Given to Participants (given freely)
1. Chief complaint: “Trouble breathing”
2. Medic report: “We got called for this kid having trouble breathing.
Mom wasn’t really sure what happened. She was out shopping
and the child’s 12 year old brother was watching him. He called
her to say the child was having trouble breathing. She returned
home to find the child in respiratory distress. The child has been
sick with a runny nose and cough over the past few days. Only
PMH is asthma.” (This history can be varied based on learner
level; for novice learners, a clear history of FOB ingestion can be
given, for intermediate learners, the mother could have “stepped
out of the room for a minute to answer the phone”, and for
advanced learners the history listed here can be used.)
3. Past medical history: Asthma
4. Medications: Albuterol prn
5. Allergies: NKDA
6. Family/social history: Nothing contributory
B. Scenario conditions initially
1. History patient gives: None – patient is 2 y/o and in respiratory
distress
2. Patients initial exam
c. VS: BP 82/52 HR 162 RR 40 SpO2 89% T 37.2
d. General: Moderate to Severe Respiratory Distress, sitting
upright on the cart
e. Neuro: Symmetric MAE
f. HENT: Drooling, no FOB visualized in oropharynx
g. Eyes: PERRL
h. Chest/Pulm: Stridor present, no wheezing
i. CV: Sinus tachycardia, no murmurs
j. Abd: Soft, NT, ND
k. Back: No lesions
l. Ext: No deformities, rashes, or lesions
m. Skin: diaphoretic
3. Patients physiology (instructor only)
2 y/o F with FOB ingestion which lodges just above the vocal
cords, creating stridor and moderate to severe respiratory distress.
Child is awake on arrival, sitting straight up in the bed, leaning
forward, and drooling. While participants are deciding how to
remove this FOB without ENT‟s assistance & setting up for this
procedure, the child has a respiratory arrest which leads to a
cardiac arrest. The patient is able to be resuscitated with removal
of the foreign body, ventilation, chest compressions, and 1 round
of epinephrine.
C. Scenario branch points
1. Pre-respiratory / cardiac arrest
a. IF the participants give O2 by face mask, THEN the patient
gets agitated and desaturates to 85%
b. IF the participants try to lay the patient down initially, THEN
she becomes agitated and desaturates further to 82%
c. IF the participants give blow-by oxygen, THEN the patients O2
saturation improves to 93%
d. IF the participants decide to perform RSI with paralysis, THEN
the patient develops a complete airway obstruction
immediately after the paralytic is given with a respiratory and
cardiac arrest
e. IF the participants decide to do nothing and wait until ENT
arrives, THEN the patient becomes somnolent and „tires out‟
d/t respiratory distress 3-4 minutes into the case
f. IF the participants still prefer to wait for ENT after the patient
becomes somnolent, THEN the patient has a respiratory and
cardiac arrest
g. IF the participants decide to take an „awake look‟ with sedation
(preferably ketamine) only, the patient remains unchanged
while they are setting up for this procedure, but THEN the
patient decompensates just prior to them administering the
sedation, and has a respiratory and cardiac arrest
2. Foreign Body Removal
a. If the participants have the Magill forceps out and ready,
THEN they should be able to remove the foreign body from the
airway with direct laryngoscopy.
b. IF the participants do not remove the FOB with the Magill
forceps, THEN they will be unable to ventilate the patient due
to complete airway obstruction
c. IF the participants decide to attempt to shove the FOB distally
with an ETT, THEN the nurse asks, “Do you want to try these
Magill forceps first?” **Do not let the participants shove any
foreign body distal to where you placed it in the mannequin;
this could ruin your mannequin**
d. IF the participants decide to attempt to use an ETT with the
murphy‟s eye cut off, a meconium aspirator, and suction to
remove the FOB, THEN the nurse asks, “Do you want to try
these Magill forceps first?” **This could shove the foreign
body distal to where you placed it in the mannequin; this could
ruin your mannequin**
e. IF the participants decide to do place the transtracheal jet
ventilation needle in the cricothyroid membrane or into the
trachea, THEN the nurse asks, “Do you want to try these
Magill forceps to see if we can pull the foreign body out first?”
f. IF the participants have no idea what to do and are doing
nothing, THEN the nurse can ask, “Do you want to try these
Magill forceps to see if we can pull the foreign body out?”
g. The foreign body is ultimately removed with the Magill
forceps.
3. Respiratory / Cardiac Arrest (PEA) Management (subsequent to
FOB removal)
a. IF the participants do not ventilate the patient with a BVM
subsequent to the FOB removal, THEN the patient remains
hypoxic and pulseless
b. IF the participants ventilate the patient with a BVM, THEN the
oxygen saturations improve to 99%. They can intubate the
patient subsequently.
c. --- The patient remains pulseless ---
d. IF the participants start chest compressions and administer one
does of epinephrine, THEN the patient has return of pulses
e. IF the participants do not do both chest compressions and
administer one dose of epinephrine, THEN the patient remains
in PEA until they do so
4. Post cardiac arrest management
a. IF the participants admit the patient to the PICU, THEN
transport arrives and the case is over
b. IF the participants do not have a disposition, THEN the charge
nurse calls in and states “You have multiple trauma victims
coming from a bus crash, and we will need all of the
resuscitation bays.”
VII. Instructors Notes (what the instructor must do to create the experience)
A. Tips to keep scenario flowing: Nurse can prompt when needed, to keep
the participants in an activated learning state without becoming overly
anxious or shutting down.
B. Tips to direct actors: Nursing prompts as above
C. Scenario programming
1. Optimal management path – Participants recognize upper airway
foreign body obstruction. They leave the patient in a comfortable
position, but when the patient starts „tiring out‟ and becoming
somnolent, they decide to perform an „awake look‟ with ketamine
only, and have multiple removal devices ready (magill forceps,
suction with meconium aspirator connected to ETT with murphy‟s
eye cut off, and rigid bronchoscopy set up if available) and a
transtracheal jet ventilation needle and cric / tracheostomy kit
available for back up. Just prior to giving the ketamine, the patient
has a respiratory and then a cardiac arrest from complete airway
obstruction. They use direct laryngoscopy and see the FOB which
is easily removed with the magill forceps. BVM is used for
ventilation which results in O2 saturations of 99%, intubation is
performed, chest compressions are started and one round of
epinephrine is given with return of pulses. The patient is then
admitted to the PICU.
2. Potential complications path(s) – See above
3. Potential errors path(s) – See above
VIII. Debriefing Plan
A. Method of debriefing – group, with or without video
B. Actual debriefing materials – Attached
C. Rules for the debriefing
How to Create a Good Learning Environment
The Basic Assumption: Assuming competence and good intention
Theory: Mistakes made in the sim lab are viewed as puzzles / mysteries, not mistakes
Debriefing: Theory & How It‟s Done. “Debriefing with Good Judgment”
Goals: Identify knowledge gaps, discover the learner‟s frames, and match teaching points
o Frames: assumptions, feelings, goals, knowledge, situational awareness, context.
Frames are what drive our actions (why the learners did what they did).
o FOCUS on changing trainee‟s frames, not just their actions
Phases of Debriefing
o Reactions Phase: Clear the air and can guide discussion (immediately after case –
listen to the participants as they are walking out of the room). Ask “How do you feel
about the case” to prompt this discussion.
o Understanding Phase: Understand what happened and explore deeper meaning
o Summary: Review what was learned and apply this to a larger context
Structure: Lead debriefer and Associate debriefer
The debriefers
o Share observations, opinions, & judgments
o Have a stance of curiosity, mutuality and respect
o Are respectful and honest; you don‟t have to be nice
The DOs:
o ADVOCACY / INQUIRY
Advocacy: “I noticed _______”…
Inquiry: “What did you think about that?”
Example: “I noticed _____, I‟m concerned that _____, and am wondering
why _____. I was hoping we could explore this more.”
Why do it: Increases participation - people are more willing to share their
thoughts if you share yours first
o Ask questions to invite the learners to participate and share their thoughts
o Use normalization “many people have trouble with this” or “this is a difficult case,
we don‟t expect you to manage it perfectly”
o Try to get everyone to participate – pull in the quiet ones
o Use group silence to your advantage – someone will eventually talk
o Use the think aloud strategy – have the leader(s) go through their thought processes
for a certain part of the case
o Have 1-2 short riffs (2-3 minutes) for clinical content you want to teach
o If using the + / Delta Debriefing technique, use it sparingly
What went well and what could be done better
Superficial debriefing style – focuses on actions (not frames)
The DON‟Ts:
o Don‟t use the omniscient voice – use first person instead (they may have done
something you didn‟t notice), “I didn‟t notice ____...”
o Don‟t use “you” (this can be interpreted as accusatory); instead of saying “why didn‟t
you do CPR?”, state “I noticed that CPR wasn‟t performed…” – this keeps the
learners from becoming defensive and promotes discussion
o Don‟t try to be “nonjudgmental” – This is interpreted as “read my mind” or “guess
what I‟m thinking” by the learners. (ie. Don‟t ask how they think the case went – they
know that you know how the case went. This also takes longer, and the learning
outcome is the same if you state the areas / actions that need discussion. A better
question is “that was a difficult case, how do you feel about it?”)
o Don‟t tell them “great job” - they may disagree and then not trust you
o Don‟t bring up the game, ie. “we tried to get you to do ____, but you did ___ instead“
o Don‟t let the participants get sidetracked with technical difficulties or limitations of
the simulator. Acknowledge these and move towards your learning points, or relate
such things to clinical practice (ie. Referred breath sounds with PTX)
My General Debriefing Molecule
1) Listen to and discuss the Reactions Phase, participants feelings & thoughts.
a. Ask, “How do you feel about that case?”
2) Quick 1 sentence recap of the case / pathology so that everyone is on the same page when
discussing MDM
3) Discuss behavioral objective first and MDM objective(s) second
a. Positive feedback
b. Give tips (simple things on how to improve performance next time)
c. Understanding Phase: Working feedback (advocacy / inquiry, use of think aloud
strategy, exploring frames, etc). The goal here is to identify why the learners did
what they did, not focus on whether the action was “right” or “wrong.”
d. Your 2-3 minute riff on important clinical content if not covered above
4) Summary: take home points (you can do this or have learners do this) & apply learning
points to a larger context
D. Questions to facilitate the debriefing
1. So, how do you feel about this case? (Reactions Phase)
2. When the patient arrived with respiratory distress, what was going
through your mind? (Understanding Phase – differential dx)
3. What is your approach to children with upper airway foreign bodies?
(Understanding Phase)
4. What pieces of equipment do you like to have available if you have to
manage a child with an upper airway obstruction? (Understanding
Phase)
5. What do you like to use for sedation if you are going to do an „awake
look‟ on a child with a foreign body? Why? (Understanding Phase)
6. What was going through your mind when the patient had a cardiac
arrest? (Understanding Phase)
7. How do you remember or figure out dosing for pediatric medications,
sizes for ETTs, etc in a pediatric resusucitation? (Understanding
Phase)
8. What main learning points will you take away from this case and apply
to your clinical practice in the future? (Summary Phase)
IX. Pilot Testing and Revisions
A. Numbers of participants: 4-6
B. Performance expectations – completing critical actions checklist
C. Anticipated management mistakes
1. Attempting to put a face mask on a scared child or lay them down
2. Not having all desired airway equipment out and ready to deal with an
upper airway foreign body
3. Not recognizing the PEA arrest when the patient becomes apneic
(focusing on the airway and forgetting to check pulses)
D. Evaluation form for participants - Attached
X. Authors and their affiliations
Danielle Hart, MD
Director of Simulation
Assistant Program Director, Emergency Medicine
Hennepin County Medical Center
Assistant Professor, University of Minnesota Medical School
Minneapolis, MN 55415
X. References
Marx et al. Rosen‟s Emergency Medicine Concepts and Clinical Practice, 7th Ed. p.2104-14
Seilheimer, D. Airway foreign bodies in children. UpToDate.com
Loftis, L. Emergent Evaluation of Acute Upper Airway Obstruction in Children. UpToDate.com
Pediatric Foreign Bodies
Stridor – from partial airway obstruction and resultant turbulent airflow around the object / mass
o Supraglottic Stridor
From nose, pharynx, epiglottis
Sonorous, gurlgling, coarse, expiratory stridor
Voice with muffled or „hot-potato‟ quality
o Glottic Stridor
From larynx & vocal cords
Biphasic high pitched stridor
Voice hoarse or weak
o Subglottic Stridor
From subglottic trachea
High pitched inspiratory stridor
Voice hoarse or weak
o Subtracheal - bronchi
Often expiratory noise such as wheezing
Offenders
o Round foods – most common
o Conformable objects – most deadly (ie. balloons, examination gloves, etc)
o Most lodge in the bronchi and aren‟t life threatening
Workup & Intervention
o Keep the child calm and in a position of comfort / optimal ventilation
o Allow the child to cough
o Soft tissue lateral of the neck & CXR (if stable)
o 2/3 of routine inspiratory CXRs in children with FOB aspiration are negative
o Expiratory CXR can be helpful to evaluate for air trapping distal to obstruction
o Partial airway obstruction – stable
o Safe to wait for ENT to do rigid bronchoscopy in the OR
o Partial airway obstruction – severe or rapidly progressing respiratory distress or respiratory failure
o Consider awake look with sedation (ketamine – slow IV push over 1-2 min to prevent
apnea)
o Complete airway obstruction – unable to ventilate
o BLS: < 1 year old – 5 back blows and 5 chest thrusts (with head below torso)
o BLS: > 1 year old – if conscious, do Heimlich maneuver; if unconscious, do chest
compressions
o Use DL to look for object & remove with Magill forceps
o If unable to see object and / or known to be in subglottic space or trachea, can try to
remove it with suction via ETT (with Murphy‟s eye cut off) and meconium aspirator
o If object visible in subglottic space, can attempt to remove it with rigid bronchoscope
o If unable to see object and / or in subglottic space or trachea, but can‟t ventilate or
remove object , attempt to intubate and push object into a mainstem bronchus with ETT
o If object doesn‟t seem to be in the airway but is still causing obstruction, it could be in
the esophagus pushing on the soft cartilage of the trachea with resultant obstruction. Try
BLS maneuvers to dislodge it into the oropharynx, or possibly esophageal bougiennage.
o If unable to remove or bypass supraglottic or glottic FOB, needle cric / trach with jet
ventilation as a bridge to surgical cricothyrotomy or tracheostomy
TTNV – can attach 3.0 ETT adapter for ventilation with BVM
- UpToDate.com
Simulation Module Evaluation – Pediatric FOB with Respiratory and Cardiac Arrest
Faculty: __________________________ Date: ____________ Your Level of Training: __________
1 2 3 4
Strongly Disagree Disagree Agree Strongly Agree
1. This teaching module met the stated clinical objectives (identify upper airway obstruction, develop an
approach to the young child with an upper airway foreign body, demonstrate pediatric resuscitation per
APLS guidelines ).
1 2 3 4
2. The presented case scenario was appropriate for my level of training.
1 2 3 4
3. It was easy to suspend disbelief and buy into the fiction contract.
1 2 3 4
4. The overall utility of this simulated case was very useful.
1 2 3 4
5. The overall quality and utility of the debriefing was good.
1 2 3 4
6. Your debriefers effectively moderated the debriefing and successfully promoted a meaningful group
discussion (versus the debriefing becoming a didactic style learning session).
1 2 3 4
7. This teaching module will better prepare me to manage this type of critically ill patient.
1 2 3 4
8. This experience was more useful than reading the chapter.
1 2 3 4
9. This experience was more useful than attending a didactic lecture.
1 2 3 4
What would you change about this teaching module? Other comments?
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Critical Actions Checklist: Pediatric Upper Airway FOB with
Respiratory and Cardiac Arrest
Other Comments
Y N VS, Monitor, Pulse Ox
Y N Performs pulmonary exam
Y N Recognizes stridor & potential for
foreign body
Y N Avoids forcing child to wear a
face mask or lay down
Y N ENT consult
Y N Obtain soft tissue lateral neck XR
Y N Plans an „awake look‟ with DL
and sedation
Y N Assembles multiple tools to
manage upper airway obstruction
Y N Removes FOB with Magill
forceps
Y N Recognizes PEA arrest (by
checking pulse when apneic)
Y N Ventilates with BVM
Y N Chest compressions
Y N Epinephrine per APLS
Y N Admit to PICU after resuscitation
