Upper Airway FOB with Resp_Cardiac Arrest NMMC

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					       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
                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,
            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

         11.5        247

         137    110    23
         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
      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
     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
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
              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
              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

    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
    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
              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

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

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