Emergency Medicine Simulation Session Shortness of Breath Module Ingham Clinical Skills and Simulation Centre

Introductions

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) A irway B reathing C irculation D isability E xposure NB If no patient response – open airway, if no normal breathing/central pulse = cardiac arrest – start CPR!!

ABCDE approach Underlying 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 approach Airway Causes of airway obstruction: CNS depression Blood Vomit Foreign body Trauma Infection Inflammation Laryngospasm Bronchospasm

ABCDE approach Airway 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 approach Airway Treatment of airway obstruction: Airway opening – Head tilt, chin lift, jaw thrust Simple adjuncts Advanced techniques – e.g. LMA, tracheal tube Oxygen

ABCDE approach Breathing 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 approach Breathing 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 approach Breathing 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 approach Circulation 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 approach Circulation Treatment of circulation problems: Airway, Breathing Oxygen IV/IO access, take bloods Treat cause Fluid challenge Haemodynamic monitoring Inotropes/vasopressors

ABCDE approach Disability 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 approach Exposure 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 consulta nt

ISBAR Handover I ntroduction - Identify yourself, your role & location S ituation - State the pt diagnosis or current problem B ackground - What is the clinical background/context? A ssessment – What are the pts current obs? - What do you think the problem is? R ecommend - What do you recommend ? - What do you want the person you have called to do?

Sim Demo

Any questions? Lets see the sim room & meet our patient!