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Emergency Medicine Simulation Session Shortness of Breath Module Ingham Clinical Skills and Simulation Centre
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Introductions
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Admin Matters Toilets Mobile phones to silent and wi-fi off! Fire Exits Post course evaluations please
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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
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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!!
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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!!
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ABCDE approach Airway Causes of airway obstruction: CNS depression Blood Vomit Foreign body Trauma Infection Inflammation Laryngospasm Bronchospasm
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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
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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
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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
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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:
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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
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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
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ABCDE approach Circulation Treatment of circulation problems: Airway, Breathing Oxygen IV/IO access, take bloods Treat cause Fluid challenge Haemodynamic monitoring Inotropes/vasopressors
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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
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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
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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!
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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.
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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?
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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
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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?
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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
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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?
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Sim Demo
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Any questions? Lets see the sim room & meet our patient!
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