Virtual 2021 - PE.pdf - T

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Massive Pulmonary Embolism Competition: Virtual SimWars 2021, Limerick Round: Heat 1 Participants: Undergraduate Medical/Nursing Students. Teams of 5 Learning Objectives 1. Identification of patient presenting with a PE 2. Student should demonstrate ABCDE approach in parallel with diagnostic synthesis by targeted history and examination 3. Identification of escalation of care and request further investigations. 4. Non -Technical CRM skills - Teamwork and communication Scenario Location: Virtual Emergency Department, Resus Patient: Virtual Actor Sudden shortness of breath and chest pain. If questioned, returned from long haul flight two days ago Condition: Massive PE “William, A 55 year old pilot, has been brought to the ED by ambulance with shortness of breath and chest pain. Paramedics report during their handover that he was initially alert but appeared to to become disorientated during transport and is now hypotensive. The nurse in resus has called the team to review the patient as the early warning score is elevated. Your team is to manage this patient.” Initial Observations: RR 28, Sp02 82% RA, HR 136 (Regular), BP 86/52, Temp 36.4 GCS: 14/15 (E4, V4, M6) Appearance: Looks pale, mildly tachypneic, but able to converse. Orientated to time and date, but not place. Thinks he is in Dubai. Complaining of 8/10 chest pain. Past Medical/Surgical: Asthma, Fractured tibia 1 year ago, managed conservatively without surgery. Medications: Salbutamol inhaler PRN Allergies: NKDA Examination Cardiac: Normal SI+ SII. No murmur. Tachycardic >130. Hypotensive 86/52. Cap refill > 3 seconds Respiratory: Air entry normal but slight pleural rub noted. RR 28, O2 Sats 82% on RA. Gastrointestinal: Abdomen Soft, non-tender Neurology: GCS 15/15 (E4, V5, M6). Normal power in the right and left limbs (5/5) PEARLA. No other neurological deficits MSK: Scar noted on left tibia. Right leg swelling and pain with palpation of the deep veins Skin: erythema, swelling tender to touch on right calf Other: Raised JVP Investigations ECG: Sinus Tachycardia, RBBB, T-wave inversions in the right precordial leads (V1-3) and lead III Portable CXR Normal Ultrasound: Right Ventricular Enlargement Progression with Appropriate Resuscitation Time 00:00 00:02 00:04 00:06 00:08 10:00 Condition Alert Alert Unresponsiv Unesponsive Voice Alert e Pulse 136 142 PEA 68 70 80 88 BP 86/52 76/50 -/- 85/45 109/74 110/72 Sp02 82% on RA 86% on O2 68% 94% on O2 96% on O2 96% on O2 RR 28 24 0 12 16 16 Without Appropriate Resuscitation Time 00:00 00:02 00:04 00:06 00:08 10:00 Condition Alert Voice Unresponsiv Unresponsive Pain e Pulse 115 125 PEA - 68 PEA - 68 78 BP 82/52 76/65 -/- -/- 68/42 Sp02 88% on RA 86% RA 68% 48% on RA 84% on RA RR 28 32 0 8 12 Exit Strategy: Senior help will support if PEA not identified or PE mis-diagnosed. Courtesy of Dr Ed Burns and Dr Robert Buttner. Used licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Based on a work at https://litfl.com. Accessible at https://litfl.com/ecg-changes-in-pulmonary-embolism/. Case courtesy of Assoc Prof Craig Hacking, Radiopaedia.org, rID: 41941 If ordered ‘fast forward’ to verbal report from radiologist. Verbal Report “Large saddle embolus over the pulmonary artery, likely occlusive to the distal branches. “ Adjuncts Pulmonary Embolism - Team Assessment Care Provided 50 Points Marks Marks Criteria Available Awarded Patient Assessment Consider - Systemic approach to assessment/exam - Recognition that the patient is acutely unwell. 15 - All medical history obtained if patient is able - Formation of differentials from medical history + risk factors. Initial Resuscitation Consider - ABCDE, Vitals - Address hypoxia - supplemental Oxygen 10 - Address hypotension - fluid bolus - differentiation of shock - Prompt consultation with Senior EM colleagues/ICU - Discuss need for thrombolysis with senior help Diagnosis Consider - Recognition of Massive PE - Recognise of Unstable Patient 10 - Recognition of PEA - Recognition of H’s & T’s Thrombus Investigations Consider - Request for ECG - Bloods (FBC, U&E, ABG/Serum Lactate, D-Dimer amylase, 10 CRP) - Request for Immediate CTPA Disposition - Need for urgent intervention /ICU level care 5 Massive PE - Team Assessment Non-Technical Skills 50 Points Marks Marks Criteria Available Awarded Team Work Consider - Demonstrating leadership. - Exchanging information. 20 - Regaining situational awareness if team loses focus - Delegating Roles/tasks - Supporting Team Task Management Consider - Planning & preparing - Prioritising 10 - Providing & maintaining standards - Identifying & utilising resources Situation Awareness Consider - Gathering information 10 - Recognising & understanding task fixation - Anticipating Decision Making Consider - Identifying options - Balancing risks & selecting options 10 - Re-evaluating