1. Emergency Medicine Simulation SessionShortness of Breath Module Ingham Clinical Skills and Simulation Centre

2. Introductions

3. Admin Matters • Toilets • Mobile phones to silent and wi-fi off! • Fire Exits • Post course evaluations please

4. 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

5. The ABCDE assessment (primary assessment) Airway Breathing Circulation Disability Exposure NB If no patient response – open airway, if no normal breathing/central pulse = cardiac arrest – start CPR!!

6. 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!!

7. Causes of airway obstruction: CNS depression Blood Vomit Foreign body Trauma Infection Inflammation Laryngospasm Bronchospasm ABCDE approachAirway

8. ABCDE approachAirway 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

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

10. ABCDE approachBreathing 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

11. ABCDE approachBreathing 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:

12. ABCDE approachBreathing 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

13. ABCDE approachCirculation 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

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

15. ABCDE approachDisability • Treatment • ABC • Treat underlying cause • Blood glucose • If < 4 mmol l-1 give glucose • Consider lateral position Recognition • AVPU or GCS • Pupils • Blood sugar • Check drug chart/med hx

16. ABCDE approachExposure • 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

17. 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!

18. 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.

19. 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?

20. 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

21. 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?

22. Tips for the Sim Cases • Decide upon a team leader before the case • TL to stand at end of bed - handsoff 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 consultant

23. ISBAR Handover Introduction - Identify yourself, your role & location Situation - State the pt diagnosis or current problem Background - What is the clinical background/context? Assessment – What are the pts current obs? - What do you think the problem is? Recommend - What do you recommend ? - What do you want the person you have called to do?

24. Sim Demo

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