Setup

Chief complaint: Shortness of breath
Patient age: 6 years old
Weight: 25 kg

Recommended Supplies

• Manikin: child
• Moulage:
  • Urticarial rash is optional moulage
  • A photo of a child with urticaria can be shown as well
• Resources: PALS cards and/or color-coded length based tape
• Manikin set up:
  • Street clothing
• Equipment
  • IM syringe for injection (if manikin is capable)
  • IV set up
  • Nebulizer set-up
• Medications
  • IM epinephrine
  • IV steroid (methylprednisolone, dexamethasone), diphenhydramine, saline, ranitidine
  • Nebulized albuterol
  • IV epinephrine drip

Supporting Files

• Labs
• Photograph of child with anaphylaxis
• Normal CXR

Participants/Roles

• Team leader: Directs the case, gathers history
• Team member (optional): Examines patient
• Team member (optional): One team member may be assigned to the parent as the case progresses
• Team member: Assesses airway, places nebulizer, possible set up for intubation “just in case”
• Nursing: Gives medications, helps with monitoring
• Patient: Will need to voice the patient, describe the HPI
• Family: One parent with the patient to give history, HPI, ask questions

Team roles may need to be adjusted in order to suit local practices and norms

Prerequisite Knowledge

• Faculty
  • PALS protocols
  • General knowledge of emergency medicine
  • Knowledge of management of severe anaphylaxis
  • Simulation implementation and debriefing experience

• Emergency medicine residents
  • Any stage of training (preferably PGY-1 or 2 year)
  • Completed PALS certification
  • Some knowledge of management of anaphylaxis
  • Some knowledge of the approach to acute shortness of breath

Case Alternatives

• If epinephrine is not administered promptly, the patient will become fatigued to lethargic, and eventually hypotensive and in shock.
• If a greater challenge is desired, the patient does not improve with initial IM epinephrine, develops hypotension quickly, and does not improve until a second dose of epinephrine is administered. The patient’s mental status can decline necessitating airway management.
• If the child becomes profoundly hypotensive and goes into cardiac or respiratory arrest, then IV epinephrine dose is required.
• Can be a difficult airway case as well for very high learners. This deviates from the core objectives (anaphylaxis management) so only to be used if the team is very successful with the primary objective.

Milestones

PC1. Emergency Stabilization
PC2. Performance of Focused History & Physical Exam
PC3. Diagnostic Studies
PC4. Differential Diagnoses and Management
PC5. Pharmacotherapy
PC6. Observation and Reassessment
PC7. Disposition
PC10. Airway Management
PC15. Medical Knowledge
ICS1. Patient Centered Communication
ICS2. Team Management

Resources

1. Anagnostou K. Anaphylaxis in Children: Epidemiology, Risk Factors and Management. Curr Pediatr Rev. 2018;14(3):180-186. PMID: 29732976
2. Poowuttikul P, Seth D. Anaphylaxis in Children and Adolescents. Pediatr Clin North Am. 2019;66(5):995- 1005. PMID: 26806049
3. Cheng A. Emergency treatment of anaphylaxis in infants and children. Paediatr Child Health. 2011;16(1):35-40. PMID: 22211074
4. Fox S. Anaphylaxis. PEM Morsels. 2014.
5. Sobolewski B. Anaphylaxis: Admit or discharge? PEM Currents. 2019.

Evaluation and Initial Stabilization

Start of case to after first dose of IM epinephrine

Critical Actions

• Placement in resuscitation
• Exam including airway and lung assessment
• Placement on cardiovascular monitoring
• IM epinephrine given

Physical Exam

Instructor Notes: Changes and Case Branch Points

After Epinephrine is Given Through Secondary Interventions

If epinephrine is not given, see stage 3

Critical Actions

• Placement of an IV with medications (at least IV fluids, optional steroids, H2 blocker, diphenhydramine) and nebulized albuterol
• Advanced learners should set up difficult airway equipment anticipating possible decompensation

Physical Exam

Instructor Notes: Changes and Case Branch Points

In this stage, the patient fails to improve with first-line medications.

Worsening Condition (Optional): IV epinephrine drip initiation

This stage occurs either (1) if no epinephrine is given initially or (2) advanced learners/challenge scenario

Critical Actions

• Repeat or initial IM epinephrine progressing to IV epinephrine drip

Physical Exam

Instructor Notes: Changes and Case Branch Points

Case Conclusion

This stage occurs either after supplemental IV medications if early IM epinephrine given from stage 2 or after IV epinephrine is started from Stage 3.

Critical Actions

• Discussion around need for admission (if from stage 2 likely not needed, if from stage 3 should be admitted to ICU)
• Discussion with family about anaphylaxis/allergic reactions. Outpatient treatment and follow up discussion.

* Unbolded items may be excluded depending on local practices and norms

Physical Exam

Describe signs/symptoms of anaphylaxis (comprehension)

Anaphylaxis is potentially a life-threatening condition that requires quick recognition and prompt treatment as epinephrine can be lifesaving. It is important to recognize anaphylaxis before the patient decompensates and develops shock.

Anaphylaxis is highly likely when any 1 of the following 3 criteria is fulfilled:

• Criterion 1 — Acute onset of an illness (minutes to several hours) involving the skin, mucosal tissue, or both (e.g., generalized hives, pruritus or flushing, swollen lips-tongue-uvula) and at least 1 of the following:
  • Respiratory compromise (e.g., dyspnea, wheeze/ bronchospasm, stridor, reduced peak expiratory flow, hypoxemia), OR
  • Reduced blood pressure (BP) or associated evidence of end-organ perfusion (e.g. decreased mental status, confusion, decreased urine output)
  • Note that skin findings are present in up to 90% of anaphylactic episodes. This criterion is helpful in making the diagnosis.
• Criterion 2 — 2 or more of the following that occur rapidly after exposure to a likely allergen for that patient (minutes to several hours):
  • Involvement of the skin-mucosal tissue (e.g., generalized hives, itch-flush, swollen lips-tongue-uvula)
  • Respiratory compromise (e.g., dyspnea, wheeze/ bronchospasm, stridor, reduced peak expiratory flow, hypoxemia)
  • Reduced BP or associated evidence of poor end-organ perfusion (e.g. decreased mental status, confusion, decreased urine output)
  • Persistent gastrointestinal symptoms and signs (e.g., crampy abdominal pain, vomiting)
  • Note that skin manifestations are not present in up to 20% of anaphylactic episodes. Criterion 2 incorporates gastrointestinal symptoms in addition to skin symptoms, respiratory symptoms, and reduced BP. It is applied to patients with exposure to a substance that is a likely allergen for them.
• Criterion 3 — Reduced BP after exposure to a known allergen for that patient (minutes to several hours):
  • Reduced BP in adults is defined as a systolic BP <90 mmHg or >30% decrease from that person’s baseline.
  • In infants and children, reduced BP is defined as low systolic BP (age-specific) or >30% decrease in systolic BP.
  • Note that criterion 3 is intended to detect anaphylactic episodes in which only one organ system is involved and is applied to patients who have been exposed to a substance to which they are known to be allergic (e.g., hypotension or shock after an insect sting).

Demonstrate early evaluation of a critically ill patient (application)

• Learners should approach a critically ill patient in a standardized fashion. Airway, breathing, and circulation should be assessed immediately. Interventions such as airway repositioning/ adjuncts, bag valve mask ventilation, and CPR should be started concurrently, if required. After A, B, C have been addressed, the patient should be evaluated for disability and exposed for a thorough head to toe exam. In pediatrics, D also stands for “don’t forget the dextrose” as a blood glucose level should be checked in any child with altered mental status.
• In this patient with obvious respiratory distress, airway and breathing are paramount. A quick evaluation including placement on continuous monitoring is important and early planning to begin addressing problems with airway and breathing must be started as quickly as they are identified.
• Alertness and airway are important early indicators of the severity of anaphylaxis.
• Understanding normal vitals in a child is important. For example, the systolic blood pressure (SBP) is generally above 70 + 2 times the age (5th percentile) and the mean is closer to 90 + 2 times the age in years. A shorter way to remember is 60-80-100 with the SBP being:
  • 60 mmHg for an infant
  • 80 mmHg for a child
  • 100 mmHg for an adolescent

Construct and implement a plan to manage anaphylaxis (application)

Epinephrine IM is the first and primary treatment for anaphylaxis.

• Dose: 0.01 mg/kg
• Standard adult dose is either 0.3 mg or 0.5 mg IM, and can be repeated in 3-5 minutes if needed
• IV infusion of epinephrine at 0.1 to 1 mcg/kg/min (maximum 10 mcg/min) can be started if needed after IM epinephrine
• Secondary treatment includes early administration of IV fluids to support early shock even before hypotension.
• 20 mL/kg IV normal saline boluses
• Bronchodilators by nebulizer can be helpful for wheezing
• Antihistamines such as diphenhydramine (PO or IV 1-2 mg/kg up to 25 or 50 mg) and ranitidine (1 mg/kg max; 50 mg) can be helpful for patient comfort and itching but do not help with the primary anaphylactic reaction.
• Steroids such as methylprednisolone (1-2 mg/kg IV) or dexamethasone (0.6 mg/kg IV or PO up to 12 mg)

Demonstrate focused history taking from a caregiver (application)

• Components of history taking: Past medical history, surgical history, family history, medications, allergies, social history, vaccination history
• For this scenario, obtaining an allergy history is important as well as:
  • Exposure or potential exposure to allergens
  • Timing of onset of symptoms and progression
  • Airway and breathing symptoms
  • Dizziness or altered mental status
  • Gastrointestinal symptoms

Explain diagnosis and management to caregivers (synthesis)

• Communicating effectively and supportively with families are important.
• Using easily understood language and common terminology are important when explaining a critical patient to their family.

Demonstrate teamwork and closed loop communication (application)

Teams may use different frameworks to improve team dynamics and communication. Below are a few definitions that may be helpful to discuss, adapted from the AHRQ TeamSTEPPS Pocket Guide.

• Brief: Short session prior to start of encounter to share the plan, discuss team formation, assign roles and responsibilities, establish expectations and climate, anticipate outcomes and likely contingencies
• Huddle: Ad hoc team discussion to re-establish Situation Awareness; designed to reinforce plans already in place and assess the need to adjust the plan
• Callout: A strategy used to communicate critical information during an emergent event. Helps the team prepare for vital next steps in patient care. (Example: Leader- “Airway status?”; Surveying provider- “Airway clear”; Leader- “Breath sounds?”; Surveying provider- “Breath sounds decreased on right”)
• Check-back: A closed-loop communication strategy that requires a verification of information ensuring that information conveyed by the sender is understood by the receiver as intended. The sender initiates the message; the receiver accepts it and restates the message. In return, the sender verifies that the re-statement of the original message is correct or amends if not. (Example: Leader- “Give diphenhydramine 25 mg IV push”; Med Prep- “Diphenhydramine 25 mg IV push”; Leader- “That’s correct”)
• SBAR: A framework for team members to structure information when communicating to one another.
  • S = Situation (What is going on with the patient?)
  • B = Background (What is the clinical background or context?)
  • A = Assessment (What do I think the problem is?)
  • R = Recommendation (What would I do to correct it?)
• Situation monitoring: The process of continually scanning and assessing a situation to gain and maintain an understanding of what is going on around you.
• Situation awareness: The state of “knowing what’s going on around you.”
• Shared mental model: Result of each team member maintaining situation awareness and ensures that all team members are “on the same page.” An organizing knowledge structure of relevant facts and relationships about a task or situation that are commonly held by team members.
• STEP: A tool for monitoring situations during complex situations. A systematic method to review Status of patient, Team members’ performance and status, Environment, and Progress towards goal.
• Cross-monitoring: A harm error reduction strategy that involves 1. Monitoring actions of other team members 2. Providing a safety net within the team. 3. Ensuring that mistakes or oversights are caught quickly and easily. 4. “Watching each other’s back.”
• CUS: Signal phrases that denote “I am Concerned,” “I am Uncomfortable,” and “This is a Safety Issue.” When spoken, all team members should understand clearly not only the issue but also the magnitude of the issue.

Download Case 1 supporting files [PDF]

Notes:

• Photo: Child with anaphylaxis from the Anaphylaxis Campaign.
• CXR: Normal radiograph. Image from Dr. Rebekah Burns.

For the embedded participant (patient’s parent)

Case Background Information

Your child is a typically healthy kid but suddenly became short of breath after eating shrimp fried rice in a restaurant. You initially thought he was choking, however he is able to speak in short phrases to you, only saying his “throat felt tight” and he “couldn’t breathe”. You think his lips might be more swollen than usual, and his face looks a bit red to you. He is otherwise healthy and has no allergies. This has never happened before. He has never had any medical problems or an allergic reaction before.

Who are the Learners?

The learners are emergency medicine residents of various stages of training (first, second, third, and possibly fourth year residents). First year residents typically are efficient at gathering a history and performing a physical exam on patients; however, they likely have limited medical knowledge and less familiarity with pediatric patients and procedures. Late second years, third years, and fourth years usually are much more comfortable with critically ill patients and have more knowledge regarding pediatric patients. For the purposes of this simulation, assume learners are in their first or second year of residency training.

Standardized Patient Information

Your 6-year-old is a healthy boy. Your family went out for dinner this evening, and shortly after eating fried rice with shrimp, your son began to cough frequently and breathe more rapidly. You thought he might be choking, but he was able to tell you that he felt like his “throat was closing” and he was “having trouble breathing”. His lips looked more swollen to you and his face turned red. He’s never had any food allergies before, but you were worried he might be having an allergic reaction. You got in the car and immediately drove to the hospital with him. On the way there he started complaining of itching, and you noticed a rash all over his body. Upon arrival to the ED, you are anxious about your son’s appearance and increased work of breathing. Allow the team to assess your child and verbalize their thoughts to one another. Ask questions frequently, but remain calm and supportive.

Patient Information

(Please remember not to offer any of this information, but when asked please respond while remaining in character.)

• CHIEF COMPLAINT: “I think he is having an allergic reaction.”
• AGE: 6 years old
• ADDITIONAL HISTORY: No additional HPI. Your child was fine earlier today.
• PAST MEDICAL HISTORY: None, goes to the doctor regularly, has all his vaccines.
• SOCIAL HISTORY: Lives at home with mother, father, older sister, and one dog. No one in the house smokes.
• FAMILY HISTORY: Older sister with asthma. Mother has no known medical diagnoses. Father has high blood pressure. Paternal grandfather with heart attack, but alive. Maternal grandmother with high blood pressure.
• PAST SURGICAL HISTORY: None
• MEDICATIONS: None
• ALLERGIES: No known drug allergies.
• IMMUNIZATIONS: Up-to-date
• BIRTH HISTORY: Full term male born normal vaginal delivery. Normal pregnancy without complications. Unremarkable newborn course.

Potential Dialogue

IMPORTANT: Do not offer unsolicited information. Please allow the learners to ask questions. Do not offer information unless they ask you.

Things you could say without being asked:

• “This has never happened to him before, someone tell me what’s going on!”
• “Why is he not getting better?”

Things you might say triggered by events in the scenario:

The learners enter the room to find a 6-year-old boy in street clothes, anxious and in respiratory distress. They immediately place him on a cardiovascular monitor and perform a quick assessment of ABCs. Noting wheezing, an urticarial rash, and lip swelling, they presume this is anaphylaxis and immediately administer IM epinephrine. Upon more thorough exam, they note his pharynx and tongue are normal, but he is wheezing with decreased air entry. Albuterol is administered by nebulizer, IV access is established, 20 m/kg of IV normal saline fluid, 2 mg/kg IV methylprednisolone, 1-2 mg/kg of IV diphenhydramine, and 0.5 mg/kg IV famotidine (or 1 mg/kg ranitidine) are given. Any x-ray, labs, or ECG ordered will be normal except sinus tachycardia on the ECG. The patient may gradually improve over 5-10 minutes with this treatment.

As an alternative for advanced learners, or learners that arrive at the initial diagnosis and give the IM epinephrine very quickly, Stage 3 can be used. Here, the IM epinephrine will be ineffective, and the patient will become lethargic and hypotensive over 3-5 minutes. Similar treatment as above should be done with the addition of a second and possible third IM epinephrine followed by initiation of an IV epinephrine drip which will improve the symptoms slowly. Teams may choose to intubate when he develops altered mental status. This patient should be admitted to the ICU for observation, weaning of the epinephrine, and ventilatory management if intubated.

Anticipated Management Mistakes

1. Difficulty with recognizing anaphylaxis: Novice learners may have difficulty with recognizing anaphylaxis as the patient has no previous history leading to a delay in epinephrine use. The nurse in the case can point out things like the lip swelling and urticarial rash to prompt the team if needed.
2. Focus on the wrong medications: Learners may focus on the diphenhydramine and other secondary medications instead of given epinephrine immediately. The nurse can prompt / encourage the medication if not given early, but the case should progress to the worsening clinical scenario so they can see what happens if early epinephrine is not given.