EM ReSCu Peds 2: Cardiac Tamponade

Brief Narrative Description of Case

8-year-old female with viral respiratory illness and urinary tract infection develops acute onset of shortness of breath and hypotension due to onset of pericarditis with effusion resulting in medical cardiac tamponade.

Primary Learning Objectives

At the end of this simulation, participants should be able to:

  1. Identify signs and symptoms of cardiac tamponade (application)
  2. Demonstrate early evaluation of a critically ill patient (application)
  3. Construct a broad differential for a child with fever, hypotension and respiratory distress (synthesis)
  4. Construct and implement initial medical management for a pediatric patient with signs of shock and respiratory distress (synthesis)
  5. Formulate a diagnostic plan to evaluate for causes of patient deterioration (synthesis)
  6. Discuss when to use point-of-care ultrasound in the evaluation and treatment of a pediatric patient with undifferentiated cardiopulmonary distress (evaluation)
  7. Interpret the sonographic findings of a pericardial effusion with cardiac tamponade (application)
  8. Demonstrate an emergent ultrasound-guided pericardiocentesis (application)
  9. Demonstrate focused history taking from a caregiver (application)
  10. Explain diagnosis and management to caregivers (synthesis)
  11. Demonstrate teamwork and closed loop communication (application)

Critical Actions

  • Assign and assume team roles
  • Obtain history from the parent or guardian
  • Perform primary assessment of the patient
  • Place the patient on a cardiac monitor with continuous pulse oximetry
  • Obtain a complete set of vital signs including heart rate, blood pressure, respiratory rate, oxygen saturation, and temperature
  • Place the patient on supplemental oxygen (titrate to keep O2 saturations >93%)
  • Place two large bore peripheral intravenous (IV) lines
  • Obtain an emergent portable chest x-ray
  • Obtain an emergent ECG
  • Send blood down for analysis including: Complete Blood Count (CBC) with differential, Complete Metabolic Panel (CMP), Lactic acid, Erythrocyte Sedimentation Rate (ESR), C-Reactive Protein (CRP), Thyroid Stimulating Hormone (TSH), Free thyroxine (T4), Blood cultures
  • Administer a 20 mL/kg bolus of crystalloid IV 3 times.
  • Initiate broad spectrum antibiotics after blood cultures have been drawn
  • Perform a point-of-care, bedside CORE (Concentrated Overview of Resuscitative Efforts) Scan
  • Recognize a pericardial effusion on bedside ultrasound
  • Recognize cardiac tamponade on bedside ultrasound
  • Determine that the patient requires an emergent pericardiocentesis for cardiac tamponade
  • Perform an ultrasound-guided pericardiocentesis at the bedside
  • Obtain a cardiology consult/cardiothoracic surgery consult
  • Admit the patient to the Pediatric Intensive Care Unit (PICU)
  • Update the patient’s family

Case Creators

Authors

  • Teresa Wu, MD, FACEP
  • James A. Lindgren, MD, FAAP, FAEP

Editors

  • Michael Nguyen, MD, FACEP
  • Rebekah Burns, MD
  • Lindsey Picard, MD
  • Yasmin Moftakhar, MD

Updated August 27, 2020

Setup

Chief complaint: Difficulty breathing
Patient age: 8 years old
Weight: 26 kg

Recommended Supplies

  • Manikin: child
  • Moulage: none
  • Resources: PALS cards and/or length-based tape (e.g., Broselow Tape)
  • Equipment
    • Cardiac monitor
    • Cardiac defibrillator
    • Peripheral IV needles (20 and 22 gauge)
    • IO catheter and drill or Jamshidi
    • Blood collection tubes (rainbow)
    • Pediatric oxygenation and ventilation equipment, such as non-rebreather (NRB), bag-mask ventilation (BMV), tubing, oral-pharyngeal airway (OPA)
    • Pediatric intubation equipment, such as laryngoscope, endotracheal tube (ETT), stylet, end tidal carbon dioxide (ETCO2) monitor, 10 mL syringe, ventilator
    • Continuous oxygen saturation monitoring
    • Oxygen source (wall tree or tank)
    • Yankauer suction catheter and suction vacuum set up/ canister
    • Ultrasound machine with 5-2 MHz phased array transducer, 5-1 MHz phased array transducer, and high frequency linear array transducer
    • Pericardial effusion task trainer
    • Pericardial needle and catheter set or substitute (central line kit, lumbar puncture kit, etc.)
    • Syringes (3 mL, 5 mL, 10 mL, and 60 mL)
    • IV fluids (normal saline, lactated ringers)
    • Code cart
  • Medications
    • Vasopressor agents
    • IV antibiotics
    • Antipyretics (acetaminophen, ibuprofen)

Supporting Files

  • Lab results
  • ECG
  • Chest x-ray (CxR) images
  • Ultrasound images/video clips of pericardial effusion with cardiac tamponade
  • Ultrasound images/video clips of distended IVC

Participants/Roles

  • Participants/Learners: ᴑ Team Leader
    • Airway Manager
    • Survey Physician
    • Medication Preparer
    • Medication Giver
    • Proceduralist
    • History Taker and Family Liaison
  • Faculty or other embedded participants can play a nurse, respiratory therapist, or tech, if there are not enough learners to perform the above roles.
  • Standardized patient (actor or faculty) to play patient’s parent

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 cardiac tamponade
    • Simulation implementation and debriefing experience
  • Emergency medicine residents
    • Any stage of training (preferably PGY-3 or greater for proceduralist)
    • Completed PALS certification
    • Use of point-of-care ultrasound (POCUS) and the CORE Scan
    • Ultrasound guided pericardiocentesis

Case Alternatives

  • Learners deviate from standard protocols or anticipated actions.
    • The Sim RN or faculty facilitator can lead the participants back down the right track with thoughtful and intentional questions.
    • Cardiology or Cardiothoracic Surgery can miraculously be walking by the room on their way out of the hospital and stop to see if the participants need any help.
  • Facilitators would like to increase the challenge of the case to target advanced learners.
  • The patient’s family member can have a syncopal event and not be available to provide any further information.
  • The patient can have a difficult airway.
  • The patient can develop disseminated intravascular coagulation (DIC) and start hemorrhaging.
  • The family member can tell everyone they are Jehovah’s Witnesses and do not want any blood products.
  • The patient’s father/mother can burst into the room and say “I do not authorize any of this! I want a mediator present for all medical decisions for my child!” (Parents are divorced.)
  • The patient can develop a pneumothorax or liver laceration depending on how the pericardiocentesis is performed.
  • The patient’s aunt can burst into the room and say she is a medicolegal attorney and will be recording the entire encounter.

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
PC8. Multi-tasking (Task switching)
PC9. General Approach to Procedures
PC10. Airway Management
PC11. Anesthesia and Acute Pain Management
PC12. Ultrasound – Diagnostic/Therapeutic
PC13. Wound Management
PC14. Vascular Access
MK. Medical Knowledge
PROF1. Professional Values
PROF2. Accountability
ICS1. Patient Centered Communication ICS2 – Team Management
PBLI. Practice Based Performance Improvement SBP1 – Patient Safety
SBP2. Systems-based Management
SBP3. Technology

Resources

  1. Wu TS. The CORE Scan: Concentrated Overview of Resuscitative Efforts. Critical Care Clinics. 2014;30:151-75. PMID: 24295844
  2. Li S, Rossfeld Z, Basu B. Cardiac Tamponade in a Child with Fever of Unknown Origin. Hospital Pediatrics. 2017;7:692-696. PMID: 29089379
  3. Alerhand S, Carter JM. What echocardiographic Findings Suggest a Pericardial Effusion is causing Tamponade? Am J Emerg Med. 2019;3 7:321-326. PMID: 30471929
  4. Parnell S. POCUS Pearls for Tamponade. JournalFeed.org (March 27, 2019).
  5. Hatch N, Wu TS. Advanced Ultrasound Guided Procedures. Critical Care Clinics. 2014;30:305-329. PMID: 24606778
  6. Barr L, Hatch N, Roque PJ, Wu TS. Basic Ultrasound Guided Procedures. Critical Care Clinics. 2014;30:275- 304. PMID: 24606777
  7. www.SonoSupport.com
ITEMFINDING
Overall Appearance8-year-old female sitting up in bed with obvious tachypnea and respiratory distress, who is diaphoretic and pale
HPIThe patient is an 8-year-old female with a history of mild intermittent asthma and neurofibromatosis type 1 who presents to the Emergency Department with shortness of breath. She was brought in via private vehicle by her mother. She has been having daily fevers between 101°F to 105°F at home for the past week. This has been accompanied by a non-productive cough, nasal congestion, sore throat, general myalgias, and dysuria. She was seen by her PCP a few days ago and was diagnosed with bronchitis. She was started on amoxicillin pills. Her PCP called her mom yesterday to tell her that the urine cultures grew out Staphylococcus epidermidis and her PCP called in an additional antibiotic (cephalexin) to the pharmacy for them. She started her cephalexin yesterday. Today, she noticed a macular hand rash bilaterally. She also started having bilateral flank pain. She became increasingly short-of-breath despite albuterol treatments at home so her mom drove her to the ED. She has tried acetaminophen and ibuprofen at home for her fevers. She has multiple sick contacts at school.
Past Medical/Surgical HistoryNeurofibromatosis (Type I), asthma (mild)
MedicationsCephalexin, acetaminophen, ibuprofen, albuterol
AllergiesNone
Family HistoryMom and grandma with NF1
Social HistoryLives with mother
Father not involved
No siblings
No tobacco/drugs or alcohol Exposed to sick contacts (school)

Initial Presentation and Primary Evaluation

Start of case through administration of crystalloid bolus

Critical Actions

  • Recognize respiratory distress
  • Obtain a complete set of vital signs
  • Place the patient on supplemental oxygen
  • Obtain a focused history
  • Perform a focused physical exam
  • Order 2 large bore peripheral IV’s
  • Recognize hypotension
  • Order a 20 mL/kg bolus of crystalloid IVFs

Physical Exam

ITEMFINDING
Vital SignsT: 38.3oC, HR: 140, BP: 77/42, RR: 62, SpO2: 89% on RA
GeneralWell developed, well-nourished female who is lying in bed in obvious respiratory distress. Diaphoretic.
HEENTPupils equally round and reactive to light (PERRL), dry mucous membranes, strawberry tongue, uvula midline
NeckIncreased jugular venous distension (JVP), trachea midline, supple with good range of motion
LungsTachypnea, clear to auscultation bilaterally, nasal flaring present, subcostal retractions present
CardiovascularTachycardic, normal S1 and S2 (no murmurs, rubs or gallops), distant heart sounds
AbdomenSoft, non-tender, non-distended. No rebound. No guarding. No masses.
BackNo flank tenderness to palpation or percussion
NeurologicalAlert, cooperative, cranial nerves 2-12 intact. Moves all extremities symmetrically. Strength is 4/5 throughout. No focal deficits.
ExtremitiesNo cyanosis, clubbing, or edema
SkinCafé-au-lait spots on her back. Dark brown freckles in her armpits. Capillary refill is 4 seconds.

Instructor Notes: Changes and Case Branch Points

INTERVENTION / TIME POINTCHANGE IN CASEADDITIONAL INFORMATION
Orders cardiac monitor.Patient is hypotensive, tachycardic, and tachypneic with hypoxia.Nurse can ask “Do you want her on the monitor?”
Orders two large bore peripheral IV’sSuccessful placement of PIVsNurse can ask “How many PIV’s do you want?”
Places the patient on supplemental oxygenWith oxygen, the patient’s oxygen saturation improves to 94%.If oxygen is not administered quickly, the patient can say: “I can’t breathe!”

Nurse can ask: “How much oxygen do you want me
to put her on?” and “How do you want the oxygen delivered?”

Administers a 20 mL/kg bolus of IVF’s (crystalloid) for hypotension on the monitor.Persistent tachycardia and hypotension despite IVF bolus. Vitals do not change. Go to Stage 2.If the participants do not bolus IV fluids by 3 minutes into the case, the nurse can prompt or operator can decrease BP by 5% and increase heart rate by 5%.
If the participants try to obtain a comprehensive history and do not treat her with crystalloid and/or oxygenReduce the BP and oxygen by 5%, and increase the RR and HR by 5%.

Reassessment

Completion of 1st crystalloid bolus through completion of 2nd crystalloid bolus

Critical Actions

  • Recognize abnormal physical exam findings
  • Consider a broad differential
  • Order a STAT portable CXR
  • Order a STAT ECG
  • Order the appropriate blood tests
  • Order additional IVF bolus

Physical Exam

ITEMFINDING
Vital SignsT: 38.3oC, HR: 140, BP: 77/42, RR: 62, SpO2: 94%
Exam ChangesNo changes in physical exam: The patient is still hypotensive, tachycardic, tachypneic, hypoxic, and febrile in respiratory distress.

Instructor Notes: Changes and Case Branch Points

INTERVENTION / TIME POINTCHANGE IN CASEADDITIONAL INFORMATION
Participants should note tachycardia, tachypnea, diaphoresis, pulsus paradoxus, muffled heart sounds, decreased capillary refill, and strawberry tongue.If participants don’t notice key findings, nurse will state: “What did you find on physical exam?” or “I thought her tongue looked odd” or “It’s weird, I can’t really hear her heart sounds very well.”
Participants formulate a broad differential: Pneumonia, sepsis, RAD, myocarditis, PTX, pleural effusions, PE, Kawasaki’s Disease, pericarditis, pericardial effusion with tamponade perforated viscus, thyrotoxicosis, toxic ingestionIf the participants do not come up with at least 5 life threatening etiologies on their differential, the nurse can say “What else could this be?”

Attending can intervene and guide with thoughtful and intentional questions if the participants go off track.

Order portable CXRRadiology technician comes into the room and places the x-ray plate behind the patient and shoots the CXR. Participants will be shown the portable CXR images after completion.If the participants do not come up with at least 5 life threatening etiologies on their differential, the nurse can say “What else could this be?”

Attending can intervene and guide with thoughtful and intentional questions if the participants go off track.

Order ECGRN or tech obtains an ECG. Participants will be shown ECG immediately after completion.Nurse can ask: “Do you want an ECG?”
Order blood work for analysisRN or tech draws blood from the patient’s peripheral IV.Nurse can prompt: “I drew some blood with the IV starts. Do you want to order anything?”
Order additional 20 mL/kg bolus (bolus #2)Go to Stage 3.If participants do not order a second bolus, then drop BP 5% and increase HR by 5%.
Order broad spectrum antibioticsIf antibiotics are not ordered, the nurse can say: “She’s febrile, tachycardic, and hypotensive. Do you think she could be septic?”
Order nebulized bronchodilatorIncrease the HR by 5% if albuterol is ordered.
Order nasopharyngeal viral studies or flu swabNurse should say “Do you really want me to swab her while she is in respiratory distress?”

Work-up

Completion of second crystalloid bolus through review of CXR, ECG, and labs

Critical Actions

  • Recognize cardiomegaly on CXR
  • Recognize low voltage and electrical alternans on the ECG
  • Interpret her blood test results correctly

Physical Exam

ITEMFINDING
Vital SignsT: 38.3oC, HR: 136, BP: 90/55, RR: 60, SpO2: 94%
Exam ChangesMinimal improvement in blood pressure and pulse. Still short of breath.

Instructor Notes: Changes and Case Branch Points

INTERVENTION / TIME POINTCHANGE IN CASEADDITIONAL INFORMATION
Patient’s vital signs are improving slightly with second bolus of IV fluids and supplemental oxygen.Vital signs improve by 5%.
Participants should review the CxR and note that there is cardiomegaly and clear lung fields.Increase HR and decrease BP by 5%.If the participants do not correctly interpret the results, the nurse can say the following: “What do you think of her heart size?”
Participants should review the ECG and note that the patient is in sinus tachycardia with low voltage throughout and electrical alternans.Increase HR and decrease BP by 5%.“What do you think of her ECG? It looks kind of odd to me.” “What do you think is going on with her heart?”
Participants are provided with the blood test results and note that the patient has leukocytosis with a left shift and bandemia, lactic acidosis, and an elevated ESR and CRP.Increase HR and decrease BP by 5%.“What did her blood tests show?”

Bedside Ultrasound

Review of CXR, ECG, and labs through bedside ultrasound

Critical Actions

  • Perform a bedside point-of-care ultrasound
  • Recognize a large pericardial effusion
  • Recognize cardiac tamponade on bedside ultrasound

Physical Exam

ITEMFINDING
Vital SignsT: 38.0oC, HR: 128, BP: 88/56, RR: 62, SpO2: 95%
Exam ChangesThe patient has worsening HR, BP, RR, oxygen saturation, and clinical status.

Instructor Notes: Changes and Case Branch Points

INTERVENTION / TIME POINTCHANGE IN CASEADDITIONAL INFORMATION
Patient is still complaining “I can’t breathe. I don’t feel good!”

Patient is still tachycardic and hypotensive, requiring a 100% NRB mask to keep oxygen saturations >93%.

Continue to decrease BP and increase HR by 5%.Nurse will say: “Are you going to order anything else for the patient?”

Nurse will say “She is looking worse. What do you want to do?”

Participants may administer another 20 mL/kg bolus of IVFs. (third IVF bolus for a total of 60 mL/kg).Continue to decrease BP and increase HR by 5%.If the participants do not administer another bolus of IV fluids, continue to drop the BP and increase the HR by another 5%.
Participants should perform a bedside point-of-care ultrasound (CORE Scan)

Participants should scan her heart and note a large circumferential pericardial effusion (subxiphoid or parasternal views).

Participants should note sonographic signs of cardiac tamponade (end-diastolic right ventricular collapse, right atrial collapse).

Participants should scan the inferior vena cava (IVC) and note IVC dilation and lack of respiratory variation.

Continue to decrease BP and increase HR by 5%.

Ultrasound images and video clips can be uploaded to a stimulus monitor or participants can use commercially available ultrasound simulators (e.g., SonoSim).

Nurse will say: “Do we need any other imaging?”

If the participants try to order a computed tomography (CT) scan, the nurse will say: “I don’t think she is stable enough to go to radiology right now. Is there anything else we can do for her at the bedside?”

If the participants do not perform a CORE Scan, the nurse can say “Is there any other way we can see what is going on with her heart and lungs?”

If the participants do not verbalize their ultrasound findings, the nurse should ask “What do you see on ultrasound?”

Participants should recognize that the patient has a pericardial effusion and cardiac tamponade.Go to Stage 5.

Pericardiocentesis

Bedside ultrasound through pericardiocentesis

Critical Actions

  • Recognize that the patient needs an emergent pericardiocentesis
  • Perform an emergent bedside pericardiocentesis
  • Place a call out to interventional cardiology or CT surgery
  • Perform the pericardiocentesis under ultrasound guidance

Physical Exam

ITEMFINDING
Vital SignsT: 38.0oC, HR: 155, BP: 74/58, RR: 8, SpO2: 89% on 100% NRB
Exam ChangesPatient is deteriorating rapidly and unable to protect her airway.

Instructor Notes: Changes and Case Branch Points

INTERVENTION / TIME POINTCHANGE IN CASEADDITIONAL INFORMATION
Participants may opt to intubate the patient.If the participants intubate the patient, have the patient go into cardiopulmonary arrest due to the sudden drop in sympathetic drive.Participants should be able to defibrillate the patient and get her back with epinephrine.

Have her go back to pre-intubation vital signs after return to spontaneous circulation (ROSC).

Participants should prepare for and perform a bedside pericardiocentesis under ultrasound guidance (parasternal, apical, or subxiphoid approach)

Participants may opt to perform the procedure under procedural sedation with oxygenation and ventilatory support given risk for decompensation with rapid sequence intubation.

Ultrasound images and video clips can be uploaded to a stimulus monitor
or participants can use commercially available ultrasound simulators (e.g., SonoSim).
If the participants do not perform the pericardiocentesis under ultrasound guidance, the nurse should say “Do you want to use ultrasound guidance when you stick the needle into her chest?”

If the participants decide to intubate her first, the RN may say “Do you think we have time to intubate her or should we sedate her quickly and get that fluid off her heart?”

Pericardiocentesis has been performed and 360 mL of thick serosanguinous fluid has been withdrawn emergently.T 38.0oC
HR 125
BP 90/54
RR 20 (with bagging)
O2 Sat 100% on 100% FiO2Go to Stage 6
Nurse can say “She’s starting to stabilize. Where is she going to go next?”

Case Conclusion

Pericardiocentesis through signout to admitting team

Critical Actions

  • Discuss with pediatric intensivist
  • Transfer the patient to the pediatric ICU
  • Update the family

Physical Exam

ITEMFINDING
Vital SignsT: 38.0oC, HR: 125, BP: 90/54, RR: 20, SpO2: 100% on 100% NRB
Exam ChangesPatient has improved color, decreased respiratory distress, and near normalization of vital signs after successful pericardiocentesis.

Instructor Notes: Changes and Case Branch Points

INTERVENTION / TIME POINTCHANGE IN CASEADDITIONAL INFORMATION
Participants can call PICU team or the PICU team can show up and say they heard there was a critical patient that needed admission.

Participants should provide a succinct and direct hand- off to the admitting team including information such as what the patient presented with, what was done for the patient, the thought process behind the treatment, and what they are hoping to have happen next.

Consultants arrive for hand-off. Patient remains stable.The consultant and admitting team can ask clarification questions if the consult or hand-off is not complete.
Participants should update the family.Patient remains stable.If the participants do not speak with mom, the nurse will say “Are you ready to talk to mom and dad?”

Identify signs and symptoms of cardiac tamponade (application)

  • Tachycardia, hypotension, muffled heart sounds

Demonstrate early evaluation of a critically ill patient (application)

  • Focused primary survey
  • Treat and think simultaneously

Construct a broad differential for a child with fever, hypotension and respiratory distress (synthesis)

  • Vasculitis
  • Infection
  • Trauma
  • Autoimmune
  • Metabolic
  • Iatrogenic
  • Neoplasm
  • Congenital

Construct and implement initial medical management for a pediatric patient with signs of shock and respiratory distress (synthesis)

  • Peripheral IV’s: 2 large bore IVs as central as possible
  • Supplemental oxygen (nasal cannula, non-rebreather, positive pressure ventilation, intubation)
  • Cardiac monitor with every five minutes automatic blood pressure readings
  • Continuous oxygen saturation monitoring: ensure that there is a good waveform and that that probe is not on a cold extremity.
  • Perform a POCUS: The CORE Scan for undifferentiated cardiopulmonary distress
  • 20 mL/kg bolus (crystalloid). Reassess after IV fluids.
  • Portable CXR: Do not send an unstable patient to radiology for PA/lateral
  • ECG
  • Draw and send blood for stat analysis.

Formulate a diagnostic plan to evaluate for causes of patient deterioration (synthesis)

  • Think and act simultaneously.
  • Perform tasks in parallel and not in series.
  • Think at least three steps ahead of every other member on the team.
  • Have backup plans for every step of assessment and treatment.
  • Speak out loud and include team members in the decision-making process.

Discuss when to use point-of-care ultrasound in the evaluation and treatment of a pediatric patient with undifferentiated cardiopulmonary distress (evaluation)

  • In undifferentiated patients, perform a POCUS early on to assess the heart, lungs, IVC, etc.
  • Obtain useful data within minutes at the bedside.
  • Act on each sonographic finding as you scan.

Interpret the sonographic findings of a pericardial effusion with cardiac tamponade (application)

  • Hypoechoic or anechoic pericardial effusion.
  • Visualize the effusion in the parasternal or subxiphoid view.
  • Is the effusion circumferential? Is it loculated?
  • Are you sure you aren’t looking at a pericardial fat pad?
  • Determine if there is end-diastolic RV collapse, RA collapse, and IVC dilation or decreased IVC variation with respirations.

Demonstrate an emergent ultrasound-guided pericardiocentesis (application)

  • Subxiphoid approach puts the patient at risk for liver puncture.
  • Consider a parasternal or apical 4 chamber approach.
  • Perform the procedure under direct ultrasound guidance.
  • Lumbar puncture or central venous access trays can be used in emergent situations.

Demonstrate focused history taking from a caregiver (application)

  • Obtain the critical information first.
  • Act immediately.
  • Supplemental information can be obtained as the patient is being stabilized.
  • Reassess regularly.

Explain diagnosis and management to caregivers (synthesis)

  • Ensure that someone is updating the family regularly and frequently.
  • Delegate this responsibility if necessary.
  • Circle back with the family members and sit down to discuss with them what happened, what you were worried about, what was done, and what next steps will be.
  • Always finish with, “Do you have any questions?” and “I am here for you if you think of any other questions later.”

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.

ECG 1

ECG 2

Point of Care Ultrasound 1: Cardiac

Point of Care Ultrasound 2

Download Case 2 supporting files

Notes:

  • Point-of-care ultrasound interpretation: Long axis view of a dilated IVC secondary to cardiac tamponade from a pericardial effusion. Image from Dr. Teresa Wu, and Sonosupport.com.

For the person running the simulated patient and serving as the voice of the simulated pediatric patient, AND for the embedded participant playing the role of the parent/guardian

Case Background Information

This 8-year-old female is brought in by her parent for fever, shortness- of-breath, and numerous other symptoms. For a few days prior, she has been managed by her primary care doctor (PCP).

Upon emergency department (ED) arrival, the treatment team should recognize that she is severely ill and immediately begin resuscitation. Provider actions will include intravenous (IV) fluids, oxygen, monitoring, diagnostic tests, and antibiotics. They may perform intubation and place a central line.

The patient will continue to be critically ill. Results from chest x-ray (CxR), electrocardiogram (ECG), and point-of-care ultrasound should allow the treatment team to recognize that she has cardiac tamponade. Ideally, they will perform a pericardiocentesis, and then transfer her care to the intensive care unit (ICU).

Who are the Learners?

Emergency medicine residents, pediatric emergency medicine residents, and undifferentiated medical students

  • The learners are expected to be proficient in gathering a history and performing a physical exam. They are capable of formulating a list of diagnoses and ordering tests.
  • Most learners will be able to perform common emergency department procedures such as:
    • Inserting a peripheral IV
    • Placing the patient on the cardiac monitor
    • Placing the patient on supplemental oxygen
    • Assisting ventilation
    • Intubating the patient
    • Performing point of care ultrasound
    • Establishing central venous access with a central line
  • They will have variable experience regarding the diagnosis of cardiac tamponade and the performance of pericardiocentesis. They have likely read about those topics, but at their stage of training, it is uncommon to have firsthand experience with either in clinical practice.

Standardized Patient Information

Parent: Your overall demeanor is concerned. Your daughter has never been this sick before. You will be cooperative with the treatment team and openly answer their questions. If the team prepares for an invasive procedure (e.g., central line, pericardiocentesis), you will ask for a justification for the procedure (“Why does this have to be done?”) and accept their explanation at face value.

Patient Information

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

  • CHIEF COMPLAINT: “She’s having difficulty breathing.”
  • AGE: 8 years old
  • ADDITIONAL HISTORY:
    • She has been having daily fevers between 101°F to 105°F at home for the past week. This has been accompanied by a non-productive cough, nasal congestion, sore throat, body aches, and burning-with-urination.
    • She was seen by her PCP a few days ago and was diagnosed with bronchitis. A urine culture was sent. No other tests were done. She was started on amoxicillin pills.
    • Her PCP called her mom yesterday to tell her that the urine cultures grew out Staphylococcus epidermidis, and her PCP called in an additional antibiotic (cephalexin) to the pharmacy for them. She started her cephalexin yesterday.
    • Today, she noticed a red rash on both hands. She also started having bilateral flank pain.
    • She became increasingly short-of-breath despite albuterol treatments at home so you drove her to the ED.
    • You have given her acetaminophen and ibuprofen at home for her fevers.
  • PAST MEDICAL HISTORY: Neurofibromatosis (Type I) and mild asthma
  • SOCIAL HISTORY: She has multiple sick contacts at school. Lives with mother. Father not involved. No siblings. No tobacco/drugs or alcohol.
  • FAMILY HISTORY: Mom and grandma both have Neurofibromatosis (Type I)
  • PAST SURGICAL HISTORY: None
  • MEDICATIONS: Cephalexin, acetaminophen, ibuprofen, albuterol
  • ALLERGIES: No known allergies
  • IMMUNIZATIONS: Up-to-date
  • BIRTH HISTORY: Unremarkable. She was born full term, no medical complications (patient is 8 years old, ok if they don’t ask about birth history)

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:

  • “She looks really sick.“
  • “What do you think is going on with her?”
  • “She looks really uncomfortable.“

Things you might say triggered by events in the scenario:

EVENTYOUR POTENTIAL RESPONSE
If the patient has not received supplemental oxygen“Can you help her with her breathing?”
If the learners delay other initial resuscitative measures“She looks really sick! What are you going to do for her?”
If half of the duration of the case goes by without the learners considering the diagnosis of tamponade“What else do you think is going on?”, “Is there another test you can do?”
If the learners recognize tamponade, but don’t perform a pericardiocentesis“How do you treat that?”
If the learners perform invasive procedures like central lines or pericardiocentesis“What procedure is that?” or “Why do you have to do that?”

The learners enter the room to find a febrile female 8-year-old child in respiratory distress. They immediately place the patient on bedside cardiac monitors and recognize that the patient is in critical condition and imminent cardiopulmonary arrest. Supplemental oxygen is provided, peripheral IVs are placed, and IV fluid boluses are ordered. Blood is drawn and sent for analysis. The patient’s oxygen saturation improves slightly with supplemental oxygen, but the respiratory distress does not resolve, and her hypotension is refractory to IV fluids. After completing a focused physical examination and obtaining a focused history, the providers begin prompt, aggressive resuscitation. A portable chest x-ray reveals an enlarged cardiac silhouette. An ECG shows sinus tachycardia with low voltage and electrical alternans. Point-of-care ultrasound (the CORE Scan) is performed and confirms the diagnosis of pericardial effusion with cardiac tamponade. The providers perform an ultrasound-guided pericardiocentesis. Blood test results are provided to the participants. The patient’s vital signs and clinical status improve after emergent pericardiocentesis. The patient’s case is discussed with the pediatric intensivist and arrangements are made to admit the patient to the pediatric intensive care unit. The family is updated. All questions are answered.

Anticipated Management Mistakes

  1. Participants do not act in a parallel fashion (e.g., take too long to perform a primary survey, resuscitation, history, or physical): A faculty member or embedded participant could ask the team to reinforce team assignments, including the team leader role. This could focus individual team members on specific critical actions, while allowing the team leader to account for every task.
  2. Participants do not consider cardiac tamponade on the differential diagnosis: During piloting, this occurred because
    the learners anchored on another diagnosis, did not perform an ultrasound, or perceived that classic tamponade exam findings were absent. In any of these situations, an embedded participant could explicitly suggest the use of bedside ultrasound.
  3. Participants hesitate to perform a pericardiocentesis: Since the procedure ideally occurs near the end of the case, faculty can discuss this during debriefing.

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