Date Submitted:
Oct 01, 2007
Peer Review:
Requested
PEA due to tension PTX v. 1
Topic:
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PEA
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Target Audience:
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Case Description:
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VI. Case Narrative
A. Scenario Background Given to Participants—given by Nurse on entry to room—no documentation started yet as patient presents through triage.
1. Chief complaint: ‘SOB’. 70 year old male patient.
2. Past medical history: ‘COPD, DM, renal failure/dialysis’
3. Meds and allergies: ‘Glyburide, albuterol, phos-lo, no allergies’
4. Family/social history: ‘past cigarette smoking’
B. Scenario conditions initially
1. History patient gives: ‘I’m having trouble breathing’
-patient is confused, short answers due to moderate respiratory distress
-if asked about chest pain, says he has ‘tightness and some left shoulder ache—it feels like my COPD sometimes feels’
-has tried MDI at home ‘many times’ without success
-missed dialysis yesterday because ‘I didn’t feel well’
2. Patient’s initial exam (see additional Instructors Notes for full details)
Vitals: HR 110, BP 130/80, RR 40, Sats 88%, T97.7
Patient sitting up in bed, moderate respiratory distress
Exam significant for bilateral wheezing, slight decreased BS on L that progresses as case progresses
C. Scenario branch points
1. Patient deteriorates despite any treatment interventions for COPD
2. Patient requires intubation for respiratory failure
3. Post intubation L side pneumothorax worsens with positive pressure ventilation ---**NOTE: delay giving labs and CXR until after PEA develops to allow time for clinical decision making
4. Patient stabilizes after L side needle thoracostomy
5. See attached ‘Instructors Notes’
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Simulator Details
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Age:
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70 |
Gender:
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Male |
Chief Complaint:
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Shortness of breath |
Diagnosis:
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COPD exacerbation
Tension pneumothorax
PEA |
Setting:
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Emergency Department |
Equipment:
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METI HPS, could be easily done with Laerdal SimMan |
Actors:
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Nurse and/or tech depending on number of participants |
Timeline:
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Yes
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Usage Details:
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X. Instructors Notes---Simulation Program and Flowsheet
Case: ‘SOB -- respiratory distress and PEA
(saved as METI HPS case = EM-PEA-TensionPTX.STUDENT.hs6)
Scene: Rural Hospital, single RN, lab tech and radiology tech busy in the hospital
Pt arrives through triage. Student team is called and case begins.
*NOTE: Start AV equipment if taping for debriefing
-Baseline: normal standard man settings without physiologic changes
On entry to room, manually transition to ‘ED Presentation’
-ED Presentation (time 0:00): HR 110, BP 130/80, Sat 88%, RR 40
-physiologic changes include:
HR factor 1.25
Shunt fraction = 0.5
I to E ratio: 3:1
Pneumothorax enabled
Left interpleural volume 500
Respiratory rate factor to 1.4
Breath sounds to wheezing
ischemic index sensitivity to 0.1
-transition = manual at about 3 minutes (depending on group, can have control of speed of deterioration)
-Worsening Status (time 3:00): HR 110, BP 130/800, Sat 90% (on oxygen), RR 40
-physiologic changes include:
Left interpleural volume to 1000
Rhythm change to sinus with PVCs
Blink/eyes to ‘closed’
-transition = manual in the first minute after intubation
-Tension PTX (time = just after intubation)
-HR 110, BP 130/80, Sat 90%, RR bagged
-physiologic changes include:
Left interpleural volume to 3000
-transition = if time in state > 10 seconds, go to PEA-Tension PTX
-PEA-Tension PTX
-HR 110, BP 40 (PEA), RR bagged
-physiologic changes include:
Left lung compliance factor 0.15
Rhythm: PEA
-transition = if left interpleural volume < 2980, go to needle decompression
Note: If needle thoracostomy done and no change in status, manually advance
Needle Decompression
-HR 110, BP 130/80, Sat 97%, RR bagged
-physiologic changes include:
Rhythm to sinus
I to E ratio to 2:1
RR factor to 1
HR factor to 0.8
Shunt fraction to 0.1
Left lung compliance factor to 1.0
Left interpleural volume to 0
-transition = if epinephrine >= .0001 go to stabilized (can manually advance as
well)
Stabilized
-HR 90, BP 140/90, Sat 97%, RR bagged
-physiologic changes include:
HR factor 0.5
Packed RBC infusion 400
Bolus: Nitroglycerine 200mcg
Case concludes after final disposition for patient has been coordinated.
*NOTE: Stop AV equipment if taping for debriefing
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Evaluation Tool:
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Yes
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Case Designed For:
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Education |
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Keywords:
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PEA |
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(File Size:
150528
bytes)
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