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Gilbert Program in Medical Simulation Simulation Casebook Harvard Medical School Draft of the 1 st edition (2011), updated 3/2/12 Administering over 500 CC’s IV fluid Administering large dose of Nitroglycerin, B-blocker, Morphine VI. Debriefing Plan A. Method of debriefing: Group with multimedia teaching materials B. Debriefing materials: See Appendix C C. Potential debriefing topics 1. Team dynamics a. Leadership b. Collaboration c. Communication d. Professionalism 2. Didactic material a. Presentation i. Appropriate differential diagnosis ii. Varying presentation of MI in different location 1. Contrast fluid overload requiring + inotropy from anterior MI with preload dependence and need for IV fluids in inferior MI b. Pathophysiology i. Atherosclerotic vs. nonatherosclerotic causes ii. Laboratory results: troponin, CKMB levels c. Treatment i. Need for immediate diagnosis and reperfusion for the acute MI 1. “Time is muscle” ii. Role of aspirin therapy: decrease mortality/reinfarction rates iii. Role of other antiplatelet therapy 1. Clopidogrel (Plavix) at 600mg dose if emergent CABG not anticipated iv. Role of pressors vs. fluids in the anterior MI patient v. Role of anticoagulants 1. Heparin: indicated in recurrent/persistent chest pain, AMI, positive biomarkers, dynamic EKG changes. Dose is 60U/kg bolus followed by 12U/kg infusion, titrating to apt 1.5-2.5 times control 2. LMWH at 1mg/kg BID, adjusted for renal insufficiency 3. GP IIb/IIIa inhibitor vi. Role of acute beta-blockade and nitrates 1. B-blocker: heart rate control and resultant decrease of myocardial O 2 demand to reduce rates of reinfarction, recurrent ischemia and potentially mortality 2. Nitrates: preload reduction and symptomatic relief 3. Contraindications in the hypotensive MI patient a. Hold NTG for SBP < 90 b. Hold BB if signs of cardiogenic shock vii. Treatment options: thrombolytic therapy vs. heart catheterization (PCI) vs. coronary bypass graft 10
Gilbert Program in Medical Simulation Simulation Casebook Harvard Medical School Draft of the 1 st edition (2011), updated 3/2/12 VII. Development and Deployment This case, along with it precursors (reference Gordon, below) and variants have been used over several years for a wide range of students, including high school, college, masters/PhD candidates, medical students (preclinical and clinical) and resident trainees. The presentation and progression is tailored to the level of the learner; often the Anterior MI case is paired with the Inferior MI case to allow students to compare and contrast diagnosis, anatomy, physiology, and management. It is commonly used as part of a “train the trainer” curriculum for faculty development in the use of simulation. VIII. Authors/Contributors Case drafted by Rami Ahmed, D.O, with contributions and updates by the Gilbert Simulation Team. Compiled and formatted by Elan Guterman. Reviewed and edited with references by Jeffrey Siegelman, M.D. and Zoë Howard, M.D. IX. References Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, Hochman JS, Krumholz HM, Kushner FG, Lamas GA, Mullany CJ, Ornato JP, Pearle DL, Sloan MA, Smith SC Jr. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction. A report of the Am Coll of Cardiol/Am Heart Assoc Task Force on Practice Guidelines (Committee to revise the 1999 guidelines). Bethesda (MD): American College of Cardiology, American Heart Association; 2004. Brady, WJ, Harrigan, RA, and Theodore Chan. “Acute Coronary Syndromes.” In: Rosen’s Emergency Medicine: Concepts and Clinical Practice, 6 th ed. Marx, et al, eds. pp 1154-99. Gordon, JA. Macy Cases for Realistic Patient Simulation in Critical Care and Emergency Medicine. Harvard Medical School, Boston: President and Fellows of Harvard College, 2002 11
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