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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 NEURO: Largely nonfocal without rigidity but unable to fully comply with exam LABS: Pending throughout the case IMAGES: See Appendix B Angiogram ECG X CT Scan, with contrast MRI CT Scan, without contrast X-Ray X Echocardiogram Ultrasound Additional Images: none CONSULTS: Toxicologist – Dr. Frank: Will recommend any tests and imaging forgotten in lab workup and will advise treating for organophosphate intoxication with airway control and adequate oxygenation, aggressive atropine, consideration of pralidoxime (2-PAM) and benzodiazepines and appropriate HAZMAT decontamination. Will recommend continuous close monitoring and re-evaluation. CLINICAL PROGRESSION: History and physical, IV/O 2 /monitor. Students should recognize strong likelihood of organophosphate poisoning, take decontaminating actions, order laboratory studies and imaging studies. Patient will continue to complain about the symptoms: “Oh, my stomach! Please stop the vomiting and diarrhea” and ask for something to make her/him feel better. Labs will be pending throughout the case so students are expected to take action with suspected diagnosis of organophosphate overdose based on clinical presentation alone. ***If students give atropine the heart rate and blood pressure will normalize, if they the antidote (2- PAM), the muscle fasiculations will stop. HR BP Temperature ( o C) O 2 Sats (RA) RR 60 120/74 37.0 o 90% 32 VI. Instructor Notes A. Tips to keep scenario flowing 1. If students are unsure of pathology, instructor can prompt the students to create differential diagnosis by calling in as a consultant 2. If airway management, oxygen therapy and atropine not initiated, nurse can verbalize need for supportive care B. Scenario programming 1. Optimal management path: O 2 /IV/monitor History and physical examination Aggressive airway management/oxygenation Decontamination Consider administering atropine 146
Gilbert Program in Medical Simulation Simulation Casebook Harvard Medical School Draft of the 1 st edition (2011), updated 3/2/12 Consult toxicology/poison control 2. Potential complications/errors path(s): Failure to protect airway, provide oxygen Failure to provide antidote 3. Program debugging: N/A VII. VIII. 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. Pathophysiology i. Review/reinforce parasympathetic function ii. Rest and digest Cholinergic excess iii. ACh accumulation throughout the nervous system results in overstimulation of muscarinic and nicotinic receptors iv. Pesticide poisonings are the most common modes of poisoning fatalities b. Presentation i. SLUDGE: salivation, lacrimation, urination, defecation, gastric distress, emesis ii. BBB: bradycardia, bronchorrhea, bronchospasm iii. DUMBBELS: defecation-diaphoresis, urination, miosis, bronchorrhea, bradycardia, emesis, lacrimation, salivation c. Treatment i. Atropine, atropine, atropine (and more atropine until respiratory secretions decrease) ii. Pralidoxime (2-PAM) iii. Emphasis that organophosphate toxicity is a clinical diagnosis Development and Deployment This case was developed as part of a graduate-level science course (college, PhD students), and has been deployed as a standard course offering. Variants have also been used to teach medical students as part of an instructional pharmacology module. IX. Authors/Contributors Case drafted and revised by Nancy Oriol, M.D., Tania Fatovich, M.D., and Emily Hayden, M.D., 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. 147
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