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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 Cardiac Markers (optional) X Thyroid Panel Coagulation Profile Toxicology Screen Complete Blood Count (CBC) Urinalysis CBC with differential Urine HCG Additional Labs: none IMAGES: See Appendix B Angiogram ECG X CT Scan, with contrast MRI CT Scan, without contrast X-Ray Echocardiogram Ultrasound Additional Images: none CONSULTS: Cardiology – Dr. Jones: ECG will indicate atrial fibrillation with rapid ventricular response. Cardiology will recommend immediate cardioversion given the hemodynamic instability of the patient. Depending on the level of the learner, cardiology may give options to the novice learner (chemical cardioversion with beta-blocker, calcium-channel blocker, amiodarone, digoxin, or synchronized electrical cardioversion at 50 joules) and without specific examples of interventions for more advanced learners. . CLINICAL PROGRESSION: IV access and monitoring already established. Obtain additional history, repeat physical exam, and provide supplemental O 2 and IV fluids as patient progresses to atrial fibrillation. ECG will indicate atrial fibrillation with RVR and participants may take one of the following courses of treatment to cardiovert patient. They should also consider administering anticoagulant (e.g. heparin). ***If participants fail to order ECG after 3 minutes of atrial fibrillation, patient will become increasingly hypotensive and less responsive. Nurse will prompt participants to obtain ECG and consult cardiology. Option #1: Chemical cardioversion ***If participants administer AV-nodal blocking agent along with IV fluids, patient’s heart rate and rhythm will revert to sinus tachycardia and vitals will read as below. Option #2: Electrical cardioversion ***Chemical cardioversion will fail to convert rhythm. Only if participants electrically cardiovert patient, heart rate and rhythm will revert to sinus tachycardia and vitals will read as below. HR BP Temperature ( o C) O 2 Sats (RA) RR 102 140/100 37.0 o 96% 16 18
Gilbert Program in Medical Simulation Simulation Casebook Harvard Medical School Draft of the 1 st edition (2011), updated 3/2/12 VII. Instructor Notes A. Tips to keep scenario flowing 1. If need for further evaluation not recognized (Case: Part I), primary care provider will call and request cardiology consult. Cardiology consult will admit patient. If unsure of management strategy (Case: Part II), cardiology consult can call to check on their admitted patient and provide guidance with cardioversion. 2. Nurse will prompt participants to obtain ECG if not ordered after patient becomes unresponsive due to atrial fibrillation 3. Encourage participants to develop plans independently as much as possible. B. Scenario programming 1. Optimal management path: Part I O 2 /IV/monitor History and physical examination Follow rule-out MI protocol o Labs: CBC, BMP, cardiac markers, coagulation profile o Images: ECG, CXR IV fluid resuscitation Admit patient Order stress test and echocardiogram 2. Optimal management path: Part II O 2 /IV/monitor (assumed present) Additional history and physical examination IV fluids Continue rule-out MI (optional) Immediate cardioversion Administer anticoagulant 3. Potential complications/errors path(s): Part I: Administration of nitrates Part II: Failure to obtain immediate ECG 4. Program debugging: N/A 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: Part I e. Etiology/Presentation i. Rheumatic fever ii. Systolic ejection murmur iii. EKG criteria for LVH, demonstration of LVH strain pattern 19
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