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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 If diuretics, nitroglycerin, morphine, or B-blocker given, patient complains of lightheadedness: HR BP Temperature ( o C) O 2 Sats (RA) RR 120 80/50 37.5 o 90% 18 If pressor agent given (except if phenylephrine by itself), blood pressure increases and patient improves: HR BP Temperature ( o C) O 2 Sats (RA) RR 110 110/64 37.5 o 94% 16 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 and lead them towards imaging and laboratory studies necessary to confirm diagnosis. B. Scenario programming 1. Optimal management path: O 2 /IV/monitor History and physical examination Immediate aspirin Appropriate lab workup: CBC, BMP, cardiac markers, coagulation profile Appropriate imaging: stat portable CXR, ECG within 10 minutes Recognize shock and administer pressor agent (e.g. Dopamine) Administer anticoagulation medication (e.g. Heparin) Consult cardiology and request to activate catheterization lab 2. Potential complications/errors path(s): Failure to administer O 2 Administering over 500 CC’s IV fluid Administering large dose of Nitroglycerin, B-blocker, Morphine 3. Program debugging: N/A VII. 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. Shock pathophysiology i. Define shock: Perfusion insufficient to meet metabolic demand (often noted by low blood pressure < 90, MAP < 65, or other markers e.g. lactic acid) ii. Blood pressure is factor of heart rate, stroke volume, systemic vascular resistance. 28
Gilbert Program in Medical Simulation Simulation Casebook Harvard Medical School Draft of the 1 st edition (2011), updated 3/2/12 Drugs b. Different types of shock i. Volume problem: Hypovolemic (eg, - Hemorrhagic) ii. Pump problem: Cardiogenic iii. Other problem: Septic, Neurogenic, Anaphylactic c. Cardiogenic shock: presentation and etiology d. Treatment Can just focus on cardiogenic shock, but also may want to compare to treatment of other types of shock, such as septic shock written below i. Septic shock: infection/systemic inflammatory response leading to decreased vascular tone and capillary leakage leading to depleted intravascular volume 1. Fill ‘tank’- add volume until MAP >65 or tank full [CVP 8- 12] 2. If tank adequately filled [CVP] but not enough to maintain blood pressure, increase tone with pressors 3. Source control: identify causative agent and treat early ii. Cardiogenic shock: Pump problem. CO = SV x HR 1. Increase CO [remember that HR and SV are related factors] 2. Address underlying cause of pump failure (e.g. STEMI reperfusion/cath) 3. Medications: Receptors Alpha (1) Beta 1 Beta 2 Vasoconstriction “pressors” Contractility/HR, vaso/bronchodilation “ino-/chrono-tropes” Epinephrine ++++ ++++ ++ Norepi/Levophed ++++ ++ 0 Phenylephrine/Neo ++++ 0 0 Dobutamine* 0 ++++ ++ Dopamine ALL, in dose dependent fashion B2, B1, then Alpha as dose increases *Not technically a “pressor” as it lacks Alpha-1 properties ***NOTE: Teaching points in addition to shock can include EKG reading and treatment for ACS VIII. Development and Deployment This case was developed for a widely subscribed fourth year medical school elective (emergency medicine/transition to internship), and has been used over several years as part of an instructional module on the physiology and management of shock. 29
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