I.

‘Shortness of Breath/PEA’
-2005 Model of the Clinical Practice of Emergency Medicine 1.1 Chest: Shortness
of Breath, critical. 3.1 Cardiopulmonary Arrest, critical. 16.2 Disorders of the
pleura, mediastinum and chest wall, tension pneumothorax, critical.
-Appendix 1: Airway Techniques, Intubation. Resuscitation, CPR. Thoracic,
thoracostomy.

II. Target Audience: Medical students, junior residents (EM/medicine)

III. Learning Objectives or Assessment Objectives

A. Primary
1. Demonstrate understanding and general management of shortness
of breath and respiratory distress (PATIENT CARE and
MEDICAL KNOWLEDGE)
2. Demonstrate understanding and management of PEA (PATIENT
CARE and MEDICAL KNOWLEDGE)
3. Perform intubation (PATIENT CARE)
4. Perform needle thoracostomy (PATIENT CARE)

B. Secondary
1. Describe the differential diagnosis for PEA (MEDICAL
KNOWLEDGE)

C. Critical actions checklist (included at end for check list use)

Obtain IV access
Provide oxygen
Place patient on monitor
Order appropriate labs and tests—Labs: CBC, chemistry panel (can
request iSTAT), Tests: EKG, CXR
Perform physical examination
Manage patient’s respiratory distress
Establish definitive airway
Recognize PEA
Treat PEA
Coordinate final disposition for patient

IV. Environment
A. Lab Set Up – Emergency Department Critical Care with necessary
equipment/supplies for airway management, needle thoracostomy

B. Manikin Set Up – METI HPS (for program attached using Standard Man
as patient), certainly would work well with ECS or SimMan.
 Moulage: None

Clothing: Wig, any other dress to make patient seem like elderly male.

C. Props:
• IV lines with mock fluid
• Oxygen mask, have nasal cannula available as well as nebulizer
• BiPAP machine/ventilator optional
• Drugs: Albuterol/atrovent, steroids (PO/IV), magnesium, induction
agents, paralytics
• Labs/Studies: Optional—can add basic labs (attached), CXR with L
sided pneumothorax, negative cardiac US picture.

D. Distractors: optional, can add wife of patient in room

V. Actors
A. Roles: Nurse, RT
B. Who may play them: Usually actors, could be other participants
C. Action Role – Nurse to assist with IV, monitor/vitals, and drug
administration. RT to assist with oxygen/nebs, BiPAP, bagging

III. 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’

VI. Debriefing Plan

A. Method of debriefing: group debriefing with video review of case/key
portion(s) optional
B. Debriefing material: see attached flowsheet and slides (powerpoint)
Student reading: for our EMMD 7500 ‘Core EM’ Medical Students, they
pre-read-- Emergency Medicine: An Approach to Clinical Problem-
Solving
Glenn C. Hamilton, Arthur B. Sanders, Gary Strange, Alexander T. Trott.
Chapter 3: Cardiopulmonary cerebral resuscitation

VII. Pilot Testing and Revisions

A. Numbers of participants: Usually a student case with 4-6 participants.
For larger groups we have had 4-6 participants performing the case with 4-
6 participants watching the live feed of the case.
B. Anticipated management mistakes: Waiting for a prolonged time for
either the electrolyte panel and/or the CXR, not recognizing PEA
C. Evaluation form for participants: standard center post-course feedback
form.
D. Simulation failure: Breath sounds seeming equal throughout the case
despite changes to make a PTX and tension PTX on the HPS software.
VIII. Authors and their affiliations:

Cullen B. Hegarty, M.D., FACEP.

Assistant Residency Director
Director of Medical Simulation
Director of Medical Student Education
Department of Emergency Medicine
Regions Hospital, St. Paul, MN
Assistant Professor of Emergency Medicine
University of Minnesota
Cullen.B.Hegarty@healthpartners.com

Jessie Nelson, M.D.

Physician Faculty
HealthPartners Simulation Center for Patient Safety at Metropolitan State
University
Senior Staff Physician
Department of Emergency Medicine
Regions Hospital, St. Paul, MN
Assistant Professor of Emergency Medicine
University of Minnesota
Jessie.G.Nelson@healthpartners.com
IV. 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

(see final attachment, METI program coding for more details about case program)
Critical Actions Checklist

Obtain IV access
Provide oxygen
Place patient on monitor
Order appropriate labs and tests—
Labs: CBC, chemistry panel (can
request iSTAT), Tests: EKG, CXR
Perform physical examination
Manage patient’s respiratory
distress
Establish definitive airway
Recognize PEA
Treat PEA
Coordinate final disposition for
patient
09/14/2007 Rurual Hospital AUT O RES ULT

LOC: ER Age:70 Sex:M

Name: Bradley Quaderson

IX. X69955 COLL: 09/14/2007 07:00 REC: 09/14/2007 07:05

He m o gra m + Platelets
WBC 12.5
HGB 11.1
PLTS 355

Basic M etabolic Panel

BU N 45
Sodiu m 140
Potassiu m 5.3
Chloride 102
CO2 22
Glucose 125
Creatinine 4.5
Calciu m 8.9
Simulation Workshop Case
SOB, PEA, Acute Resuscitation

Debriefing guidelines:

1. How did the scenario feel?

2. What did you do right?

3. What would you do differently in the future?

4. Briefly describe the ideal management of this patient.

5. Review the basics of Medical resuscitation:

a. Systematic approach
b. ABCs within primary survey, stop ONLY for management of
airway, breathing, or circulation.
c. Secondary survey, including IV start, appropriate drugs.
d. Reassess after every intervention.
6. Discuss respiratory failure.

7. Review procedure needle decompression and thorocotomy.

8. Review PEA algorithm.

METI Case program information:

-- HPS: STATE: Baseline

-- HPS: EVENTS: BEGIN_GENERATED_CODE
-- HPS: EVENTS: END_GENERATED_CODE
-- HPS: TRANSITIONS: BEGIN_GENERATED_CODE
-- HPS: TRANSITIONS: END_GENERATED_CODE

-- HPS: STATE: ED_Presentation

-- HPS: EVENTS: BEGIN_GENERATED_CODE
-- HPS: EVENT: SET: HR_FACTOR = 1.25 ... 0
-- HPS: EVENT: SET: SF = 0.5 ... 0
-- HPS: EVENT: SET: ITOE_RATIO = 3 ... 0
-- HPS: EVENT: SET: PNEUMO_ENABLE = 1 ... 0
-- HPS: EVENT: SET: LEFT_IPL_VOL = 500 ... 0
-- HPS: EVENT: SET: RR_FACTOR = 1.4 ... 0
-- HPS: EVENT: SET: ISCHEMIC_INDEX_SENS = 0.1 ... 0
-- HPS: EVENT: SET: BR_SOUND = 21 ... 0
-- HPS: EVENTS: END_GENERATED_CODE
-- HPS: TRANSITIONS: BEGIN_GENERATED_CODE
-- HPS: TRANSITIONS: END_GENERATED_CODE

-- HPS: STATE: Worsening_Status

-- HPS: EVENTS: BEGIN_GENERATED_CODE
-- HPS: EVENT: SET: LEFT_IPL_VOL = 1000 ... 0
-- HPS: EVENT: SET: RHYTHM_OVERRIDE = 9 ... 0
-- HPS: EVENT: SET: USER_BLINK_MODE = 0 ... 0
-- HPS: EVENTS: END_GENERATED_CODE
-- HPS: TRANSITIONS: BEGIN_GENERATED_CODE
-- HPS: TRANSITIONS: END_GENERATED_CODE

-- HPS: STATE: Tension_PTX

-- HPS: EVENTS: BEGIN_GENERATED_CODE
-- HPS: EVENT: SET: LEFT_IPL_VOL = 3000 ... 0
-- HPS: EVENTS: END_GENERATED_CODE
-- HPS: TRANSITIONS: BEGIN_GENERATED_CODE
-- HPS: TRANSITION: IF: STATE_TIME >= 10 GOTO: PEA-Tension_PTX
-- HPS: TRANSITIONS: END_GENERATED_CODE

-- HPS: STATE: PEA-Tension_PTX

-- HPS: EVENTS: BEGIN_GENERATED_CODE
-- HPS: EVENT: SET: LEFT_LUNG_COM_FACTOR = 0.15 ... 0
-- HPS: EVENT: SET: RHYTHM_OVERRIDE = 14 ... 0
-- HPS: EVENTS: END_GENERATED_CODE
-- HPS: TRANSITIONS: BEGIN_GENERATED_CODE
-- HPS: TRANSITION: IF: LEFT_IPL_VOL <= 2980 GOTO: Needle_Decompression
-- HPS: TRANSITIONS: END_GENERATED_CODE

-- HPS: STATE: Needle_Decompression

-- HPS: EVENTS: BEGIN_GENERATED_CODE
-- HPS: EVENT: SET: RHYTHM_OVERRIDE = 0 ... 0
-- HPS: EVENT: SET: ITOE_RATIO = 2 ... 0
-- HPS: EVENT: SET: RR_FACTOR = 1 ... 0
-- HPS: EVENT: SET: HR_FACTOR = 0.8 ... 0
-- HPS: EVENT: SET: SF = 0.1 ... 0
-- HPS: EVENT: SET: LEFT_LUNG_COM_FACTOR = 1 ... 0
-- HPS: EVENT: SET: LEFT_IPL_VOL = 0 ... 0
-- HPS: EVENTS: END_GENERATED_CODE
-- HPS: TRANSITIONS: BEGIN_GENERATED_CODE
-- HPS: TRANSITION: IF: EPINEPHRINE >= .0001 GOTO: Stabilized
-- HPS: TRANSITIONS: END_GENERATED_CODE

-- HPS: STATE: Stabilized

-- HPS: EVENTS: BEGIN_GENERATED_CODE
-- HPS: EVENT: SET: HR_FACTOR = 0.5 ... 0
-- HPS: EVENT: SET: PACKED_RED_BLOOD_CELL_INFUSION = 400 ... 0
-- HPS: EVENT: BOLUS: NITROGLYCERINE = 200 mcg
-- HPS: EVENTS: END_GENERATED_CODE
-- HPS: TRANSITIONS: BEGIN_GENERATED_CODE
-- HPS: TRANSITIONS: END_GENERATED_CODE