Emergency Medicine Simulation Workbook

Broad‐spectrum intravenous antibiotics.

Intravenous fluids.

Surgical intervention, if pneumatosis is present.

Survival rates depend on disease severity:Those requiring surgical management have worse outcomes with mortality, around 35%.If treated medically, mortality is around 20%.

Allow approximately 20–30 minutes for debriefing after this scenario.

What are pertinent history and physical exam findings in a vomiting neonate/infant?

What is the differential diagnosis of bilious compared with nonbilious vomiting in neonates?

If unable to obtain peripheral IV access in an infant, what alternatives are available for fluid resuscitation?

What is the management for an infant with NEC?

1 1. Shields, T.M. and Lightdale, J.R. (2018). Vomiting in children. Pediatr. Rev. 39 (7): 342–358.

2 2. Rich, B. and Dolgin, S. (2017). Necrotizing enterocolitis. Pediatr. Rev. 38 (12): 552–559.

3 3. Burge, D. (2016). The management of bilious vomiting in the neonate. Early Hum. Dev. 102: 41–45.

4 4. Frost, B., Modi, B., Jaksic, T. et al. (2017). New medical and surgical insights into neonatal necrotizing enterocolitis. JAMA Pediatr. 171 (1): 83.

5 5. Ratnayake, K. and Kim, T.Y. (2014). Evidence‐based management of neonatal vomiting in the emergency department. Pediatr. Emerg. Med. Pract. 11 (11): 1–20.

1 Demonstrate focused history and physical examination skills (PC, MK).

2 Identify the need for blood work and imaging studies (MK).

3 Recognize signs and symptoms of sepsis (MK).

4 Initiate appropriate management of sepsis (MK, PC).

5 Demonstrate appropriate consultation for acute cholangitis (MK, ICS, P, SBP)

6 Demonstrate ability to obtain collateral history from family members, emergency medical services (EMS), and/or nursing home staff, for a patient who is unable to provide a history (ICS, P, SBP).

Obtain IV access (PC).

Administer IV fluids (30 cc/kg IV fluid bolus) (MK, PC).

Administer broad‐spectrum IV antibiotics (MK, PC).

Obtain computed tomography (CT) to evaluate for causes of acute abdominal pain and to rule out life‐threatening pathology (MK, PC).

Consult general surgery and/or gastroenterology (ICS, P, SBP).

This scenario may begin on scene at the patient's home with EMS gathering information from family, then transition to the ED.

Images (see online component for acute cholangitis, Scenario 1.2 at https://www.wiley.com/go/thoureen/simulation/workbook2e):Chest x‐ray showing no active pulmonary disease ( Figure 1.6).Radiology reading of chest x‐ray (normal) ( Figure 1.7).Head CT (static image 1‐cut) showing no intracranial abnormality ( Figure 1.8).Radiology read CT head (normal) ( Figure 1.9).Ultrasound of right upper quadrant (static image) showing biliary dilation ( Figure 1.10).Radiology read showing biliary dilation concerning for choledocholithiasis ( Figure 1.11).CT abdomen/pelvis with IV contrast (static image, 1‐cut) showing grossly dilated common bile duct ( Figure 1.12).CT read concerning for acute cholangitis ( Figure 1.13).Electrocardiogram (ECG) showing sinus tachycardia ( Figure 1.14).

Laboratory tests (see online component as above):Complete blood count ( Table 1.12).Basic metabolic panel ( Table 1.13).Liver function panel ( Table 1.14).Lipase ( Table 1.15).Lactic acid ( Table 1.16).Coagulation panel ( Table 1.17).Troponin ( Table 1.18).Type and screen ( Table 1.19).Urinalysis ( Table 1.20).Urine microscopy ( Table 1.21).

Available supplies:

Adult code cart with basic airway supplies.

Central line kit (triple lumen).

Medications:0.9% saline, LR IV bags.Pre‐labeled IV bags.IV vasopressor infusion (norepinephrine or similar).Broad‐spectrum antibiotics.Pre‐labeled syringes:Antiemetics (ondansetron, metoclopramide).Analgesic medications (morphine, fentanyl, hydromorphone).Rapid sequence intubation medications (sedative/paralytics typical to your institution).

Distractor: none

The patient is slightly confused as to the timeline of events/illness, but able to answer some questions. Occasionally moans due to abdominal pain. May have dry heaving if no antiemetics are ordered.

EMS to share information gathered from family regarding how long he has been sick, what symptoms they have noticed (significantly less energetic and interactive, slow to respond to basic questions).

ED nurse can cue the learners if needed to progress the case.

Family member (patient's adult child) available by phone.

General surgery and/or gastroenterology available for phone consultation.

Admitting physician available for phone consultation.

A 60‐year‐old man presents for gradually worsening confusion over the course of two to three days. He reports having mild diffuse abdominal pain that is most severe in the upper abdomen. Over the course of the past one to two days, pain has become worse and he has begun to have vomiting and increased confusion.

A 60‐year‐old man is brought in by EMS from home. Patient is moaning due to abdominal pain, complaining of feeling sick.

Physical exam findings that are not available on your mannequin may be offered verbally to learners if they ask (e.g. if unable to simulate icteric sclera, can verbally report the scleral exam to the learners if they specifically ask for this information).