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Case Report/Stimulation Scenario

Shock in a Pediatric Patient: An Electrical Diagnosis

Cheng, Adam MD, FRCPC, FAAP

Author Information
Simulation In Healthcare: The Journal of the Society for Simulation in Healthcare: December 2007 - Volume 2 - Issue 4 - p 235-240
doi: 10.1097/SIH.0b013e318150c8e5
  • Patient File Name: Standard Child
  • Scenario Name: Purulent Pericardial Effusion With Cardiac Tamponade
  • Simulation Developer: Adam Cheng, MD
  • Simulator: Meti Pediasim Hps
  • Date of Development: July 2006

SOURCE FOR CONTENT

Clinical case encountered in a pediatric emergency room. Peer reviewed and revised by pediatric cardiology and pediatric intensive care specialists.

APPROPRIATE FOR THE FOLLOWING LEARNING GROUPS

Pediatric and emergency medicine residents (postgraduate years 1–4), pediatric emergency medicine and pediatric critical care/transport fellows, pediatric nursing staff, pediatric respiratory therapists, advanced level paramedics (EMT-P). This scenario has been run eight times with multidisciplinary groups of learners comprised of physicians, nursing staff, and respiratory therapists.

CURRICULAR INFORMATION

Educational Rationale

Pediatric shock has a broad differential diagnosis. One of the rarer causes of shock in the pediatric patient is cardiac tamponade caused by a purulent pericardial effusion. Diagnosis of tamponade can be difficult, especially because it is so infrequently encountered in the pediatric population. Management of this condition can be tricky, and early intubation can often lead to patient deterioration if medical personnel are not aware of the risks associated with cardiac tamponade.1–3 This scenario provides learners the opportunity to diagnose and manage this challenging medical problem. We hope it will raise their awareness of the issues that may arise when dealing with cardiac tamponade, thus leading to improved patient management and ultimately, better patient outcome.

Learning Objectives

Accreditation Council for Graduate Medical Education General Competencies:

  1. Medical knowledge
  2. Patient care
  3. Practice-based learning and environment
  4. Interpersonal and communication skills
  5. Professionalism
  6. Systems-based Practice
  • (1) Discuss the differential diagnosis of shock
  • (1) Describe the initial management of shock in a pediatric patient
  • (1) Identify the clinical and radiographic features of cardiac tamponade
  • (1) Describe the management of cardiac tamponade
  • (1) Discuss the potential complications associated with intubating a patient with cardiac tamponade
  • (2) Recognize the importance of early identification and proper management of this potentially fatal condition
  • (3) Describe how to perform needle pericardiocentesis in a pediatric patient
  • (4) Demonstrate proper teamwork and communications skills during a resuscitation

Guided Study Questions

  • What is the differential diagnosis of shock?
  • How is shock managed in the emergency department?
  • How would the patient's past medical history and underlying illnesses influence your initial categorization and assessment of his/her condition?
  • What are the clinical and radiographic features of cardiac tamponade, and how is this condition managed?
  • What options for medications do you have when considering rapid sequence intubation of a patient in decompensated shock?
  • What are the indications for and how would you perform a needle pericardiocentesis?

Didactics

None.

Assessment Instruments

None.

PREPARATION

Personnel Required:

  • Simulator Operator/Technician/Jockey
  • Simulation instructor
  • Actor: playing the role of the mother
  • Learning group of 3–4 students

Monitors Required:

  • Noninvasive blood pressure cuff
  • Three-lead cardiac monitor
  • Pulse oximeter
  • Capnograph
  • Temperature probe

Other Equipment Required:

  • Simple oxygen mask
  • Bag and mask for ventilation
  • Endotracheal tube and stylet
  • Laryngoscope
  • IV needles
  • IV line and bag
  • Labeled syringes
  • Appropriate medications
  • Pericardiocentesis kit/tray

Supporting Files:

  • Chest radiograph with enlarged heart (Fig. 1).
  • Figure 1.
    Figure 1.:
    Chest radiograph with enlarged heart.
  • Twelve-lead EKG demonstrating ST-segment elevation (Fig. 2).
  • Figure 2.
    Figure 2.:
    Twelve-lead EKG demonstrating ST-segment elevation.
  • Rhythm strip demonstrating electrical alternans (Fig. 3).
  • Figure 3.
    Figure 3.:
    Rhythm strip demonstrating electrical alternans.
  • Echocardiography still photo demonstrating massive pericardial effusion (Fig. 4).
  • Figure 4.
    Figure 4.:
    Echocardiography still photo demonstrating massive pericardial effusion.

Time Duration

  • Setup: 5 minutes
  • Preparation: 2 minutes
  • Simulation: 15 minutes (Tables 1 and 2)
  • Table 1
    Table 1:
    Scenario States and Teaching Points
    Table 1
    Table 1:
    (Continued)
    Table 2
    Table 2:
    Case Simulation Parameters for METI HPS
  • Debrief: 20 minutes

CASE STEM

You are an attending physician in a busy emergency department. A 7-year-old boy is brought into the resuscitation room by the triage nurse who is concerned about his appearance. The child is accompanied to hospital by his mother. You have been called in to the room to manage this child.

Your patient is a previously healthy child who weighs 25 kg. He has been brought in to hospital by ambulance, and appears quiet and motionless on the stretcher. You notice that the paramedics have applied cardiac monitors and oxygen by simple face mask. The patient has no IV access.

FACILITATOR/COORDINATOR'S BACKGROUND AND BRIEFING INFORMATION

A member of the simulation staff plays the role of the mother. He/she calls in the resident to help. He/she tells the resident the history as above, and expresses his/her concern about the patient's appearance. Additional background information is given when requested by learners.

PATIENT DATA BACKGROUND AND BASELINE STATE

History of Present Illness

The child has had a 1-day history of fever, decreased appetite, and a fluctuating level of consciousness. He has been dozing off to sleep today after being awake for only several minutes at a time. He has not had anything to eat in the past 2 days. He has urinated only once in the last 24 hours. There is no history of vomiting, diarrhea, or cough.

Past Medical History

He is a previously healthy child. He was born at term by spontaneous vaginal delivery with no complications. There is no history of any septic risk factors during pregnancy. There are no prior hospitalizations. The child has no known drug allergies. He is not taking any medications. Immunizations are up to date.

Social History

The patient is the only child to a 35-year-old mother who works as an accountant, and a 42-year-old father who is an investment banker. They live together at home and there are no financial strains on the family. The child attends grade school and is a high achiever. He has many friends, and competes in a soccer league 2 nights a week.

Review of Systems

  • CNS: no headache or stiff neck
  • Cardiovascular: no chest pain or palpitations
  • Pulmonary: no shortness of breath
  • Renal/hepatic: no jaundice, hematuria or dysuria
  • Heme: no bruising or rash

Physical Examination

On physical examination, the child looks unwell and mot tled. Weight is 25 kg. His temperature is 38.6°C, heart rate is 150 beats/min, respiratory rate is 40 breaths/min, blood pressure is 80/40 mm Hg and oxygen saturation is 86% in room air. He requires 10 L of oxygen to maintain his oxygen saturation above 95%. He is sleepy but will open his eyes occasionally and respond to commands. Heart sounds are normal, capillary refill is 3 seconds and femoral pulses are weak. His lungs are clear and there is no sign of respiratory distress. His abdomen is not tender and the liver is palpable 5 cm below the right costal margin. The remainder of the physical findings are normal.

REFERENCES

1. Cakir O, Gurkan F, Erasian Balci A, et al.: Purulent pericarditis in childhood: Ten years of experience. J Pediatr Surg 2002;37:1404–1408.
2. Roodpeyma S, Sadeghian N: Acute pericarditis in childhood: A 10 year experience. Pediatr Cardiol 2000;21:363–367.
3. Dupuis C, Gronnier P, Kachaner J, et al.: Bacterial pericarditis in infancy and childhood. Am J Cardiol 1994;74:807–809.
© 2007 Society for Simulation in Healthcare