Pratica di Shadowing: Inside a Tox Resuscitation - Hyperthermia & Seizures [Medical Simulation] - Impara a parlare inglese con i video

Scegli una modalità di pratica

Ogni modalità apre una sala di pratica a schermo intero.

653 frasi

Se le frasi sono troppo corte o troppo lunghe, clicca su Edit per modificarle.

Jeff, we got a rectal temperature of 41 degrees Celsius.

Okay, so the patient's hot.

I think that this is most likely due to a toxicologic cause, so we should start cooling the patient as soon as possible.

So why don't we just start missing the patient and turning on the fans?

You want pads on?

I notice they're quite tachycardic.

Yes, we should.

So let's just quickly review the vital signs.

The patient is now having a seizure.

Seizing.

Okay, patient's seizing.

I have Ativan here.

Yeah, so let's give Ativan 2 milligrams IV.

Hi, I'm Dr. Jeff Yu, a board -certified emergency physician in both the USA and Canada,

and this video demonstrates a simulated resuscitation of a young patient presenting with status epilepticus and severe hypothermia.

This scenario was inspired by a series of real patients treated at our hospital over the past couple of years, many of whom had tragic outcomes.

And this simulation is performed by me and my real emergency department colleagues,

including nurses, respiratory therapists, and emergency physicians that I work with in real life.

The case is run in real time, in a single take, and it's completely unscripted.

Nothing has been removed for the sake of brevity, and because of that, mistakes are expected, and they're valuable learning opportunities.

The purpose of simulation is to improve together as a team

so that when we encounter a critically ill patient in real life,

we're prepared to perform at our very best and give that patient the greatest possible chance of survival.

Simulation is designed to replicate the real -world stress of managing critically ill and dying patients,

which can be really intense and triggering for both participants and viewers.

So after the simulation, stay around for the debriefing session, which is often the most important part of the learning process.

Let's begin.

So your team is in an emergency department in an urban center,

and you've been notified about a female patient in her 20s who's going to arrive in about five minutes.

Paramedics called for a pre -arrival.

She was found confused outside of a rave tonight and reportedly used some substances.

She was complaining of being hot when the paramedics arrived and shortly afterwards she had a generalized seizure.

The paramedics gave her five milligrams of IM midazolam.

Post seizure she was postictal.

Her GSCS is eight.

She's not intubated.

She's got IV access and her ETA is about five minutes.

Okay, great.

So since we have a couple minutes before the patient arrives, let's just quickly do a round of introductions with roles.

So I'm Jeff Yu.

I'm going to be the team leader for this case.

I'm Scott, one of the residents here at St. Paul's.

I'll be the second physician on.

I'm Reed.

I'm a respiratory therapist.

Moses, I'll be the monitor nurse.

Dave, I'll be the bedside owner.

I'm Anna.

I'll be the nurse lead.

Okay, great.

So I think we have everything here.

So it sounds like the patient might have seized.

It sounds like she's hot, a little bit confused.

So I'm really concerned that the patient might be coming in with a toxicologic seizure hot and bothered.

So the priorities when she arrives is to get her hooked up to the monitors, get two large bore IVs as soon as possible.

We might need to give her some cooled IV fluids as well.

We'll get her hooked up to, yeah, monitors get a full set of vital signs, including a core temperature and glucose

and we'll send off a full tox panel as well so

if we could send off like acetaminophen levels salicylate levels ethanol levels along with rapid metabolic panels

so that we're getting that back as quickly as possible

and then scott when the patient arrives maybe you can just start with a primary survey

while i get collateral history from the paramedics

and we'll go from there is everyone clear does anyone have any questions

or suggestions before the patient arrives do you want any medications prepped ahead of time?

Yeah, that's a good point.

Why don't we get lorazepam prepped ahead of time in case we have to abort any seizures?

And in case the patient does need to be intubated,

we can get propofol and maybe get succinylcholine and rocuronium prepared just so that we can choose between the two,

but we can discuss that when the patient arrives okay

so we'll get ativan um

and the intubation medication is ready to go yeah exactly great any other questions

or suggestions before the patient arrives no great okay

so we'll just glove up get ready and uh okay

so it looks like the patient's rolling in now

and they're coming in with a friend who can provide some collateral history great

hello hi are you uh what's your relationship to the person um she's my friend okay yeah tell me What happened?

We were at a rave and we just took some MDMA and I think some cocaine.

And she just left somewhere and she came back unconscious.

Okay.

Does she have any past medical conditions that I should be aware of?

She has anxiety.

Ma 'am?

Ma 'am, my name is Dr. Bell.

Can you tell me your name?

There's no verbal response, just a bit of moaning.

There is some rigidity in the jaw a little bit.

I'm looking in the airway.

I'm listening to both lungs and the heart.

You're hearing breath sounds present on both sides and the heart sounds are normal, but she's very tachycardic.

Okay.

I'm checking her cap refill.

A bit delayed.

Okay.

I'm going to quickly check her eyes.

What are her pupils?

Is there any movements? quite dilated and you notice

that there there's clonus as well okay heart rate is 160 is she moving all four limbs

she is moving all of her extremities yeah you notice

that she's hyper reflexic when you check her reflexes

100

and you see some clonus there as well inducible

101

and the feet blood pressure 168 it sounds like she's quite sick right now so we're gonna do some investigations and start

102

But you know, why don't you have a seat in the waiting room?

103

I'll get the social worker too.

104

Can I walk you up there quickly?

105

You notice that her skin is quite hot.

106

And she's sweaty.

107

Okay.

108

So, can we just regroup as a team and we'll just,

109

I'll quickly summarize what I got from collateral and then you can summarize what you have from primary survey.

110

Okay.

111

So the patient's friend tells me that they were at the club, they used some MDMA and cocaine.

112

Sounds like she's been taking tramadol for a recent dental surgery and she's on,

113

I believe, citalopram or some kind of other antidepressant or anti -anxiety medication.

114

And it sounds like she went outside for a bit, possibly used some drugs and then had felt really hot and might have had a seizure.

115

What did you find on primary?

116

So she's hot, she's diaphoretic, she's got dilated pupils with ocular colonists.

117

She also has colonists bilaterally in her lower extremities.

118

She's hyperreflexic.

119

Vitally, she's tachycardic and she's on a few liters of oxygen, maintaining her saturations at 94%.

120

Okay.

121

Okay.

122

Okay, so guys, I'm really concerned that this patient might have toxicologic seizures.

123

You said that she felt hot to be, you said we got a temp on her?

124

Yeah, oh yeah, we're going to get a temp for now.

125

Okay, let's get a temp and a glucose as well.

126

But the things that I'm concerned about are neuroleptic malignant syndrome,

127

malignant hyperthermia, serotonin syndrome, meningitis and sepsis,

128

anticholinergic syndrome, thyroid storm, sympathomimetics and salicylates.

129

So these are all the things that we need to be considering right now.

130

I think we should send off a full tox panel.

131

Yeah, Jeff, we had a rectal temperature of 41 degrees Celsius.

132

Okay, so the patient's hot.

133

I think that this is most likely due to a toxicologic cause, so we should start cooling the patient as soon as possible

134

so why don't we just start missing the patient

135

and turning on fans you want pads on i know they're quite tachycardic yes we should

136

so let's just quickly review the vital science patient patient is now having a seizure okay okay she's seizing

137

i have ativan here yeah so let's give ativan two milligrams iv patient as tachycardic

138

and a bit hypoxic as well so yeah read you can just assist for ventilations and Anna

139

if you could just let me know how long the patients been seizing for just keep track of

140

that okay and let me know when three minutes has elapsed

141

and we'll give another day at a van two milligrams given okay okay excellent so patients oxen saturations are

142

You do have air entry.

143

She's got good chest rise.

144

I've got good air entry bilaterally.

145

Does she sound clear to both lungs as well?

146

Yes, both lungs are clear.

147

Sorry, ma 'am.

148

We're gonna need to take your clothes off so we can cool you down, okay?

149

It's been one minute.

150

Is she still actively seizing?

151

She's still actively seizure.

152

Okay, let's just prep Adavan 4 milligrams IV so that we can give that to her if...

153

In two minutes.

154

Yeah, just get that prepped and ready.

155

That's rough for now.

156

You can let me know in two minutes.

157

We'll do.

158

So the patient hasn't returned to her mental baseline between her first seizure en route to hospital and this one.

159

So I'm concerned that she has status epilepticus.

160

So we're currently in the status algorithm as well.

161

So we'll give, if she's still seizing in a couple of minutes, we'll give another dose of Ativan.

162

We should also call pharmacy and ask them to send up a Keppra 2 grams IV.

163

Okay, we'll do that.

164

Excellent.

165

Excellent.

166

Can we also, Dave, do you mind just grabbing some medications for intubation as well?

167

Sure.

168

What medications do you want for the patient?

169

So given that the patient is in status epilepticus,

170

I think that we should probably give propofol as the induction medication because that will cause birth suppression of the seizures.

171

And I think for the paralytic medication, because we don't know if this patient's in ribbomyelitis we don't know

172

if she has neuroleptic malignant syndrome

173

or malignant hyperthermia we probably should not use succinylcholine even though I think

174

we should probably use rocuronium even though there is a risk of possible subclinical seizures with the rocuronium

175

but yeah why don't we drop propofol 150 milligrams

176

and rocuronium 150 milligrams as well okay so it's been three minutes we can give four milligrams of IV Ativan.

177

Okay let's do four milligrams IV Ativan.

178

Just let me know when that's done.

179

Dave or Moses?

180

Yeah.

181

Dave's gonna get that.

182

Can you remind me of the...

183

Now for prepping the intubase, do you mind taking the airway?

184

I can take the airway.

185

150 of all.

186

The patient's still seizing.

187

Four milligrams IV Ativan administer is still seizing so we should definitely prep for intubation.

188

Scott if you want to just work with Reed and just get all the equipment ready.

189

Yep.

190

I'll just quickly summarize the case while we're we're getting prepared.

191

Perfect.

192

So we both have status epilepticus and we're in kind of like the active cooling hyperthermia algorithm.

193

Is that a three?

194

We think

195

that this is most likely due to serotonin syndrome

196

she does meet a lot of hunter criteria for serotonin syndrome with the octaloclonus

197

with the agitation confusion and the inducible myoclonus as well

198

so can we also call the tox uh the poison control center

199

and just ask them for advice like particularly

200

if you could just call them to ask if we should be giving cypher heptidine that'd be great.

201

So the seizure has aborted, but she's still very uptended.

202

Okay.

203

Okay.

204

Well, we should definitely proceed with intubation as well.

205

Intubation meds are proof.

206

Okay.

207

Did we already give Keppra two grams IV as well?

208

We have not.

209

No. It's coming from the pharmacy.

210

It's coming from pharmacy.

211

Okay.

212

If you could just let me know when Keppra arrives, that'd be great.

213

Okay.

214

Okay.

215

So let me know when you guys are prepped

216

and ready to go we'll do a quick pre -intivation pause to discuss the plan.

217

Get your boozy and your LMA, or IGEL as backup.

218

Okay.

219

7 .5 tubes.

220

Fantastic.

221

Sats are still 90.

222

Let's see if I can bag her up just a little bit for those saturations.

223

Yeah, it's weird that her O2 sats haven't come up at all.

224

Mm -hmm.

225

Okay, so her sats are kind of you're you're begging her she's got good air

226