Prática de Shadowing: Inside a Tox Resuscitation - Hyperthermia & Seizures [Medical Simulation] - Aprenda a falar inglês com vídeo

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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

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and you see some clonus there as well inducible

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

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

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I'll get the social worker too.

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Can I walk you up there quickly?

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You notice that her skin is quite hot.

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And she's sweaty.

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Okay.

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

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

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Okay.

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

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

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

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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.

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What did you find on primary?

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

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She also has colonists bilaterally in her lower extremities.

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She's hyperreflexic.

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

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Okay.

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Okay.

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

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

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

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

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

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malignant hyperthermia, serotonin syndrome, meningitis and sepsis,

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anticholinergic syndrome, thyroid storm, sympathomimetics and salicylates.

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

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I think we should send off a full tox panel.

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

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Okay, so the patient's hot.

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

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so why don't we just start missing the patient

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

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

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

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

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

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that okay and let me know when three minutes has elapsed

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

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You do have air entry.

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She's got good chest rise.

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I've got good air entry bilaterally.

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Does she sound clear to both lungs as well?

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Yes, both lungs are clear.

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Sorry, ma 'am.

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

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It's been one minute.

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Is she still actively seizing?

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She's still actively seizure.

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

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In two minutes.

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Yeah, just get that prepped and ready.

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That's rough for now.

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You can let me know in two minutes.

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We'll do.

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

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So I'm concerned that she has status epilepticus.

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

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

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

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Okay, we'll do that.

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Excellent.

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Excellent.

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

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Sure.

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What medications do you want for the patient?

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So given that the patient is in status epilepticus,

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

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

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if she has neuroleptic malignant syndrome

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

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

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but yeah why don't we drop propofol 150 milligrams

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

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Okay let's do four milligrams IV Ativan.

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Just let me know when that's done.

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Dave or Moses?

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Yeah.

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Dave's gonna get that.

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Can you remind me of the...

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

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I can take the airway.

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150 of all.

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The patient's still seizing.

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

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

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Yep.

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

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Perfect.

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

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Is that a three?

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We think

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that this is most likely due to serotonin syndrome

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

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with the agitation confusion and the inducible myoclonus as well

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

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and just ask them for advice like particularly

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

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

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Okay.

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Okay.

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Well, we should definitely proceed with intubation as well.

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Intubation meds are proof.

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Okay.

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Did we already give Keppra two grams IV as well?

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We have not.

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No. It's coming from the pharmacy.

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It's coming from pharmacy.

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Okay.

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

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Okay.

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Okay.

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So let me know when you guys are prepped

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

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

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Okay.

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7 .5 tubes.

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Fantastic.

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Sats are still 90.

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

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

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Mm -hmm.

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

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