In Situ ED & ITU Simulation - Betablocker (and Co-codamol) overdose

Learning Objectives

Learning objectives - Non clinical

• Inter-departmental and interdisciplinary (medical/nursing) teamwork
• Leadership and task allocation
• Effective communication and recognition of demands on nursing team/recognition when extra nursing staff may be useful

Learning objectives - Clinical (Medical)

• Initial Assessment of the unwell overdose and initial management/supportive care
• Utilisation of paramedic history/collecting packets in overdose to gain clues re: extent/composition of overdose
• Recognition of Toxidromes
• Specific Management of Beta-blocker (and opiate overdose)
• Utilisation of High-dose Insulin therapy

Learning objectives - Clinical (Nursing)

• Drawing up and administration of Naloxone, adrenaline and High dose insulin therapy
• Task prioritisation and allocation
• Communication when demands on nursing team outweigh physical capability (multiple requests for multiple medications/infusions to be prepared concurrently)

Faculty: Alex Belcher, Ben Short, Joe Schrieber, Tom Talbot

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RCEM Curriculum Coverage Topics (SLOs)

SLO 3 – Identify sick adult patients, be able to resuscitate and stabilise and know when it is appropriate to stop

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FICM Curriculum Coverage Topics (HiLLOs)

HiLLO 5 - Doctors specialising in Intensive Care Medicine can identify, resuscitate and stabilise a critically ill patient, as well as undertake their safe intra-hospital or inter-hospital transfer to an appropriately staffed and equipped facility.

HiLLO 6 - Intensive Care Medicine specialists will have the knowledge and skills to initiate, request and interpret appropriate investigations and advanced monitoring techniques, to aid the diagnosis and management of patients with organ systems failure. They will be able to provide and manage the subsequent advanced organ system support therapies. This will include both pharmacological and mechanical interventions.

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The Case

50yo presented following significant beta blocker and co-codamol OD. Initially ok with ambulance crew then became more unwell en-route so only 2 minute pre-alert. Reduced GCS, hypoventilation and hypotensive on presentation. Initially managed by ED – simple airway adjuncts, fluids and Naloxone given. Some improvement with ventilation after Naloxone but remains hypotensive and bradycardic. Also requires management of hypoglycaemia.

ITU called at some point during presentation. Toxbase reviewed and discussion around high dose insulin and glucagon therapies. Discussion around intubation as patient not managing airway safely and appropriate drugs to use.

Take Home Points

• Verbal orders – These should be the exception rather than the rule. There is often time to document prescriptions, and this reduces potential for error
• Multiple vial safe check – If multiple vials are required (i.e glucagon dose/naloxone infusion), double check that the prescription/intended amount is correct.
• High Dose Insulin Infusion Protocol (link in ICU guideline page to local policy and in Toxbase to national guidance)
• Consider Utilisation of a scribe when multiple medications required

Latent Threats identified

• No easily identifiable Insulin Policy direct from ED
• Prompt card to be created and link to be made on the ED guideline page and to local (ICU) policy

Some comments from participant feedback:

• 6 x feedback forms completed, mix of medical and nursing staff.
• Ratings varied from 8/10 – 10/10 for usefulness of the session to their training and development.
• Importance of handover when further team members later in scenario/patient journey
• Utility of double checking when unsure (and utilising others for this)
• Reminder to consider demands on nursing team
• Helpful for finding easy access to information that need to be available ‘now’.
• “This was excellent, and one of the best learning opportunities afforded so far”

Suggested improvements from participants:

• Nil specific to future simulations (except request for more/frequent simulations)

Faculty Debrief:

• Session went well, good mix of ED Learners, limited representation from ICU due to operational demand, positive feedback in general.
• Encourage ICU/all staff to remain for debrief where possible
• Good mix of both nursing and medical team as well as observers.
• Good effective in-situ brief – for future clarity regarding who’s clinically involved / who’s observing. Short term plan is to utilised plastic apron for those clinically involved to differentiate. Stickers to be ultimately utilised to indicate involvement.
• Perhaps shouldn’t make TOXBASE printout immediately available to allow real-time process of gaining access to TOXBASE

Future sessions:

• Planned next simulation on 23/12/21
• Aim for minimum 2 consultant faculty +/- sim/resus fellow involvement.
• Trauma focus for next simulation, with Paediatric one planned for the new year
• Faculty to take turns in designing the scenario and writing up the session report.
• Aim to keep things in house between ED/ITU currently but possibly as things develop look at involving other specialities, e.g., hospital trauma team.