In Situ ED & ITU Simulation - House fire with severe burns, cyanide & carbon monoxide poisoning

Learning Objectives

Learning objectives - Non clinical

• Inter-departmental teamwork
• Leadership and role allocation / delegation
• Time critical decision making  
• Prebrief / zero-point survey
• Multi-disciplinary communication

Learning objectives - Clinical (Medical)

• Identification of potential airway problem
• Planning for an RSI
• Safe RSI
• Aftercare
• Management of CO/HCN poisoning
• Burns management

Learning objectives - Clinical (Nursing)

• Identification of potential airway problem
• Planning for an RSI
• Safe RSI
• Aftercare
• Management of CO/HCN poisoning
• Burns management

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Faculty - Alex Belcher, Matt Sawyer, Millie ACCP & Ben Atkinson

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RCEM Curriculum Coverage Topics (SLOs)

SLO 2 - Support the ED team by answering clinical questions and making safe decisions

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

SLO 6 – Proficiently deliver key procedural skills needed in Emergency Medicine

SLO 7 - Deal with complex and challenging situations in the workplace

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

• 33 year old male
• Left phone charging on a sofa
• Sofa caught fire. Tried to put out flames himself
• Suffered smoke inhalation, anterior chest and forearm burns as well as inhalation poisoning with Cyanide and Carbon Monoxide from the burning furniture
• Left house via front door, overwhelmed with smoke.
• Brought to ED by paramedic crew
• Hoarse voice en route, becoming stridulous
• One episode of vomiting and mild confusion

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ATMIST handover on phone

• A - 33 year old male
• T - 30 minutes ago
• M - House fire
• I - Smoke inhalation, airway burns, vomiting, confusion. Burns to airway, anterior chest/arms
• S - Hoarse voice, RR 28, SpO2 98% on 15L, HR 120, BP 110/60, T 36.2, BM 6.3
• T - O2 via NRB, IV cannula & 1g IV Paracetamol / 10mg Morphine

5 minute ETA

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Team leader performed Zero Point survey

• Vital to prepare your self, team and environement before your patient arrives
• Useful tool to use as a cognitive aid when preparing under stressful circumstances to minimise cognitive error
• Original article describing the Zero Point Survey can be accessed here

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Importance of a rigorous RSI checklist to avoid error

• 1st intubator
• 2nd operator / airway assistant
• 2nd inbtubator
• Drug administrator
• Nursing staff
• Team leader

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Take Home Points

• Importance of a prebrief / zero point survey
• Medic 5 info – suggestions of modifying sheet
• Consideration for pre prepping dex/adrenaline nebs
• Importance of scribe
• Number of staff required and importance of speaking out
• RSI planning
• Ergonomics of room – extraneous equipment
• 2^nd intubator position
• Antidote location / protocols

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Latent Threats identified

• EPIC awareness of sim
• HCN antidote location – Pharmacy out of hours cupboard, now moving stock to ED antidote cupboard
• Antidote cupboard labelling incorrect (remove incorrect labelling on one cupboard)

Some comments from participant feedback from own reflections:

• Teamwork, Knowledge of area
• How to assist my team
• Learn where equipment is
• Thinking about cyanide poison - it is first time for me in this situation
• Education around medications
• Ask for help if not sure
• Stay calm
• Pre prepare required medication initially

Suggested improvements from participants:

• More sessions
• More warning there is going to be an in-situ simulation and have a nurse observer to provide feedback from a nursing point of view after each session
• Please could we have more opportunities to do this

Faculty Debrief:

• Lots going on in scenario for time allocated
• Tabards for participants to identify who in scenario
• Uniform for faculty to make clearer
• Use stickers for names / roles

Future sessions:

• Planned next simulation (Paeds Medical Theme) June-July 2023
• SAU session TBC