Anaphylaxis with Angioedema 1

Section I: Scenario Demographics

Scenario Title: Anaphylaxis with Angioedema

Date of Development: (17/01/2017)
Target Learning Group: Juniors (PGY 1 2) Seniors (PGY 3) All Groups

Section II: Scenario Developers

Scenario Developer(s): Ahmed Taher

Affiliations/Institution(s): University of Toronto
Contact E-mail (optional): [email protected]

Section III: Curriculum Integration

Learning Goals & Objectives

Educational Goal: To review a difficult airway scenario requiring cricothyrotomy
CRM Objectives: Communicate clearly with team members regarding difficult airway planning
Medical Objectives: 1. Efficiently treats anaphylaxis in an organized manner, including the
prioritization of epinephrine administration
2. Recognizes and plans appropriately for the management of a difficult airway
3. Recognizes the need for surgical airway and successfully performs a surgical
cricothyrotomy

Case Summary: Brief Summary of Case Progression and Major Events

A 45-year-old patient who has already been seen in the ED begins treatment for pyelonephritis with IV
antibiotics. Soon after initiated, she develops stridor and respiratory distress, as part of an anaphylactic
reaction. The team is called into the room to assess the patient. After standard anaphylaxis treatment is
given, the airway is still of concern. Intubation attempts are not successful and the patient will need a
surgical airway.

References
http://lifeinthefastlane.com/ccc/anaphylaxis/
https://www.aaaai.org/Aaaai/media/MediaLibrary/PDF%20Documents/Practice%20and%20Parameters/Anaphylaxis-Practice-Parameter-2014.pdf
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1343032/
http://militarymedicine.amsus.org/doi/abs/10.7205/MILMED.172.12.1228

2015 EMSIMCASES.COM Page 1

This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.
Anaphylaxis with Angioedema 2

Section IV: Scenario Script

A. Clinical Vignette: To Read Aloud at Beginning of Case

You are working a night shift at your local Emergency Department. You are called STAT to the bedside of a
patient in the department who was seen by your colleague earlier and has recently been started on IV
ceftriaxone for a pyelonephritis. You recall from handover that this is a 45-year-old previously healthy
female patient with a diagnosis of a UTI two weeks ago, who returned after failing treatment and was
diagnosed with pyelonephritis today. The nurse tells you she started the IV antibiotics and fluids 20 min
ago, and then started to experience respiratory distress and a full body rash.

B. Scenario Cast & Realism

Patient: Computerized Mannequin Realism: Conceptual
Mannequin Physical
Standardized Patient Select most Emotional/Experiential
Hybrid important Other:
Task Trainer (for Cric) dimension(s) N/A
Confederates Brief Description of Role
Nurse Assist with delegated tasks, cue learners as to patients respiratory status and
appearance

C. Required Monitors
EKG Leads/Wires Temperature Probe Central Venous Line
NIBP Cuff Defibrillator Pads Capnography
Pulse Oximeter Arterial Line Other:
D. Required Equipment
Gloves Nasal Prongs Scalpel
Stethoscope Venturi Mask Tube Thoracostomy Kit
Defibrillator Non-Rebreather Mask Cricothyroidotomy Kit
IV Bags/Lines Bag Valve Mask Thoracotomy Kit
IV Push Medications Laryngoscope Central Line Kit
PO Tabs Video Assisted Laryngoscope Arterial Line Kit
Blood Products ET Tubes Other: bougie
Intraosseous Set-up LMA Other: 6-0 ETT
E. Moulage
-Urticaria
-If mannequin allows: angioedema

F. Approximate Timing
Set-Up: 10min Scenario: 15min Debriefing: 15min

2015 EMSIMCASES.COM Page 2

This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.
Anaphylaxis with Angioedema 3

Section V: Patient Data and Baseline State

A. Patient Profile and History

Patient Name: Anna Palmer Age: 45 Weight: 70kg
Gender: M F Code Status: Full code
Chief Complaint: Flank Pain, fever
History of Presenting Illness: Dysuria and treatment for UTI 2 weeks ago. Symptoms worsening with new
onset fever, nausea and vomiting. Your colleague in the ED diagnosed her with pyelonephritis, has started
IV ceftriaxone, and the general medicine team has been consulted but hasnt been by to assess yet. Twenty
minutes after starting the antibiotics, she began to develop stridor, respiratory distress and a pruritic rash.
Past Medical History: Healthy Medications: Recent nitrofurantoin

Allergies: None known

Social History: Lives with partner
Family History: Non-contributory
Review of Systems: CNS: Feeling Faint
HEENT: Swollen lips, tongue, throat feels tight
CVS: No chest pain, but does feel a little dizzy
RESP: Feels hard to breathe
GI: Feels nauseous
GU: Nil
MSK: Nil INT: Pruritic rash
B. Baseline Simulator State and Physical Exam
No Monitor Display Monitor On, no data displayed Monitor on Standard Display
HR: 130/min BP: 100/65 RR: 30/min O2SAT: 88% on room air
Rhythm: Sinus Tach T: 37.3oC Glucose: 8.2mmol/L GCS: 15 (E4 V5 M6)
General Status: Notable respiratory distresses with 3-4 word dyspnea
CNS: Anxious but alert
HEENT: Angioedema (swollen tongue, lips). Clear stridor.
CVS: Normal heart sounds, no murmur. Normal peripheral pulses. One peripheral IV in situ.
RESP: Stridorous. Also bilateral wheezes and in-drawing
ABDO: No tenderness
GU: N/A
MSK: N/A SKIN: Widespread urticarial rash

2015 EMSIMCASES.COM Page 3

This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.
Anaphylaxis with Angioedema 4

Section VI: Scenario Progression

Scenario States, Modifiers and Triggers

Patient State Patient Status Learner Actions, Modifiers & Triggers to Move to Next State
1. Baseline State Patient in severe Learner Actions Modifiers
Rhythm: sinus tach respiratory - Apply oxygen and monitors Changes to patient condition based on
HR: 130/min distress. - Obtain 2nd IV learner action
BP: 100 /65 Speaking 3-4 - Initiate IV NS 1L bolus - O2 placed Sats to 91%
RR: 30/min word sentences, - Discontinue antibiotics - Epi, ventolin given HR 150
O2SAT: 88% RA audible stridor, - Epinephrine 0.5mg IM - If Abx still going at 3 min, RN asks
T: 37.3 oC swollen lips and - Solumedrol 125mg IV x 1 should we stop the antibiotics?
tongue. - Ventolin 5mg nebulized
- Consider 5mg nebulized Triggers
For progression to next state
epinephrine
- Consideration of intubation
- Benadryl 50mg iv (low 2. Peri-Intubation
priority) - No epi given or no discussion of
- Ranitidine 50 mg iv (low airway management by 5 min
priority) 3. Desaturating
2. Peri-Intubation Respiratory Learner Actions Modifiers
HR: 150/min distress, patient - Airway assessment - Propofol used BP to 70/50
BP: 100/65 getting fatigued - Identify difficult airway - Paralytic given unable to bag
RR: 20/min unable to talk, - Call for help (extra ERP, patient, O2 sats drop to 60%
O2SAT: 91% baseline stridor anesthesia, ENT)
- Prepare intubation
equipment, including back-ups
(DL, VL, bougie & LMA in room)
- Call for surgical airway kit in
room, prep equipment, prep neck Triggers
- Push dose pressor at bedside - Intubation attempt
- Ketamine 1-2mg/kg airway 4. Intubation
- Airway topicalization - Attempt cricothyrotomy
- Consider apneic oxygenation 5. Cricothyrotomy
- Consider epinephrine infusion
3. Desaturating Same as Learner Actions Modifiers
HR: 150/min previous state - Epinephrine 0.5mg IM - If no move to airway management
BP: 100/65 - Ventolin 5mg nebulized 3 min into state RN to prompt
RR: 20/min - Consider 5mg nebulized Are you going to intubate?
O2SAT: 85% epinephrine
Triggers
- Consideration of intubation
2. Peri-Intubation
4. Intubation Patient Learner Actions Modifiers
HR: 150/min deteriorates - Attempt intubation (grade 4 - 1st intubation attempt grade IV
BP: 100/65 despite mgmt view) view, SpO2 70%
RR: 20/min shallow (Sats drop with - Verbalize need for cric - BVM after attempt SpO2 75%
O2SAT: 85% (will drop any intubation - 2nd attempt SpO2 60%
to 70% after first attempt, do not
attempt) rise with BVM) Triggers
2015 EMSIMCASES.COM - Prepare for cric5. Cric Page 4
This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.
Anaphylaxis with Angioedema 5

5.Cricothyrotomy Learner Actions Modifiers

HR: 120 - Analgesia/sedation prior to - Any method of surgical airway is
BP: 100/65 cric (if not yet given) acceptable
RR: 5/ shallow - Prep the neck
O2 sat: 65% - Vertical skin incision over
cricothyroid membrane Triggers
- Blunt dissection through - Cric successful 6. Resolution
subcutaneous tissue
- Horizontal incision through
cricothyroid membrane
- Dilate with gloved finger
- Pass bougie into trachea
beside finger
- Pass ETT over bougie and
intubate trachea
6. Resolution Patient cric +/- Learner Actions
HR: 110 sedated - Confirm placement (breath
BP: 115/65 sounds, ETCO2, CXR) END CASE PRN
RR: 12 - Consult ICU
O2 sat: 95% - Epinephrine infusion
- Initiate sedation

2015 EMSIMCASES.COM Page 5

This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.
Anaphylaxis with Angioedema 6

Section VII: Supporting Documents, Laboratory Results, & Multimedia

Laboratory Results
None provided.

Images (ECGs, CXRs, etc.)

(ECG source:
http://i0.wp.com/lifeinthefastlane.com/wp-
content/uploads/2011/12/sinus-tachycardia.jpg)

(CXR source:
https://radiopaedia.org/cases/normal-chest-
radiograph-female)

Ultrasound Video Files (if applicable)

None provided.

2015 EMSIMCASES.COM Page 6

This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.
 Anaphylaxis with Angioedema 7

Section VIII: Debriefing Guide

General Debriefing Plan

Individual Group With Video Without Video
Objectives
Educational Goal: To review a difficult airway scenario requiring cricothyrotomy
CRM Objectives: Communicate clearly with team members regarding difficult airway
planning
Medical Objectives: 1. Efficiently treats anaphylaxis in an organized manner, including the
prioritization of epinephrine administration
2. Recognizes and plans appropriately for the management of a difficult
airway
3. Recognizes the need for surgical airway and successfully performs a
surgical cricothyrotomy
Sample Questions for Debriefing
1. How did the team initially approach the airway management task? Did the team decide to avoid any
particular agents?
2. What equipment should be available at the bedside for an emergency cricothyrotomy?
3. What are the features of difficult cricothyrotomy? Any contraindications to cricothyrotomy?
4. How did you feel in making the decision to perform a cricothyrotomy? Were there any steps you
would improve upon thinking about the case now?
5. Was there any hesitation in performing the cricothyrotomy? Why do you think this is?
6. How can a team ensure that a critical procedure, such as a cric, is performed in a timely fashion? Are
there any communication tactics that can be used?
Key Moments
Recognition of anaphylaxis and initiation of treatment
Recognition of difficult airway
Recognition of failed intubation and need for surgical airway

2015 EMSIMCASES.COM Page 7

This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.