Simulation 05: 41 Year-Old Female with Muscle Weakness and Dyspnea

Transcription

1 Simulation 05: 41 Year-Old Female with Muscle Weakness and Dyspnea Flow Chart Opening Scenario 41 year-old female admitted 3 days ago with fever, myalgia, and a nonproductive cough after a bout of flu Section 1 Type: IG Pt on 2 L/min nasal O2 complains of leg weakness, tingling, dyspnea on exertion; SpO2 91%; breath sounds Section 2 ABG: mild resp acidosis + hypoxemia; X-ray, CB normal; recommend O2 flow and monitoring Q4H Section 3 Type: IG Section 4 Section 5 Next day pt C/O extremity weakness, worse dyspnea; recommend CSF protein, EMG, Anti-AchR antibody Based on the clinical presentation, CSF protein, normal anti-achr levels, slow nerve conduction, likely diagnosis = Guillain Barré syndrome Based on Dx, recommend assessing MIP/NIF and VC, SpO2, overall respiratory status now and Q4H Section 6 Select equipment to measure patient's MIP/NIF and vital capacity Section 7 Over 4 hours, MIP/NIF + VC, RR but remain above threshold. Continue to assess, initiate plasmaphoresis NIF, VC ; bulbar dysfunction present; -> intubation + MV Section 8 Section 11 NIF, VC ; pt cannot speak; recommend intubation + MV Section 9 Select mode and ventilator settings for a female 60 in tall, 110 lbs Section 10: Suggest supportive care including nutrition, phys. therapy, as well as monitoring such as NIF and VC End 1

2 Opening Scenario (Links to Section 1) Scenario Header (Briefly describe the setting, role and current situation): You are a respiratory therapist in a 350 bed urban hospital. A senior resident asks you to assess the respiratory status of a patient admitted 3 days ago with fever, myalgia, and a nonproductive cough after "a bout of flu." (Click the Start button below when ready to begin) 2

3 Information-Gathering Section Simulation Section #: 1 Links from Section #: Opening Scenario Links to Section #(s): 2 Scenario Header (Briefly describe current situation requiring gathering/evaluation of patient information): Upon arrival at the bedside you observe a 41 year-old female on a nasal cannula at 2 L/min, with mild dyspnea. Which of the following would you evaluate during your initial assessment of this patient? (SELECT AS MANY as you consider indicated in this Section, then click on the Go To Next Section button below to proceed) Requested Information Data Response Score Pulse oximetry (SpO2) 92% +1 Arterial blood gas Pending +1 Sputum sample Physician disagrees -1 Chest X-ray Pending +1 Current medications Patient was on oral antibiotics the prior week +1 Breath sounds Decreased at bases; otherwise clear +1 Vital signs HR = 105/min; RR = 28/min; BP = 115/77 +1 mm Hg; T = 99 F Complete blood count (CBC) Pending +1 Recent history Patient reports prior flu symptoms but now +2 also has some leg weakness and tingling in her toes as well as shortness of breath on exertion Peak expiratory flow Physician disagrees Perfect Score: 9 Minimum Pass Score: 8 3

4 Simulation Section #: 2 Links from Section #: 1 Links to Section #(s): 3 Scenario Header (Briefly describe current situation requiring recommendation or action): The blood gas lab report is as follows: ph = 7.34; PCO2 = 49 torr; HCO3 = 25 meq/l; PO2 = 59 torr; SaO2 = 90%. CBC results are normal. An AP chest X-ray indicates slight under inflation but is otherwise unremarkable. Which of the following actions would be appropriate at this time (CHOOSE ONLY ONE unless you are directed to Make another ) Action/Recommendation Increasing the O2 flow to 4 L/min and re-assessing her respiratory status Q4H Increasing the O2 flow to 4 L/min and recommending 3 puffs albuterol MDI Q6H Changing to a simple mask at 10 L/min and recommending postural drainage with percussion and vibration Q6H Increasing the O2 flow to 8 L/min and recommending a STAT aerosol treatment with 2.5 mg albuterol in 3 ml NS via SVN Initiating noninvasive ventilation with IPAP = 20 cm H2O, EPAP = 5 cm H2O, 50% O2, repeating the ABG and monitoring closely Response Link to Response to Selection Score Section Physician agrees Perfect Score: 2 Minimum Pass Score: 1 4

5 Information-Gathering Section Simulation Section #:3 Links from Section #: 2 Links to Section #(s): 4 Scenario Header (Briefly describe current situation requiring gathering/evaluation of patient information): When assessing the patient the following day, she complains of greater extremity weakness and worsening dyspnea. Which of the following additional information would you assess at this time? (SELECT AS MANY as you consider indicated in this Section, then click on the Go To Next Section button below to proceed) Requested Information Data Response Score Vital signs (HR + RR) HR=120/min, RR=32/min +1 Pulse oximetry (SpO2) 93% (4 L/min nasal cannula) +1 Cerebral spinal fluid (CSF) protein Pending +2 level Breath sounds Decreased breath sounds; otherwise clear. +1 Electromyography (EMG) Pending +1 Repeat chest X-ray Physician disagrees -1 General appearance No evidence of cyanosis; skin is cool and +1 clammy; normal sensorium Chest percussion (diagnostic) Normal resonance -1 Anti-AchR antibody blood levels Pending +1 End tidal CO2 (capnometry) Physician disagrees Perfect Score: 8 Minimum Pass Score: 7 5

6 Simulation Section #:4 Links from Section #: 3 Links to Section #(s): 5 Scenario Header (Briefly describe current situation requiring recommendation or action): The lab reports a normal CBC and Anti-AChR antibody, but elevated CSF protein levels. The EMG indicates slowed nerve conduction velocity. Based on this new data and the patient s clinical presentation, which of the following is the most likely diagnosis? (CHOOSE ONLY ONE unless you are directed to Make another ) Action/Recommendation Response to Selection Response Link to Score Section Myasthenia gravis -1 Polymyositis Myotonic dystrophy Guillain-Barre syndrome Physician agrees Amytrophic lateral sclerosis Perfect Score: 2 Minimum Pass Score: 1 6

7 Simulation Section #: 5 Links from Section #: 4 Links to Section #(s): 6 Scenario Header (Briefly describe current situation requiring recommendation or action): After agreeing with your diagnosis of Guillain Barré syndrome, the resident asks for your advice regarding respiratory management of this patient. Which of the following would you recommend? (CHOOSE ONLY ONE unless you are directed to Make another ) Action/Recommendation Intubating the patient and initiating mechanical ventilation Response to Selection Response Score -3 Link to Section Assessing MIP/NIF, VC, SpO2, and overall respiratory status Q4H Initiating positive expiratory pressure (PEP) therapy Administering pyridostigmine (Mestinon) orally TID Scheduling an elective thymectomy Physician agrees Perfect Score: 2 Minimum Pass Score: 1 7

8 Simulation Section #: 6 Links from Section #: 5 Links to Section #(s): 7 Scenario Header (Briefly describe current situation requiring gathering/evaluation of patient information): Which of the following equipment would you gather to measure this patient's MIP/NIF and vital capacity? (SELECT AS MANY as you consider indicated in this Section, then click on the Go To Next Section button below to proceed) Requested Information Data Response Score Peak flow meter Make another selection -1 In-line HEPA filter Done +1 Inspiratory force meter Done +2 One-way valve and adaptor Done +1 Respirometer Done +2 Mouthpiece and mask Done +1 Nose clips Done +1 Douglas bag Make another selection -1 Colorimetric CO2 detector Make another selection -1 U-tube manometer Make another selection -1 Perfect Score: 8 Minimum Pass Score: 7 8

9 Simulation Section #: 7 Links from Section #: 6 Links to Section #(s): 8 Scenario Header (Briefly describe current situation requiring recommendation or action): Your initial assessment reveals MIP/NIF = -35 cm H2O; VC = 1.8 L; SpO2 = 93% L/min), RR = 30/min with decreased breath sounds. Four hours later, your repeat assessment indicates: MIP/NIF = -32 cm H2O; VC = 1.4 L; SpO2 = 92%; and RR = 33/min. Based on these data, which of the following would you recommend at this time? (CHOOSE ONLY ONE unless you are directed to Make another ) Action/Recommendation Response to Selection Response Link to Score Section Intubating the patient and initiating -3 mechanical ventilation selection in the section. Initiating noninvasive ventilation with IPAP = 20 cm H2O, EPAP = 5 cm H2O, 50% O2, repeating the ABG and monitoring closely selection in the section. Continuing to assess MIP/NIF, VC, SpO2, respiratory status Q4H Physician agrees and initiate plasmaphoresis Administering 2.5mg albuterol with 3 ml normal saline via SVN Q4H Discontinuing respiratory monitoring and initiating plasmaphoresis selection in the section. selection in the section. Perfect Score: 2 Minimum Pass Score: 2 9

10 Simulation Section #: 8 Links from Section #: 7 Links to Section #(s): 9, 11 Scenario Header (Briefly describe current situation requiring recommendation or action): Four hours later, your assessment reveals: MIP/NIF = 2 cm H2O; VC = 600 ml, SpO2 = 90% 4 L/min); RR = 36/min with decreased breath sounds. A neurological exam indicates bulbar dysfunction with bilateral facial weakness, and the patient is complaining of difficulty swallowing. Which of the following would you recommend? (CHOOSE ONLY ONE unless you are directed to Make another ) Action/Recommendation Response to Selection Response Link to Score Section Initiating noninvasive ventilation by oronasal mask selection in the section. -1 Intubating the patient and initiating Physician agrees mechanical ventilation Increasing the frequency of Physician agrees 11 respiratory assessment to every 30 minutes Changing to a nonrebreathing Physician agrees 11 mask at 10 L/min O2 Calling for the Rapid Response/Medical Emergency Team selection in the section. -1 Perfect Score: 2 Minimum Pass Score: 1 10

11 Simulation Section #: 9 Links from Section #: 8 Links to Section #(s): 10 Scenario Header (Briefly describe current situation requiring recommendation or action): The patient is 60 inches tall and weighs 110 pounds. What initial ventilator settings would you recommend? (CHOOSE ONLY ONE unless you are directed to Make another ) Action/Recommendation Response to Selection Response Score Mode = volume targeted assist/control; VT = 800 ml; rate = selection in the section. 12/min; FIO2 = 0.35; PEEP = 5 cm H2O Mode = volume targeted SIMV; VT = 400 ml; rate = 12/min; FIO2 = 0.40; PEEP = 5 cm H2O Mode = pressure limited assist/control; PIP = 40 cm H2O; rate = 12/min; FIO2 = 0.60; PEEP = 5 cm H2O Mode = volume targeted SIMV; VT = 600 ml; rate = 6/min; FIO2 = 1.00; PEEP = 10 cm H2O Mode = volume targeted assist/control; VT = 400 ml; rate = 12/min; FIO2 = 0.40; PEEP = 5 cm H2O Physician agrees selection in the section. selection in the section. Physician agrees Perfect Score: 2 Minimum Pass Score: 2 Link to Section 11

12 Simulation Section #: 10 Links from Section #: 9 Links to Section #(s): End Scenario Header (Briefly describe current situation requiring gathering/evaluation of patient information): The patient is stable on the ventilator with recommended settings. Which of the following additional interventions would you recommend at this time? (SELECT AS MANY as you consider indicated in this Section, then click on the Go To Next Section button below to proceed) Requested Information Data Response Score Continue plasmaphoresis Physician agrees +1 Enteral nutritional support Physician agrees +1 Monitoring MIP/NIF and VC Q8H Physician agrees +2 Hemodynamic monitoring via a selection PA catheter in this section. Daily range of motion exercises Physician agrees +2 Pyridostigmine (Mestinon) therapy selection in this section. VAP bundle/ protocol Physician agrees +2 MDI albuterol (3 puffs) Q6H selection -1 in this section. Protective (reverse) isolation selection -1 in this section. ECG/cardiac monitoring Physician agrees. +2 Perfect Score: 10 Minimum Pass Score: 9 12

13 Simulation Section #: 11 Links from Section #: 8 Links to Section #(s): 9 Scenario Header (Briefly describe current situation requiring recommendation or action): At the request of the resident, you reassess the patient 30 minute later, with the following results: MIP/NIF = -17 cm H2O; VC = 425 ml, SpO2 = 88% 4 L/min); RR = 8/min with decreased breath sounds. The patient appears alert but can no longer speak coherently. Which of the following would you recommend at this time? (CHOOSE ONLY ONE unless you are directed to Make another ) Action/Recommendation Response to Selection Response Link to Score Section Initiating noninvasive ventilation by oronasal mask with IPAP = 20 cm H2O, EPAP = 5 cm H2O, 50% O2 Performing nasotracheal -3 suctioning PRN Performing mechanical insufflation-exsufflation (MI-E) Q1H Intubating the patient and initiating mechanical ventilation Performing a STAT percutaneous dilatational tracheotomy Physician agrees +1 9 Perfect Score: 1 Minimum Pass Score:

14 RTBoardReview.com NBRC RRT Review Simulation Year Old with Muscle Weakness Condition/Diagnosis: Guillain-Barré Syndrome Simulation Scoring Individual Response Scoring (Used for All RTBoardReview.com Simulations) Score Meaning +2 Essential/optimum to identifying or resolving problem +1 Likely helpful in identifying or resolving problem 0 Neither helpful nor harmful in identifying or resolving problem -1 Unnecessary or potentially harmful in identifying or resolving problem Wastes critical time in identifying problem or causes direct harm to patient -3 Results in life-threatening harm to patient Summary Scoring of Simulation 05 Section IG Max IG Min DM Max DM Min Corrective DM from Section 8 TOTALS

15 RTBoardReview.com NBRC RRT Review Simulation Year Old with Muscle Weakness Condition/Diagnosis: Guillain-Barré Syndrome Take-Home Points Assessment/Information Gathering History and Physical o Recent febrile illness o Rapidly progressing ascending symmetrical muscle weakness/paralysis o Sensory dysesthesias (pain or discomfort to touch) o Decreased or absent deep tendon reflexes o Dysautonomia (rapid, wide fluctuations in BP, frequent cardiac arrhythmias) o Dysphagia (indicating bulbar muscle involvement), loss of gag reflex o Dyspnea, often progressing to respiratory insufficiency o Breath sounds - normal unless aspiration and/or pneumonia due to loss of upper airway reflexes (indicated by basilar crackles and wheezes) Diagnostic Tests o Antibody tests - antiganglioside antibodies o Liver enzymes - AST, ALT o Serology - positive for C. jejuni or CMV o Lumbar puncture to gather cerebral spinal fluid - showing protein, WBC o Electromyography (EMG) and nerve conduction studies (NCS) - demonstrating slowing or blockage of nerve conduction o Spirometry - VC, MIP/NIF, MEP o ABGs - if resp involvement: resp acidosis; hypoxemia if aspiration or pneumonia o Chest X-ray - normal unless aspiration and/or pneumonia Treatment/Decision-Making General Medical/Surgical Treatment to Recommend o Vital signs, SpO2 and continuous ECG monitoring (for dysautonomia) o Plasmapheresis (plasma exchange) o IV immunoglobulin therapy o Analgesics for dysesthesia (NSAIDs, opioids) o Fluids/Trendelenburg positioning for hypotension (sensitivity to vasoactive drugs) o Deep vein thrombosis (DVT) prophylaxis for immobility o Physical rehabilitation during recovery stage Respiratory Management to Implement/Recommend o Implement VC, NIF, MEP monitoring every 8 hours o Provide O2 therapy as needed to keep SpO2 > 90% o Recommend intubation and mechanical ventilation if: VC < 1.0 L or < 15 ml/kg MIP/NIF < 5 cm H2O, MEP < 40 cm H2O Inability to cough, swallow and protect the airway ABG evidence of respiratory failure Aspiration pneumonia with severe hypoxemia o Recommend trach if: Severe weakness, especially if bulbar involvement (e.g., dysphagia) Likely need for mechanical ventilation > 10 days Implement rigorous infection control/vap protocol 15

16 Follow-up Resources Standard Text Resources: Des Jardins, T., & Burton, G.G. (2011). Guillain-Barré Syndrome (Chapter 28). In Clinical Manifestations and Assessment of Respiratory Disease, 6th Ed. Maryland Heights, MO: Mosby- Elsevier. Specht, N.L., & Bartos, R. (2007). Neuromuscular Diseases (Chapter 15). In Wilkins, R.L., Dexter, J.R., & Gold, P.M. (Eds). Respiratory Disease: A Case Study Approach to Patient Care. 3rd Edition. Philadelphia: F.A. Davis. Useful Web Links: Andary, MT. Guillain-Barré Syndrome. E-Medicine/Medscape. Mehta, S. (2006). Neuromuscular disease causing acute respiratory failure. Respir Care, 51, Newswanger, DL, et al. Guillain-Barré syndrome. (2004). Am Fam Physician, 69,