PATIENT NAME: Sarah

PATIENT AGE: 12 months

PATIENT WEIGHT: 10 kg
CHIEF COMPLAINT: Difficulty breathing

Brief narrative The nurse at the Emergency Room (ER) of a Primary Health Care Centre (PHCC) calls the
description of the case doctor to care for an ill-appearing female patient aged 12 months. The patient was brought
to the ER by her father. She developed hives and difficulty breathing after consuming cow’s
milk.
The participants are expected to assess ABC, take SAMPLE history, conduct the initial
assessment (physical examination and vital signs), and initiate anaphylaxis management.
The ambulance will be called, and IM epinephrine and oxygen will be adminstered. The
patient does not respond to the initial epinephrine dose, and another dose of IM epinephrine
and IV fluid will be given. Her condition deteriorates, and she develops respiratory arrest. The
scenario ends when the ambulance arrives.

Primary Learning 1. Recognise anaphylaxis in children.

Objectives 2. Treat anaphylaxis following the flowcharts manual and assess response to treatment.
3. Recognise respiratory arrest in children and provide BLS following the flowcharts manual.

Critical Actionss  Perform initial primary assessment of the airway, breathing, and circulation and conduct
the physical examination.
 Call the ambulance.
 Give IM epinephrine 1:1000.
 Administer supplemental oxygen.
 Give IV fluid.
 Reassess the patient's condition and recognise any deterioration in his status or vital
signs.
 Notify the receiving hospital and support the patient while awaiting hospital transfer.
 Recognise respratory arrest and start BLS.

Learner Preparation or  Introduce the simulation concept to the learners and orient them about the setting and
Prework available resources.
 Inform the learners about the expected actions and the evaluation method.
 Encourage the learners to treat the simulated case as a real emergency (engaged
psychologically).

Simulation scenario 2: Anaphylaxis (Paediatrics)

Initial Presentation

Initial Vital Signs None

Overall Setting and A female infant lying down on the stretcher in the ER. She is fully dressed and breathing
Appearance rapidly. She is not on the monitor.

Standardised Trainer #1: A doctor who is the team leader and conducts the initial assessment.
Participants (and Their Trainer #2: A supporting doctor who helps in the survey and deciding the management plan.
Roles in the Room at Trainer #3: A nurse who prepares, administers, and documents the medication(s). If more
Case Start) trainers are available, they will support the management according to the role assigned by
the team leader.
Instructor #1: Simulation instructor who introduces the scenario, controls the monitor, fills
the simulation checklist, and acts as a debriefer.
Instructor #2: Simulation instructor who provides the findings of the physical examination,
acts as the patient's father and is available to answer questions.

HPI The patient is a 12-month-old female with no prior history of allergies brought by her father
because she is having difficulty breathing. Her father stated that he gave her milk 15 minutes
before arriving at the ER and then started having difficulty breathing and becoming less
 conscious.

Past Medical/Surgical Medications Allergies Family History

History

(When asked) (When asked) (When asked) (When asked)

Full term, immunisations None. None to date. Her father has an allergy to
up-to-date. peanuts.

Physical Examination (Primary Assessment)

General Crying, alert.

HEENT Patent airway, no lip or tongue swelling, no cyanosis.

Lungs Tracheal tug and deep retractions, wheezing bilaterally.

Cardiovascular Rapid pulse, capillary refill=3 seconds

Skin Diffuse hives

Instructor Notes - Changes and CASE Branch Points

Intervention / Time Point Change in Case Additional Information

At the start of the simulation (0-3 - Patient is alert, crying, and has difficulty Physical examination findings will
minutes): breathing. be provided via paper when
- Assign the roles - Vital signs will be displayed on the screen appropriately performed.
- Assess ABC as follows:
- Conduct initial assessment • RR 34
- Take SAMPLE history • HR 146
- Attach the monitors • BP 86/55
- Insert two large IV cannula • SatO2 90% (room air)

Initial management (3-5 minutes) - Vital signs: - Ambulance does not arrive yet.
- Recognise anaphylaxis • SatO2 decreases to 88% (on O2) - The nearest hospital does not
- Refer to the flowcharts manual • RR 32 respond.
- Call the ambulance • HR 145 - Parent states: “Why is my child
- Notify the nearest hospital • BP 85/54 breathing so fast? Look – what
- Give 150 μg (0.15 mL) IM is that rash?!”
epinephrine 1:1000 (1 mg/mL)
- Give 8 to 10 L/minute
supplemental oxygen via face
mask.
- Place the patient in a supine
position with legs elevated.
- Consider nebulised Salbutamol (2.5
mg).

After 5 mins - Vital signs: - Ambulance does not arrive yet.

- Reassess ABC • SatO2 88% (on O2) - The hospital responded.
- Give IV fluids (200ml 0.9% normal • RR decreases to 24
saline) over 5 to 10 minutes. • BP decreases to 82/50
- Increase oxygen flow • HR 110
- Re-call the hospital - Lip swelling develops

- Give another dose of IM - Vital signs:

epinephrine. • SatO2 87% (on O2)
 - Give another bolus of IV fluids • RR decreases to 18
(200ml 0.9% normal saline) over 5 • BP decreases to 80/48
to 10 minutes. • HR 70
- Cyanosis develops

10 minutes into the case - Vital signs:

The patient becomes unresponsive • SatO2 85% (on O2)
- Check responsiveness • RR 0
- Reassess ABC • BP decreases to 70/48
- Refer to Basic Life Support and • HR 55
Cardiac Arrest (Paediatrics)
flowchart
- Recognise respiratory arrest
- Insert OPA
- Start CPR

15 minutes into the case Simulation scenario ends

- Ambulance arrives
- Fill referral form

Ideal Scenario Flow

The learners enter the room to find a patient in respiratory distress. Following assigning the roles and the initial
assessment, the team will recognise that the patient has anaphylaxis. They will call the ambulance, give 0.15 mL IM
epinephrine, and 8 to 10 L/minute supplemental oxygen. However, the patient's condition will not improve, and the
patient’s respiratory and circulatory status does not improve, for which another dose of 0.15 mL of epinephrine in addition
to 200 ml of 0.9% NS will be given. Ten minutes into the case, the patient will develop respiratory arrest with signs of poor
perfusion, for which the team will support ABC and start CPR. The simulation ends when the ambulance arrives.

Required medication and equipment to implement the simulation

 Medications and supplies:

- Epinephrine ampoules (1:1000)
- Oxygen
- 0.9% saline 500 ml
- Cannulas

 Equipment
- Infant mannequin
- Monitor (TruMonitor app, table, and smartphone)
- Cannulas and IV line
- Face mask
- OPA
- Bag-mask