MOCK CODE / EMERGENCY SITUATION SCENARIO: HEMORRHAGIC SHOCK SPECIFIC OBJECTIVES FOR THIS SCENARIO: After participating in this mock code, participants will be able to 1. Recognize hemorrhagic shock 2. Resuscitate a patient in hemorrhagic shock 3. Anticipate respiratory compromise in a patient with GI bleeding Introduction: 16 month old undergoing chemotherapy for neuroblastoma, has developed gross hematuria, passing large blood clots this morning

RN Facilitator (to Charge/Bedside RN): This is a 16 mo Initial assessment: pale, lethargic child old girl, 12 kg, with neuroblastoma who is undergoing FIRST THINGS FIRST: Assess - ABC chemotherapy with daunorubicin, cyclophosphamide, Airway: patent carboplatin, and epotoside. She has developed hematuria Breathing: mildly tachypneic which has gotten much worse over the past few hours, Circulation: cool, pulses rapid and diminished, delayed cap she passed a few large clots this morning. She has a Broviac, no known drug allergies, is getting 1½ x refill maintenance IVFs. Morning labs are pending. Disability: lethargic, but does respond to stimulation MD Facilitator (to bedside RN): You go in to assess the Expose the child! patient, and find her pale and lethargic. Categorize: tachycardia / (compensated) shock (be prepared for: decompensated shock/cardiopulmonary arrest) Action: 1. Call for help! 2. Give oxygen 3. Get the child on a heart rate monitor with pulse oxymetry & blood pressure (cycle q 1-3 min) Continue assessment: More large clots in diaper. Weight: 12 kg. Broviac in place. Vital signs: HR 165 BP 92/40 RR 35 O2 Sat 97% Temp 36.7 Categorize: Compensated shock (be prepared for: decompensated shock/cardiopulmonary arrest) Action: 1. Make sure you have IV access: test existing IVs and place an additional one, large bore preferred. 2. Fluid resuscitate: 20 cc/kg as fast as you can give it: push or open to gravity) 3. Order blood, consider O- if no cross matched blood is available 4. Call the Rapid Response Team (RRT 3-1611) 5. Order FFP, platelet transfusion, cryoprecipitate, consider Factor VII 6. Order labs: CBC with platelets, type and cross, coags 7. Apply oxygen Reassess: Patient vomits and aspirates, rapidly desaturates. HR 185 BP 52/29. Pulses diminished, patient now unconscious. Categorize: Decompensated shock with respiratory failure (be prepared for: decompensated shock/cardiopulmonary arrest)

Action: 1. Call the code 6-1234 2. Get the code cart & defibrillator 3. Suction the airway, start bag-mask ventilation, get ready of intubation 4. Draw up epinephrine (0.01 mg/kg of 1:10,000) 5. Finger (literally) on the pulse and a close eye on the monitor: be prepared for pulseless arrest Case description: Blood loss with hemorrhagic cystitis can be significant, and it sometimes is difficult to know how much blood loss there is because clots can obstruct the outflow. When blood loss is significant it can result in hemorrhagic shock, and although fluid resuscitation should start with crystalloids, blood transfusion is part of the early management in this situation. Crystalloid therapy alone can cause hemodilution with decrease in oxygen carrying capacity as a result. Also remember that acute blood loss of any cause results in loss of clotting factors and platelets in addition to red blood cells; with massive blood loss these should be replenished as well.

svs 1/04/11

GENERAL OBJECTIVES Situational Awareness Recognition of critical problem Complete ABC assessment Vital signs (incl. O2 sat) obtained Vital signs correctly interpreted Focused physical exam performed SAMPLE information obtained Adequate and frequent reassessment Anticipation of next events Resource Utilization Patient put on appropriate monitor Help requested in timely fashion Help requested in correct way (per unit protocol/recommendations) Code cart and defibrillator brought in Leadership Role identification: both physician leader and charge nurse Appropriate delegation and role assignment to others (RN and MD) Summarizes and categorizes Makes prompt and firm decisions Leader communicates with team effectively (RN and MD) Teamwork/ Communication Initial responder provides summary Team members offer to take on tasks Team members choose appropriate tasks Team members stick to task Team members collaborate Closed-loop communication Calm atmosphere Airway/Breathing Adequate assessment: patient exposed, auscultation Appropriate interpretation of pulse oxymetry Need for respiratory support appropriately identified Appropriate O2 delivery equipment Circulation Adequate assessment: pulses vs heart rate on monitor, blood pressure Need for access assessed Access obtained as appropriate (site, use of IO when IV unsuccessful) Other Broselow tape used if appropriate Use of gloves Parents involvement/awareness SCENARIO SPECIFIC OBJECTIVES Prompt recognition of shock Adequate fluid resuscitation Appropriate access obtained Blood ordered immediately






Appropriate labs obtained Clotting factors and platelets ordered Adequate bag-mask ventilation when indicated

svs 1/04/11



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