POCCENT+Simulations

=POCCENT Simulations=

For Phase 2 of the project, we will be creating simulations of various scenarios. See below for more details.

CURRENT SCRIPT:

POC-CENT Clinical Scenario: Seizure
An ALS ambulance is called to the scene of a 14 year old male found down. Witnesses came upon the victim on the sidewalk near his bicycle with demonstrable uncontrolled movements of the arms and legs. He had lost bladder control and had sanguineous saliva and blood coming from his mouth. The patient was unresponsive, non verbal, and did not respond to noxious stimuli. There was evidence of minor cuts and scrapes on his face, head and hands.

Witnesses denied observing a fall or accident with the victim and no medical alert, medications or medical records were available on the victim to suggest a seizure disorder.

Patient continued to seize at the scene, was immobilized to decrease further trauma, an airway was secured, an IV was attempted, and the patient transported to the local CEC. The EMS needs to know if a seizure is occurring as part of a seizure disorder or trauma so that the patient could be transported to a trauma center or local facility.

The unresponsive patient was transported to the closest facility, not a trauma center, based on getting fastest care for seizure/status epilepticus.

Upon arrival to the CEC, the patient remains unresponsive with minimal response to noxious stimuli. A non-contrast head CT was performed along with lab work (CBC, Renal, ABG, etc.) to determine if any type of head trauma occurred to cause the patient to seize at the scene.

Unmet need 1: A point of care technique in the field to determine if any type of head trauma has occurred to cause the patient to seize. Once this diagnosis is ruled in our out the physicians can determine next steps to care for the pt. The pt would be transported to the trauma center and not stop at the local facility. Time is brain.

Unmet need 2: A point of care technology within the local CEC, not a trauma center, without any type of EEG service in house. By creating a way to hook up 4-6 EEG leads to record seizure activity and remotely transmit to the trauma center would help to quickly assess whether the pt is in status epilepticus or not.

POC-CENT Clinical Scenario: Acute Ischemic Stroke
EMS is dispatched to a call, “Man Down” no other details supplied. The ALS ambulance arrives on scene of a public park to find a 60 year old male agitated and confused. The patient had no shortness of breath, blood pressure of 140 / 90, and was lethargic and not speaking or responding to questions. Ambulance personnel note on the run sheet a sweet smell that similar to alcohol. No trauma is noted but the victim has multiple healed scars on the face and hands of the patient. The patient has no medic alert bracelet or medical information on his person.

A brief neurological exam performed by EMS personnel suggests differences in arm movements in reaction to stimulation. His pupils were equal but sluggishly reactive. Some dried blood was seen in his nares.

At this point EMS is considering: intoxication, diabetic episode, a stroke or other medical event. A field blood glucose shows a glucose of 60. Dextrose is administered with some change in blood glucose but no change in mental status.

Patient is transported to nearest emergency room to be evaluated and treated for stroke, stroke mimic, or intoxication.

Upon arrival in the emergency department, the patient remained lethargic with a slight difference between his right and left in responding to noxious stimulation. A non-contrast head CT is performed which looked normal. This rules out an intracranial hemorrhage but does not indicate the cause of the patient’s condition.

ANALYSIS: Numerous clinical trials indicate that thrombolytic therapy is effective in reducing the brain injury and disability from ischemic stroke as long as the treatment is given within the first 4.5 hours after symptom onset and ideally, within the first 90 to 120 minutes after symptom onset.

UNMET NEED 1: A point of care technique to confirm that a patient with unexplained neurologic deficits is in fact suffering from an ischemic stroke rather than other illnesses such as recent hypoxic-ischemic injury, drug overdose, non-convulsive status epilepticus, encephalitis, meningitis, or has a facititious or conversion disorder.

UNMET NEED 2: A point of care device that could accurately indicate the time of onset of an ischemic stroke. Assuming the clinical diagnosis is clear as an ischemic stroke, thrombolytic therapy cannot be given unless the time of symptom onset is unknown. In patients who were asleep when symptoms began or who cannot communicate and were alone when the symptoms began, thrombolytic therapy is currently withheld. Current standard of care is that the therapy can only be given when there is positive information regarding symptom onset. A point of care device that could indicate the time of symptom onset would allow patients who have strokes during sleep (“wake-up strokes” or patients whose stroke onsets are unwitnessed to be eligible for therapy.

POC-CENT Clinical Scenario: Hemorrhagic Stroke
EMS is dispatched to a call, “Man Down” no other details supplied. The ALS ambulance arrives on scene of a public park to find a 60 year old male agitated and confused. The patient had no shortness of breath, blood pressure of 140 / 90, and was lethargic and not speaking or responding to questions. Ambulance personnel note on the run sheet a sweet smell that similar to alcohol. No trauma is noted but the victim has multiple healed scars on the face and hands of the patient. The patient has no medic alert bracelet or medical information on his person.

A brief neurological exam performed by EMS personnel suggests differences in arm movements in reaction to stimulation. His pupils were equal but sluggishly reactive. Some dried blood was seen in his nares.

At this point EMS is considering: intoxication, diabetic episode, a stroke or other medical event. A field blood glucose shows a glucose of 60. Dextrose is administered with some change in blood glucose but no change in mental status.

Patient is transported to nearest emergency room to be evaluated and treated for stroke, stroke mimic, or intoxication.

Upon arrival in the emergency department, the patient remained lethargic with a slight difference between his right and left in responding to noxious stimulation. A non-contrast head CT was performed which showed bleeding in left frontoparietal cortex and subarachnoid space.

UNMET NEED 1: A point of care technique to confirm that a patient with unexplained neurologic deficits is in fact suffering from intracranial bleeding rather than other illnesses such as recent hypoxic-ischemic injury, drug overdose, non-convulsive status epilepticus, encephalitis, meningitis, or has a facititious or conversion disorder. A number of the causes of intracranial bleeding are known to cause continue bleeding in the first hours after symptom onset. Hemorrhage growth has a clear association with poor longterm outcome. Clinical trials have shown that thrombostatic agents can reduce hematoma growth in subsets of patients with intracerebral bleeding and possibly improve their outcomes. If the EMS crew could determine in the field that an intracranial bleed was present, they could potentially administer a thrombostatic agent without have to wait until his ED evaluation and Head CT results were obtained. Hence, 30 – 60 minutes or more could be saved in making a diagnosis if an accurate point-of-care test for field use was available.

UNMET NEED 2: A point of care device that could accurately indicate the time of onset of intracranial bleeding. Similar to the situation with ischemic stroke, the time of onset of hemorrhagic stroke is relevant to the patient’s risk for hemorrhage growth or rapid deterioration.

UNMET NEED 3: A point of care device that could pinpoint the exact cause or source of bleeding in the brain. There are many potential causes of bleeding in the brain including aneurysms, arteriovenous malformations, ischemic strokes, tumors, trauma, or a rupture of a small arterial vessel in a patient with a history of hypertension. The last cause is the most common but it is a diagnosis of exclusion based on ruling out other causes. This can be laborious and lengthy. If the ED personnel could determine the location and type of vascular lesions in the brain, an early and more accurate diagnosis could be made and focused interventions could be considered.

POC-CENT Clinical Scenario: Traumatic Brain Injury
EMTs are called to the site of an automobile collision. A man appearing to be in his late 40’s is found unconscious at the wheel of a car that has run off the road in an apparent single car accident. He is mildly hypotensive and tachycardic (SBP = 100; HHR = 110) with a respiratory rate of 25 and an O2 saturation of 94%. He does not respond verbally or open his eyes to pain, but does withdraw his arms (GCS = V1, E1, M4 = 6). His pupils are reactive but assymmetrical, with the right measuring 3mm and the left at 4 mm. He seems to bleed fairly significantly from multiple abrasions and from IV sites as the paramedics start IV fluids and apply pressure to the bleeding abrasions. Bleeding from the orophayrnx is also noted during intubation. No medical ID tag or information is available in his belongings. Immediate clinical concerns are for a closed head injury with raised intracranial pressure that may respond to mannitol and hyperventilation and for a bleeding abnormality that may be from post-traumatic disseminated intravascular coagulopathy (DIC) or from a pre-existing / iatrogenic medication related coagulopathy resulting in a spontaneous intracerebral hemorrhage that caused the car accident.

The EMTs secure his airway and start oxygen and IV fluids. This brings his heart rate down to 100, raises his SBP to 110, and O2 sat to 98%. He is transported to the nearest Level 1 Trauma Center. On arrival his vitals are unchanged, but his left pupil is now 5 mm and reactive, and it is noted that his right arm withdraws slower than his left side. He continues to ooze from multiple abrasions and puncture sites.

Unmet need #1: a point of care device to non-invasively measure the intracranial pressure. The pupil asymmetry raises concern for enlarging intracranial mass of worsening cerebral edema. Early awareness of this problem could guide acute interventions (ie, mannitol or hypertonic saline, hyperventilation) to avoid cerebral herniation and minimize secondary injury.

Unmet need #2: a point of care device to assess for bleeding and clotting problems (ie, coagulopathy). This may be due to a trauma induced DIC process, or from the use of medications such as warfarin or antiplatelet agents (aspirin, Plavix). Rapid differentiation between these possibilities would allow the immediate use of appropriate blood products to correct the abnormalities.

POC-CENT Clinical Scenario: Altered Mental Status
EMS is called by the parents of a 17 year-old male who is “not acting right.” The parents describe that their son has had “flu-like” symptoms over the last 2 days, including fatigue, body aches, rhinorrhea, sinus congestion, and mild headache. They are unaware of existence of a fever, but do remember that he had been complaining of chills. The patient had been “okay” earlier in the day and went to his room to take a nap; when his parents went to get him for dinner, they noticed him sitting on the edge of his bed, disoriented, and called 911 when he became combative as they approached him.

The parents deny use of alcohol, tobacco, and illicit substances; other than this recent illness, the patient has no medical problems. He has been taking over-the-counter medications for symptom relief. His parents also remember that some of his closest friends have missed school for a similar illness.

Paramedics find a well-developed, well-nourished young man crouched between a bed and a wall, shouting obscenities towards them and apparently interacting with unseen others. Police are summoned for assistance, the patient is restrained and placed on the stretcher and taken to the closest Emergency Department (ED). The patient becomes more agitated en route and, fearing for patient and crew safety, medical control allows the paramedics to administer 5mg of intramuscular midazolam prior to hospital arrival.

In the ED, the patient is somnolent but arouses to voice. He is tachycardic (126 bpm), hypertensive (144/98), febrile (101.4 axillary), tachypneic (22 bpm), and has a normal oxygen saturation. Pertinent findings on physical exam include dilated but reactive pupils, hot/flushed skin without rashes or lesions, orientation only to person, and apparent auditory and visual hallucinations. The patient requires continued physical restraint for his safety, and the treating physician begins a broad work-up, including blood and urine samples, computed tomography of the head, and lumbar puncture prior to admitting the patient to the hospital.

Unmet need 1: The differential diagnosis for this patient is substantial and includes the life threatening (including but not limited to meningitis) and the more benign (anticholinergic toxicity from over the counter cold medicines). Treatments are equally disparate (empiric antibiotics vs. supportive care). There is no diagnostic test to assess anti-cholinergic toxicity; a trial of physostigmine may be both diagnostic and therapeutic, but is not widely used. A point of care technique to rule-in or rule-out such a toxic ingestion could allow more rapid diagnosis and tailored treatments in scenarios like this one.

Unmet need 2: Meningitis/encephalitis must be considered in patients with altered mental status and elevated body temperature. Current routine treatment includes hospital admission and empiric antibiotics after lumbar puncture while awaiting CSF culture results, which require extended wait times. CSF gram stain and cell counts can provide clues on the possibility of viral or bacterial origin, but are not specific enough to guide therapy. The result is unnecessary broad spectrum antibiotic coverage to many cases of non-bacterial meningitis. A point of care technique that could differentiate among the etiologies of infectious meningitis would allow more tailored treatment regimens to be given sooner.

POC-CENT Clinical Scenario: Cardiac Arrest
EMS is dispatched to a call, “Non-Breather” no other details supplied. The ALS ambulance arrives on scene of a shopping mall to find a 60-year-old male pulseless and unresponsive. The patient was witnessed to collapse, but bystander CPR was not initiated. The patient had not had any complaints prior to collapse. The patient has no medic alert bracelet or medical information on his person.

Upon EMS arrival, they note the patient to be pulseless and apneic and initiate CPR. Bag valve mask ventilation is initiated as well. The first cardiac rhythm recorded is ventricular fibrillation. A 200J biphasic shock is delivered, and the patient remains in V-fib. CPR is continued for 2 minutes and epinephrine is administered. A 2nd 200J biphasic shock converts the patient to a sinus rhythm with a pulse. The patient remains unresponsive, and is subsequently intubated.

His first set of vitals are: HR 50 BP 90/50 RR 12 via BVM O2sats 100% on 100% NRB

A brief neurological exam performed by EMS personnel demonstrates an unresponsive patient with minimally reactive pupils. He has no motor response to painful stimulus.

A field blood glucose shows a glucose of 60. Dextrose is administered with some change in blood glucose, but no change in mental status.

A field EKG is performed and read by EMS as consistent with an ST-elevation myocardial infarction.

Upon arrival in the emergency department, the patient remained unresponsive. A non-contrast head CT was negative for acute hemorrhage, ischemia or mass.

ANALYSIS: Numerous clinical trials indicate that therapeutic hypothermia after cardiac arrest is beneficial to improving neurologic morbidity after cardiac arrest.

UNMET NEED 1: A point of care technique to assist pre-hospital personnel in efficient and accurate diagnosis of the cause of cardiac arrest. This would be beneficial to implementing time-dependent therapies and triage to appropriate hospitals.

UNMET NEED 2: A point of care device that could accurately provide neurologic prognosis in a patient who has suffered a cardiac arrest. This information would be invaluable for counseling families, as well as resource utilization. If a test demonstrated that a patient would remain in a permanent vegetative state, this would be important information. Conversely, if a patient presents with a devastating exam, and a POC test indicated that the patient could obtain full recovery, this would validate resources used.

UNMET NEED 3: For unwitnessed arrests, a point of care device that could accurately pinpoint how long the patient was pulseless and apneic. This information is valuable to contribute to total anoxic time.

UNMET NEED 4: Patients treated with therapeutic hypothermia after cardiac arrest may be subjected to an iatrogenic coagulopathy. A point of care device that could predict those patients prone to coagulopathy during hypothermia treatment could help screen patients at risk for excessive bleeding during hypothermia.