Dysrhythmia Secondary to Hyperkalemia

This case is written by Dr. Kyla Caners. She is a PGY5 emergency medicine resident at McMaster University and has previously completed a fellowship in simulation and medical education. She is also one of the editors-in-chief here are EMSimCases.

Why it Matters

When studied in isolation, the ECG findings of hyperkalemia can seem straight-forward. However, placed out of context, the recognition of severe hyperkalemia on ECG can be quite challenging. This case highlights a few important points:

  • Hyperkalemia should be suspected as a possible cause of almost any symptom in a hemodialysis-dependent patient
  • Recognizing hyperkalemia on ECG allows for the critical intervention of administering calcium gluconate
  • ACLS should be modified in hyperkalemia to include aggressive calcium chloride and bicarbonate administration in an attempt to correct the underlying cause of cardiac arrest

Clinical Vignette

Geoff is a 52 year old male who is brought to the ED by EMS as a STEMI activation. He is not having chest pain, but has been feeling weak and dizzy today. He is diabetic and hypertensive and was started on hemodialysis 3 months ago for ESRD. He missed dialysis on the weekend for the first time so that he could attend his niece’s wedding.

Case Summary

A 52 year-old male with end-stage renal disease (requiring dialysis) is brought in by EMS feeling weak and dizzy. He missed dialysis for the first time over the weekend to attend his niece’s wedding. On presentation, his heart rate is 50 and his ECG demonstrates a wide complex rhythm with peaked T waves that EMS interprets as a STEMI. If the team recognizes the possibility of hyperkalemia and treats it appropriately, the patient’s QRS will narrow. If the hyperkalemia is not recognized, the patient will arrest.

Download the case here: Hyperkalemia Case

1st ECG for the case found here:

Hyperkalemia STEMI mimic

(ECG source: http://lifeinthefastlane.com/ecg-library/basics/hyperkalaemia/)

2nd ECG for the case found here:

normal-sinus-rhythm

(ECG source: : http://cdn.lifeinthefastlane.com/wp-content/uploads/2011/12/normal-sinus-rhythm.jpg)

How to develop targeted simulation learning objectives – Part 2: The Practice

In part 1 of this two part series (https://emsimcases.com/2015/04/21/how-to-develop-targeted-simulation-learning-objectives-part-1-the-theory/), we used the revised Bloom’s taxonomy to describe an approach to developing simulation-based learning objectives by targeting a specific, complex knowledge domain and a higher level cognitive process.

Now that we know the theory behind making targeted simulation learning objectives, what kind of learning objectives should be included in a team-based resuscitation simulation scenario?

Team based simulation can be used to learn and assess a variety of different components of resuscitation skills. These simulated events display the knowledge, skills and attitudes of learners in a controlled setting. What makes simulation different from other traditional models of learning is that it combines components of crisis resource management (CRM) with medical knowledge and skills into a complex educational event. Keeping this in mind, while developing objectives for a simulated scenario, it helps to separate the CRM and medical knowledge objectives. A separation of these two key components allows for targeted feedback directed at specific areas of the learners’ performance and aids in their assessment.

A common pitfall in the development of objectives for a simulated case is including too many of them! While there are a multitude of soft skills as well as medical decisions being made during the simulated event, both the learners and assessors benefit from having a limited amount of clear objectives. Debriefing after a simulation is critical for the learning experience and having too many objectives may dilute the main teaching points of the case. As an example, at the McGill University Emergency Medicine residency program, we aim for 2 CRM based objectives and 3 medical knowledge objectives. While this is in no way the rule, we have found that tailoring the case to a smaller number of clear and well-developed objectives allows for productive and high yield debriefing sessions.

Learning Objectives for a Tricyclic Antidepressant Overdose Case

Learning Objectives for a Tricyclic Antidepressant Overdose Case

As discussed in a previous post (https://emsimcases.com/2015/04/07/crisis-resource-management/), the main components of CRM include communication, leadership, resource utilization, situational awareness and problem solving.1 A case can be specifically tailored toward a CRM objective or vice versa. For example, an objective focusing on resource utilization and triage can guide the development of a simulated case with two patients in a resource-limited setting. Conversely, a simulated STEMI case can include an objective focusing on leadership and the team leader maintaining a global perspective of the case. There are no guidelines on which CRM based objectives to include, but ensuring that your cases utilize different CRM components allows your learners to focus on a few important skills at a time and ensures that your learners are exposed to each component of CRM in a simulated setting.

Medical objectives encompass the core medical content that the simulated case was designed to address. When developing the medical objective, remember to focus on a higher cognitive process, such as “applying” over “remembering”, and a higher-level knowledge domain, such as “procedural knowledge” that includes skills and algorithms. Again, there is no limit to what medical objectives you can include, as long as they are well developed and specific. When developing the medical objective for the case, it may help to take a step back and ask yourself “what do I want my learners to take away from this case?” It also helps to consider the training level of the learners, where simulation fits within your full educational curriculum as well as your setting and to develop the objectives accordingly. As an example, an airway case may contain an objective on the choice of an induction and paralytic agent for intubation for junior learners, whereas an objective on a “can’t intubate, can’t ventilate” situation may be more suitable for senior learners.

Defining learning objectives for your simulated scenarios is key for case development, debriefing and, ultimately, learning. Using theory, we can create targeted objectives that optimize the learning time spent in the simulated setting. Breaking up the objectives into CRM and medical knowledge while limiting the total number of objectives can help focus both the learner and educator on the teaching points from the case. Through careful consideration of learning objective development, simulation can be used to both fill potential gaps in you educational curriculum and to enhance the resuscitation skills, CRM skills and medical knowledge of your learners.

Take Home Points

1) Divide simulation objectives into CRM or medical objectives

2) Limit the number of objectives for each case

3) Apply theory to develop targeted and specific objectives to align them with the teaching strategy of simulation

4) Diversify your CRM objectives throughout your simulation curriculum

5) For medical objectives, ask yourself “what do I want my learners to take away from this case?”

6) Consider the training level, full training curriculum and setting when developing medical objectives.

  1. 1) Hicks CM, Kiss A, Bandiera GW, Denny CJ. Crisis Resources for Emergency Workers (CREW II): Results of a pilot study and simulation-based crisis resource management course for emergency medicine residents. Can J Emerg Med. 2012;14(Crew Ii):354-362. doi:10.2310/8000.2012.120580.

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The EM Sim Cases Team