Duodenal Atresia / Hypovolemic Shock: A Case for High-Fidelity Simulation in Emergency Medicine
|Case||8505||1||June 20, 2011|
This high-fidelity patient simulation case involves a 3 day old child with a diagnosis of duodenal atresia. Evaluation in the emergency department demonstrates a severely dehydrated neonate with a history of greenish/yellow emesis. Appropriate treatment with IV fluids will allow stabilization of the patient. Residents will also have to discuss the patient’s disposition with an attending pediatric surgeon. Debriefing materials are provided to illustrate and stimulate discussion of the important concepts for diagnosing and treating patients’ duodenal atresia and bilious emesis.
O'Neill J, Fitch M. Duodenal Atresia / Hypovolemic Shock: A Case for High-Fidelity Simulation in Emergency Medicine. MedEdPORTAL; 2011. Available from: www.mededportal.org/publication/8505
A. Primary Learning Objectives:
- To demonstrate an appropriate initial approach for a patient with hypovolemic shock and duodenal atresia.
- To identify and treat hypovolemic shock.
- To recognize a “double bubble” sign on radiograph.
- To list the diagnostic features of duodenal atresia.
- To understand the treatment of duodenal atresia with possible malrotation.
B. Secondary Goals:
- To differentiate between different causes of vomiting in a neonate.
- To understand the pathophysiology of duodenal atresia.
- To illustrate the emergency department disposition for a neonate with bilious emesis.
- Duodenal Atresia, Duodenal Obstruction (MeSH), Hypovolemic Shock, Intestinal Volvulus (MeSH), Newborn Infant (MeSH)
- Neonatal-Perinatal Medicine
- Pediatric Emergency Medicine
- Medical Knowledge
- Patient Care
- Systems-based Practice
- Clinical Sciences
- Clinical Exam
- Clinical Skills/Doctoring
- Evaluation of Clinical Performance
- Instructional Materials/Methods
- Professional School
- Medical Student
- Professional School Post-Graduate Training
- Problem-based Learning
Authors & Co-Authors
Wake Forest University School of Medicine
Michael Fitch, M.D.
Wake Forest University Baptist Medical Center
Effectiveness and Significance
- Number of participants – This scenario has been presented for small groups of 3-4 participants, and has been field tested approximately 12 times over the past 2 years. All participants have been 4th year medical students.
- Performance expectations – Our experience to date has been medical students are able to successfully negotiate this case. Several students have successfully diagnosed hypovolemic shock and related this to vomiting. Most others have successfully gone through the majority of the possible causes of an ill neonate. While many students are unfamiliar with how to do a complete workup of a neonate, after the discussion and with repetition the majority of participants felt more comfortable with the workup of a sick neonate.
Special Implementation Guidelines or Requirements
- Scenario flow – Instructors can directly influence the flow of the scenario by providing the initial patient history via both nursing report and mother’s verbal responses. One key aspect of the case flow is recognition of hypovolemic shock and rapidly correcting this with one or two fluid boluses. After this is accomplished the participant should be asked to verbalize an appropriate differential diagnosis of a sick neonate. The results of the x-ray should trigger a consultation with a pediatric surgeon.
- Information for actors – This case can easily be presented without formal “actors” and by using other participants to serve as the nursing staff or other collaborating physicians. Any specific actors used outside of participants should be briefed about the critical actions and anticipated flow of the case ahead of time.
- Scenario programming – The settings for a high-fidelity patient simulator are fairly straightforward for this scenario and do not require specific programming. Our program typically presents this scenario with the initial vital signs as presented above, with the major branch points to be the correction of hypovolemic shock and the diagnosis of duodenal atresia versus malrotation and midgut volvulus.
- Anticipated management mistakes:
a.) Failure to ask consultant to see the patient immediately – A number of students have failed to properly appreciate that the concern for midgut volvulus in the patient could be life threatening if not differentiated from duodenal atresia immediately.
b.) Confusion about the sick neonate workup – We found that a number of participants were not completely comfortable with the differential diagnosis of a sick neonate and did not complete a full workup of the patient. This included considering malrotation with volvulus, sepsis, cardiac abnormalities and thyroid dysfunction.
- Evaluation form for participants – Appendix C includes an evaluation form that can be used for this case.
This information is made available under the Creative Commons license.