Cardiac Arrest in an Adolescent with Pulmonary Embolism.

Audience: The target audience of this simulation is emergency medicine residents and medical students. The simulation is based on a real case of a 13-year-old female who presented with seizures and hypoxia and was ultimately diagnosed with pulmonary embolism. The case highlights diagnosis and management of an adolescent with new onset seizures, deterioration in status, and treatment options in pediatric cardiac arrest due to pulmonary embolism.

Background: Pulmonary embolism (PE) is an uncommon cause of hypoxia in children making diagnosis difficult. A study looking at 23 years of admission and autopsy data on children found the incidence of clinically significant pulmonary embolism to be 25 per 100,000.1 However, when children present to the emergency department with hypoxia and altered mental status, a diagnosis of pulmonary embolism cannot be excluded. Risk factors such as use of estrogen containing oral contraceptives, immobilization, and recent surgery should raise suspicion for pulmonary embolism in the clinically deteriorating adolescent patient.2,3.

Educational Objectives: By the end of the simulation, learners will be able to:1) develop a differential diagnosis for an adolescent presenting with hypoxia and seizure-like activity2) discuss the utility of bedside ultrasound in helping to differentiate causes of hypoxia3) discuss management of cardiac arrest due to PE in the pediatric patientSecondary learning objectives include:4) discuss indications for emergent use of thrombolytics and Extracorporeal Membrane Oxygenation (ECMO) while becoming aware of institution-based limitations5) demonstrate interpersonal communication with family, nursing, pharmacy, and consultants during high stress situations.

Educational Methods: This is a high-fidelity simulation that allows learners to manage the diagnosis and treatment of pulmonary embolism in an adolescent patient. Participants participated in a debriefing after the simulation.The effectiveness of this case was evaluated by surveys given to learners after debriefing. Learners gave quantitative and qualitative results of their feedback using a 1-5 rating scale and leaving written feedback. This case was performed with residents in their first and second years of training.

Results: Feedback was overall positive, with many of the residents giving the case high scores on effectiveness of the simulation in their education. They enjoyed the case and reported they would feel more comfortable in a comparable situation in the future.

Discussion: Pulmonary embolism is an uncommon but important diagnosis for emergency medicine physicians to consider in pediatric cardiac arrest. This case has multiple parts and was based on a real case in our emergency department in which a patient presenting with new seizure-like activity followed by cardiac arrest was ultimately diagnosed with a PE. The case was well received by our learners who felt it improved their identification of this diagnosis and its management.

Topics: Pulmonary embolism, oral contraceptives, altered mental status, pediatric, adolescent, cardiac arrest, ECMO, thrombolytic, hypoxia, emergency medicine, medical simulation.