Case 慈恵医大 No. 2 (For instructor)
RRS: Declining consciousness due to sepsis

1. Scenario Concept
Urinary tract infections (UTIs) are considered to be the most common
bacterial infection. According to the 1997 National Ambulatory Medical
Care Survey and National Hospital Ambulatory Medical Care Survey, UTI
accounted for nearly 7 million office visits and 1 million emergency
department visits, resulting in 100,000 hospitalizations. Infectious
condition could progress to shock and CPA if not response immediately.
In this scenario, it represented a diabetic male admission to general wardwith UTI. Conscious change and sepsis are needed to be observed andprompt treatment and RRS activation are practiced.

2. Education Purpose Identify respiratory pattern and desaturation and provide treatment
 Activate RRS promptly according to RRS activation criteria
 Perform communication with SBAR
(Situation-Background-Assessment-Recommendation) skill for RSS
staff

3. Patient backgroundA 57-year-old man was hospitalized yesterday for pyelonephritis.
Originally insulin was given in the morning, but he hoped waiting for wife
to have breakfast. Till his wife coming, she reported the nurse that theappearance is strange.

4. Observation and debriefing
Initiate assessment
Identify consciousness level and neurologic examination
Perform further examination and first treatment

Inform nurses and activate RRS

5. Hardware preparedness□ Resuscitation kit□ IV fluid and IV setting□ Oxygen devise: nasal cannula, simple mask, ventri mask,
non-rebreathing mask, bag-valve-mask□ EKG monitor, BP monitor□ The simulator manikin: SimMan□ Medication: Dextrose 50%

6. Scenario staging
Scenario Phase 1 ( 0-3 minutes)□ Initial vital sign: HR 120 /minutes, BP 100 / 60 mmHg, RR 20 /minutes, Temperature: 39 oC, Consciousness: E1 V2 M4 , SpO2: 98 %(Room air)
□ Volunteered information: A 57-year-old man was hospitalized
yesterday for acute pyelonephritis. Insulin was given before
breakfast. But the patient hope to eat after his wife arrival. On hiswife arrival, she reported to the nurse that the appearance isstrange.
□ Manikin setting: Initial vital sign: HR 120 /minutes, BP 100 / 60 mmHg, RR 20/ minutes, Temperature: 39 oC, Consciousness: E1 V2 M4 , SpO2:
98 % (Room air) Pupils: 3mm/ 3mm, light reflex: +/+ Voice: moaning EKG: sinus tachycardia, rate: 120 /minutes
 Chest: bilateral clear breathing sound Heart: clear
 Abdomen: WNL
 Extremities: warm
 Pulse pressure: strong
 Finger sugar: LOW□ Treatment: Check vital sign Primary airway, breathing, circulation, and defib (ABCD) survey
 Arrange Teamwork (leader, mutual support, communication,situation monitor) Set O2, IV, monitor (EKG, BP, pulse oximeter) Activation RRS according to consciousness change (GCSdecreased> 2 points)
 Medication:
 Dextrose 50% 20ml

Scenario Phase 2 (3-6 minutes)□ Vital sign: HR 136 /minute, BP 90 / 60 mmHg, RR 40 / minute,Temperature: 39.5 oC, Consciousness: E2 V3 M5, SpO2: 98 % (Roomair)□ Volunteered information: After glucose given, the consciousness
improved partially□ Manikin setting: EKG: sinus tachycardia , rate: 136 /minutes
 Vital sign: HR 136 /minute, BP 90 / 60 mmHg, RR 40/ minute,Temperature: 39.5 oC, SpO2: 98 %□ Treatment:
 Quick re-assess ABCD
 Activation RRS according to consciousness change (increasedrespiratory rate and heart rate) Arterial blood gas
 Complete EKG
 Sugar recheck 200
 Give normal saline hydration

7. Image and Laboratory data
□ Arterial blood gas
Lab
pHPCO2
HCO3

Data
7.38
38
20Normal
7.36 - 7.44
36 - 44 mm Hg
22 - 26 mEq/L

8. Task checklist□ Recognize symptoms associated with sepsis□ Use SBAR to make appropriate reports to RRSNs.
□□□□□□

Check vital sign
Take a medical record
Evaluation of Consciousness
Evaluation of airway / respiration
Evaluation of circulation
Application of monitor (AED or defibrillator)□ Move the bed and remove the head board and side fence ifnecessary□ Perform ventilation support by using oxygen advice or BVM ifnecessary□ Secure infusion route and start fluid infusion□ Blood sampling and search for cause of lower consciousness level(hypoglycemia etc.)□ Re-evaluate patient condition