A patient in acute respiratory distress tests the ability to rapidly recognize the underlying cause and implement appropriate interventions. This is a scenario script of dyspnea with acute pulmonary edema for PGY3-5 emergency medicine residents.
Clinical Impact of Delayed/Mismanaged Pulmonary Edema
- Progression to respiratory failure and mechanical ventilation
- Development of complications like aspiration pneumonia
- Increased risk of cardiovascular complications and shock
- Higher mortality rates, especially in elderly patients
- Longer ICU stays and increased ventilator days
- Delayed discharge and poorer long-term outcomes
Acute Pulmonary Edema Medical Simulation Scenario
A 68 yo male/female has just been brought into the emergency department by EMS with shortness of breath (dyspnea). He has a history of myocardial infarction and coronary artery bypass graft (CABG) 6 years ago. He woke from his sleep at 5AM with dyspnea…worsening on route despite O2 in ambulance.
The scenario challenges learners to recognize the signs of acute cardiogenic pulmonary edema, initiate appropriate non-invasive ventilatory support, and determine the appropriate timing for endotracheal intubation.
Download the Dyspnea With Pulmonary Edema scenario script for free via the link below
On ‘theSimTech’ website in the Medical Simulation Scenarios section (Scroll to 20a. Dyspnea #1)
Includes
- Patient Case Documents – EKG/ECG, X-Ray
- Scenario Development Template
- Scenario Flow
Target Audience and Learning Objectives
This simulation scenario is specifically designed for PGY3-5 emergency medicine residents, though it can be adapted for:
- Internal medicine residents
- Critical care fellows
- Nurse practitioners and physician assistants
The scenario aims to achieve several key educational objectives:
- Recognition and assessment of acute pulmonary edema
- Management of non-invasive positive pressure ventilation (NIPPV)
- Indications and techniques for endotracheal intubation
- Hemodynamic management of the patient with pulmonary edema
- Effective communication and teamwork within the resuscitation team
Scenario Preparation Checklist
- Equipment Setup:
- Vital signs monitoring
- Oxygen delivery devices (NRB, CPAP/BiPAP)
- Airway management equipment (BVM, laryngoscopes, ETT)
- Vasopressor medications (phenylephrine)
- Infusion pumps for IV nitrates
- Staff Roles:
- Respiratory therapist
- Registered nurse
- Senior resident (optional)
- Simulation technician
- Documentation:
- Laboratory results showing metabolic acidosis (pH 7.21, pCO2 53, HCO3 25)
- Chest X-ray demonstrating pulmonary edema
- ECG with LBBB
- Troponin I elevated at 0.095
Key Timeline Events
- 0:00 – Initial presentation: Tachypneic, hypoxic, hypertensive
- 0:05 – Initiation of NIPPV (BiPAP) and IV nitrates
- 0:10 – Worsening respiratory status, decision to intubate
- 0:15 – Successful intubation, hypotension requiring pressors
Critical Decision Points
- Recognition of acute pulmonary edema
- Initiation of NIPPV
- Timing of endotracheal intubation
- Hemodynamic management with IV nitrates
- Choosing vasopressor for post-intubation hypotension
Special Considerations
The scenario includes specific institutional limitations that add realism:
- Restriction on immediate availability of mechanical ventilators
- Single-unit blood product ordering policy
- Limited access to certain medications outside the ICU
Debriefing Guidelines
Structure your debrief around:
- Emotional Processing:
- “How did you feel about the patient’s rapid deterioration?”
- “What concerns did you have about the intubation process?”
- Clinical Decision-Making:
- Rationale for NIPPV vs. immediate intubation
- Titration of IV nitrate infusion
- Choice of vasopressor for post-intubation hypotension
- Team Dynamics:
- Communication with the respiratory therapist
- Delegation of tasks during the resuscitation
- Managing family/partner expectations
- Learning Points:
- Review of acute pulmonary edema pathophysiology
- Indications and techniques for NIPPV
- Approach to intubation in pulmonary edema
- Hemodynamic management strategies
Note: While this scenario is freely available, educators should always review and adapt materials to meet their specific institutional guidelines and educational objectives.
Tips for Successful Implementation
- Pre-scenario:
- Ensure all equipment is functional and available
- Brief confederate staff on their roles and expected responses
- Review current guidelines for the management of acute pulmonary edema
- During scenario:
- Allow appropriate time for decision-making
- Use progressive vital sign changes to drive learner actions
- Document key interventions for debriefing discussion
- Post-scenario:
- Focus on achieving the defined learning objectives
- Encourage self-reflection and provide specific, actionable feedback
- Discuss the integration of simulation-based learning into clinical practice
Why This Resource Matters To Healthcare Educators
This simulation scenario stands out for several reasons:
- Comprehensive Design: The scenario incorporates multiple aspects of patient care, from initial assessment to critical care management.
- Reality-Based Challenges: Institutional limitations built into the scenario mirror real-world constraints healthcare providers face.
- Structured Learning: Clear objectives and performance metrics allow for standardized evaluation and feedback.
- Flexibility: The scenario can be modified based on learner level and specific educational needs.
The acute pulmonary edema simulation scenario represents a valuable addition to any healthcare simulation program. Its well-structured design, comprehensive documentation, and clear learning objectives make it an excellent tool for developing clinical competence in managing critical respiratory emergencies.
Healthcare educators will find this resource particularly useful for its ready-to-use editable format and potential for customization. The scenario’s attention to institutional limitations and team dynamics adds an extra layer of realism that prepares learners for actual clinical practice.
Supporting Information
Acute Pulmonary Edema
Acute pulmonary edema is a life-threatening condition characterized by the rapid accumulation of fluid in the lungs, often due to left ventricular dysfunction or acute decompensated heart failure. Patients typically present with severe shortness of breath, cough, and crackles on lung examination.
Key Pathophysiology
- Increased hydrostatic pressure in the pulmonary capillaries
- Impaired fluid clearance mechanisms in the lungs
- Disruption of the alveolar-capillary barrier
Risk Factors
- Myocardial infarction
- Heart failure
- Hypertension
- Valvular heart disease
- Renal dysfunction
- Fluid overload
Management Principles
- Supplemental oxygen
- Diuretics
- Vasodilators (e.g., nitroglycerin)
- Noninvasive positive pressure ventilation (NIPPV)
- Invasive mechanical ventilation (if NIPPV fails)
- Treatment of underlying cause
Download the Dyspnea With Pulmonary Edema scenario script for free via the link below
On ‘theSimTech’ website in the Medical Simulation Scenarios section (Scroll to 20a. Dyspnea #1)
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