Simulation in Acute Neurology

Sara E. Hocker, Eelco F. M. Wijdicks

• Publisher: Elsevier
• Year: 2018
• ISBN:
  9780323551359
• Topic: Medicine
• Subtopic: Neurology

Simulation in Acute Neurology is a reference on the execution of a simulation-based educational program in the management of acute neurologic emergencies. Simulation inAcute Neurology has practical value because it contains detailed descriptions of our simulation scenarios. The foundation of this book is our experience with neurosimulation?and it has been a very good one

Part I provides an overview of the principles of simulation in medicine and examines the many unique opportunities simulation provides as an educational tool. Barriers to simulating neurologic emergencies are also discussed. Simulation allows a physician-in-training to be observed directly as he or she evaluates and manages acute neurologic disease.

Part II is the core of the book. Fifteen acute neurologic emergencies, including complex neuroethical quandaries, are presented in detail, step by step, decision by decision, error after error. Each chapter in this section starts with an explanation of the essence of the discussed neuroemergency (THE PROBLEM BEFORE US), followed by a description of the scenario itself (THE PRESENTING CLINICAL PROBLEM), how scenarios can be adjusted to different types of learners (ADAPTING THE SCENARIO), and ends with a discussion of topics for feedback, which are generally focused around errors and pitfalls (DEBRIEFING). To show the flow of scenarios, we created two additional main headings: (THE IDEAL LEARNER) and (THE NOT-SO IDEAL LEARNER).

Section II

Teaching Scenarios

Outline

Chapter 4. Simulating Traumatic Brain Injury

Chapter 5. Simulating Acute Carotid Artery Occlusion

Chapter 6. Simulating Basilar Artery Occlusion

Chapter 7. Simulating Aneurysmal Subarachnoid Hemorrhage

Chapter 8. Simulating Delayed Cerebral Ischemia

Chapter 9. Simulating Cerebral Venous Thrombosis

Chapter 10. Simulating Coma of Unknown Cause

Chapter 11. Simulating Neuromuscular Respiratory Failure

Chapter 12. Simulating Status Epilepticus

Chapter 13. Simulating Encephalitis

Chapter 14. Simulating Acute Spinal Cord Compression

Chapter 15. Simulating Acute Bacterial Meningitis

Chapter 16. Simulating Posterior Reversible Encephalopathy Syndrome

Chapter 17. Simulating Brain Death

Chapter 18. Simulating Problematic Family Conferences

Chapter 4

Simulating Traumatic Brain Injury

Abstract

Any curriculum on simulation of trauma needs inclusion of traumatic brain and spine injury. Most programs have concentrated on early triage, but the priorities of action, interpretation of neuroimaging, and brain-protection strategies are even more important and can be simulated in a realistic fashion. The objectives in the acute neurology scenario should include (1) stabilization of the cervical spine, (2) correction of hypotension, (3) correction of hypoxemia, (4) interpretation of CT scan, (5) treatment of increased intracranial pressure, (6) anticipating risk of deterioration, and (7) indications for neurosurgical procedures. Teamwork is common in any level I trauma center and can be taught.

Keywords

Deterioration; Neurosurgery; Osmotic diuretics; Traumatic brain injury

Traumatic brain injury (TBI) is seen by multiple disciplines, often starting in the emergency department, and its presentation to emergency departments can trigger involvement of trauma surgeons, neurosurgeons, and neurointensivists. Priorities of care are determined by the type and severity of injury and cause of the decline in vital signs.

Simulation in trauma—polytrauma in particular—is well established as an educational model, and current simulation centers are offering sophisticated scenarios for training. Healthcare worker from multiple disciplines have gone through these training sessions, which have led to improved knowledge and skills in team management of any type of severe trauma.¹ As most previous simulation studies have discovered, training of trauma teams using simulation improves most learners' ability to recognize the need for procedures and hones the skills necessary to perform these procedures, but there is yet no evidence to support improvement in clinical parameters.² Most evaluations of simulation of trauma have only shown that simulation scenarios can improve teamwork coordination, which could theoretically help the patient.^3,4 Experience on simulating TBI and using brain-protection strategies could be further developed.

Management of TBI has multiple tiers and goals that must be achieved within the first 12 h.^5,6 The principles of early management of TBI in the emergency department remain fairly established, and regularly revised guidelines have been proposed by multiple organizations.^7,8 These guidelines—providing the necessities of brain protection—can readily be a basis for scenario development. In this chapter, we describe a simulation scenario that highlights the initial management, correction of vital signs, and reasoned approach to increased intracranial pressure.

The Problem Before Us

TBI can occur in the setting of polytrauma or in isolation. Both are equally important, but TBI is often overshadowed by polytrauma and emergent surgical interventions needed to, frankly, save the patient's life. Often, assessment will have already begun in the field at the site of the accident. There, acute management of TBI is initially performed by paramedic units. Severe trauma is always anticipated, particularly if the patient has been extracted from a serious car wreck.

Many patients with severe TBI come to the emergency department with a decreased level of consciousness or deteriorate soon after arrival (the so-called “walk, talk, and deteriorate” category). For attending physicians, it is important to realize immediately that no patient with TBI is truly stable or, indeed, anything less than serious and that the clinical situation can change rapidly from probl...