9 Rapid Response Team Training

http://tulane.edu/som/sim/curriculum/rapidresponse.cfm

Scenario 1: Acute Myocardial Infarction

Mr. Roger Durkins is a 47 year old man with Type II diabetes and polycystic kidney disease and now three days post cadaveric
kidney transplant. Two years pre-op he had a cardiac catheterization with normal coronary arteries and normal left ventricular
function. Good renal function post-op was exhibited, and he was transferred out of the ICU 18 hours post-operatively.
Today, on post-op day three, at 0900, the patient called the nurse to complain of difficulty breathing and coughing. The nurse
observed a small amount of yellowish sputum and the following vital signs were obtained: pulse 90 and respirations 20,
temperature 37, BP 150/80.
At 0930, the patient was experiencing increased trouble breathing and the nurse was called again. Pulse oximetry showed SpO2
of 80%, and the nurse applied 6L o2 facemask with immediate improvement to SpO2 of 94%.
The intern was notified and ordered a stat EKG. The EKG has been obtained, and the report is on the chart. The EKG has not
been interpreted. Radiology is ready for the patient to be transported for a chest x-ray and a ventilation and perfusion (VQ)
scan. The nurse is now returning to put the patient onto a stretcher for the test.

Scenario 2: Ventricular Tachycardia

Mr. Steven Brown is a 55 year old male with known heart failure. He was transferred out of the Critical Care Unit to the medical
floor yesterday. He had an episode of chest pain relieved by one Nitroglycerine sublingual, and then develops shortness of
breath. You are now reassessing the patient after five minutes.

Scenario 3: Opioid Overdose

Ms. Jacqueline Hope is a 45 year old female with a history of subarachnoid henorrhage (SAH) and fall (with knee injury) one
year ago has completely recovered from her neurologic deficit. She had uncomplicated knee surgery yesterday. She has
complained of a lot of pain. Morphine IV 5mg every four hours was not effective in treating her pain last night. This morning at
4:00am, she was placed on a PCA with 1 mg/dose with an eight minute lockout interval with some improvement. At 9:00am,
Pain Service increased the PCA to a 2 mg/hour continuous infusion rate plus 2gm/dose with six minute lockout. It is now
11:30am and the family approached the nurses' station to notify the nurse that Ms. Hope would not wake up to eat for her lunch.
Scenario 4: Subarachnoid Hemorrhage

Ms. Stephanie Winters is a 55 year old female with a history of atrial fibrillation who was admitted yesterday with syncope and
fall. She fractured her upper arm and hip. The arm has a closed reduction, the hip an open reduction internal fixation
(ORIF). Last night she had pain and rapid ventricular response to her atrial fibrillation with rates up to 160. She was treated with
Dilaudid PCA, 0.3 mg/dose every six minutes after loading with a total of Dilaudid. She was also treated with 5 mg of
Metoprolol, with control of the ventricular response to 110. The family approached the nurses' station to notify the nurse that
Ms. Winters would not wake up to eat her lunch.
Scenario 5: Ventricular Fibrillation Arrest
Ms. Anita Hart is newly admitted on a medical floor at change of shift. The nurse is per diem and seeing the patient for the initial
admission assessment.

Scenario 6: Null
Mr. Donald Wilson is a 79 year old man with a history of COPD, CHF, and prostate cancer. He was admitted two days ago for
respiratory and mental status depression due to hypercalcemia. He has been rehydrated with normal saline and has had a total
urine output of three liters over the past two days. He was given Palmidronate to reduce his serum calcium level. His creatinine
was elevated at 3.1 on admission, but had improved yesterday to 2.4 Today's labs are pending.
Last night, the nurse reported that the patient was confused, and sundowning. He was given Diphenhydramine by the house
officer and the patient settled down. This morning the nursing assistant reports that the patient did not respond when she arrived
to take his vital signs.
Scenario 7: Post Operative Bleed
Mrs. Sheila Taylor is a 78 year old woman with a history of peripheral vascular disease, smoking, Type 2 diabetes, and distant
history of breast cancer treated with bilateral mastectomies, radiation, and hormonal therapy. She was admitted two days ago for
repair of an abdominal aortic aneurysm (AAA), which during surgery was found to be leaking. In the first few hours after
surgery, the patient had surgical wound oozing, which resolved after two units of fresh frozen plasma (FFP) were given. The
post-op EKG was negative, and she has had negative troponin levels. It is post-op day one, and this morning she felt weak. Her
blood pressure was normal, but she was tachycardic to 120 (up from her peri-operative baseline of 95). Her condition was
otherwise normal. One hour later, the nurse is responding to a pulse oximeter alarm.
This morning, her creatinine is elevated at 3.1, and her international normalized ratio (INR) is 1.9. Her hematocrit is 24; it was
28 yesterday. Capillary blood glucose readings have been in the 200's. She is on a 20 unit sliding scale every six hours, which
was increased last night to 28 units with capillary blood glucose testing ordered every four hours.
Scenario 8: Pulseless Electrical Activity
Mr. Michael Cooper is a 74 year old man with a history of COPD, CAD, CABG five days ago, CHF, and prostate cancer. He
was admitted six days ago for elective CAGB x four vessels, which was complicated by difficulty weaning from mechanical

ventilation for two days post-op. He was weaned on post-op day two and observed in the ICU for another day due to elevated
respiratory rates. He was transferred to a step down unit yesterday. He had been diuresed four liters over the last two days.
Today the patient developed a fever of 38.6 degrees C, tachypnea to a rate of 26, and tachycardia to 120. His creatinine increased
from 1.2 pre-op to 1.7 today. Due to the fever, blood cultures were drawn, Acetaminophen was given, Piperacillin/Tazobactam
(Zosyn) was started, and his central line was removed. A new right internal jugular triple lumen catheter was inserted. An EKG
showed sinus tachycardia. ABG showed a mild respiratory and metabolic alkalosis, with adequate oxygenation on six liters nasal
cannula. The chest x-ray is performed and available, but not interpreted. The nurse is responding to the alarms in the patient
room.
Scenario 9: Do Not Resuscitate
Mrs. Denise Shaler is on a medical floor. House staffs know the patient and the nurse is per diem.
Scenario 10:
Participants are not provided any information prior to the start of the scenario.

http://tulane.edu/som/sim/curriculum/procedure-videos.cfm