An Appy That Needs Epi: An Atypical Presentation of Anaphylaxis

Ryan O’Neill; Cyrus Adeli; Christopher E San Miguel

doi:10.21980/J80H14

. 2024 Jan 31;9(1):S1–S41. doi: 10.21980/J80H14

An Appy That Needs Epi: An Atypical Presentation of Anaphylaxis

Ryan O’Neill ^*, Cyrus Adeli ^{^}, Christopher E San Miguel ^*,^✉

PMCID: PMC10854882 PMID: 38344051

Abstract

Audience

This simulation is intended for 4^th year medical students.

Background

Shock is the result of inadequate circulation and failure to perfuse tissues, leading to cellular and organ dysfunction.1 Anaphylactic shock specifically is a type of distributive shock secondary to an IgE (immunoglobulin E) dependent reaction, which can result in respiratory compromise and cardiovascular collapse. The National Institute of Allergy and Infectious Diseases/Food Allergy and Anaphylaxis Network (NIAID/FAAN) laid out three diagnostic criteria for the diagnosis of anaphylaxis. Fulfillment of any one of the three following criteria likely indicates anaphylaxis: 1) acute onset of illness with skin findings and either respiratory compromise or reduced blood pressure, 2) involvement of two or more organ systems after exposure to a likely allergen, 3) reduced blood pressure after exposure to a known allergen.2 While not a required component of the pathology, hives and cutaneous findings often prompt clinicians to consider anaphylaxis in their differential diagnosis. However, skin findings are absent in 10–20% of cases of anaphylaxis.3 It is therefore important for physicians to quickly recognize anaphylactic shock and begin appropriate management in a timely manner even in the absence of skin findings. A previous study of fatal anaphylactic reactions showed a median time to respiratory or cardiac arrest as 30 minutes for foods, 15 minutes for envenomations, and five minutes for iatrogenic reactions.4 Drugs are the most common reported cause of fatal anaphylaxis in the United States,5 and penicillin allergy is the most common drug allergy reported by patients.6 This simulation will help learners recognize an atypical presentation of anaphylactic shock, encourage them to consider anaphylaxis in their differential diagnosis for decompensated patients, and reinforce the correct management of anaphylaxis.

Educational Objectives

At the conclusion of the simulation, learners will be able to: 1) demonstrate ability to efficiently review patient records to optimize patient care and identify relevant details to current presentation, 2) rapidly assess a patient when there is a change in clinical status, 3) recognize the need to start resuscitative fluids for undifferentiated hypotension, 4) identify anaphylaxis, 5) demonstrate the medical management of anaphylaxis, 6) utilize the I-PASS framework to communicate with the inpatient team during the transition of care.

Educational Methods

This summative simulation was designed to assess competence in two of the core Entrustable Professional Activities (EPAs), as defined by the Association of American Medical Colleges (AAMC). These include EPA 8 (Give or Receive a Patient Handover to Transition Care Responsibility) and EPA 10 (Recognize a Patient Requiring Urgent or Emergent Care and Initiate Evaluation and Management). It was performed with 4^th year medical students at the conclusion of their month-long emergency medicine (EM) clerkship. This scenario joined seven other scenarios in our pool of potential cases. These sessions are conducted using a high-fidelity manikin as the patient and a confederate/actor in the nursing role. After each scenario concludes, there is a post-simulation debriefing session on the presentation, differential diagnosis, physical exam findings, and management of the target pathology. A Gather-Analyze-Summarize technique was used for the debriefing session.7

Research Methods

Facilitators provided informal feedback to the scenario developers after the case was introduced into the assessment rotation. Learners completed a standard evaluation issued by the College of Medicine for the entire session, rather than for individual scenarios. These evaluations were reviewed in aggregate for the first year of implementation. Over this time frame, approximately half the students were run through this scenario.

Results

Overall, our facilitators felt the case fit well into our pool of simulation cases. They felt they were adequately able to assess the students’ ability to respond to a decompensating patient and thought the difficulty level was appropriate for 4^th year medical students. The simulation assessment exercise as a whole was highly rated by the students. Of the 198 students who completed an evaluation, 93% rated the overall quality of the session as Very Good or Excellent.

Discussion

Our department has run formative simulations during the 4^th year EM clerkship for over ten years. Our primary objective is to assess 4^th year students’ competence in EPA 10 (Recognize a Patient Requiring Urgent or Emergent Care and Initiate Evaluation and Management). This case was developed to replace another scenario of anaphylaxis which was felt to be too straightforward and easier than other scenarios in our repertoire. By making the scenario more difficult and the presentation of anaphylaxis a bit atypical, we were able to reinforce the need to include anaphylaxis in the differential diagnosis for any patient who rapidly decompensates. We are also able to review the diagnostic criteria for anaphylaxis and the appropriate treatment, including stopping the exposure to the antigen. This simulation proved to be highly engaging for 4^th year medical students, and students seemed to perform at a similar level as previous summative simulations. Overall, we felt this simulation successfully achieved the objectives of the simulation session as a whole, and it was integrated into our 4^th year EM clerkship simulation curriculum.

Topics

Medical simulation, emergency medicine, anaphylaxis, anaphylactic shock, allergic reaction, penicillin allergy.

USER GUIDE

List of Resources:
Abstract	1
User Guide	3
Instructor Materials	5
Operator Materials	22
Debriefing and Evaluation Pearls	29
Simulation Assessment	33
Simulation EPA Assessment	38

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Learner Audience:

Medical Students

Time Required for Implementation:

Instructor Preparation: 10 minutes

Time for case: 15 minutes

Time for debriefing: 20 minutes

Recommended Number of Learners per Instructor:

3–4

Topics:

Medical simulation, emergency medicine, anaphylaxis, anaphylactic shock, allergic reaction, penicillin allergy.

Objectives:

At the conclusion of this simulation, learners will be able to:

Demonstrate ability to efficiently review patient records to optimize patient care and identify relevant details to current presentation
Rapidly assess a patient when there is a change in clinical status
Recognize the need to start resuscitative fluids for undifferentiated hypotension
Identify anaphylaxis
Demonstrate the medical management of anaphylaxis, including:
1. Stop the offending agent (piperacillin/tazobactam)
2. Administer IM epinephrine
3. Provide supportive care
Utilize the I-PASS framework to communicate with the inpatient team during the transition of care

Linked objectives and methods

Anaphylaxis is a life-threatening and time-sensitive form of shock requiring rapid diagnosis and appropriate management. Learners will be given prior documentation on the patient and have the opportunity to identify relevant details to the current presentation (Objective 1). The patient’s clinical status will change from his initial presentation, enabling learners to initiate assessment of a patient in response to this change (Objective 2). As the patient begins to develop hemodynamic instability, the learners will need to recognize the need to start resuscitative fluids while determining the etiology of the patient’s hypotension. (Objective 3). The learners will then have to identify the presentation of anaphylaxis (Objective 4) and initiate the appropriate treatment (Objective 5). Finally, learners will need to update the admitting team utilizing the IPASS framework (Objective 6).

This scenario has also been designed to assess competence in two of the core Entrustable Professional Activities (EPAs), as defined by the Association of American Medical Colleges (AAMC). These include EPA 8 (Give or Receive a Patient Handover to Transition Care Responsibility) and EPA 10 (Recognize a Patient Requiring Urgent or Emergent Care and Initiate Evaluation and Management). These objectives were tracked by facilitators utilizing an institution-specific EPA evaluation form which is provided as Appendix A. Facilitators used this form to observe critical actions, mark performance, and take notes during the simulation for further discussion during debriefing.

This scenario joined seven other scenarios in our pool of potential cases. At the end of each four-week clerkship, the learners are split into groups of three or four, and they complete three or four simulation scenarios as a team with each learner serving as the team leader once. These sessions are conducted using a high-fidelity manikin as the patient and a confederate/actor in the nursing role. After each scenario concludes, there is a post-simulation debriefing session on the presentation, differential diagnosis, physical exam findings, and management of the target pathology, with this case being anaphylaxis. A Gather-Analyze-Summarize technique was used for the debriefing session.7

Recommended pre-reading for instructor

The instructors should familiarize themselves with the National Institute of Allergy and Infectious Diseases/Food Allergy and Anaphylaxis Network (NIAID/FAAN) diagnostic criteria for anaphylaxis.2 They should also review the consensus treatment for anaphylaxis. One good resource for this would be the chapter “Allergy, Hypersensitivity, and Anaphylaxis” from the 9^th edition of Rosen’s Emergency Medicine: Concepts and Clinical Practice.8 Suggested readings include materials listed below in the “References/suggestions for further reading” section.

Results and tips for successful implementation

This scenario was developed specifically to replace another case of anaphylaxis. In the previous scenario, a patient with a known bee allergy presented to the emergency department with a rash after a bee sting that then progressed to anaphylaxis. The general consensus among facilitators was that the old case did not appropriately challenge learners because the diagnosis was much clearer than in our other simulation scenarios. In order to avoid this same problem, we intentionally did not use moulage to simulate urticaria and only allowed the patient to report mild tongue swelling if specifically asked about this symptom. Since 10–20% of anaphylaxis cases do not involve cutaneous findings, we regarded this atypical presentation as an important learning point rather than an unfair withholding of information from the learners.3

Prior to using this scenario as a summative assessment, we ran two rehearsal sessions. The first involved an emergency medicine intern as the sole learner. Initially, the case was written for a patient with no known drug allergies. This seemed to make the scenario significantly more difficult. Based on the first trial run and feedback from experienced facilitators, we decided to include an amoxicillin allergy in the patient’s medical record and include it in the patient’s script if specifically asked about allergies by the learners. The second rehearsal included a group of three 4^th year medical students who volunteered to complete an additional simulation case after the completion of their summative simulation session. This group felt the case was similar to the other three scenarios they were given that day and had equally valuable learning points. No substantial changes were made to the case after this second trial run.

Since implementation over a year ago, our facilitators feel the case fits well into our pool of simulation cases. They report being able to adequately assess the students’ ability to respond to a decompensating patient and think the difficulty level is appropriate for 4^th year medical students.

As previously described, all 4^th year medical students complete a simulation session consisting of three to four scenarios at the conclusion of the EM clerkship. Students are asked to assess the simulation session as a whole, using a standard evaluation form from the College of Medicine. In its first year of use, approximately half of the 4^th year students completed the anaphylaxis scenario as part of their simulation session. The simulation session as a whole is highly rated by the students. Of the 198 students who completed an evaluation, 93% rated the overall quality of the session as “very good” or “excellent.” None of the collected comments explicitly mentioned the anaphylaxis case.

Supplementary Information

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INSTRUCTOR MATERIALS

Case Title: Penicillin-Induced Anaphylaxis

Case Description & Diagnosis (short synopsis): This scenario presents an atypical case of anaphylaxis. This case involves an established ED patient with a known diagnosis of appendicitis that the learners receive in sign out. The scenario begins after the patient has been diagnosed with appendicitis, started on piperacillin/tazobactam, and is waiting to go to the operating room. While the initial complaint of not feeling well, nausea, and right lower quadrant (RLQ) abdominal pain could be caused by worsening appendicitis, the patient will have wheezing, which will exacerbate throughout the case. This, along with the rapidity of clinical decline, is the key aspect leading to the correct diagnosis. With tongue swelling (which will likely be difficult for learners to appreciate on the manikin), wheezing, dry heaving, and hypotension, there is clear indication for the use of epinephrine. The offending agent, piperacillin/tazobactam, also needs to be stopped. If the learner gives epinephrine without stopping the antibiotic, the patient will continue to decompensate. Another key learning point is the use of IM or subcutaneous epinephrine, rather than IV epinephrine, to treat anaphylaxis. If given IV epinephrine, the patient will go into an unstable ventricular tachycardia, requiring cardioversion. The ideal management would be the following: Obtain vital signs, perform history and physical exam, review the medical record, identify anaphylaxis, stop the piperacillin/tazobactam infusion, and give IM epinephrine.

Equipment or Props Needed:

High fidelity simulator (this study used a SimMan® 3G Manikin)
Hospital-grade defibrillator
Cardiac monitor
Pulse oximetry
IV pole
Peripheral IV line
Crash cart with ambu-bag and intubation kit
Non-rebreather mask
Nasal cannula
Zosyn bag (100 ml) (see Appendix C)
IV Pump
Epi auto-injector (at most 2)
“Demo Dose” Epi boxes
Nebulizer mask w/oxygen tubing (adult). For delivery of aerosol medications, such as albuterol or DuoNeb. Insert water into the chamber for effect.
Three 1 L bags of fluid (either NS or LR)
Other simulated medications with labeling (not limited to: epinephrine syringe epinephrine bag, diphenhydramine, methylprednisolone, levophed, albuterol, duoneb, prednisone tablet)

Actors needed:

One actor or confederate in the nursing role and the facilitator to provide the initial patient handoff as the off-going emergency physician and then to accept handoff at the end of the case as the surgery attending.

Stimulus Inventory:

#1	Handoff report
#2	ED physician documentation
#3	Initial lab results
#4	Radiology results
#5	Medication administration report (MAR)
#6	Repeat CBC
#7	Repeat chemistry
#8	ABG (arterial blood gas)
#9	EKG showing sinus tachycardia
#10	EKG showing ventricular tachycardia
#11	Chest X-ray

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Background and brief information: The patient is one of four patients being given to the learner in sign-out in the emergency department. He is a 19-year-old male who presented with RLQ abdominal pain, and his computerized tomography (CT) showed simple uncomplicated appendicitis. He’s been started on antibiotics and is waiting to be taken to surgery. The facilitator begins the scenario by entering the learner waiting area and saying the following: “Hey, I’m glad you’re here. I need to get out of here. Can I tell you about a couple of patients?” The facilitator will then hand the learner a list of patients and briefly talk about each patient. They will talk fast and not take questions. After the learners have 30 seconds to read the handoff report, prompt the nurse to interrupt their conversation in the hallway and bring the learners into the bay, while asking them to come assess the patient.

Initial presentation: The patient is overall well-appearing, but intermittently dry heaving. Eyes are wide open. He is speaking in full sentences, but anxious and scared. He is complaining of nausea, lightheadedness, shortness of breath, and heart racing. The patient’s abdominal pain is similar to his original presentation. It had gotten a little better after pain medication, but now it’s back to a five out of ten. The onset of symptoms was acute (over a few minutes). The patient was admitted to the ED two hours ago. He has no chest pain, rashes, itchiness, headaches, or diarrhea.

How the scene unfolds: This case starts with an established ED patient with a known diagnosis of appendicitis. The learners receive a rushed handoff from the off-going emergency physician, who gives them four potential patients. Shortly after receiving this handoff, the nurse asks the learners to come assess the patient because he is not feeling well. If asked any questions about the patient’s history, the nurse will only tell them that she is covering for a colleague on lunch, and all she knows is that he has appendicitis. There are a few ways in which the learners can identify anaphylaxis: clinically, via his rapid decline and wheezing, or ask the patient about his known allergies, or review the medical record which lists his allergy to amoxicillin. If the piperacillin/tazobactam is stopped, and the patient receives IM or subcutaneous epinephrine, he will recover. If at any point the patient is given IV epinephrine, he will go into ventricular tachycardia, requiring cardioversion to recover. If the patient does not receive epinephrine and/or the piperacillin/tazobactam isn’t stopped, his condition will worsen until he ultimately suffers a PEA cardiac arrest. The case ultimately ends with a verbal handoff to general surgery.

Critical actions:

Performs a focused history and physical exam (including obtaining vital signs)
Reviews the existing medical record
Gives IV Fluid Bolus (LR or NS acceptable)
Gives diphenhydramine
Stops piperacillin/tazobactam infusion
Gives 0.3–0.5 mg epinephrine SQ or IM (no credit for IV)
Updates the admitting surgical team

Case Title: Penicillin-Induced Anaphylaxis

Chief Complaint: Right lower quadrant (RLQ) abdominal pain. The patient is a 19-year-old male who presented with RLQ abdominal pain. His CT showed simple uncomplicated appendicitis. He’s been started on antibiotics and is waiting to be taken to surgery.

Vitals:	Heart Rate (HR) 115	Blood Pressure (BP) 90/64
	Respiratory Rate (RR) 20	Temperature (T) 99.5°F
	Oxygen Saturation (O₂Sat) 98% on room air

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General Appearance: Alert and interactive, intermittently dry heaving without vomiting

Primary Survey:

Airway: Speaking in full sentences
Breathing: Diffuse mild wheezing bilaterally
Circulation: 2+ pulses to all extremities

History:

History of present illness: 19 y.o. male who presents with abdominal pain. It started two to three days ago. Initially, it was generalized, but now has migrated to the RLQ. Has experienced nausea, but no vomiting. No fevers. No diarrhea or constipation, no urinary symptoms.
Past medical history: Eczema, attention deficit/hyperactivity disorder (ADHD)
Past surgical history: None
Patient’s medications: Adderall (10mg once daily)
Allergies: Amoxicillin
Social history: None
Family history: None

Secondary Survey/Physical Examination:

General Appearance: Alert and interactive, intermittently dry heaving without vomiting

HEENT
- ○ Head: within normal limits
- ○ Eyes: within normal limits
- ○ Ears: within normal limits
- ○ Nose: within normal limits
- ○ Throat/oropharynx: tongue edema
Neck: within normal limits
Heart: tachycardic
Lungs: mild diffuse wheezes bilaterally
Abdominal/GI: soft with mild rlq pain and positive rebound, unchanged from arrival
Genitourinary: deferred/within normal limits
Rectal: within normal limits
Extremities: within normal limits
Neuro: within normal limits
Skin: within normal limits.
Lymph: within normal limits
Psych: within normal limits

Handoff Report

Handoff from ED attending

Room 13:

Mary Morrison is a 65-year-old female who presented with left-sided chest pain. She is stable-appearing and her EKG is non-diagnostic. Given her risk factors, if her troponin is negative, she will need to be placed in observation for a stress test tomorrow.

Room 25:

Cody Henderson is a 19-year-old male who presented with RLQ abdominal pain. His CT showed simple uncomplicated appendicitis. He’s been started on antibiotics and is waiting to be taken to surgery.

Room 18:

Jonathon Lemming is a 25-year-old male who presented with right ankle pain after rolling it while playing soccer. He is pending an x-ray of the ankle. If it shows a fracture, he will need an orthopedic surgery consult. If the x-ray is negative, he will need an ace wrap, crutches, and discharge as an ankle sprain.

Room 7:

Henrietta Jones is a 78-year-old female who presented with cough and fever. She was hypoxic on arrival and is now on heated high flow. She is COVID+ and will go to the ICU when a bed is made available.

ED Physician Documentation

Documentation from ED Physician

Patient Information
	Date of Birth: 6/28/20xx	Age: 19
	Weight: 180 lbs.	MRN: 529374839
History of Present Illness
Cody Henderson is a 19 y.o. male who presents with abdominal pain. It started 2 to 3 days ago. Initially, it was generalized, but now has migrated to the RLQ. Has experienced nausea, but no vomiting. No fevers. No diarrhea or constipation, no urinary symptoms. No history of abdominal surgeries.
Patient History
Past Medical: Eczema, ADHD		Past Surgical: Right ACL repair (age 17)
Medications: Adderall (10mg once daily)		Allergies: Amoxicillin
Review Of Systems
CNS: non-contributory		Renal: non-contributory
Cardiovascular: non-contributory		Abdominal: abdominal pain started 2 days ago with anorexia
Pulmonary: non-contributory		Psychiatric: non-contributory
Physical Exam
Vitals: 108/78, HR 96, RR 15, O2 98% RA, T 99.5 °C
HEENT: normal		Lungs: Clear auscultation bilaterally
Neuro: AOx4. Grossly normal.		Abdomen: Mild tenderness to RLQ. Positive rebound, no guarding.
GU: normal		Extremities/MSK: normal
Cardiovascular: Regular rate & rhythm. No murmurs, rubs, or gallops.		Skin: warm & dry
Assessment & Plan
Differential Diagnosis: Appendicitis, viral gastroenteritis. Less likely: renal stone, pyelonephritis
Medical Decision Making: Patient presents with migrating pain to RLQ of his abdomen. He has a mild tenderness and rebound on exam. I will obtain basic lab work and CT scan to evaluate for acute appendicitis. Clinical Course: The patient’s CT scan shows acute uncomplicated appendicitis. He also has a mild leukocytosis. I will consult surgery and start the patient on piperacillin/tazobactam. I anticipate he will be admitted to the hospital for appendectomy.

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Initial CBC

Complete Blood Count (CBC)
Test	Value	Reference Range
White Blood Cells (WBC) !	14.0 × 10³/μL	4.5–11.0 × 10³/μL
Red Blood Cells (RBC)	5.2 × 10⁶/μL	4.5–5.5 × 10⁶/μL
Hemoglobin (Hgb)	16 g/dL	14–17.4 g/dL
Hematocrit (Hct)	48%	42–52%
Platelets	340 × 10³/μL	150–450 × 10³/μL

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Initial Chemistry

Chemistry (Chem-7)
Test	Value	Reference Range
Sodium (Na) !	131 mmol/L	135–145 mmol/L
Potassium (K)	4.0 mmol/L	3.5–5.0 mmol/L
Chloride (Cl)	96 mmol/L	95–105 mmol/L
Bicarbonate (CO ₂ ) !	20 mmol/L	23–29 mmol/L
BUN	15 mg/dL	5–20 mg/dL
Creatinine	0.8 mg/dL	0.6–1.2 mg/dL
Glucose	95 mg/dL	70–100 mg/dL

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CT results

Radiology Results

EXAM: CT ABDOMEN/PELVIS WITH CONTRAST, 13:35 PM

CLINICAL INDICATIONS: RLQ Abdominal Pain

TECHNIQUE: CT images of the abdomen and pelvis were performed from the lung bases through the ischial tuberosities following the administration of intravenous contrast. CONTRAST: Iohexol (OMNIPAQUE) 350 MG/ML injection 1–171 mL; Route of Administration: Intravenous; Dose: 110 mL.

FINDINGS:

Lung Bases: The visualized lung bases and lower mediastinal structures are unremarkable.
Liver: Liver is normal in size. No focal lesions.
Biliary/Gallbladder: The gallbladder is normal in size without evidence of stones or sludge. There is no pericholecystic fluid. The biliary tree is nondilated.
Spleen: Spleen is normal in size and CT density.
Pancreas: Pancreas is normal. There is no evidence of pancreatic mass or peripancreatic fluid.
Adrenals: Adrenal glands are unremarkable.
Kidneys: Kidneys are normal in size. There are no stones or hydronephrosis.
Retroperitoneal/Vasculature: No retroperitoneal adenopathy is identified.
Gastrointestinal/Mesentery: Increased appendiceal caliber with diameter of 1.1 cm with wall thickening up to 5 mm and adjacent fat stranding. Multiple enlarged lymph nodes surrounding the appendix. No adjacent extraluminal collection of gas or pus. The bowel loops are non-dilated without wall thickening or mass.
Bladder: The bladder is normal.
Genital: The prostate and seminal vesicles are unremarkable.
Bony Structures: Visualized bony structures are consistent with the patient’s age.

IMPRESSION:

Acute uncomplicated appendicitis. No CT evidence of perforation. This critical finding has been discussed with the ED Attending with a read back at 1405.

Medication Administration Report (MAR)

Medication Name	Dose & Route of Administration	Order Time	Administration Time
Morphine	6 mg IV	13:07	13:20
Ondansetron	4 mg IV	13:07	13:20
Normal Saline (0.9% NaCl)	1 L IV	13:07	13:20 – 13:56
Iohexol (Omnipaque)	38.5 g IV	13:15	13:35
Piperacillin/Tazobactam	4.5 g IV	14:15	15:03 -

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Repeat CBC

Complete Blood Count (CBC)
Test	Value	Reference Range
White Blood Cells (WBC) !	15.6 × 10³/μL	4.5–11.0 × 10³/μL
Red Blood Cells (RBC)	5.0 × 10⁶/μL	4.5–5.5 × 10⁶/μL
Hemoglobin (Hgb)	15.4 g/dL	14–17.4 g/dL
Hematocrit (Hct)	46%	42–52%
Platelets	360 × 10³/μL	150–450 × 10³/μL

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Repeat Chemistry

Chemistry (Chem-7)
Test	Value	Reference Range
Sodium (Na) !	133 mmol/L	135–145 mmol/L
Potassium (K)	4.2 mmol/L	3.5–5.0 mmol/L
Chloride (Cl)	96 mmol/L	95–105 mmol/L
Bicarbonate (CO ₂ ) !	19 mmol/L	23–29 mmol/L
BUN	13 mg/dL	5–20 mg/dL
Creatinine	0.76 mg/dL	0.6–1.2 mg/dL
Glucose	98 mg/dL	70–100 mg/dL

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ABG

Arterial Blood Gas (ABG)
Test	Value	Reference Range
pH !	7.3	7.35–7.45
PaCO ₂	38 mm Hg	35–45 mm Hg
PaO ₂	91 mm Hg	80–100 mm Hg
HCO₃ !	19 mm mEq/L	22–28 mEq/L
O₂ Saturation	96%	92–100%
Lactate !	2.8 mmol/L	< 1.7 mmol/L

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EKG showing sinus tachycardia

Ewingdo. ECG Sinus Tachycardia 132 bpm. In: Wikimedia Commons.

https://en.wikipedia.org/wiki/File:ECG_Sinus_Tachycardia_132_bpm.jpg Published November 13, 2020. Accessed November 18, 2023. CC BY-SA 4.0.

graphic file with name jetem-9-1-s1f1.jpg

EKG showing ventricular tachycardia

Buttner R, Burns E. Monomorphic ventricular tachycardia. In: Life in the Fast

Lane. https://litfl.com/ventricular-tachycardia-monomorphic-ecg-library. CC BY-NC-SA 4.0.

graphic file with name jetem-9-1-s1f2.jpg

Chest X-ray

Gaillard, Frank. Normal frontal chest x-ray. In:

Radiopaedia. https://radiopaedia.org/cases/normal-frontal-chest-x-ray. CC BY-NC-SA 3.0.

graphic file with name jetem-9-1-s1f3.jpg

OPERATOR MATERIALS

SIMULATION EVENTS TABLE:

Minute (state)	Participant action/trigger	Patient status (simulator response) & operator prompts	Monitor display (vital signs)
State 1 (Baseline)	If IM epinephrine not given in first 5 minutes, go to State 2 (Worsening anaphylaxis) If IM epinephrine given, but piperacillin/tazoba ctam not stopped in first 7 minutes, go to State 2 (Worsening anaphylaxis) If IV code epinephrine given, go to State 4 (V- tach) If IM epinephrine given and piperacillin/tazoba ctam stopped, go to State 5 (Recovery) Learner Objectives and Interventions: - Complete Physical Exam - Start resuscitating fluids (ie, NS or LR) - Stop piperacillin/tazobactam - Administer IM epinephrine Further details: Learners are expected to either know or look up the dosages of epinephrine specifically (and not any other medications). If learners give a dose of IM or subcutaneous epi that is too little (ie, < 0.3 mg), then proceed like they haven’t given epi. If learners give a dose of IM or subcutaneous epi that is too large (ie, > 0.5 mg), then proceed as if the patient has received IV code epi, and go to State 4: V-tach. If learners start an epinephrine drip or norepinephrine (Levophed) drip, then proceed as if they have given IM epinephrine. Inaccurate dosages for drips will not affect the state progression, but should be debriefed.	Sounds/Auscultations: Mild wheezing bilaterally. “Wheezes” sound effect at 50% volume in every lung speaker. Normal heart and abdominal sounds at normal volume. Patient Responses: ○ “I don’t feel good. Feeling lightheaded and nauseated.” ○ “I feel like I need to throw up.” ○ “Started kind of suddenly a few minutes ago.” ○ “Feels like it is getting harder to breathe.” ○ “I’ve never felt like this before.” ○ “My heart is racing.” ○ Only if specifically asked if there is any swelling or if tongue feels strange: “Yeah, my tongue does feel a little bigger than normal.” ○ Only if specifically asked if he has any allergies: “My mom told me that I got a rash as a kid when I got antibiotics for an ear infection.” Speaking in full sentences, but anxious and scared. Patient’s abdominal pain is similar to original presentation. It had gotten a little better after pain medication, but now it’s back to a 5 out of 10. Onset of symptoms was acute (over minutes). Patient was admitted to the ED two hours ago. No chest pain, rashes, itchiness, headaches, or diarrhea. Appearance/PE: Intermittently dry heaving/retching w/no vomit (use sound effects handlers). Eyes wide open, blinking at normal rate. Tongue edema: max.	T 99.5°C HR 115 BP 90/64 RR 20 O2 98% EKG on monitor: Sinus Tachycardia
State 2 (Worsening Anaphylaxis)	If either IM epinephrine not given or pip/tazo not stopped in 2 minutes, go to State 3 (PEA) If IV code epinephrine given, go to State 4 (V- tach) If IM epinephrine given and pip/tazo stopped, go to State 5 (Recovery) Learner Objectives and Interventions: - Continue resuscitating fluids (ie, NS or LR) - Stop piperacillin/tazobactam - Administer IM epinephrine	Sounds/Auscultations: Severe wheezing bilaterally. “Wheezes” sound effect at 80% volume. Patient Responses: ○ “It’s getting harder for me to breathe.” ○ “What’s happening to me? Am I going to die?” ○ “My chest feels tight.” ○ “Is this supposed to happen?” Appearance/PE: Continue dry heaving. Unwell appearing. Tongue edema: max.	T 99.5° C HR 125 BP 70/50 RR 30 O2 94% End-tidal CO2 (EtCO2) 34 EKG on monitor: Sinus Tachycardia
State 3 (PEA)	If 1 minute has passed after epinephrine given (in any form), but piperacillin/tazobactam not stopped, go to State 2 (Worsening anaphylaxis) If epinephrine given (in any form) and piperacillin/tazobactam stopped, go to State 5 (Recovery) If epinephrine (in any form) not given after 3 rounds of ACLS, END CASE Learner Objectives and Interventions: - Follows ACLS - Give IV code epinephrine	Sounds/Auscultations: Severe wheezing bilaterally. “Wheezes” sound effect at 80% volume. Patient Responses: Appearance/PE: Eyes closed. Tongue edema: max. Operator details: If learners perform adequate compressions, click “Good Compressions” handler (sets EtCO2 to 22 and SpO2 to 92%). Further details: If learners have still not recognized that the patient is having an allergic reaction, have the nurse prompt: “His tongue looks swollen. How do his lungs sound?” If learners have recognized that the patent has had an allergic reaction, but they have still not stopped piperacillin/tazobactam, have the nurse prompt: “What do you think he is having an allergic reaction to? We don’t use latex anymore.”	T 99.5° C HR 160 BP 0/0 RR 0 O2 0% EtCO2 12 EKG on monitor: PEA. Underlying rhythm: sinus tachycardia
State 4 (V-tach)	If patient is cardioverted but piperacillin/tazobactam not stopped, go to State 2 (Worsening anaphylaxis) If 3 minutes in this state elapse, and no cardioversion, go to State 3 (PEA) If cardioversion occurs and piperacillin/tazobactam has been stopped, go to State 5 (Recovery) Learner Objectives and Interventions: - Follows ACLS - Synchroninzed cardioversion (minimum 50 J) Further details: While learners should deliver a synchronized cardioversion, if learners deliver an unsynchronized cardioversion, proceed as if it were synchronized (for the sake of time). Facilitator should address this mistake during the debrief session.	Sounds/Auscultations: Normal lung sounds at normal volume. Patient Responses: ○ Patient in an anxious panic for the first 20 seconds: “What’s happening? My heart is racing!” ○ After 20 seconds of being in this state, patient quickly progressively becomes lethargic and can only moan unintelligibly. Appearance/PE: Eyes half open. No tongue edema.	T 99.5° C HR 200 BP 60/43 RR 34 O2 92% EtCO2 40 EKG on monitor: V-tach (LLEAP: Ventricular Tachycardia Type 2)
State 5 (Recovery)	If IM epi given and piperacillin/tazobactam stopped before minute 5, go to Challenge Track If complete handoff to general surgery, go to END CASE Learner Objectives and Interventions: - Inform patient of likely allergy - Select new antibiotic for intra-abdominal infection (eg, cipro, flagyl, clinda, ertapenem) - Contact surgical team and give update/handoff	Sounds/Auscultations: Normal lung sounds at normal volume Patient Responses: “I feel a lot better. What happened?” Patient no longer nauseous, lightheaded, dry heaving, and no longer has difficulty breathing. Appearance/PE: Appears well. Eyes wide open. No tongue edema. Further details: If learners do not call Gen Surge back on their own, prompt them with the following dialogue: Nurse: “The OR called for him. Is he okay to go up now?” “OK, we’ll take him up.” Facilitator (overhead): “Hey, this is Gen Surge. I looked up that patient that is coming to the OR, and saw that their antibiotics were stopped earlier. Can you tell me what happened?” “OK. I will update his allergies in the chart. What antibiotic should we put him on instead?”	T 99.5° C HR 108 BP 146/86 RR 14 O2 98% EtCO2 44 EKG on monitor: Sinus tachycardia
Challenge Track		If the learner has progressed rapidly through the case, the facilitator can take the patient to State 2: “Worsening Anaphylaxis,” with the goal of having the learner treat refractory anaphylaxis with an epinephrine drip. This is “bonus” territory, however, and the learner must receive “Exceeds Expectations” on their EPA 10 assessment, regardless of performance after this point. Ideal management of refractory anaphylaxis is an epinephrine drip. They should start the IV epinephrine infusion at 0.1 mcg/kg/minute (range: 0.05 to 0.2 mcg/kg/minute) and increase it every two to three minutes by 0.05 mcg/kg/minute until BP and perfusion improve.

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Diagnosis:

Penicillin-induced anaphylaxis

Disposition:

Admission to surgery

DEBRIEFING AND EVALUATION PEARLS