Table 3. Stepwise progression of care.

PICU = pediatric intensive care unit

Stepwise progression of the case
Intervention/Time Point in scenario	Change in case	Additional information
State #1, Initial presentation: Triage nurse notifies the team of patients arrival, providers go to the bedside	Learners should enter the patient room with assigned team roles, assess ABCs, confirm monitors in place, ask for current history and vitals, and examine the patient	See Table 2 for HPI, current vitals, and physical exam
Bedside management of epistaxis	The learner should optimize head positioning (forward tilt, nose down, and firmly compress nasal cartilage just inferior to nasal bone). Can perform oral suctioning. If correct positioning and compression occur, nasal bleeding slows but continues. The learner should recognize the need to call ENT emergently and discuss bedside nasal packing options (supplies including topical medication agents). Consider hepatology consult	Packing options: foley, nasal packing sponge, nasal balloon
Nasal packing initiated on patient	Learner should request material. If learner does not know what material to request, nurse can prompt with, “We have a bedside nasal balloon or a foley.” If the learner does not request a topical medication on packing material, a nurse can ask, “Would you like any topical medication to place on the packing materials to help with clotting?” The case advances to the next section after 1-2 minutes with continued oozing blood from the nose	Packing materials: nasal packing sponge, nasal balloon, foley, suction. Topical medications: oxymetazoline, phenylephrine TXA, lidocaine
IV access obtained x 1. Lab results requested. State #2 triggered when the patient begins vomiting bright red blood or after 5 minutes from case start	Lab results available upon request. If the participants do not request any labs, can have the embedded participant nurse prompt when putting in the IV: “Do you want me to collect any blood for labs?” Learners should contact hepatology specialists due to concern for esophageal varices, need for additional interventions	EPOC labs immediately available: pH: 7.37, pCO2: 37 mmHg, pO2: 43 mmHg, Na: 134 mmol/L, K: 4.4 mmol/L, Ca: 8.6 mg/dL, Cl: 105 mmol/L, glucose: 100 mg/dL, lactate: 1.9 mmol/L, creatinine: 0.2 mg/dL, hematocrit: 31 %. See Table 4 for additional labs available at a later time point
State #2, Worsening: Vitals reassessed. Heart rate 190, blood pressure 75/40, respiratory rate 50, SaO2 96%, Temperature 37.0°C, ETCO2 patient unable to tolerate/obtain nasal ETCO2. Physical exam: as initial, but with bright red emesis, 4-5 sec CR and feeling cooler, seems sleepier, and vital signs as above	If the team doesn’t initiate fluid resuscitation, the nurse asks, “Are we worried about hemorrhagic shock?” The nurse asks, “She has significant blood loss and worsening tachycardia. When should we consider the massive transfusion protocol?” If the team does not ask for the second point of IV access, the nurse should prompt, “Do you want me to get another IV line on this patient?”
Volume resuscitation	If >15 mL/kg blood is given or MTP initiated, advance to State 3 or after 10 minutes in State 2. Additionally, consider octreotide	If check bedside EPOC Hgb again, should be 6. If hepatology not yet consulted, prompt learner with, “Are there any additional consultants who you would like to call?” If no blood ordered after 3 minutes, facilitator can prompt with, “Are there any additional fluids or meds you want to give?” Note, octreotide is initiated as bolus of 1-2 µg/kg (max 100 µg), followed by 1-2 µg/kg/hour IV infusion, titrated to response (3-4 µg/kg/hour maximum)
State #3, Airway management: Once the airway is secured, move to State #4. Or if the airway not secured after 10 minutes in State #3, end scenario. Physical exam: same as State #3 (until sedated/paralyzed for airway)	The facilitator states there are copious bloody secretions in the oropharynx. The learner should identify pooling blood in the oropharynx without source control. If intubation is deferred, saturations decrease to the upper 80s from likely aspiration. If the team proceeds with intubation, note sedation meds, ETT size, and blade size. The team should discuss calling for anesthesia (or the most experienced advanced airway provider). If the team does not call, the facilitator to note and discuss in debrief	ETT: 3.5-4.0 cuffed. Blade: MIL 1 Intubation meds for sedation: etomidate 0.3 mg/kg, ketamine 1-2 mg/kg. Not as ideal due to cause of hypotension/unstable: propofol 1-1.5 mg/kg, midazolam 0.2-0.3 mg/kg. Other: fentanyl 1-5 µg/kg. Intubation meds for paralysis: rocuronium 1-1.2 mg/kg. If a chest X-ray requested post-intubation, it will show ETT at 1.7 cm above the carina. See Figure 1. ETC02: 38 or positive color change
State #4. Stabilization: Completion and signout to PICU/25 minutes. Vitals: Heart rate 160, blood pressure 85/45, respiratory rate 40, SaO2 98%, temperature 37.0°C. Physical exam: sedated/paralyzed, blood in bilateral nares, airway secured, tachycardic, perfusion 2-3 seconds, CTAB, abdomen continues with mild distension/telangiectasis, liver edge felt about 2 cm below RCM		The facilitator can play the role of PICU attending. Sample sign out: “11 mo F with liver failure presenting with hemorrhagic shock 2/2 to epistaxis vs variceal bleed, given ___ blood products, ___ fluid, airway secured with TT. Should consider bcx and abx given potential gastrointestinal bleed with risk of bacterial translocation not ruled out at this time.”