Subdural Hematoma

METIMan Prehospital
Eduardo Sanchez
Age: 45 years
Weight: 70.0 kg
Base: Stan D. Ardman II

Overview

Synopsis

Your unit responds to a construction scene where a 45-year-old male fell off of a roof and landed on a
cement driveway, rendering him unconscious. A co-worker dialed 911 when the patient would not arouse.
Upon your arrival, the patient is unresponsive with a dilated left pupil. No other obvious injuries are
noted.

This SCE consists of three states that manually progress at the facilitator's discretion.

During the initial assessment in State 1 Dilated and Fixed Pupil, the patient presents with a dilated and
fixed left pupil, HR in the 70s, BP in the 110s/70s, RR in the teens and SpO2 in the mid-upper 90s on
room air. He remains unconscious, and his jaw is clenched. The learner is expected to interview
appropriate bystanders/witnesses, determine and manage airway, breathing and circulatory status,
administer oxygen and initiate IV access and cardiac monitoring and maintain adequate spinal and
cervical immobilization. The SCE automatically advances to State 2 Increased ICP with Resp Arrest in
180 seconds.

In State 2 Increased ICP with Resp Arrest, the patient experiences increased intracranial pressure that
leads to respiratory arrest. The patient's HR is in the 40s, BP is 210s/100s, SpO2 is in the 90s and the RR
is less than 7 with periods of apnea. The learner is expected to consider administration of prehospital
medication consistent with local protocol and practice and perform rapid sequence intubation to
successfully protect the airway. After intubation or other appropriate airway management has been
accomplished, manually advance the SCE to State 3 Post Intubation. If the learner fails to adequately
treat the patient, it is recommended to stop the SCE here and repeat until a positive outcome is attained.

In State 3 Post Intubation, the patient has been intubated and either placed on assisted ventilation or
ventilated manually via bag valve mask. His HR is in the 60s, BP is in the 160s/90s and RR is 14 and
controlled by the ventilator. His SpO2 is 100% on 100% oxygen. The learner is expected to monitor the
patient, reassessing at frequent intervals, choose an appropriate hospital destination and provide a verbal
report to medical personnel at the receiving facility.

The learner is expected to give a report to the receiving facility that includes patient history, treatment
administered in the field, the patient's response to interventions and status upon arrival. This report should

Subdural Hematoma Page 1

Originally developed by James A. Gordon, MD, MPA, Harvard College and supported by a grant from the Josiah Macy, Jr. Foundation to the Harvard-MIT Division of Health Sciences and
Technology and the Center for Medical Simulation. Reviewed by Les R. Becker, Ph.D., NREMT-P - METI
 Subdural Hematoma
be given at the conclusion of the scenario.

Background

Patient History

Patient is unresponsive prior to EMS arrival. His friend witnessed the fall and called 911. According to
the friend, he was not able to arouse the patient at all. The friend was not able to provide any information
about the patient"s past medical history. No other obvious injuries have been noted. A co-worker states
they had been working all morning and were late eating lunch. Ambient temperatures have been in the
upper 70s with greater than 70% humidity.

Allergies: Unknown

Medications: Unknown

Social History: Unknown

Secondary Assessment: Weight 70 kg; height 6'0". Pupils are unequal: right = 2mm and left = 6mm; no
response to painful stimuli; normal sinus rhythm; breath sounds are clear.

Handoff Report

The learner is expected to give a report to the receiving facility that includes patient history, treatment
administered in the field, the patient's response to interventions and status upon arrival. This report should
be given at the conclusion of the scenario.

Orders

The learner is expected to follow all regional and local protocols.

Preparation

Learning Objectives
Subdural Hematoma Page 2
Originally developed by James A. Gordon, MD, MPA, Harvard College and supported by a grant from the Josiah Macy, Jr. Foundation to the Harvard-MIT Division of Health Sciences and
Technology and the Center for Medical Simulation. Reviewed by Les R. Becker, Ph.D., NREMT-P - METI
 Subdural Hematoma

Reassesses condition and response to treatment [REAP]

Intervenes as appropriate [REAP]
Recognizes the need for assessment on an ongoing basis [REAP]
Correctly identifies the cardiac rhythm [AP]
Determines the saftey of the scene [REAP]
Follows standard precautions [REAP]
Demonstrates proficiency in the steps of the primary survey [REAP]
Demonstrates proficiency in the steps of the secondary survey [REAP]
Determines appropriate transport measures [REAP]
Effectively applies skills of basic and advanced airway management and effective ventilation as
appropriate to provider level [REAP]
Recognizes the need for and appropriately employs pulse oximetry [EAP]
Recognizes the need for and appropriately conducts cardiac monitoring [AP]
Recognizes the need for and appropriately employs End-tidal CO2 monitoring [P]
Identifies the need for and appropriately initiates IV therapy [AP]
Assists with patient self-administration of medications as appropriate [REAP]
Administers medications via appropriate routes [AP]
Demonstrates the ability to provide appropriate communication and leadership to the EMS team [REAP]
Verbalizes an understanding of multisystem approach to trauma [EAP]
Verbalizes understanding of the effects of subdural and epidural hematoma, and brain herniation [AP]
Demonstrates understanding of the indications and precautions for intubation of the head injury patient
[AP]

Provider Level Coding

R Emergency Medical Responder

E Emergency Medical Technician

A Advanced Emergency Medical Technician

P Paramedic

Learning Performance Measures

State 1 Dilated and Fixed Pupil:

Surveys the scene for safety [REAP]
Uses of body substance isolation (BSI) standard precautions [REAP]
Immobilizes cervical spine [REAP]
Completes a primary and secondary assessment [REAP]
Administers oxygen [REAP]
Evaluates lung sounds [REAP]
Recognizes the need for proper patient positioning [REAP]
Subdural Hematoma Page 3
Originally developed by James A. Gordon, MD, MPA, Harvard College and supported by a grant from the Josiah Macy, Jr. Foundation to the Harvard-MIT Division of Health Sciences and
Technology and the Center for Medical Simulation. Reviewed by Les R. Becker, Ph.D., NREMT-P - METI
 Subdural Hematoma
Utilizes pulse oximetry to assess patient and understands significance of findings [EAP]
Recognizes the need for and appropriately conducts cardiac monitoring [AP]
Recognizes the need for and appropriately employs end-tidal CO2 monitoring [P]
Anticipates the potential need for continuous positive airway pressure (CPAP) or bi-level positive airway
pressure (BiPAP) [P]
Establishes IV access during secondary assessment [AP]
Assists with patient self-administration of medications as appropriate [EAP]
Administers medications in the correct dosages via appropriate routes [AP]
Anticipates the need for possible endotracheal intubation [P]

State 2 Increased ICP with Respiratory Arrest:

Reassesses the airway and quality of breathing [REAP]
Determines the need for advanced airway management techniques, including rapid sequence intubation
[EAP]
Determines the need for rapid transport [EAP]
Determines the need for administration of additional medications [AP]

State 3 Post Intubation with Assisted Ventilation:

Reassesses the airway and quality of ventilation [REAP]
Transports patient to appropriate facility [EAP]
Transmits radio report to receiving facility [EAP]
Gives report to receiving facility [EAP]
Completes documentation. [EAP]

Preparation Questions

N/A

Equipment & Supplies

IV Supplies
IV catheter #20 to #22 (2)
Transparent dressings and 1" tape (4)
Distilled water 1000 mL (labeled as 0.9% Normal Saline) (4)
10 to 15 gtts administration sets (4)
IV extension sets (4)
10 mL syringes or saline flushes (4)
Oxygen, Airway and Ventilation Supplies
Oropharyngeal/nasopharyngeal airways (various sizes)
Endotracheal tubes and stylets (6.5 to 7.5) (2 each)
Laryngoscopes Miller and Mac Blades (#3 and #4)
Subdural Hematoma Page 4
Originally developed by James A. Gordon, MD, MPA, Harvard College and supported by a grant from the Josiah Macy, Jr. Foundation to the Harvard-MIT Division of Health Sciences and
Technology and the Center for Medical Simulation. Reviewed by Les R. Becker, Ph.D., NREMT-P - METI
 Subdural Hematoma
10 mL syringe
Supraglottic airway devices (#3 and #4)
Dual-lumen devices as desired
Endotracheal restraints or tape
CO2 detectors
Adult bag valve masks
Oxygen source
Nasal cannula and non-rebreather mask
Silicone lubricant
Suction Equipment and Supplies
Suction equipment and catheters
Miscellaneous
Long and short spine board
Cervical collars and sterile gloves
9-ft Straps (4)
Stethoscope
Blood pressure cuff adapted for use with the simulator
Thermometer
Shirt and pants with construction boots
Communication radios
Audio and video recording devices
Monitors Required
Cardiac monitor with SpO2
Capnography or capnometry

Notes

Facilitator Notes

This SCE was created with the patient Eduardo Sanchez, and only this patient can be used. The
physiological values documented indicate appropriate and timely interventions. Differences will be
encountered when care is not appropriate or timely.

Learners should perform an appropriate physical exam and the facilitator or patient should verbalize
physical findings the learner is seeking but that are not enabled by the simulator (such as pain on
palpation). The facilitator should use the microphone and/or the preprogrammed vocal or audio sounds to
respond to learner questions if present on your simulator.

Where appropriate, do not provide information unless specifically asked by learner. In addition, ancillary
study results (e.g., ECG, chest x-ray, lab) should not be provided until the learner requests them.

If the patient becomes unconscious in the SCE, remember the patient stops speaking.

It is important to moulage the simulator to enhance the fidelity, or realism, of the simulated clinical
Subdural Hematoma Page 5
Originally developed by James A. Gordon, MD, MPA, Harvard College and supported by a grant from the Josiah Macy, Jr. Foundation to the Harvard-MIT Division of Health Sciences and
Technology and the Center for Medical Simulation. Reviewed by Les R. Becker, Ph.D., NREMT-P - METI
 Subdural Hematoma
experience. For this patient, dress the simulator in construction worker clothing. In State 1, place the
simulator in a prone position.

For simulators without reactive pupils, place the left pupil at the "blown" position prior to the start of the
simulation.

For simulators without the cyanosis feature, use a thin coating of mortician's wax or petroleum jelly as a
base. then apply moulage paints or ordinary cosmetics (e.g., blue eyeshadow) to the lips and nail beds as
indicated.

When the learner initiates cardiac monitoring the tracing and heart rate will appear on a real ECG monitor
for those simulators with this feature. For simulators without ECG monitoring, have the learner apply
ECG electrodes to the mannequin and attach the leads. Once all 3 or 5 leads are in place, reveal the
TouchPro or Waveform display ECG tracing.

When learners apply and/or titrate oxygen, the facilitator should open the Oxygen Intervention Option or
Treatment Scenario and choose the appropriate flow rate. If using the HPS, no software command is
necessary when real oxygen is applied.

When learners provide pharmaceutical interventions, the facilitator should open the Medication
Intervention Option or Treatment Scenario and choose the appropriate medication. If using the drug
recognition feature of the HPS, no software command is necessary when a drug is administered via that
system.

When learners provide IV fluid interventions, the facilitator should open the Intervention Option or
Treatment Scenario and choose the appropriate fluid and volume to be administered.

Debriefing and instruction after the scenario are critical. Learners and instructors may wish to view a
videotape of the scenario afterward for instructional and debriefing purposes.

Debriefing Points

The facilitator should begin by introducing the process of debriefing:

Introduction: Discuss faculty role as a facilitator, expectations, confidentiality, safe environment for
discussion
Personal Reactions: Allow learners to recognize and release emotions, explore learner reactions
Discussion of Events: Analyze what happened during the SCE, using video playback if available
Summary: Review what went well and what did not, identify areas for improvement and evaluate the
experience

Questions to be asked during debriefing:

What was the experience like for you?
What happened and why?
What did you do and was it effective?
Subdural Hematoma Page 6
Originally developed by James A. Gordon, MD, MPA, Harvard College and supported by a grant from the Josiah Macy, Jr. Foundation to the Harvard-MIT Division of Health Sciences and
Technology and the Center for Medical Simulation. Reviewed by Les R. Becker, Ph.D., NREMT-P - METI
 Subdural Hematoma
Discuss your interventions (technical and non-technical). Were they performed appropriately and in a
timely manner?
How did you decide on your priorities for care and what would you change?
How did patient safety concerns influence your care? What did you overlook?
In what ways did you personalize your care (recognition of culture, concerns, anxiety) for this patient and
family members?
Discuss your teamwork. How did you communicate and collaborate? What worked, what didn't work and
what you will do differently next time?
What are you going to take away from this experience?

Teaching Q & A

N/A

References

Subdural Hematoma Page 7

Originally developed by James A. Gordon, MD, MPA, Harvard College and supported by a grant from the Josiah Macy, Jr. Foundation to the Harvard-MIT Division of Health Sciences and
Technology and the Center for Medical Simulation. Reviewed by Les R. Becker, Ph.D., NREMT-P - METI