EDD/581 ACTION

RESEARCH PROPOSAL

RACHEL KELLEREDD 581

FEBRUARY 17, 2014SUSAN GERTEL

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PROBLEM STATEMENT

The problem is the sequence of education in medical simulation. Upon narrowing of the problem, an intervention will be implemented.

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PROBLEM DESCRIPTION The problem is inconsistent sequence of education. Setting problems include

Acceptability to standardize Student’s knowledge

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WRITER’S ROLE

Education Specialist Train multi-discipline medical personal With high fidelity simulation

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PURPOSE OF THE PROJECT

The purpose of this project is to standardize the sequence of education in medical simulation.

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(Microsoft, 2010)

PROBLEM DOCUMENTATION Problem is inconsistent sequence of

education Pre Simulation versus Post Simulation

Influence learners Perspective Facilitator Conformability Experience

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SURVEY1. Please rank your value of receiving simulation as part of you educational experience.

1 2 3 4 5 6 7 Least Valuable Neutral Most Valuable

2. As the participant, please rank your perception of your facilitator’s attitude with delivering education pre simulation.

1 2 3 4 5 6 7 Negative Neutral Positive

3. As the participant, please rank your perception of your facilitator’s attitude with delivering education post simulation.

1 2 3 4 5 6 7 Negative Neutral Positive

4. Rank your conformability with receiving education pre simulation.

1 2 3 4 5 6 7 Least comfortable Neutral Completely comfortable

5. Rank your conformability with receiving education post simulation.

1 2 3 4 5 6 7 Least comfortable Neutral Completely comfortable

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SURVEY

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Rank how your knowledge increased with first receiving education, then followed by simulation.

1 2 3 4 5 6 7 No Change Increase

Rank how your knowledge increased with first receiving simulation, then followed by education.

1 2 3 4 5 6 7 No Change Increase

Please explain why you would prefer education pre simulation:

Please explain why you would prefer education post simulation:

Have you had experience with medical simulation prior to this training?

Yes No

LITERATURE REVIEW

Simulation in medical education More effective Structure is key component

Simulation before education Better performance Increase knowledge

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(Microsoft, 2010)

LITERATURE REVIEW

Education before simulation Improves learning

Simulation before education Negative attitude

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(Microsoft, 2010)

LITERATURE REVIEW

Authors of the study

Title of the study 

Purpose of the study

Pertinent findings that support your project

Cendan, J. C. and T. R. Johnson

Enhancing Learning through Optimal Sequencing of Web-Based and Manikin Simulators to Teach Shock Physiology in the Medical Curriculum.

Investigate proper linkage of simulation experiences with medical curricula.

The data suggest improved learning when education precedes simulation.

Ciceroa, M., Auerbacha, M., Zigmonta, J., Rieraa, A., Chinga, K., and Baum, C.

Simulation training with structured debriefing improves residents' pediatric performance.

Measure the efficacy simulation in learners' skills. Hypothesis simulations and a structured debriefing would improve performance.

Structured education is a key component of simulation education to improve learners’ performance.

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LITERATURE REVIEW

Authors of the study

Title of the study

Purpose of the study

Pertinent findings that support your project

Lee, J.

Effectiveness of computer-based instructional simulation: A meta analysis.

Analyze effectiveness between two forms of simulation and modes of instruction.

Simulation before education may indicate better performance, but negative attitude towards simulation education.

Issenber, B., & McGaghie, E. 

Features and uses of high-fidelity medical simulations that lead to effective learning. 

Exploring features and uses of high-fidelity medical simulations that lead to most effective learning

High-fidelity medical simulations are effective in medical education.

McGaghie, W., Issenber, B., Cohen, E., Barsuk, J., Wayne, D.

Does Simulation-based Medical Education with DeliberatePractice Yield Better Results than Traditional ClinicalEducation? A Meta-Analytic Comparative Review of theEvidence

This article presents a comparison of the effectiveness of traditional clinical education toward skill acquisition goals versus simulation-based medical education.

Simulation is superior to traditional clinical medical education in achieving specific clinical skill acquisition goals.

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LITERATURE REVIEW

Authors of the study

Title of the study 

Purpose of the study

Pertinent findings that support your project

Stefaniak, J., & Turkelson, C. 

Does the sequence of instruction matter during simulation.  

Examine sequence of instruction during simulation. 

Learners who participated in simulation before education demonstrated increased knowledge compared with learners who participated in simulation after a education.

Zendejas, B., Cook, D., & Farley, D.

Teaching first or teaching last: Does the timing matter in simulation-based surgical scenarios.

Examine sequence of instruction during simulation. 

Participants who received instruction after simulated scenarios achieved higher mean knowledge scores than those who received instruction before simulated scenarios.

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ACTION GOAL The goal of the intervention is to improve

knowledge of participants in implementing a standardization in the sequence of education in medical simulation. A three-prong intervention will be implemented to meet the goal, which includes standardizing the sequence of education in medical simulation, instructor training, and weekly collaboration time supported by the administration.

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(Microsoft, 2010)

SELECTED SOLUTIONS Standardizing the sequence of education Instructor training Weekly collaboration

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CALENDAR PLAN Study Duration

March 3, 2014 – May 2, 2014 Instructors

Educators at the simulation center Participants

Nurses <1 year

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1 2 4 6 83/3 - 3/7

3/10- 3/14

3/21- 3/28

4/7- 4/11

4/21- 4/25

Instructor TrainingGroup AGroup BWeekly CollaborationEvaluate Results

WEEK

3/17- 3/21

3/31- 4/4

4/28- 5/2

4/14- 4/18

7 93 5

WEEK 1: MARCH 3-7, 2014

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Monday TuesdayWednesda

yThursday Friday

Instructor training

8:00- 10:00

Instructor training

8:00- 10:00

Instructor training

8:00- 10:00

Instructor training

8:00- 10:00

Instructor training

8:00- 10:00

Weekly Collaboration

1:00- 2:00

INSTRUCTOR TRAINING

Participant Date Time Where

Jerome March 3, 2014 8:00-10:00 Oak Classroom

Jamie March 4, 2014 8:00-10:00 Oak Classroom

Suzanne March 5, 2014 8:00-10:00 Oak Classroom

Rami March 6, 2014 8:00-10:00 Oak Classroom

Cheryl March 7, 2014 8:00-10:00 Oak Classroom

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INSTRUCTOR TRAINING AGENDA

8:00- 8:30 Welcome and explain purpose of study

8:30- 9:00 Explain the education process with groups A and B

9:00- 9:10 Break

9:10- 9:50 Equipment, technology, and scenarios

9:50- 10:00 Questions and wrap-up

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STUDENT AGENDA

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Group A

8:00- 8:05 Welcome and explanation of study

8:05- 8:25 Education

8:25- 8:45 Simulation

8:45- 8:50 Questions

8:50- 9:00 Student complete survey and test

STUDENT AGENDA

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WEEK 2: MARCH 10-14, 2014

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Monday TuesdayWednesda

yThursday Friday

Group A8:00- 9:00

Weekly Collaboration

1:00- 2:00

WEEK 3: MARCH 17-21, 2014

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Monday TuesdayWednesda

yThursday Friday

Group B8:00- 9:00

Evaluate Results

Weekly Collaboration

1:00- 2:00

WEEK 4: MARCH 24-28, 2014

Study Group A Weekly collaboration

Friday, March 28

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Wednesday

Thursday Friday

Group A8:00- 9:00

Weekly Collaboration

1:00- 2:00

WEEK 5: MARCH 31-APRIL 4, 2014

Study Group B Weekly collaboration

Friday, April 4 Evaluate Results

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Wednesday

Thursday Friday

Group B8:00- 9:00

Evaluate Results

Weekly Collaboration

1:00- 2:00

WEEK 6: APRIL 7-11, 2014

Study Group A Weekly collaboration

Friday, April 11

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Wednesday

Thursday Friday

Group A8:00- 9:00

Weekly Collaboration

1:00- 2:00

WEEK 7: APRIL 14-18, 2014

Study Group B Weekly collaboration

Friday, April 18 Evaluate Results

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Wednesday

Thursday Friday

Group B8:00- 9:00

Evaluate Results

Weekly Collaboration

1:00- 2:00

WEEK 8: APRIL 21-25, 2014

Study Group A Weekly collaboration

Friday, April 25

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Wednesday

Thursday Friday

Group A8:00- 9:00

Weekly Collaboration

1:00- 2:00

WEEK 9: APRIL 28-MAY 2, 2014

Study Group B Weekly collaboration

Friday, May 2 Evaluate Results

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Wednesday

Thursday Friday

Group B8:00- 9:00

Evaluate Results

Weekly Collaboration

1:00- 2:00

EXPECTED OUTCOMES

Standardization of course sequence is complete

The outcomes:1. 100% of courses are sequenced2. 90% of instructor’s trained in course

sequence 3. 100% of staff have time established

for weekly collaboration

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MEASUREMENT OF OUTCOMES

The outcomes:1. Knowledge Acquisition

Learners tests2. Acceptability of Sequence

Learners surveys Educators journal entries

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(Microsoft, 2010)

ANALYSIS OF RESULTS

Implemented plan has impacted the problem Quantitative

Learner’s Test Qualitative

Learner’s Survey Educator’s Journal Entries

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ANALYSIS OF RESULTS

Present findings to leadership Written report Presentation

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QUESTIONS

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(Microsoft, 2010)

REFERENCES Cendan, J. and Johnson, T. (2011). Enhancing Learning

through Optimal Sequencing of Web-Based and Manikin Simulators to Teach Shock Physiology in the Medical Curriculum. Advances in Physiology Education, 35(4), 402-407.

Ciceroa, M., Auerbacha, M., Zigmonta, J., Rieraa, A., Chinga, K., and Baum, C. (2012). Simulation training with structured debriefing improves residents' pediatric disaster triage performance. Prehospital Disaster Medicine, 27(3), 239-244.

Lawrence D. (2007). The ethics of educational research. Journal Of Manipulative & Physiological Therapeutics, 30(4), 326-330.

Lee, J. (1999). Effectiveness of computer-based instructional simulation: A meta analysis. International Journal of Instructional Media, 26(1), 71-85.

Hendricks, C. (2009). Improving schools through action research: A comprehensive guide for educators (2nd ed.). Upper Saddle River, NJ: Pearson

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REFERENCES CONTINUED Issenber, B., & McGaghie, E. (2005). Features and uses of

high-fidelity medical simulations that lead to effective learning. Medical Teacher, 27(1), 10-28.

McGaghie, W., Issenber, B., Cohen, E., Barsuk, J., Wayne, D. (2011). Does simulation-based medical education with deliberate practice yield better results than traditional clinical education? A Meta-analytic comparative review of the evidence. Academic Medicine, 86(6), 706–711.

Microsoft, (2010). Image “All graphics”. Stefaniak, J., & Turkelson, C. (2013). Does the sequence of

instruction matter during simulation. Society for Simulation in Healthcare, 00(00), 1-6.

Zendejas, B., Cook, D., & Farley, D. (2010). Teaching first or teaching last: Does the timing matter in simulation-based surgical scenarios. Journal of Surgical Education, 67(6), 432-438.

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APPENDIX A: EDUCATION SCENARIOS

STATUS ASTHMATICUS

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Level II (In-Hospital)

Your patient is a 6-year old male, who was playing outside and developed difficulty breathing and shortness of breath. The patient came into the Emergency Department by his parents, who are currently out registering him into the ED. The patient is unable to answer the ED staff in complete sentences. Patient has audible wheezing upon presentation. The parents are unable for additional until midway through the scenario.

STATUS ASTHMATICUS ALGORITHM

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RR 48, sats 88% HR 150, BP 108/82

Expected evaluation: Primary assessment = A, B, C’s Identification of poor air movement upon auscultation. Determine severe respiratory distress and pending failure likely due to asthma Expected management: 1. Identify need for high flow oxygenation via a NRB mask. 2. Gather further patient history. 3. Preparation of nebulized medication: albuterol and atrovent

Recognizes distress and wheezing, but maintains large differential diagnosis – foreign body, chemical aspiration, viral pneumonitis, cardiomyopathy Administers O2 Orders CXR

Fail to recognize severity of respiratory distress Focus on only diagnosis – obtain CXR and blood gas

Sats improve with O2, but RR now 50, HR 160, more distress

Sats drop to low 80s, poor air movement and loss of wheezing due to decreased effort

Bronchodilator & steroid tx: Albuterol # 2 & 3 Atrovent #2 IV access Solumedrol administration

CXR with hyperinflation, no infiltrate, normal heart size

Apply oxygen as NRB Prepare for intubation – spend time drawing up medications and obtaining IV access No BVM applied

Recognize as asthma, initiates albuterol, atrovent and steroids as first line management

Attempt intubation without medications – despite placement of ETT with lower airway disease pt becomes asystolic and arrests

6yo male presents with: 1. Severe respiratory distress 2. Audible wheezing upon auscultation. 3. Cannot answer questions w/ complete sentences 4. Tachycardia

1. Patient’s sats improve with O2 and medication. 2. HR 160, RR 40, BP 110/83 3. Bilateral wheeze, better air movement

Maintains sats in 90s, but decreased mental status; more distress

Continued slow improvement: RR 38, HR 160, BP 112/81 Better aeration, able to speak more freely Still with significant wheezing

Pt becomes apneic, HR drops to 100, pt unresponsive

1. Determination of destination (e.g. ICU) 2. Consideration of additional medications, specifically magnesium sulfate 3. NS bolus since increased insensible losses 4. Reassessment of patient’s respiratory status. Pt death

ALTERNATE PROCESS Delay Action

INCORRECT PROCESS Fail to Act

Does not recognize as asthma

FBAO ARREST

Level II (In-Hospital)

Your patient is a 7-year old male, who was playing in the lobby and collapsed suddenly. Witness assesses the child and called for help. He is unresponsive, blue, and apneic.

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FBAO ALGORITHM

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Assessment And Decision

S&S’s: Inc SOB; fluttering in chest

Vagal maneuvers Prepare IV Prepare for Adenosine

Initial exam performed Differentiate between SVT and sinus tachycardia

Complete Initial exam not done. Patient continues to deteriorate

Assessment and Decision

Assessment and Decision

Stable SVT (cont.) 1st dose Adenosine (HR slows to

190) 2nd dose Adenosine Becomes hypotensive (55/30)

Unstable SVT develops if SVT not recognized. Patient stops moaning and respiratory effort diminishes

Unstable SVT Patient continues to deteriorate Patient stops moaning and respiratory effort diminishes Prepare for BVM and possible intubations

Assessment and Decision

Unstable SVT Decompensated – Unresponsive Cardioversion 0..5-1j/kg Cardioversion – double dose of energy

Unstable SVT (Defibrillation Error)

Decompensated – Unresponsive Cardioversion 0.5-1 j/kg…Goes into vfib if not

synchronized Vfib; defibrillate at 2-4 J/kg Can go to Desired process final outcome if correct

defibrillation and meds are given

Baseline HR-220; T-37; RR- 60; BP 65/40, 02 sats-low 90’s ; Pupils and mental status normal, lungs clear, intact pulses; cap refill 3 sec, grunting and irritable

Assessment and Decision

Assessment and Decision

Assessment and Decision

SVT Recovery - END Reassess Confused mental status Awake Maintain oxygenation Sinus tachycardia

If v-fib algorithm not followed, patient death will occur

sinus tachycardia

SVT

SUPRAVENTRICULAR TACHYCARDIA

Level II (In-Hospital)

Your patient is an 8-month-old male, Mother reports several days of increased fussiness, breathing hard and sweating when eating. Today seems short of breath and pale, refusing to eat or drink. Seen at PCP and referred to the ED. HR 220, CR- 3 seconds. Liver down. Patient irritable with decreased responsiveness.

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SUPRAVENTRICULAR TACHYCARDIA ALGORITHM

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Assessment And Decision

S&S’s: Inc SOB; fluttering in chest

Vagal maneuvers Prepare IV Prepare for Adenosine

Initial exam performed Differentiate between SVT and sinus tachycardia

Complete Initial exam not done. Patient continues to deteriorate

Assessment and Decision

Assessment and Decision

Stable SVT (cont.) 1st dose Adenosine (HR slows to

190) 2nd dose Adenosine Becomes hypotensive (55/30)

Unstable SVT develops if SVT not recognized. Patient stops moaning and respiratory effort diminishes

Unstable SVT Patient continues to deteriorate Patient stops moaning and respiratory effort diminishes Prepare for BVM and possible intubations

Assessment and Decision

Unstable SVT Decompensated – Unresponsive Cardioversion 0..5-1j/kg Cardioversion – double dose of energy

Unstable SVT (Defibrillation Error)

Decompensated – Unresponsive Cardioversion 0.5-1 j/kg…Goes into vfib if not

synchronized Vfib; defibrillate at 2-4 J/kg Can go to Desired process final outcome if correct

defibrillation and meds are given

Baseline HR-220; T-37; RR- 60; BP 65/40, 02 sats-low 90’s ; Pupils and mental status normal, lungs clear, intact pulses; cap refill 3 sec, grunting and irritable

Assessment and Decision

Assessment and Decision

Assessment and Decision

SVT Recovery - END Reassess Confused mental status Awake Maintain oxygenation Sinus tachycardia

If v-fib algorithm not followed, patient death will occur

sinus tachycardia

SVT

HEAT ILLNESS

Level II (In-Hospital)

Your patient is a 6-month old male, who was not “acting like himself”, is poorly responsive and “sweaty”, and seems to becoming progressively worse over past few minutes. Help was called. He still has poor responses, labored breathing, pale, and clammy upon assessment.

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HEAT ILLNESS ALGORITHM

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HR 200, RR 60 labored, BP 85/50, Temp 41.6C Rectal; O2 Sat 90%, Cap refill 4-5 sec, skin flushed and sweating; pupils dilated, responds to pain

Expected interventions: Assess ABCs Recognize deteriorating condition O2/airway support, anticipate need for control IV access, initial labs – especially I-stat NS bolus 20 ml/kg Attempt cooling measures: ice to groin, axilla, neck; fan

Assess ABCs Apply O2 IV access and NS bolus But, delay in aggressive cooling

Failure to assess ABCs Failure to obtain access Do not recognize hyperthermia as heat illness

Develops generalized seizure; poor respiratory effort, BP 60/40

Reassessment Labs more specific to heat illness: risk of liver, renal, cardiac injury; risk of rhabdomyolysis Continue cooling patient Consults: ICU for disposition

O2/Airway Support with BVM IV Ativan 20ml/kg NS bolus Reassessment

O2/Airway Support with BVM Need to establish access – now more difficult with seizure Try IM Ativan – no success

IV D10w or D25W Continue volume resuscitation for metabolic acidosis

Airway control with RSI and intubation 20 ml/kg NS bolus Consult ICU for disposition Screening labs

CPR Intubation (no need RSI) Defibrillation But, failure to treat underlying hyperthermia

HR 160, RR 48, BP 90/55, Temp 38.1, O2 sat 94%

Seizure stops; HR 170, RR 12/poor effort, BP 80/50, Temp 40.8, O2 sat 94%

Vitals normalize I-stat: pH 7.2, PCO2 25, BD -12, HCO3 10, Gluc 46, NA 130, K 5.5, iCa 1.1

Temp 42.8, now Apnea (but easy to bag) without pulses; monitor: V-Fib Arrest

Pt stable for admission

Poor Outcome/Pt Death

Alternate process: Delay in care

Incorrect process

Your patient is a 6-month old male, who was left in a hot car for “just a minute.” The child was not “acting like himself”, is poorly responsive and “sweaty”, and seems to becoming progressively worse over past few minutes. 911 is called. He is pink in color upon presentation.

Once recognize need for cooling, move back to here

HR 170, BP 90/55, Temp 40.6, O2 sat 99%

APPENDIX B: PARTICIPANT TESTS AND ANSWERS

Action Research Proposal Test Weeks 2 and 3

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1. What is not a typical sign of respiratory distress?

a. tachypnea

b. fever

c. nasal flaring

d. tachycardia

2. What is the most common form of infectious pneumonia, which often causes empyema?

a. streptococcus pneumoniae

b. mycoplasma pneumoniae

c. chlamydia pneumoniae

d. staphylococcus pneumoniae

3. Children with increased ICP typically will present with all the following except which?

a. irregular breathing

b. bradycardia

c. tachycardia

d. hypertension

4. Shock occurs with which level of blood pressure?

a. decreased

b. increased

c. normal

d. all the above

CONTINUED ACTION RESEARCH PROPOSAL TEST

WEEKS 2 & 3

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6. Myocardial dysfunction impairs cardiac output and stroke volume, which can typically lead to which shock?

a. cardiogenic shock

b. septic shock

c. anaphylactic shock

d. neurogenic shock

7. What should be the first priority when assisting a critically ill or injured child in shock?

a. oxygen administration

b. monitoring

c. positioning

d. fluid resuscitation

8. Which is not a common assessment when determining the effectiveness of fluid resuscitation?

a. temperature

b. heart rate

c. skin coloration

d. urine output

9. Monitoring of continuous arterial blood pressure can be accomplished with placement of a __________.

a. central venous catheter

b. arterial catheter

c. pulmonary artery catheter

d. none of the above

10. To treat cold shock, _____________ is preferred.

a. dopamine

b. norepinephrine

c. epinephrine

d. dobutamine

5. The recommended priority of treatment of ischemic hypoxia is what?

a. oxygen administration

b. increase cardiac output

c. restore hemoglobin concentration

d. none of the above

ACTION RESEARCH PROPOSAL ANSWERS WEEKS 2 & 3

ANSWERS

1.B

2.D

3.B

4.D

5.B

6.A

7.C

8.C

9.B

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Action Research Proposal Test Weeks 4 and 5

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1. For cardiogenic shock, you should deliver a fluid challenge (5 to 10 mL/kg bolus) over what length of time?

a. 1-5 minutes b. 5-10 minutes c. 10-20 minutes d. under 3 minutes

2. ______________ is described as an accumulation of pressurized air in the pleural space.

a. tension pneumothorax b. cardiac tamponade c. massive pulmonary embolism d. none of the above

3. In a case of sinus tachycardia, the heart rate is ___________.

a. increased b. decreased c. unsteady d. faint

4. Ventricular tachycardia is common in children.

a. true b. false

5. What is the first sign of the body's defensive response when a child or infant is in shock?

a. body temperature drop b. body temperature rise c. heart rate increase d. heart rate decrease

Continued Action Research Proposal Test Weeks 4 & 5

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7. The first warning sign of respiratory dysfunction is:

a. decrease of heart rate b. increase in blood pressure c. increase in respiratory rate d. decrease in body temperature

8. During resuscitation of a newborn infant, the blow-by oxygen rate of flow should always be more than:

a. 2 L/min. b. 5 L/min. c. 6 L/min. d. 8 L/min.

9. What age period is croup most common to occur?

a. 3 - 5 years b. 6 months - 3 years c. 4 - 7 years d. 1 month - 12 months

10. What is the recommended first energy level used for defibrillation?

a. 0.3 joules/kg. b. 1.5 joules/kg. c. 2.0 joules/kg. d. 2.5 joules/kg.

6. Each attempt for catheter insertion and suctioning of an infant should not surpass:

a. 3 seconds b. 5 seconds c. 7 seconds d. 10 seconds

ACTION RESEARCH PROPOSAL ANSWERS WEEKS 4 & 5

ANSWERS

1. C 2.A 3.C 4.B 5.C 6.D 7.C 8.B 9.B 10.C

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ACTION RESEARCH PROPOSAL TEST WEEKS 6 & 7

1. Simple measures to restore upper airway patency in a child may include any of the following EXCEPT:a. Using head tilt - chin lift to open the airwayb. Cricothyrotomyc. Perform foreign body airway obstruction relief techniquesd. Use airway adjuncts (e.g., nasopharyngeal or oropharyngeal airway)

2. Stridor is a sign of what?a. Pneumoniab. Aspirationc. Upper airway obstructiond. Bronchoconstriction

3. The Glasgow Coma Scale (GCS) is scored based on response to all of the following EXCEPT:a. Eye openingb. Verbal responsec. Motor responsed. Cardiac Output

4. Medications used in the treatment of Croup may include:

a.  Dexamethasoneb.  Nebulized epinephrinec.  Helioxd.  All of the above

5. Common causes of upper airway obstruction include all of the following EXCEPT:

a. Aspirated foreign bodyb.  Asthmac.  Swelling of the airwayd.  Retropharyngeal abscess

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CONTINUED ACTION RESEARCH PROPOSAL TEST WEEKS 6 & 7

6. The initial impression consists of assessing all of the following EXCEPT:

a. Consciousnessb.  Deformityc.  Breathingd.  Color

7. Types of shock include all of the following EXCEPT:

a.  Hypovolemic shockb.  Hypoglycemic shockc.  Distributive shockd.  Cardiogenic shock

8. Common causes of acute community-acquired pneumonia include which of the following?

a.  Streptococcus pneumoniab.  Mycoplasma pneumoniac.  Chlamydia pneumoniad.  All of the above 

9. A room air SpO2 reading less than _____ in a child indicates hypoxemia.

a.  99%b.  97%c.  95%d.  94% 

10. Signs of increased respiratory effort include all of the following EXCEPT:a.  Abdominal bloatingb.  Nasal flaringc.  Chest retractionsd.  Head bobbing or seesaw respirations

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ACTION RESEARCH PROPOSAL ANSWERS WEEKS 6 & 7

ANSWERS

1. B

2. C

3. D

4. D

5.  B

6. B

7. B

8. D

9. D

10. A53

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ACTION RESEARCH PROPOSAL TEST WEEKS 8 & 9

1. You are caring for a 5-year-old patient with supraventricular tachycardia (hear rate = 220/min). The child is lethargic. The skin is pale and cool with delayed capillary refill. Distal pulses are not palpable. Which of the following would be the best treatment to provide without delay?

a) Place cold packs on the distal upper and lower extremitiesb) Ask the child to blow through a small strawc) Exert light pressure on the eyes bilaterallyd) Provide synchronized cardioversion at 0.5 to 1 joules/ kilogram

2. You are initiating treatment for a child with septic shock and hypotension. While administering high-flow oxygen you determine that the child’s respirations are adequate and SpO2 is 100%. You have just established vascular access and obtained blood samples. Which of the following is the next most appropriate therapy to support systemic perfusion?

a) Administer repeated fluid boluses of isotonic colloidb) Administer repeated fluid boluses of isotonic crystalloidc) Begin immediate dopamine infusiond) Begin immediate dobutamine infusion

3. You arrive on the scene of a 12-year-old who suddenly collapsed on the playground. The child is unresponsive, apneic, and pulseless and CPR is in progress. A lay rescuer just brought the school AED, turned it on, and attached it. The AED recommends a shock. Which of the following should be done next?

a) Obtain intravenous accessb) Attempt defibrillationc) Change compressions: ventilations from 30:2 to 15:2d) Attempt endotracheal intubation

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CONTINUED ACTION RESEARCH PROPOSAL TEST WEEKS 8 & 9

4. You attempted synchronized cardioversion for an infant with supraventricular tachycardia (SVT) and poor perfusion. The SVT persists after the initial 1 J/kg shock. Which of the following should you attempt now? 

a) Synchronized cardioversion at a dose of 2 J/kgb) Synchronized cardioversion at a dose of 4 J/kgc) Unsynchronized cardioversion at a dose of 2 J/kgd) Unsynchronized cardioversion at a dose of 4 J/kg

5. You are treating a 5-month old with a 2-day history of vomiting and diarrhea. The patient is listless. The respiratory rate is 52 breaths/ minute and unlabored. The heart rate is 170/ minute and pulses are present but weak. Capillary refill is delayed. You are administering high-flow oxygen, and intravenous access is in place. At this point, the most important therapy is to:

a) Administer an epinephrine bolusb) Begin bag-mask ventilationc) Provide a rapid 20ml/kg isotonic crystalloid fluid bolusd) Administer a bolus of 0.5 g/kg of dextrose

6. Which of the following groups of clinical findings would be most consistent

with categorizing a patient with compensated shock?  Normal systolic blood pressure, decreased level of consciousness, cool extremities with

delayed capillary refill, and faint or nonpalpable distal pulses Decreased level of consciousness, extensor posturing in response to pain, hypertension, and

apnea Normal blood pressure, normal level of consciousness, bounding distal pulses, hypercarbia,

hypoxemia, and normal urine output Unresponsiveness, normal breathing, and good distal pulses.

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CONTINUED ACTION RESEARCH PROPOSAL TEST WEEKS 8 & 9

7. You are caring for an 8-month-old with bradycardia and very poor perfusion that has persisted despite effective ventilations with high-flow oxygen. You should begin chest compressions if the heart rate is: 

a) More than 200/minb) More than 150/minc) Less than 100/mind) Less than 60/min 

8. You are called to treat a 5-year-old with a 3-day history of worsening respiratory distress. The child responds only to pain. The heart rate is initially 45/ min and regular with poor capillary refill. You provide bag-mask ventilations (BVM) with high-flow oxygen that produces good chest rise with full and clear bilateral breath sounds. The heart rate rises in response to ventilation, but after you suction the posterior pharynx, bradycardia recurs (40/min). Which of the following interventions would be most appropriate for you to do first? 

a) Perform transcutaneous pacingb) Administer epinephrine IVc) Administer atropine IVd) Resume bag-mask ventilations

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CONTINUED ACTION RESEARCH PROPOSAL TEST WEEKS 8 & 9

9. You are caring for a child who was resuscitated after a drowning event. The child is intubated and ventilated with 100% oxygen with equal breath sounds and exhaled CO2 detected. The heart rate is slow and the monitor shows a sinus bradycardia. The skin is cool, mottled, and moist; distal pulses are not palpable and central pulses are weak. Intravenous access has been established. The core temperature is 37.3 Celsius. Based on the PALS bradycardia algorithm, which of the following should be provided first?

a) Epinephrine IVb) Transcutaneous pacingc) Atropine IVd) Dobutamine IV infusions

10. When monitoring the quality of chest compressions during resuscitation, you should ensure that providers are

a) Pushing hard – ensure that the chest is compressed ¾ of the anterior-posterior diameterb) Pushing fast – compress at a rate of 150/ minc) Allowing complete recoil – let the chest return to its original position between compressionsd) Minimizing interruptions – do not permit interruptions for more than 1 minute

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ACTION RESEARCH PROPOSAL ANSWERS WEEKS 8 & 9

ANSWERS1.D2.B3.B4.A5.C6.B7.D8.D9.A10.C

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