Morris Victoria, Wians Robert, Wilson Jessica, Stevens Gowri
McGovern Medical School at the University of Texas Health Science Center, Department of Emergency Medicine, Houston, TX.
J Educ Teach Emerg Med. 2022 Apr 15;7(2):S48-S77. doi: 10.21980/J8X35W. eCollection 2022 Apr.
Emergency medicine and pediatric residents, and pediatric emergency medicine (PEM) fellows.
Botulism is a rare but serious cause of infant hypotonia, vomiting, and respiratory failure. The differential diagnosis and management of a hypotonic infant with progressive weakness leading to respiratory failure is a rare presentation with high morbidity and mortality.1 Infants with botulism generally present with vague complaints that progressively worsen over time.2 Recognition of descending paralysis in an infant as well as signs of respiratory failure are key to preventing an adverse outcome. A key component of botulism treatment is recognizing the need to mobilize local resources to obtain BabyBIG (botulism immune globulin). This process can and should begin in the emergency department.
After this simulation learners should be able to: 1) develop a differential diagnosis for the hypotonic infant, 2) recognize signs and symptoms of infant botulism, 3) recognize respiratory failure and secure the airway with appropriate rapid sequence intubation (RSI) medications, 4) initiate definitive treatment of infant botulism by mobilizing resources to obtain antitoxin, 5) continue supportive management and admit the patient to the pediatric intensive care unit (PICU), 6) understand the pathophysiology and epidemiology of infant botulism, 7) develop communication and leadership skills when evaluating and managing critically ill infants.
This simulation case was performed using a high-fidelity Laerdal SimBaby with intubating capabilities and real-time vital sign monitoring. Additionally, this case can be performed with low fidelity manikins with supplemental scripting and visual stimuli. With minor adjustments, this case could be modified into an oral boards case.
We obtained feedback from a convenience sample of random participants after the simulation case and debrief were completed. The sample of emergency medicine residents (N=21) and PEM fellow (N=1) completed 5 questions on a 5-point Likert scale.
The emergency medicine residents and PEM fellow had mostly favorable feedback regarding the simulation and debriefing. Most strongly agreed or agreed that this would improve their performance in an actual clinical setting.
Infant botulism is a rare condition, presenting as vague non-specific complaints that worsen over time. It is important to differentiate infant botulism from other causes of weakness, hypotonia, and respiratory failure. This case presents learners with a high acuity, rare case of infant botulism and allows them to work through a complex pediatric patient encounter in a psychologically safe space. The presence of a standardized patient to play the patient's parent is key to assess learners' nontechnical communication skills and to increase fidelity during the simulation.
Infant botulism, pediatric emergency medicine, respiratory failure, hypotonia, toxicology.
急诊医学和儿科住院医师，以及儿科急诊医学（PEM）研究员。
肉毒中毒是导致婴儿肌张力减退、呕吐和呼吸衰竭的一种罕见但严重的病因。对于出现进行性肌无力并导致呼吸衰竭的低张力婴儿进行鉴别诊断和管理是一种罕见的情况，其发病率和死亡率很高。1 患肉毒中毒的婴儿通常表现为模糊不清的症状，且会随着时间逐渐加重。2 识别婴儿的下行性麻痹以及呼吸衰竭的迹象是预防不良后果的关键。肉毒中毒治疗的一个关键组成部分是认识到需要调动当地资源以获取婴儿肉毒抗毒素（BabyBIG）。这个过程可以而且应该在急诊科开始。
在这个模拟之后，学习者应该能够：1）对低张力婴儿进行鉴别诊断，2）识别婴儿肉毒中毒体征和症状，3）识别呼吸衰竭并用适当的快速顺序诱导插管（RSI）药物确保气道安全，4）通过调动资源获取抗毒素开始对婴儿肉毒中毒进行确定性治疗，5）继续进行支持性管理并将患者收入儿科重症监护病房（PICU），6）了解婴儿肉毒中毒的病理生理学和流行病学，7）在评估和管理危重症婴儿时培养沟通和领导技能。
本模拟病例使用具有插管能力和实时生命体征监测功能的高保真Laerdal SimBaby进行。此外，该病例也可以使用带有补充脚本和视觉刺激的低保真人体模型进行。稍作调整，该病例可改编为口试病例。
在模拟病例和汇报完成后，我们从随机抽取的便利样本参与者那里获得了反馈。急诊医学住院医师样本（N = 21）和PEM研究员样本（N = 1）完成了一份5级李克特量表上的5个问题。
急诊医学住院医师和PEM研究员对模拟和汇报大多给予了积极反馈。大多数人强烈同意或同意这会提高他们在实际临床环境中的表现。
婴儿肉毒中毒是一种罕见病症，表现为随着时间推移而加重的模糊不清的非特异性症状。将婴儿肉毒中毒与其他导致肌无力、肌张力减退和呼吸衰竭的病因区分开来很重要。这个病例为学习者呈现了一个高敏锐度、罕见的婴儿肉毒中毒病例，并让他们在心理安全的空间中处理一个复杂的儿科患者病例。有标准化病人扮演患者家长对于评估学习者的非技术沟通技能以及在模拟过程中提高逼真度至关重要。
婴儿肉毒中毒、儿科急诊医学、呼吸衰竭、肌张力减退、毒理学
