1. Dr. _______, Mr. Jones is awaiting your arrival in the CT room where you will perform a CT scan to confirm the diagnosis of SAH stroke. Be sure to follow the protocol for the procedure carefully and refer to your EMR if you have any questions. Keep up the good work! Scene B Introduction

2. CT Scan Activity Here Adjust height of gurney so bottom of gurney bed is level with inner CT circle. Adjust patient’s gurney forward until the base of his skull is on the other side of the CT machine (scan runs anteriorly from base of skull). Go into the CT control room. Select the “routine head scan parameters” option on the monitor.

3. CT Scan Activity cont’d… Push “run scan”. Locate the suspected bleed on the CT scan results. Order your next diagnostic test.

4. Dr. _______’s Notes (Scene B) Ordered CT Scan: faster, can find bleed in brain, less expensive Subarachnoid hemorrhagic (SAH) stroke diagnosed SAH stroke is probably due to an aneurysm since there is no trauma in Mr. Jones’ recent patient history CT angiogram ordered to located suspected aneurysm Return to ER Bleeding

5. EMR (Scene B) How a CT scan works How to program a CT machine How to read a CT scan Normal brain CT Descriptions of nSAH and SAH strokes CT scan of nSAH stroke CT scan of SAH stroke Causes of SAH hemorrhagic strokes and their treatments Uses of MRI, PET scans, & CT angiograms Return to ER

6. Dr. _______, Great job! Mr. Jones is certainly benefiting from your expertise and hard work. Mr. Jones will be waiting for you in the CT angiogram room. Scene B Conclusion

7. Dr. _______, Now that you have determined that Mr. Jones’ hemorrhage is probably being caused by an aneurysm, you have ordered a CT angiogram to locate the suspected aneurysm. Mr. Jones has been transported to the CT angiogram room, where they have readied him for the CT angiogram procedure. Please remember to consult the hospital protocol and EMR as necessary. Scene C Introduction

8. CT Angiogram Activity Here Select the “Circle of Willis scan parameters” option. Push “inject contrast dye”. Push “run scan”. Locate the aneurysm on the scan results. Highlight the area of the aneurysm and select “see in 3D”. Determine the appropriate course of treatment for this aneurysm.

9. Dr. _______’s Notes (Scene C) CT Angiogram shows aneurysm in the anterior communicating artery Aneurysm in Anterior Communicating Artery Have decided to coil/embolyze the aneurysm due to the patient’s age and lack of invasiveness of this procedure. Return to ER

10. Description of how/why CT Angiograms are performed. How to program CT angiogram machine Brain Blood Vessel Anatomy Information about Clipping AneurysmsClipping Aneurysms Information about Coiling AneurysmsCoiling Aneurysms Insert a coil into the aneurysm. (animation)Insert a coil into the aneurysm. Return to ER EMR (Scene C)

11. Dr. _______, Congratulations! You found the aneurysm in Mr. Jones’ anterior communicating artery and have to decided to coil the aneurysm. In order to do this, you must first perform a catheter angiogram in order to reach the aneurysm. Mr. Jones is waiting for you in the CT angiogram room. Scene C Conclusion

12. Dr. _______, Now that you have located Mr. Jones’ aneurysm in his anterior communicating artery, you need to perform a catheter angiogram in order to reach the aneurysm and embolyze it. Mr. Jones has been transported to the catheter angiogram room where he has been prepped for the procedure. Be sure to consult the protocol manual and EMR if you are in need of assistance with the procedure. Scene D Introduction

13. Scene D 1 – Catheter Angiogram Procedure Tool Tray Trash Protocol EMREMR Dr.’s Notes Patient History

14. Scene D 1 – Catheter Angiogram Procedure Tool Tray Trash Protocol EMREMR Dr.’s Notes Patient History Protocol: 1. Select needle and insert into the right femoral artery. 2. Select the appropriate guidewire and insert into needle. 3. Select short sheath and thread it over guidewire.

15. Scene D 2 – Catheter Angiogram Procedure Tool Tray Trash Protocol EMREMR Dr.’s Notes Patient History Protocol: 4. Remove guidewire. 5. Select new appropriate guidewire and insert. 6. Select appropriate catheter and insert. 7. Inject dye and take picture. Hospital Announcements

16. Scene D 3 – Catheter Angiogram Procedure Tool Tray Trash Protocol EMREMR Dr.’s Notes Patient History Protocol: 8. Advance the guidewire/catheter combination up through the external iliac artery. 9. Inject dye and take image. Hospital Announcements

17. Scene D 4 – Catheter Angiogram Procedure Tool Tray Trash Protocol EMREMR Dr.’s Notes Patient History Protocol: 10. Advance the guidewire/catheter combo up through the abdominal aorta. 11. Inject dye and take image.. Hospital Announcements

18. Scene D 5 – Catheter Angiogram Procedure Tool Tray Trash Protocol EMREMR Dr.’s Notes Patient History Protocol: 12. Advanced guidewire/catheter combo up through the aortic arch. 13. Inject dye and take image. Hospital Announcements

19. Scene D 6 – Catheter Angiogram Procedure Tool Tray Trash Protocol EMREMR Dr.’s Notes Patient History Protocol: 14. Remove wire 15.Select appropriate microguidewire and thread through catheter. 16. Select appropriate microcatheter and thread over microguidewire. 17. Advance microguidewire/microcatheter combo up through the left common carotid artery. 18. Inject dye and take image. Hospital Announcements

20. Scene D 7 – Catheter Angiogram Procedure Tool Tray Trash Protocol EMREMR Dr.’s Notes Patient History Protocol: 19. Advance microguidewire/microcatheter combo through the left internal carotid artery. 20. Inject dye and take image. Hospital Announcements Map of Brain Arteries Here

21. Scene D 8 – Catheter Angiogram Procedure Tool Tray Trash Protocol EMREMR Dr.’s Notes Patient History Protocol: 21. Advance microguidewire/microcatheter combo through the middle cerebral artery. 22. Inject dye and take image. Hospital Announcements Map of Brain Arteries Here

22. Dr. _______’s Notes (Scene D) Catheter angiogram performed. Catheter run through femoral artery to abdominal aorta to thoracic aorta to aortic arch to common carotid artery to internal carotid artery to middle cerebral artery, finally ending in the anterior communicating artery. Aneurysm is ready to be coiled Aneurysm in Anterior Communicating Artery Middle Cerebral Artery Internal Carotid Artery

23. Catheter angiogram procedure. Blood vessel sizes. Catheter and guidewire sizes. Blood vessel anatomy. Return to ER EMR (Scene D)

24. Dr. _______, Congratulations! You successfully navigated the microcatheter and microguidewire up to the anterior communicating artery. You are now ready to embolyze the aneurysm. Mr. Jones is ready for you to perform the procedure. Scene D Conclusion

25. Dr. _______, Mr. Jones’ aneurysm is now ready to be embolyzed. He is waiting for you in the catheter angiogram room. Be sure to consult the protocol manual and EMR if you are in need of assistance. Good luck! Scene E Introduction

26. Coiling Procedure Activity Here Select coil type and select the number desired. Click & drag coils from tray to aneurysm. Inject dye and check image for blood flow. Select coil type and select the number desired. Click & drag coils from tray to aneurysm. Inject dye and check image for blood flow.

27. Coiling Procedure Activity cont’d Select coil type and select the number desired. Click & drag coils from tray to aneurysm. Inject dye and check image for blood flow. Remove catheter.

28. Dr. _______’s Notes (Scene E) Aneurysm successfully coiled. Sent patient to ICU for recovery. Ordered HHH therapy and monitoring for vasospasms. Aneurysm in Anterior Communicating Artery now embolyzed Middle Cerebral ArteryInternal Carotid Artery

29. You have successfully treated Mr. Jones within the necessary 3 hour time window! If you have scored a ___ or higher, you are still in the running to become Chief of Staff – great job! If you have scored lower than a ___, perhaps the next stroke patient to come through the doors of St. Normal Hospital will have better results. Also, please realize that Mr. Jones’ journey is not over. He will have a 10-14 day stay in the ICU (where the rate of mortality from strokes is very high 2- 12 days following the initial stroke) and then undergo physical therapy. Scene E Conclusion