Belhassen Tachycardia in a Pediatric Patient: A Simulation for Pediatric Emergency Medicine Fellows

Ventricular tachycardia in pediatric emergency department patients is a high-risk, low-frequency event well suited for education through simulation. This technical report describes a simulation-based curriculum for Pediatric Emergency Medicine fellows and senior residents involving the evaluation and management of a 10-year-old female presenting with palpitations who is ultimately diagnosed with Belhassen tachycardia. The curriculum highlights the features that differentiate Belhassen tachycardia (idiopathic left posterior fascicular ventricular tachycardia) from supraventricular or other tachycardias, building upon foundational pediatric resuscitation skills and Pediatric Advanced Life Support (PALS) algorithms for advanced learners.


Introduction
Due to the relative infrequency of non-sinus tachycardias in Pediatric Emergency Medicine (PEM), exposure to ventricular tachycardias through simulation can help identify and address the knowledge gaps of trainee physicians. Belhassen tachycardia (idiopathic fascicular ventricular tachycardia) is an atypical ventricular tachycardia [1], which requires rapid identification and targeted intervention to prevent progression to hemodynamic decompensation or other comorbid conditions such as tachycardia-induced cardiomyopathy. Standard interventions for supraventricular tachycardia (SVT) such as vagal maneuvers, adenosine, betablockers, lidocaine, synchronized cardioversion, and atrial overdrive pacing are ineffective in treating Belhassen tachycardia. Integrating a rapid clinical assessment with diagnostic test results (i.e., ECG) in formulating a management plan and directing resuscitation of tachycardic pediatric patients is a key objective for PEM fellows and senior emergency medicine residents.
Belhassen tachycardia typically presents in older children, adolescents, and young adults and mimics SVT with aberrancy, right bundle branch block, and left anterior hemiblock [2,3]. There have also been case reports in infants and young children [4]. Unlike monomorphic ventricular tachycardia where 90% of cases occur in patients with underlying heart disease, patients who present with Belhassen tachycardia typically have no underlying structural heart disease [5]. A combination of ECG findings including rSR' V1 morphology, QRS width, positive QRS in aVR and the V6 R/S ratio has been shown to differentiate Belhassen tachycardia from SVT with right bundle branch block and left anterior hemiblock with a sensitivity of 82% and specificity of 78% [6]. An additional key ECG finding is left axis deviation. Belhassen tachycardia can be acutely and chronically managed with verapamil; however, this drug may cause adverse side effects, including hypotension. Particular caution in infants is necessary as their immature myocardium poses an increased risk of verapamil-induced cardiovascular collapse. Intravenous calcium should be immediately administered in all cases to treat verapamil-induced hypotension [7,8].
This technical report was designed for advanced learners, that is, PEM fellows, with strong foundational resuscitation skills and familiarity with Pediatric Advanced Life Support (PALS) algorithms to help them develop a differential diagnosis and management approach for a refractory tachyarrhythmia through the example of Belhassen tachycardia [9]. It would also be appropriate for Pediatric Cardiology fellows and senior Emergency Medicine or Pediatric residents. The case details require learners to recognize the need to deviate from PALS algorithmic management of ventricular tachycardia. While simulation cases that address ventricular tachycardia in pediatric patients are available, there are currently no published resources addressing Belhassen tachycardia [10,11]. Methods   1  2  3  4  1 This simulation case was developed by the PEM physicians with expertise in curriculum development and simulation and in consultation with a pediatric cardiologist to complement the existing content of the PEM fellowship simulation curriculum. The scenario was based on an actual patient case. In this participation scenario, participants underwent a rapid patient assessment, interpretation of diagnostic tests, and critical management interventions for Belhassen tachycardia. The simulation was implemented with PEM fellows at three institutions as part of their routine fellow education program. Prerequisite knowledge included an understanding of PALS algorithms [12].

Setting and equipment
This scenario occurred in an emergency department patient room or a simulation lab with a high-technology child manikin. A separate space was used for a debriefing where necessary. The case could be modified to reflect a younger child or older teenager depending upon the availability of the manikin. Medications and equipment typically found in EDs, including medications required to participants for this case were available.

Participants
We implemented this simulation with a total of 18 PEM fellows and two senior Emergency Medicine residents across three training sites. Participants had prior experience with simulation and medical resuscitations. Participants were oriented to the simulator prior to the case if they had not previously worked with that manikin. Each site conducted the simulation once. Due to scheduling constraints, all team roles were filled by physicians.

Personnel
Facilitators were PEM supervising physicians with expertise in simulation development, facilitation, and debriefing methods. The facilitator or simulation specialist provided the voice of the patient. When available a second facilitator acted as the parent. If a single facilitator led the case, they provided the parents' replies to history questions. A simulation technician familiar with the operation of the child-sized simulator and simulation software managed the simulator.

Pre-briefing
The sessions began with a facilitator-led pre-briefing including a simulation learning contract, orientation to the manikin, and expectation setting for the session including role assignments. The participants were told that a debriefing would be held following the simulation. Participants were given approximately three minutes to huddle to assign team roles.

Case summary
Facilitators and technicians used a comprehensive, detailed stepwise scenario flowsheet to run the case ( Table 1). ECGs (Figures 1 and 2) and a chest X-ray ( Figure 3) were available upon request. Throughout the scenario, the simulation facilitator provided additional history and laboratory findings, included in the scenario template, upon request and clinical updates. If using a low-technology simulator, vital signs and physical examination findings may be provided verbally at the learners' request.

FIGURE 3: Normal chest X-ray
The scenario begins with the patient sitting on a hospital stretcher on a monitor, alert, and speaking, with no IV access. Her parent (a second facilitator if available) is present at the bedside to provide additional history. The patient's examination was notable for tachycardia and evidence of decreased perfusion as evident by diminished pulses, delayed capillary refill, and hypotension. Participants were expected to complete an evaluation including ECG and devise a differential diagnosis. The case concluded when they identified ECG findings concerning Belhassen tachycardia and administered the appropriate medical intervention, verapamil, or after 15 min elapsed since the onset of Belhassen tachycardia. If they proceeded with the management of SVT with adenosine or cardioversion, treatment was unsuccessful.

Debriefing
The guidelines available in Appendix A is used to facilitate debriefing sessions after the simulation. This tool allowed each facilitator to tailor the discussion based on the needs and performance of the participants. We began the debrief by allowing participants to provide general reflections on their experience followed by a discussion of the components of the case. Observations made by participants and facilitators were then used as lead points into discussions on teamwork, communication, as well as diagnostic and management skills. The didactic PowerPoint slides (Appendix B) were then briefly reviewed to provide additional information to reinforce the content of the scenario. Depending on the learner's experience level, the PowerPoint slides could also be presented before the scenario or reviewed by participants asynchronously in a flipped classroom model to prime participants for the scenario.

Assessment
Facilitators provided formative feedback to participants on their performance mapped to the learning objectives. All participants completed an evaluation form after the completion of the debriefing. Participants were asked to state their agreement with evaluative statements using a Likert scale (1=strongly disagree, 2=disagree, 3=neutral, 4=agree, 5=strongly agree). They were asked about their experience during the educational session and about their clinical confidence related to the learning objectives after participating in the session. They were also asked to answer free-response questions related to their experience.
Participants gave high ratings to the simulation ( Table 2) and reported a high level of confidence with skills and knowledge related to the content after participating in the session ( Table 3).

Participant survey question Mean Likert score Range
This simulation case provided is relevant to my work 4.7 4-5 The simulation case was realistic 4.6 3-5 This simulation case was effective in teaching basic resuscitation skills 4.7 3-5 The debrief created a safe environment 4.9 4-5 The debrief promoted reflection and team discussion 4.8 4-5  Participants reported several ways in which the simulation session would change how they do their job and how the scenario could be improved. Their comments and implementation experience are summarized in Table 4.

Implementation site Participant comments
Site #1 Exposure to case increased depth of understanding of how to approach pediatric patients with tachycardia and medical decision-making when adenosine fails to abort SVT or suspected SVT

Site #2
Participants identified that the didactic PowerPoint reinforced knowledge learned during the simulation session. Participants suggested that it may be helpful to have didactic PowerPoint first to prime them for participation in the simulation scenario. This order could be considered depending on the experience level of participants Site #3 Multiple participants commented that participation in the scenario would encourage them to consider a broader diagnosis for pediatric tachycardia in their clinical practice in the future. The scenario exposed them to a less common tachycardia that they were unfamiliar with from their clinical experience

Discussion
The goal of the case was to challenge advanced learners who have experience treating patients using PALS algorithms, with the opportunity to manage a more nuanced case in a simulated environment while continuing to hone teamwork and communication skills. Belhassen tachycardia is unique in that it does not typically respond to the standard therapeutic measures for ventricular tachycardia, as outlined in PALS. Fortunately, characteristic findings on the ECG help differentiate it from other forms of wide complex tachycardia. This simulation allows participants to evaluate a simulated patient and trial therapeutic interventions in a safe learning environment.
Physicians caring for pediatric patients in emergency settings must be prepared to rapidly handle unexpected and rare presentations. They must be able to apply life-saving algorithms and be able to identify when illness patterns are falling outside of the expected course and respond appropriately. However, in practice, exposure to acutely ill patients and critical procedures within the pediatric emergency department is often limited [13,14]. To supplement traditional training, simulation can be used to teach and reinforce clinical and procedural skills [15]. Nearly all PEM fellowships within the United States incorporate simulation into their education [16]. The case described in this technical report can be incorporated into a longitudinal curriculum to challenge advanced learners to think beyond standard algorithms.
This simulation was implemented with learners from multiple institutions using the materials provided in this technical report. While the scenario was implemented with advanced trainees, it could also be run in an interdisciplinary setting with a combination of attending and trainee physicians, nurses, and respiratory therapists. If members of multiple disciplines are present, individuals should function in a role consistent with their role in a clinical setting. The proportion of time spent on the debrief and didactic slides as well as debrief topic emphasis may be adjusted to the learner's needs.
Participants rated their confidence related to the learning objectives high after participation. A limitation to the evaluation of this simulation is that we were unable to measure the actual clinical performance of learners after participation, given the extremely rare occurrence of rhythm disturbances in pediatric patients. Furthermore, we did not measure changes in knowledge after participation, as this is not routine practice during the standard fellow education. Participants expressed positive reactions to the session. Some learners provided feedback that the didactic slides could be provided before the case as a primer related to the content.

Conclusions
Teaching advanced learners responsible for the emergency care of pediatric patients to identify arrhythmias that are unusual and do not respond to typical treatments outlined by PALS through simulation is a valuable experience. It allows learners to develop broad differentials, practice diagnostic reasoning, and trial interventions in an environment that is safe for patients and providers. Simulation as an instructional method also allows participants to engage in teamwork and practice communication skills that are crucial for patient care within the ED environment, regardless of the case. This technical report provides facilitators with the materials required to implement the simulation with learners at their institution.

Debriefing overview
We believe that reflective learning occurs in the debrief. It is an opportunity for learners to reflect on their medical decision-making, technical, teamwork, and communication skills. The ultimate goal is to identify the gaps and potential solutions to close those gaps, leading to improved patient safety and better quality of care.

Framework for Debriefing:
We model our debriefing after PEARLS [1]. Each debrief typically has four phases. (1) Reactions phase: an opportunity for learners to express their emotional experience, where they may reveal key areas that are important to them. (2) Description phase: an opportunity for learners to summarize key events in the scenario to ensure that educators and learners are on the same page. (3) Analysis phase: opportunity to explore the medical decisions, technical, teamwork, and communication performance of the team.
(4) Summary phase: a review of key take-home points, led by learners or educators.

General Debriefing Goals:
Following are the goals of a debriefing session: (i) creating a safe learning environment; (ii) normalizing gaps in performance, if at all possible; (iii) using open-ended questions rather than yes/no questions; and (iv) trying to facilitate the team's discussion (avoid lecturing).

1) Reactions phase
There are different perspectives on emotions and debriefing. One perspective is that learners may find it difficult to engage in the analysis of performance until emotions are addressed. A different perspective is that adult learners should process their emotions independently outside the context of the debrief.
Our perspective aligns with the first described. If a group or team member is feeling emotionally charged (e.g., ashamed, angry, or frustrated), it may be difficult to be actively engaged, receptive to feedback, and able to engage in learning, until the emotions are addressed.
What you might say to start the debrief: -"How did that feel?" -"How did that go for you?" -"What are your initial reactions?" -"How is everyone else feeling?" 2) Description phase Summary of key events to ensure that educators and participants are on the same page.
What you might say: -"Could someone summarize the case, so we are all on the same page?" -"From your perspective, what were the main issues you dealt with?"

3) Analysis phase
Promote reflection on performance (medical decision-making, technical skills, teamwork, and communication) and identify opportunities for improvement.
What you might say: -"Let's talk more about the case." -"What aspects did your team manage well? Why?" -Recognize the need for a full resuscitation team when a patient has a potentially unstable arrhythmia.
-Designate team member roles including the leader to support coordination and team functioning.
-Role assignment to specific individuals to avoid duplication/omission of tasks.
-Respect all team members is key to enable empowerment to speak up if patient safety issues arise.
-Use briefs and/or huddles to create a shared mental model for the working diagnosis and management plan.
-Closed-loop communication is of paramount importance to ensure safe and adequate communication.

Debriefing guide
Below are examples of learning objective-based statements and questions you may use to debrief the team.

Examples of debriefing for different learning objectives
Assess a patient with tachycardia assure that important orders/questions are specifically directed to one individual (rather than called out into the air). Example: "Jonathan -What is the SaO2%?" "Kim -Give normal saline 500 mL" "Team leader -she stopped responding to pain" How were the communication loops in the team? How did that impact your team? Has anyone seen problems with this in a patient resuscitation? Has anyone seen closed-loop communication prevent an error? How could you do it differently next time?
Closed-loop communication/check back is a strategy that requires verification of information. This enables the sender of the message to verify that it has been heard and heard correctly. It enables the receiver to confirm what they heard is correct. Team leader, "Call for ECG." Float nurse, "calling technician for an ECG." Team leader, "correct"