Journal of Education and Teaching in Emergency Medicine

Audience: This simulation is intended for Post-Graduate Level 1-4 Residents and Attending Physicians.   

Introduction: Although uncommon in the Northeastern United States, emergency physicians may encounter exotic envenomation through zoological institutions, research facilities, or privately owned exotic reptiles.¹ These cases present unique diagnostic and logistical challenges because management frequently requires species-specific antivenom and early consultation with regional toxicology experts.^1,2,3 Emergency providers may be unfamiliar with such presentation, evaluation, and treatment steps. Simulation-based education can bridge this gap by allowing interprofessional teams, including residents, attendings, nurses, and pharmacists, to practice coordinated management in a safe environment.^4,5This project evaluates the feasibility, learner-reported preparedness, and educational outcomes associated with a multidisciplinary snakebite simulation.

Educational Objectives: By the end of the simulation, participants will be able to recognize and appropriately manage neurotoxic snakebite envenomation, including initiating first-line management and toxicology consultation, coordinating antivenom administration, recognizing and treating antivenom-associated anaphylaxis, assessing and managing progressive respiratory failure, demonstrating effective interprofessional communication using TeamSTEPPS principles,⁴and coordinating timely consultation, handoff, and disposition with toxicology, pharmacy, and the critical care team.

Educational Methods: High-fidelity simulation will be used to provide an immersive environment. TeamSTEPPS (team strategies and tools to enhance performance and patient safety), an evidence-based communication training toolkit, will be used.⁴ High-fidelity simulation for snakebite education has been shown to enhance clinical skills, foster teamwork, and enable more timely and proficient provider care in snakebite cases.⁵ The simulation will depict an Indian Cobra snakebite case with evolving neurotoxicity and potential anaphylaxis after antivenom. Teams will manage airway, antivenom reconstitution, and anaphylaxis using TeamSTEPPS principles.⁴ Scenario branches depend on learner actions; facilitators will provide physiologic cues accordingly. 

Research Methods: The study consisted of a prospective, single-center, pre/post simulation-based educational pilot study. Physician participants completed pre- and post-surveys and objective multiple-choice tests. Observers used checklists to assess performance. Given the pilot nature of the simulation, no a priori sample size calculation was performed. The simulation was conducted using an interprofessional team model that included emergency medicine physicians, bedside nurses, pharmacists, and a toxicologist. Although all disciplines participated in the simulation to replicate real-word emergency department management of snakebite envenomation, only physician participants completed the pre- and post-intervention knowledge and confidence assessments. The educational study was designed to evaluate physician learning outcomes. 

Results: Seven emergency medicine physicians from varying training levels participated in the simulation, with a post-test response rate of 85.7% (n=6). Participants demonstrated significant improvements in self-reported knowledge regarding overall snakebite management (p = 0.042), appropriate first aid (p = 0.010), antivenom complications (p = 0.010), and recognition of both neurotoxic (p = 0.012) and hemotoxic envenomation patterns (p = 0.010). Confidence in administering antivenom (p = 0.025) and working effectively within a team during high-stress emergencies (p = 0.042) improved as well. No significant improvement was observed in objective multiple-choice knowledge scores. Critical action checklists demonstrated that all members were able to identify key clinical findings, communicate with toxicology, and recognize anaphylaxis, although adherence to antivenom preparation steps varied. 

Discussion: The simulation-based didactic was feasible and associated with improvements in self-reported knowledge, confidence, and perceived teamwork related to snakebite management among physician participants. However, objective knowledge scores did not significantly improve, highlighting the need for continued reinforcement of cognitive knowledge and anti-venom related procedural and systems-based skills. Given the pilot design and limited sample size, these findings should be interpreted as preliminary and hypothesis-generating. Future iterations of the simulation will include larger sample sizes, expand emphasis on antivenom logistics, and incorporate deliberate practice stations to ensure both cognitive and procedural fidelity.

Topics: Snakebite, antivenom, anaphylaxis, neurotoxicity, communication, teamwork.