CaseData[33] = {
    "title": "Case 33 - 4 year old with head injury", 
    "badDrugs": ["Dantrolene"], 
    "coMin": 1.2, 
    "debriefMsg": "\nThis pediatric patient with head trauma requires numerous interventions: rapid sequence induction with propofol, hyperventilation, administration of mannitol, maintenance anesthesia with one MAC or less inhalation agent.\n\n", 
    "depthCarina": 17, 
    "depthCords": 13, 
    "depthTubeInitial": 15, 
    "durationPrep": 60, 
    "durationSurgery": 1200, 
    "helpFlag": true, 
    "imageSet": 1, 
    "initialSat": 96, 
    "leanBodyMass": 22, 
    "learningObj": "\n4 year old with head injury (22 kg)\n\nThis patient was healthy until accidentally hit in the head with a baseball bat.\n\nLearning Objectives\n1.  Evaluate the neurologic status of children after head trauma.\n2.  List the anesthetic considerations of children with increased intracranial pressure.\n3.  Describe the fluid management of children after head trauma.\n4.  Describe airway management of children with head trauma and suspected neck injury.\n\nIncreased Intracranial Pressure\n1.  Symptoms - postuiral headaches, vomiting without nausea, blurred vision, diplopia, lassitude, irritability\n2.  Early signs - vomiting, papilledema, depressed sensorium, depressed Glasgow coma score (eye opening, verbal, motor)\n3.  Late signs - further decreased consciousness, cranial nerve palsies (III, VI), setting sun sign (upward gaze palsy), pupil area changes, Cushing's triad (hyperventilation, bradycardia, hypertension), further decrease in Glasgow coma score\n\nGlasgow Coma Scale\nOpening of Eyes\nSpontaneously - 4 \nTo speech - 3 \nTo pain - 2 \nNone - 1\n\nBest verbal response\nOriented/smiles, interacts - 5 \nConfused/consolable when crying - 4 \nInappropriate words/inconsolable - 3 \nIncomprehensible words/irritable - 2 \nNone - 1 \n\nBest motor response\nSpontaneous - 6 \nLocalizes to pain - 5 \nWithdrawal - 4 \nAbnormal flexion to pain - 3  \nAbnormal extension to pain - 2 \nNone - 1\n\nDifferential Diagnosis for Depressed Consciousness\n1.  Elevated intracranial pressure\n2.  \"Sleepy\" child (up past her bed time)\n3.  Metabolic - hyponatremia, diabetic coma, hypoglycemia\n4.  Hypovolemia\n5.  Post-ictal\n6.  Hypoxemia\n\nTreatment of Increased Intracranial Pressure\n1.  Endotracheal intubation and hyperventilation\n2.  Administration of mannitol\n3.  Surgical decompression\n4.  Avoid hypercarbia, hypoxemia, and hypotension\n5.  Maintain neck in midline position to avoid jugular compression\n6.  Elevate head of bed 30 degrees\n7.  Maintain normothermia to prevent shivering and increased oxygen consumption\n8.  Control seizures\n9.  Provide isotonic fluid in appropriate amounts to prevent both hypovolemia and volume overload\n10. Avoid glucose containing solutions\n\nFluid Management of the Head Injured Patient\n1.  Restoration of volume in hypovolemic children with closed head injury almost always takes priority over raised ICP considerations.\n2.  Isotonic crystalloid may be used for fluid resuscitation. Colloid offers no clinical advantage and is more expensive. \n3.  Since lactated ringer's is not isotonic (273 mOsm/l), measure hematocrit and osmolarity if large amounts need to be given.\n4.  Administration of mannitol diuresis is followed by a triphasic respose consisting of :\na) hypotension\nb) increased blood volume, blood pressure, and possibly ICP\nc) return to normal blood pressure\n5.  Therefore the administration of mannitol should be delayed until children are hemodynamically stable.\n\nSuggested Anesthetic Plan for Pediatric Patients with Head Trauma\n1.  If the child is hemodynamically stable, induction of anesthesia may be accomplished with propofol (2-2.5 mg/kg) or thiopental (4-7 mg/kg). If there is no intravenous access, methohexital (25 mg/kg, 10%) may be administered rectally.\n2.  If the child is hemodynamically unstable, induction of anesthesia may be accomplished with fentanyl titrated to hemodynamic response up to 10 mcg/kg.\n3.  Use competitive NMB such as rocuronium. Avoid succinylcholine.\n4.  Anesthesia may be maintained with continuous propofol, intravenous fentanyl, or isoflurane/sevoflurane.\n5.  Adjuvant drugs at laryngoscopy include fentanyl (1-5 mcg/kg) and lidocaine (1.5 mg/kg).\n6.  Although isoflurane and sevoflurane increase cerebral blood flow, cerebral blood volume, and intracranial pressure, they can be used up to 1.0 MAC with prior hyperventilation.\n7.  Nitrous oxide is a mild stimulant of cerebral metabolic rate and cerebral blood flow, but can be safely used with hyperventilation and previous barbiturate or propofol.\n\nClinical Points:\n1.  Injury secondary to hypoxemia, hypotension, edema, and increased metbolic demand from seizures or fever, may be attenuated with appropriate care.\n2.  In hypotensive children with closed head injury, the hypotension is usually caused by something other than the head injury.\n3.  Neurologic evaluation focuses on the presence of increased intracranial pressure, which is common in children with head injury and occurs most often without a mass lesion.\n4.  The Glasgow coma Scale provides a fairly accurate estimate of ICP. A child who can \"wiggle, open, and answer\" (wiggle fingers and toes, open his eyes, and answer a simple question) probably does not have high ICP.\n5.  A child with Glasgow coma scale of 8 or less probably has a significant increased ICP and the child with a score of 6 or less demands immediate and aggressive intervention to prevent herniation. Although children frequently vomit after head injury without increased ICP, persistent vomiting and recurring seizures suggest an increase in ICP.\n\nCase author: Howard A. Schwid, M.D.\nAffiliation: Department of Anesthesiology, University of Washington \nDate of Last Modification: September 2024\n\n", 
    "possiblePoints": 1200, 
    "preopMsg": "\n4 year old with head injury\n\nHistory of Present Illness\nThe patient was accidentally, but forcibly struck in the head with a baseball bat. The patient now requires drainage of an epidural hematoma.\n\nPast Medical History\nIllnesses - none\nSurgeries - none\nMeds - none\nAllergies - none\n\nFamily History\nNo family history of anesthetic problems.\n\nPhysical Exam\nWeight: 22 kg\nHR 80,  BP 160/90,  RR 24\nWithdraws from pain, irritable, opens eyes to pain\nAirway - normal\nLungs - clear\nHeart - normal\n\nLabs\nHematocrit 38%\n\nNPO Status\nThe patient last ate one hour before the accident.\n\nPatient and Surgeon Requests\nThe surgeon states the procedure will take about two hours.\n\n", 
    "volAnDsp": 20, 
    "states": [
        {
            "name": "AWAKE", 
            "whatNextMsg": "Administer oxygen by mask prior to induction.", 
			"airwayStr": "nl",
            "aspirateCvpMsg": "10 mL blood was aspirated from the CVP catheter.", 
            "baseAbpD": 48, 
            "baseAbpM": 58, 
            "baseAbpS": 74, 
            "baseBicarb": 23.8, 
            "baseHr": 156, 
            "basePot": 4.8, 
            "breathSoundsMsg": "The breath sounds are clear bilaterally.", 
            "cardiacOutput": 2.2, 
            "contPip": 28, 
            "contPlateau": 26, 
            "cvp": 6, 
            "finalState": 0, 
            "glucose": 120, 
            "hct": 39, 
            "heartSoundsMsg": "Regular rate and rhythm, without murmurs.", 
            "hiCo2ProdFlag": false, 
            "laryTubeSuccess": 0, 
            "lidReflexMsg": "The lid reflex is present.", 
            "lmaSuccessFlag": false, 
            "mentalStatusMsg": "Withdraws from pain, irritable, opens eyes to pain", 
            "papD": 4, 
            "papM": 6, 
            "papS": 12, 
            "papW": 4, 
            "pulseMsg": "The pulse is strong and regular.", 
            "pupilsMsg": "The pupils are equal, round, and react to light.", 
            "rateEbl": 0, 
            "rateUo": 1.5, 
            "recordMsg": "Withdraws from pain, irritable, opens eyes to pain. Awaiting induction.", 
            "rhythm": "Sinus1", 
            "skinMsg": "The skin is warm and dry with normal capillary refill.", 
            "skipAheadHours": 0, 
            "skipAheadMsg": "", 
            "sodium": 144, 
            "sat20": 97, 
            "sat40": 99, 
            "sat100": 100, 
            "spSignal": 3, 
            "spontRr": 18, 
            "spontTv": 85, 
            "sputumAmount": 0, 
            "stSegII": 0.2, 
            "stSegV5": -0.3, 
            "temperature": 36.9, 
            "trans": [
                {
                    "nextState": "PREO2", 
                    "comment": "You preoxygenated appropriately. (+100 points)", 
                    "conditions": [
                        {
                            "op": "GT", 
                            "type": "o2Sat", 
                            "value": 97
                        }
                    ], 
                    "points": 100
                }, 
                {
                    "nextState": "CRICO", 
                    "comment": "You applied cricoid pressure before the patient was preoxygenated. (Lost points)", 
                    "conditions": [
                        {
                            "type": "doingCricoid", 
                            "value": true
                        }
                    ], 
                    "points": 0
                }, 
                {
                    "nextState": "ASLEEP", 
                    "comment": "You induced anesthesia without preoxygenating or applying cricoid pressure. (Lost points)", 
                    "conditions": [
                        {
                            "op": "GT", 
                            "type": "doa", 
                            "value": 0.6
                        }
                    ], 
                    "points": -500
                }, 
                {
                    "nextState": "COUGH5", 
                    "comment": "You tried to insert a laryngeal mask airway in an unanesthetized patient. (Lost points)", 
                    "conditions": [
                        {
                            "type": "tryLma", 
                            "value": true
                        }
                    ], 
                    "points": -500
                }, 
                {
                    "nextState": "COUGH5", 
                    "comment": "You tried to insert the endotracheal tube in an unanesthetized patient. (Lost points)", 
                    "conditions": [
                        {
                            "type": "tryLaryTube", 
                            "value": true
                        }
                    ], 
                    "points": -500
                }, 
                {
                    "nextState": "HURT5", 
                    "comment": "You should not have allowed the surgeon to make an incision in an unanesthetized patient. (-1000 points)", 
                    "conditions": [
                        {
                            "type": "makeIncision", 
                            "value": true
                        }
                    ], 
                    "points": -1000
                }, 
                {
                    "nextState": "AWAKEPARA", 
                    "comment": "You paralyzed an unanesthetized patient. (-500 points)", 
                    "conditions": [
                        {
                            "op": "GT", 
                            "type": "nmb", 
                            "value": 0.8
                        }, 
                        {
                            "op": "LT", 
                            "type": "doa", 
                            "value": 0.4
                        }
                    ], 
                    "points": -500
                }
            ]
        }, 
        {
            "name": "AWAKEPARA", 
            "whatNextMsg": "Call your lawyer.", 
			"airwayStr": "nl",
            "aspirateCvpMsg": "10 mL blood was aspirated from the CVP catheter.", 
            "baseAbpD": 56, 
            "baseAbpM": 68, 
            "baseAbpS": 88, 
            "baseBicarb": 24, 
            "baseHr": 166, 
            "basePot": 4.2, 
            "breathSoundsMsg": "The breath sounds are clear bilaterally.", 
            "cardiacOutput": 2.4, 
            "contPip": 28, 
            "contPlateau": 26, 
            "cvp": 8, 
            "finalState": 0, 
            "glucose": 122, 
            "hct": 38, 
            "heartSoundsMsg": "Regular rate and rhythm, without murmurs.", 
            "hiCo2ProdFlag": false, 
            "laryTubeSuccess": 1, 
            "lidReflexMsg": "The lid reflex is absent.", 
            "lmaSuccessFlag": true, 
            "mentalStatusMsg": "The patient is not moving, but is thinking about asking his parents to call a lawyer.", 
            "papD": 6, 
            "papM": 10, 
            "papS": 16, 
            "papW": 6, 
            "pulseMsg": "The pulse is strong.", 
            "pupilsMsg": "The pupils are equal, round, and react to light.", 
            "rateEbl": 0, 
            "rateUo": 1.5, 
            "recordMsg": "Paralyzed before inducing anesthesia.", 
            "rhythm": "Sinus1", 
            "skinMsg": "The skin is warm and dry with normal capillary refill.", 
            "skipAheadHours": 0, 
            "skipAheadMsg": "", 
            "sodium": 142, 
            "sat20": 97, 
            "sat40": 99, 
            "sat100": 100, 
            "spSignal": 3, 
            "spontRr": 0, 
            "spontTv": 0, 
            "sputumAmount": 0, 
            "stSegII": 0.2, 
            "stSegV5": -0.3, 
            "temperature": 36.9, 
            "trans": [
                {
                    "nextState": "AWAKE", 
                    "comment": "The muscle relaxant is wearing off.", 
                    "conditions": [
                        {
                            "op": "LT", 
                            "type": "nmb", 
                            "value": 0.6
                        }
                    ], 
                    "points": 0
                }, 
                {
                    "nextState": "ASLEEPPARA", 
                    "comment": "You sedated this patient after you administered muscle relaxant. ", 
                    "conditions": [
                        {
                            "op": "GT", 
                            "type": "doa", 
                            "value": 0.6
                        }
                    ], 
                    "points": 0
                }, 
                {
                    "nextState": "DESATBRADY1", 
                    "comment": "You allowed the patient to become severely hypoxic. (-1000 points)", 
                    "conditions": [
                        {
                            "op": "LT", 
                            "type": "o2Sat", 
                            "value": 63
                        }
                    ], 
                    "points": -1000
                }
            ]
        }, 
        {
            "name": "PREO2", 
            "whatNextMsg": "Apply cricoid pressure prior to induction.", 
			"airwayStr": "nl",
            "aspirateCvpMsg": "10 mL blood was aspirated from the CVP catheter.", 
            "baseAbpD": 50, 
            "baseAbpM": 58, 
            "baseAbpS": 76, 
            "baseBicarb": 23.8, 
            "baseHr": 158, 
            "basePot": 4.8, 
            "breathSoundsMsg": "The breath sounds are clear bilaterally.", 
            "cardiacOutput": 2.2, 
            "contPip": 28, 
            "contPlateau": 26, 
            "cvp": 6, 
            "finalState": 0, 
            "glucose": 120, 
            "hct": 39, 
            "heartSoundsMsg": "Regular rate and rhythm, without murmurs.", 
            "hiCo2ProdFlag": false, 
            "laryTubeSuccess": 0, 
            "lidReflexMsg": "The lid reflex is present.", 
            "lmaSuccessFlag": false, 
            "mentalStatusMsg": "Withdraws from pain, irritable, opens eyes to pain", 
            "papD": 4, 
            "papM": 7, 
            "papS": 12, 
            "papW": 4, 
            "pulseMsg": "The pulse is strong and regular.", 
            "pupilsMsg": "The pupils are equal, round, and react to light.", 
            "rateEbl": 0, 
            "rateUo": 1.5, 
            "recordMsg": "Preoxygenated and awaiting induction.", 
            "rhythm": "Sinus1", 
            "skinMsg": "The skin is warm and dry with normal capillary refill.", 
            "skipAheadHours": 0, 
            "skipAheadMsg": "", 
            "sodium": 144, 
            "sat20": 97, 
            "sat40": 99, 
            "sat100": 100, 
            "spSignal": 3, 
            "spontRr": 22, 
            "spontTv": 88, 
            "sputumAmount": 0, 
            "stSegII": 0.2, 
            "stSegV5": -0.3, 
            "temperature": 36.9, 
            "trans": [
                {
                    "nextState": "READY", 
                    "comment": "You applied cricoid pressure appropriately. (+100 points)", 
                    "conditions": [
                        {
                            "type": "doingCricoid", 
                            "value": true
                        }
                    ], 
                    "points": 100
                }, 
                {
                    "nextState": "COUGH5", 
                    "comment": "You tried to insert a laryngeal mask airway in an unanesthetized patient. (Lost points)", 
                    "conditions": [
                        {
                            "type": "tryLma", 
                            "value": true
                        }
                    ], 
                    "points": -500
                }, 
                {
                    "nextState": "COUGH5", 
                    "comment": "You tried to insert the endotracheal tube in an unanesthetized patient. (Lost points)", 
                    "conditions": [
                        {
                            "type": "tryLaryTube", 
                            "value": true
                        }
                    ], 
                    "points": -500
                }, 
                {
                    "nextState": "HURT5", 
                    "comment": "You should not have allowed the surgeon to make an incision in an unanesthetized patient. (-1000 points)", 
                    "conditions": [
                        {
                            "type": "makeIncision", 
                            "value": true
                        }
                    ], 
                    "points": -1000
                }, 
                {
                    "nextState": "ASLEEP", 
                    "comment": "You induced anesthesia without applying cricoid pressure. (-500 points)", 
                    "conditions": [
                        {
                            "op": "GT", 
                            "type": "doa", 
                            "value": 0.6
                        }
                    ], 
                    "points": -500
                }, 
                {
                    "nextState": "AWAKEPARA", 
                    "comment": "You paralyzed an unanesthetized  patient. (-500 points)", 
                    "conditions": [
                        {
                            "op": "GT", 
                            "type": "nmb", 
                            "value": 0.8
                        }, 
                        {
                            "op": "LT", 
                            "type": "doa", 
                            "value": 0.4
                        }
                    ], 
                    "points": -500
                }
            ]
        }, 
        {
            "name": "CRICO", 
            "whatNextMsg": "Administer oxygen by mask prior to induction.", 
			"airwayStr": "nl",
            "aspirateCvpMsg": "10 mL blood was aspirated from the CVP catheter.", 
            "baseAbpD": 50, 
            "baseAbpM": 58, 
            "baseAbpS": 76, 
            "baseBicarb": 23.8, 
            "baseHr": 158, 
            "basePot": 4.8, 
            "breathSoundsMsg": "The breath sounds are clear bilaterally.", 
            "cardiacOutput": 2.2, 
            "contPip": 28, 
            "contPlateau": 26, 
            "cvp": 6, 
            "finalState": 0, 
            "glucose": 120, 
            "hct": 39, 
            "heartSoundsMsg": "Regular rate and rhythm, without murmurs.", 
            "hiCo2ProdFlag": false, 
            "laryTubeSuccess": 0, 
            "lidReflexMsg": "The lid reflex is present.", 
            "lmaSuccessFlag": false, 
            "mentalStatusMsg": "Withdraws from pain, irritable, opens eyes to pain", 
            "papD": 4, 
            "papM": 7, 
            "papS": 12, 
            "papW": 4, 
            "pulseMsg": "The pulse is strong and regular.", 
            "pupilsMsg": "The pupils are equal, round, and react to light.", 
            "rateEbl": 0, 
            "rateUo": 1.5, 
            "recordMsg": "Cricoid pressure is being applied to this anxious patient.", 
            "rhythm": "Sinus1", 
            "skinMsg": "The skin is warm and dry with normal capillary refill.", 
            "skipAheadHours": 0, 
            "skipAheadMsg": "", 
            "sodium": 144, 
            "sat20": 97, 
            "sat40": 99, 
            "sat100": 100, 
            "spSignal": 3, 
            "spontRr": 24, 
            "spontTv": 88, 
            "sputumAmount": 0, 
            "stSegII": 0.2, 
            "stSegV5": -0.3, 
            "temperature": 36.9, 
            "trans": [
                {
                    "nextState": "READY", 
                    "comment": "You preoxygenated. (+100 points)", 
                    "conditions": [
                        {
                            "op": "GT", 
                            "type": "o2Sat", 
                            "value": 97
                        }
                    ], 
                    "points": 100
                }, 
                {
                    "nextState": "COUGH5", 
                    "comment": "You tried to insert a laryngeal mask airway in an unanesthetized patient. (Lost points)", 
                    "conditions": [
                        {
                            "type": "tryLma", 
                            "value": true
                        }
                    ], 
                    "points": -500
                }, 
                {
                    "nextState": "COUGH5", 
                    "comment": "You tried to insert the endotracheal tube in an unanesthetized patient. (Lost points)", 
                    "conditions": [
                        {
                            "type": "tryLaryTube", 
                            "value": true
                        }
                    ], 
                    "points": -500
                }, 
                {
                    "nextState": "HURT5", 
                    "comment": "You should not have allowed the surgeon to make an incision in an unanesthetized patient. (-1000 points)", 
                    "conditions": [
                        {
                            "type": "makeIncision", 
                            "value": true
                        }
                    ], 
                    "points": -1000
                }, 
                {
                    "nextState": "ASLEEP", 
                    "comment": "You induced anesthesia without adequately preoxygenating. (-500 points)", 
                    "conditions": [
                        {
                            "op": "GT", 
                            "type": "doa", 
                            "value": 0.6
                        }
                    ], 
                    "points": -500
                }, 
                {
                    "nextState": "AWAKEPARA", 
                    "comment": "You paralyzed an unanesthetized  patient. (-500 points)", 
                    "conditions": [
                        {
                            "op": "GT", 
                            "type": "nmb", 
                            "value": 0.8
                        }, 
                        {
                            "op": "LT", 
                            "type": "doa", 
                            "value": 0.4
                        }
                    ], 
                    "points": -500
                }
            ]
        }, 
        {
            "name": "READY", 
            "whatNextMsg": "Administer induction dose of propofol.", 
			"airwayStr": "nl",
            "aspirateCvpMsg": "10 mL blood was aspirated from the CVP catheter.", 
            "baseAbpD": 52, 
            "baseAbpM": 60, 
            "baseAbpS": 78, 
            "baseBicarb": 23.8, 
            "baseHr": 160, 
            "basePot": 4.8, 
            "breathSoundsMsg": "The breath sounds are clear bilaterally.", 
            "cardiacOutput": 2.2, 
            "contPip": 28, 
            "contPlateau": 26, 
            "cvp": 6, 
            "finalState": 0, 
            "glucose": 120, 
            "hct": 39, 
            "heartSoundsMsg": "Regular rate and rhythm, without murmurs.", 
            "hiCo2ProdFlag": false, 
            "laryTubeSuccess": 0, 
            "lidReflexMsg": "The lid reflex is present.", 
            "lmaSuccessFlag": false, 
            "mentalStatusMsg": "Withdraws from pain, irritable, opens eyes to pain", 
            "papD": 4, 
            "papM": 7, 
            "papS": 12, 
            "papW": 4, 
            "pulseMsg": "The pulse is strong and regular.", 
            "pupilsMsg": "The pupils are equal, round, and react to light.", 
            "rateEbl": 0, 
            "rateUo": 1.5, 
            "recordMsg": "Preoxygenated and awaiting induction.", 
            "rhythm": "Sinus1", 
            "skinMsg": "The skin is warm and dry with normal capillary refill.", 
            "skipAheadHours": 0, 
            "skipAheadMsg": "", 
            "sodium": 144, 
            "sat20": 97, 
            "sat40": 99, 
            "sat100": 100, 
            "spSignal": 3, 
            "spontRr": 24, 
            "spontTv": 80, 
            "sputumAmount": 0, 
            "stSegII": 0.2, 
            "stSegV5": -0.3, 
            "temperature": 36.9, 
            "trans": [
                {
                    "nextState": "ASLEEP", 
                    "comment": "You administered an appropriate dose of propofol. (+100 points)", 
                    "conditions": [
                        {
                            "drug": "Propofol", 
                            "op": "GT", 
                            "type": "bDrug", 
                            "value": 20
                        }, 
                        {
                            "drug": "Propofol", 
                            "op": "LT", 
                            "type": "bDrug", 
                            "value": 61
                        }
                    ], 
                    "points": 100
                }, 
                {
                    "nextState": "ASLEEP", 
                    "comment": "Avoid using etomidate. (Lost points)", 
                    "conditions": [
                        {
                            "drug": "Etomidate", 
                            "op": "GT", 
                            "type": "bDrug", 
                            "value": 0.9
                        }
                    ], 
                    "points": -300
                }, 
                {
                    "nextState": "ASLEEP", 
                    "comment": "You administered an appropriate dose of thiopental. (+100 points)", 
                    "conditions": [
                        {
                            "drug": "Thiopental", 
                            "op": "GT", 
                            "type": "bDrug", 
                            "value": 74
                        }, 
                        {
                            "drug": "Thiopental", 
                            "op": "LT", 
                            "type": "bDrug", 
                            "value": 141
                        }
                    ], 
                    "points": 100
                }, 
                {
                    "nextState": "Ketamine", 
                    "comment": "You should not have administered ketamine to this patient with high ICP. (-500 points)", 
                    "conditions": [
                        {
                            "drug": "Ketamine", 
                            "op": "GT", 
                            "type": "bDrug", 
                            "value": 4
                        }
                    ], 
                    "points": -500
                }, 
                {
                    "nextState": "ASLEEP", 
                    "comment": "You induced unconsciousness with other than bolus propofol or thiopental. (Lost points)", 
                    "conditions": [
                        {
                            "op": "GT", 
                            "type": "doa", 
                            "value": 0.6
                        }
                    ], 
                    "points": -200
                }, 
                {
                    "nextState": "READY", 
                    "comment": "You administered an inadequate dose of propofol. (Lost points)", 
                    "conditions": [
                        {
                            "drug": "Propofol", 
                            "op": "LT", 
                            "type": "bDrug", 
                            "value": 21
                        }
                    ], 
                    "points": -100
                }, 
                {
                    "nextState": "DEEP", 
                    "comment": "You administered an excessive dose of propofol. (Lost points)", 
                    "conditions": [
                        {
                            "drug": "Propofol", 
                            "op": "GT", 
                            "type": "bDrug", 
                            "value": 60
                        }
                    ], 
                    "points": -200
                }, 
                {
                    "nextState": "DEEP", 
                    "comment": "You administered an excessive dose of thiopental. (Lost points)", 
                    "conditions": [
                        {
                            "drug": "Thiopental", 
                            "op": "GT", 
                            "type": "bDrug", 
                            "value": 140
                        }
                    ], 
                    "points": -200
                }, 
                {
                    "nextState": "AWAKEPARA", 
                    "comment": "You administered muscle relaxant before inducing unconsciousness. (-500 points)", 
                    "conditions": [
                        {
                            "op": "GT", 
                            "type": "nmb", 
                            "value": 0.8
                        }, 
                        {
                            "op": "LT", 
                            "type": "doa", 
                            "value": 0.4
                        }
                    ], 
                    "points": -500
                }, 
                {
                    "nextState": "COUGH5", 
                    "comment": "You tried to insert the endotracheal tube in an unanesthetized patient. (-500 points)", 
                    "conditions": [
                        {
                            "type": "tryLaryTube", 
                            "value": true
                        }
                    ], 
                    "points": -500
                }
            ]
        }, 
        {
            "name": "COUGH5", 
            "whatNextMsg": "Wait for the patient to settle down and induce anesthesia.", 
			"airwayStr": "obstructed",
            "aspirateCvpMsg": "10 mL blood was aspirated from the CVP catheter.", 
            "baseAbpD": 54, 
            "baseAbpM": 64, 
            "baseAbpS": 84, 
            "baseBicarb": 24, 
            "baseHr": 164, 
            "basePot": 4.2, 
            "breathSoundsMsg": "The patient is coughing.", 
            "cardiacOutput": 2.4, 
            "contPip": 28, 
            "contPlateau": 26, 
            "cvp": 8, 
            "finalState": 0, 
            "glucose": 122, 
            "hct": 38, 
            "heartSoundsMsg": "Regular rate and rhythm, without murmurs.", 
            "hiCo2ProdFlag": false, 
            "laryTubeSuccess": 0, 
            "lidReflexMsg": "The lid reflex is present.", 
            "lmaSuccessFlag": false, 
            "mentalStatusMsg": "The patient is upset and uncooperative. The patient is coughing.", 
            "papD": 6, 
            "papM": 10, 
            "papS": 16, 
            "papW": 6, 
            "pulseMsg": "The pulse is strong and fast.", 
            "pupilsMsg": "The pupils are equal, round, and react to light.", 
            "rateEbl": 0, 
            "rateUo": 1.5, 
            "recordMsg": "Upset and coughing.", 
            "rhythm": "Sinus1", 
            "skinMsg": "The skin is warm and dry with normal capillary refill.", 
            "skipAheadHours": 0, 
            "skipAheadMsg": "", 
            "sodium": 142, 
            "sat20": 97, 
            "sat40": 99, 
            "sat100": 100, 
            "spSignal": 3, 
            "spontRr": 28, 
            "spontTv": 60, 
            "sputumAmount": 0, 
            "stSegII": 0.2, 
            "stSegV5": -0.3, 
            "temperature": 36.9, 
            "trans": [
                {
                    "nextState": "AWAKE", 
                    "comment": "The patient stopped coughing.", 
                    "conditions": [
                        {
                            "op": "GT", 
                            "type": "time", 
                            "value": 30
                        }
                    ], 
                    "points": 0
                }, 
                {
                    "nextState": "ASLEEP", 
                    "comment": "The sedative agent is starting to take effect.", 
                    "conditions": [
                        {
                            "op": "GT", 
                            "type": "doa", 
                            "value": 0.6
                        }
                    ], 
                    "points": 0
                }, 
                {
                    "nextState": "HURT5", 
                    "comment": "You should not have allowed the surgeon to make an incision in an unanesthetized patient. (-500 points)", 
                    "conditions": [
                        {
                            "type": "makeIncision", 
                            "value": true
                        }
                    ], 
                    "points": -500
                }, 
                {
                    "nextState": "AWAKEPARA", 
                    "comment": "You paralyzed an unanesthetized patient. (-500 points)", 
                    "conditions": [
                        {
                            "op": "GT", 
                            "type": "nmb", 
                            "value": 0.8
                        }, 
                        {
                            "op": "LT", 
                            "type": "doa", 
                            "value": 0.4
                        }
                    ], 
                    "points": -500
                }, 
                {
                    "nextState": "DESATBRADY1", 
                    "comment": "You allowed the patient to become severely hypoxic. (-1000 points)", 
                    "conditions": [
                        {
                            "op": "LT", 
                            "type": "o2Sat", 
                            "value": 63
                        }
                    ], 
                    "points": -1000
                }
            ]
        }, 
        {
            "name": "HURT5", 
            "whatNextMsg": "Wait for the patient to settle down and induce anesthesia.", 
			"airwayStr": "nl",
            "aspirateCvpMsg": "10 mL blood was aspirated from the CVP catheter.", 
            "baseAbpD": 60, 
            "baseAbpM": 72, 
            "baseAbpS": 92, 
            "baseBicarb": 24, 
            "baseHr": 168, 
            "basePot": 4.2, 
            "breathSoundsMsg": "The patient is screaming but the breath sounds seem to be clear bilaterally.", 
            "cardiacOutput": 2.4, 
            "contPip": 28, 
            "contPlateau": 26, 
            "cvp": 8, 
            "finalState": 0, 
            "glucose": 122, 
            "hct": 38, 
            "heartSoundsMsg": "Regular rate and rhythm, without murmurs.", 
            "hiCo2ProdFlag": false, 
            "laryTubeSuccess": 0, 
            "lidReflexMsg": "The lid reflex is present.", 
            "lmaSuccessFlag": false, 
            "mentalStatusMsg": "The patient is screaming and writhing in pain.", 
            "papD": 6, 
            "papM": 10, 
            "papS": 16, 
            "papW": 6, 
            "pulseMsg": "The pulse is bounding.", 
            "pupilsMsg": "The pupils are equal, round, and react to light.", 
            "rateEbl": 8, 
            "rateUo": 1.5, 
            "recordMsg": "Screaming and writhing in pain.", 
            "rhythm": "Sinus1", 
            "skinMsg": "The skin is warm and dry with normal capillary refill.", 
            "skipAheadHours": 0, 
            "skipAheadMsg": "", 
            "sodium": 142, 
            "sat20": 97, 
            "sat40": 99, 
            "sat100": 100, 
            "spSignal": 3, 
            "spontRr": 34, 
            "spontTv": 90, 
            "sputumAmount": 0, 
            "stSegII": 0.2, 
            "stSegV5": -0.3, 
            "temperature": 36.9, 
            "trans": [
                {
                    "nextState": "AWAKE", 
                    "comment": "The patient stopped screaming.", 
                    "conditions": [
                        {
                            "op": "GT", 
                            "type": "time", 
                            "value": 30
                        }
                    ], 
                    "points": 0
                }, 
                {
                    "nextState": "ASLEEP", 
                    "comment": "The sedative agent is starting to take effect.", 
                    "conditions": [
                        {
                            "op": "GT", 
                            "type": "doa", 
                            "value": 0.6
                        }
                    ], 
                    "points": 0
                }, 
                {
                    "nextState": "DESATBRADY1", 
                    "comment": "You allowed the patient to become severely hypoxic. (-1000 points)", 
                    "conditions": [
                        {
                            "op": "LT", 
                            "type": "o2Sat", 
                            "value": 63
                        }
                    ], 
                    "points": -1000
                }
            ]
        }, 
        {
            "name": "ASLEEP", 
            "whatNextMsg": "Now administer rocuronium to facilitate endotracheal intubation.", 
			"airwayStr": "nl",
            "aspirateCvpMsg": "10 mL blood was aspirated from the CVP catheter.", 
            "baseAbpD": 36, 
            "baseAbpM": 46, 
            "baseAbpS": 68, 
            "baseBicarb": 24, 
            "baseHr": 148, 
            "basePot": 4.2, 
            "breathSoundsMsg": "The breath sounds are equal bilaterally.", 
            "cardiacOutput": 1.8, 
            "contPip": 28, 
            "contPlateau": 26, 
            "cvp": 4, 
            "finalState": 0, 
            "glucose": 122, 
            "hct": 38, 
            "heartSoundsMsg": "Regular rate and rhythm, without murmurs.", 
            "hiCo2ProdFlag": false, 
            "laryTubeSuccess": 0, 
            "lidReflexMsg": "The lid reflex is absent.", 
            "lmaSuccessFlag": true, 
            "mentalStatusMsg": "The patient is unresponsive.", 
            "papD": 2, 
            "papM": 4, 
            "papS": 8, 
            "papW": 2, 
            "pulseMsg": "The pulse is present.", 
            "pupilsMsg": "The pupils are pinpoint.", 
            "rateEbl": 0, 
            "rateUo": 1.5, 
            "recordMsg": "Asleep.", 
            "rhythm": "Sinus1", 
            "skinMsg": "The skin is warm and dry with normal capillary refill.", 
            "skipAheadHours": 0, 
            "skipAheadMsg": "", 
            "sodium": 142, 
            "sat20": 97, 
            "sat40": 99, 
            "sat100": 100, 
            "spSignal": 2, 
            "spontRr": 0, 
            "spontTv": 0, 
            "sputumAmount": 0, 
            "stSegII": 0.2, 
            "stSegV5": -0.3, 
            "temperature": 36.9, 
            "trans": [
                {
                    "nextState": "DESATBRADY1", 
                    "comment": "You took too long to intubate and the patient aspirated massive quantities of acidic fluids. (-500 points)", 
                    "conditions": [
                        {
                            "op": "GT", 
                            "type": "time", 
                            "value": 180
                        }
                    ], 
                    "points": -500
                }, 
                {
                    "nextState": "ASLEEPPARA", 
                    "comment": "You administered an appropriate amount of rocuronium. (+100 points)", 
                    "conditions": [
                        {
                            "drug": "Rocuronium", 
                            "op": "GT", 
                            "type": "bDrug", 
                            "value": 11
                        }, 
                        {
                            "drug": "Rocuronium", 
                            "op": "LT", 
                            "type": "bDrug", 
                            "value": 61
                        }
                    ], 
                    "points": 100
                }, 
                {
                    "nextState": "ASLEEPPARA", 
                    "comment": "You administered an excessive amount of rocuronium. (Lost points)", 
                    "conditions": [
                        {
                            "drug": "Rocuronium", 
                            "op": "GT", 
                            "type": "bDrug", 
                            "value": 60
                        }
                    ], 
                    "points": 0
                }, 
                {
                    "nextState": "ASLEEPPARA", 
                    "comment": "You administered an inadequate amount of rocuronium. (Lost points)", 
                    "conditions": [
                        {
                            "drug": "Rocuronium", 
                            "op": "LT", 
                            "type": "bDrug", 
                            "value": 11
                        }
                    ], 
                    "points": -100
                }, 
                {
                    "nextState": "ASLEEPPARA", 
                    "comment": "You administered a competitive neuromuscular blocker. (+100 points)", 
                    "conditions": [
                        {
                            "op": "GT", 
                            "type": "nmb", 
                            "value": 0.8
                        }
                    ], 
                    "points": 100
                }
            ]
        }, 
        {
            "name": "ASLEEPPARA", 
            "whatNextMsg": "Now perform laryngoscopy and place the endotracheal intubation.", 
			"airwayStr": "nl",
            "aspirateCvpMsg": "10 mL blood was aspirated from the CVP catheter.", 
            "baseAbpD": 34, 
            "baseAbpM": 46, 
            "baseAbpS": 66, 
            "baseBicarb": 24, 
            "baseHr": 144, 
            "basePot": 4.2, 
            "breathSoundsMsg": "The breath sounds are equal bilaterally.", 
            "cardiacOutput": 1.8, 
            "contPip": 28, 
            "contPlateau": 26, 
            "cvp": 4, 
            "finalState": 0, 
            "glucose": 122, 
            "hct": 38, 
            "heartSoundsMsg": "Regular rate and rhythm, without murmurs.", 
            "hiCo2ProdFlag": false, 
            "laryTubeSuccess": 1, 
            "lidReflexMsg": "The lid reflex is absent.", 
            "lmaSuccessFlag": true, 
            "mentalStatusMsg": "The patient is unresponsive.", 
            "papD": 2, 
            "papM": 4, 
            "papS": 8, 
            "papW": 2, 
            "pulseMsg": "The pulse is present.", 
            "pupilsMsg": "The pupils are pinpoint.", 
            "rateEbl": 0, 
            "rateUo": 1.5, 
            "recordMsg": "Anesthetized and paralyzed.", 
            "rhythm": "Sinus1", 
            "skinMsg": "The skin is warm and dry with normal capillary refill.", 
            "skipAheadHours": 0, 
            "skipAheadMsg": "", 
            "sodium": 142, 
            "sat20": 97, 
            "sat40": 99, 
            "sat100": 100, 
            "spSignal": 2, 
            "spontRr": 0, 
            "spontTv": 0, 
            "sputumAmount": 0, 
            "stSegII": 0.2, 
            "stSegV5": -0.3, 
            "temperature": 36.9, 
            "trans": [
                {
                    "nextState": "DESATBRADY1", 
                    "comment": "You took too long to intubate and the patient aspirated massive quantities of acidic fluids. (-500 points)", 
                    "conditions": [
                        {
                            "op": "GT", 
                            "type": "time", 
                            "value": 180
                        }
                    ], 
                    "points": -500
                }, 
                {
                    "nextState": "GA1", 
                    "comment": "You placed the endotracheal tube in a timely fashion. (+100 points)", 
                    "conditions": [
                        {
                            "type": "tryLaryTube", 
                            "value": true
                        }
                    ], 
                    "points": 100
                }, 
                {
                    "nextState": "GA1", 
                    "comment": "Wait for the drugs to take full effect before placing the endotracheal tube. (Lost points)", 
                    "conditions": [
                        {
                            "type": "airwayTube", 
                            "value": true
                        }
                    ], 
                    "points": 100
                }
            ]
        }, 
        {
            "name": "DEEP", 
            "whatNextMsg": "Now administer rocuronium to facilitate endotracheal intubation.", 
			"airwayStr": "nl",
            "aspirateCvpMsg": "10 mL blood was aspirated from the CVP catheter.", 
            "baseAbpD": 42, 
            "baseAbpM": 50, 
            "baseAbpS": 62, 
            "baseBicarb": 24, 
            "baseHr": 154, 
            "basePot": 4.2, 
            "breathSoundsMsg": "The breath sounds are equal bilaterally.", 
            "cardiacOutput": 1.6, 
            "contPip": 28, 
            "contPlateau": 26, 
            "cvp": 4, 
            "finalState": 0, 
            "glucose": 122, 
            "hct": 38, 
            "heartSoundsMsg": "Regular rate and rhythm, without murmurs.", 
            "hiCo2ProdFlag": false, 
            "laryTubeSuccess": 1, 
            "lidReflexMsg": "The lid reflex is absent.", 
            "lmaSuccessFlag": true, 
            "mentalStatusMsg": "The patient is unresponsive.", 
            "papD": 2, 
            "papM": 4, 
            "papS": 8, 
            "papW": 2, 
            "pulseMsg": "The pulse is present.", 
            "pupilsMsg": "The pupils are pinpoint.", 
            "rateEbl": 0, 
            "rateUo": 1.5, 
            "recordMsg": "Deeply anesthetized.", 
            "rhythm": "Sinus1", 
            "skinMsg": "The skin is warm and dry with normal capillary refill.", 
            "skipAheadHours": 0, 
            "skipAheadMsg": "", 
            "sodium": 142, 
            "sat20": 97, 
            "sat40": 99, 
            "sat100": 100, 
            "spSignal": 2, 
            "spontRr": 0, 
            "spontTv": 0, 
            "sputumAmount": 0, 
            "stSegII": 0.2, 
            "stSegV5": -0.3, 
            "temperature": 36.9, 
            "trans": [
                {
                    "nextState": "DESATBRADY1", 
                    "comment": "You took too long to intubate and the patient aspirated massive quantities of acidic fluids. (-500 points)", 
                    "conditions": [
                        {
                            "op": "GT", 
                            "type": "time", 
                            "value": 180
                        }
                    ], 
                    "points": -500
                }, 
                {
                    "nextState": "DEEPPARA", 
                    "comment": "You administered an appropriate amount of rocuronium. (+100 points)", 
                    "conditions": [
                        {
                            "drug": "Rocuronium", 
                            "op": "GT", 
                            "type": "bDrug", 
                            "value": 11
                        }, 
                        {
                            "drug": "Rocuronium", 
                            "op": "LT", 
                            "type": "bDrug", 
                            "value": 61
                        }
                    ], 
                    "points": 100
                }, 
                {
                    "nextState": "DEEPPARA", 
                    "comment": "You administered an excessive amount of rocuronium. (Lost points)", 
                    "conditions": [
                        {
                            "drug": "Rocuronium", 
                            "op": "GT", 
                            "type": "bDrug", 
                            "value": 60
                        }
                    ], 
                    "points": 0
                }, 
                {
                    "nextState": "DEEPPARA", 
                    "comment": "You administered an inadequate amount of rocuronium. (Lost points)", 
                    "conditions": [
                        {
                            "drug": "Rocuronium", 
                            "op": "LT", 
                            "type": "bDrug", 
                            "value": 11
                        }
                    ], 
                    "points": -100
                }, 
                {
                    "nextState": "DEEPPARA", 
                    "comment": "You administered a competitive neuromuscular blocker. (+100 points)", 
                    "conditions": [
                        {
                            "op": "GT", 
                            "type": "nmb", 
                            "value": 0.8
                        }
                    ], 
                    "points": 100
                }
            ]
        }, 
        {
            "name": "DEEPPARA", 
            "whatNextMsg": "Now perform laryngoscopy and place the endotracheal intubation.", 
			"airwayStr": "nl",
            "aspirateCvpMsg": "10 mL blood was aspirated from the CVP catheter.", 
            "baseAbpD": 44, 
            "baseAbpM": 52, 
            "baseAbpS": 64, 
            "baseBicarb": 24, 
            "baseHr": 152, 
            "basePot": 4.2, 
            "breathSoundsMsg": "The breath sounds are equal bilaterally.", 
            "cardiacOutput": 1.8, 
            "contPip": 28, 
            "contPlateau": 26, 
            "cvp": 4, 
            "finalState": 0, 
            "glucose": 122, 
            "hct": 38, 
            "heartSoundsMsg": "Regular rate and rhythm, without murmurs.", 
            "hiCo2ProdFlag": false, 
            "laryTubeSuccess": 1, 
            "lidReflexMsg": "The lid reflex is absent.", 
            "lmaSuccessFlag": true, 
            "mentalStatusMsg": "The patient is unresponsive.", 
            "papD": 2, 
            "papM": 6, 
            "papS": 8, 
            "papW": 2, 
            "pulseMsg": "The pulse is present.", 
            "pupilsMsg": "The pupils are pinpoint.", 
            "rateEbl": 0, 
            "rateUo": 1.5, 
            "recordMsg": "Deeply anesthetized and paralyzed.", 
            "rhythm": "Sinus1", 
            "skinMsg": "The skin is warm and dry with normal capillary refill.", 
            "skipAheadHours": 0, 
            "skipAheadMsg": "", 
            "sodium": 142, 
            "sat20": 97, 
            "sat40": 99, 
            "sat100": 100, 
            "spSignal": 2, 
            "spontRr": 0, 
            "spontTv": 0, 
            "sputumAmount": 0, 
            "stSegII": 0.2, 
            "stSegV5": -0.3, 
            "temperature": 36.9, 
            "trans": [
                {
                    "nextState": "DESATBRADY1", 
                    "comment": "You took too long to intubate and the patient aspirated massive quantities of acidic fluids. (-500 points)", 
                    "conditions": [
                        {
                            "op": "GT", 
                            "type": "time", 
                            "value": 180
                        }
                    ], 
                    "points": -500
                }, 
                {
                    "nextState": "GA2", 
                    "comment": "You placed the endotracheal tube in a timely fashion. (+100 points)", 
                    "conditions": [
                        {
                            "type": "tryLaryTube", 
                            "value": true
                        }
                    ], 
                    "points": 100
                }, 
                {
                    "nextState": "GA2", 
                    "comment": "You placed the endotracheal tube in a timely fashion. (+100 points)", 
                    "conditions": [
                        {
                            "type": "airwayTube", 
                            "value": true
                        }
                    ], 
                    "points": 100
                }
            ]
        }, 
        {
            "name": "GA1", 
            "whatNextMsg": "Deepen the anesthetic.", 
			"airwayStr": "nl",
            "aspirateCvpMsg": "10 mL blood was aspirated from the CVP catheter.", 
            "baseAbpD": 46, 
            "baseAbpM": 58, 
            "baseAbpS": 80, 
            "baseBicarb": 24, 
            "baseHr": 150, 
            "basePot": 4.2, 
            "breathSoundsMsg": "The breath sounds are equal bilaterally.", 
            "cardiacOutput": 1.8, 
            "contPip": 28, 
            "contPlateau": 26, 
            "cvp": 4, 
            "finalState": 0, 
            "glucose": 122, 
            "hct": 38, 
            "heartSoundsMsg": "Regular rate and rhythm, without murmurs.", 
            "hiCo2ProdFlag": false, 
            "laryTubeSuccess": 1, 
            "lidReflexMsg": "The lid reflex is absent.", 
            "lmaSuccessFlag": true, 
            "mentalStatusMsg": "The patient is unresponsive.", 
            "papD": 2, 
            "papM": 4, 
            "papS": 8, 
            "papW": 2, 
            "pulseMsg": "The pulse is present.", 
            "pupilsMsg": "The pupils are small.", 
            "rateEbl": 0, 
            "rateUo": 1.5, 
            "recordMsg": "Lightly anesthetized.", 
            "rhythm": "Sinus1", 
            "skinMsg": "The skin is warm and dry with normal capillary refill.", 
            "skipAheadHours": 0, 
            "skipAheadMsg": "", 
            "sodium": 142, 
            "sat20": 97, 
            "sat40": 99, 
            "sat100": 100, 
            "spSignal": 2, 
            "spontRr": 0, 
            "spontTv": 0, 
            "sputumAmount": 0, 
            "stSegII": 0.2, 
            "stSegV5": -0.3, 
            "temperature": 36.9, 
            "trans": [
                {
                    "nextState": "HURT1", 
                    "comment": "You should not have allowed the surgeon to make an incision in a lightly anesthetized patient. (Lost points)", 
                    "conditions": [
                        {
                            "type": "makeIncision", 
                            "value": true
                        }
                    ], 
                    "points": -500
                }, 
                {
                    "nextState": "GA2", 
                    "comment": "You administered enough induction agent to adequately anesthetize this patient. (+100 points)", 
                    "conditions": [
                        {
                            "op": "GT", 
                            "type": "doa", 
                            "value": 1.4
                        }
                    ], 
                    "points": 100
                }, 
                {
                    "nextState": "DESATBRADY1", 
                    "comment": "You allowed the patient to become severely hypoxic. (-1000 points)", 
                    "conditions": [
                        {
                            "op": "LT", 
                            "type": "o2Sat", 
                            "value": 63
                        }
                    ], 
                    "points": -1000
                }
            ]
        }, 
        {
            "name": "GA2", 
            "whatNextMsg": "Maintenance phase - monitor the patient carefully. Tell the surgeon to make the incision.", 
			"airwayStr": "nl",
            "aspirateCvpMsg": "10 mL blood was aspirated from the CVP catheter.", 
            "baseAbpD": 48, 
            "baseAbpM": 60, 
            "baseAbpS": 82, 
            "baseBicarb": 24, 
            "baseHr": 152, 
            "basePot": 4.2, 
            "breathSoundsMsg": "The breath sounds are equal bilaterally.", 
            "cardiacOutput": 2, 
            "contPip": 28, 
            "contPlateau": 26, 
            "cvp": 4, 
            "finalState": 0, 
            "glucose": 122, 
            "hct": 38, 
            "heartSoundsMsg": "Regular rate and rhythm, without murmurs.", 
            "hiCo2ProdFlag": false, 
            "laryTubeSuccess": 1, 
            "lidReflexMsg": "The lid reflex is absent.", 
            "lmaSuccessFlag": true, 
            "mentalStatusMsg": "The patient is unresponsive.", 
            "papD": 4, 
            "papM": 6, 
            "papS": 8, 
            "papW": 4, 
            "pulseMsg": "The pulse is present.", 
            "pupilsMsg": "The pupils are pinpoint.", 
            "rateEbl": 0, 
            "rateUo": 1.5, 
            "recordMsg": "Adequately anesthetized.", 
            "rhythm": "Sinus1", 
            "skinMsg": "The skin is warm and dry with normal capillary refill.", 
            "skipAheadHours": 0, 
            "skipAheadMsg": "", 
            "sodium": 142, 
            "sat20": 97, 
            "sat40": 99, 
            "sat100": 100, 
            "spSignal": 2, 
            "spontRr": 0, 
            "spontTv": 0, 
            "sputumAmount": 0, 
            "stSegII": 0.2, 
            "stSegV5": -0.3, 
            "temperature": 36.9, 
            "trans": [
                {
                    "nextState": "GA3", 
                    "comment": "You instructed the surgeon to make the incision appropriately. (+200 points)", 
                    "conditions": [
                        {
                            "type": "makeIncision", 
                            "value": true
                        }
                    ], 
                    "points": 200
                }, 
                {
                    "nextState": "GA3", 
                    "comment": "You instructed the surgeon to operate. (+200 points)", 
                    "conditions": [
                        {
                            "type": "doingSurgery", 
                            "value": true
                        }
                    ], 
                    "points": 200
                }, 
                {
                    "nextState": "DESATBRADY1", 
                    "comment": "You allowed the patient to become severely hypoxic. (-1000 points)", 
                    "conditions": [
                        {
                            "op": "LT", 
                            "type": "o2Sat", 
                            "value": 63
                        }
                    ], 
                    "points": -1000
                }
            ]
        }, 
        {
            "name": "GA3", 
            "whatNextMsg": "Administer mannitol (12.5-25 gms).", 
			"airwayStr": "nl",
            "aspirateCvpMsg": "10 mL blood was aspirated from the CVP catheter.", 
            "baseAbpD": 36, 
            "baseAbpM": 48, 
            "baseAbpS": 68, 
            "baseBicarb": 24, 
            "baseHr": 148, 
            "basePot": 4.2, 
            "breathSoundsMsg": "The breath sounds are equal bilaterally.", 
            "cardiacOutput": 2, 
            "contPip": 28, 
            "contPlateau": 26, 
            "cvp": 4, 
            "finalState": 0, 
            "glucose": 122, 
            "hct": 38, 
            "heartSoundsMsg": "Regular rate and rhythm, without murmurs.", 
            "hiCo2ProdFlag": false, 
            "laryTubeSuccess": 1, 
            "lidReflexMsg": "The lid reflex is absent.", 
            "lmaSuccessFlag": true, 
            "mentalStatusMsg": "The patient is unresponsive.", 
            "papD": 4, 
            "papM": 6, 
            "papS": 8, 
            "papW": 4, 
            "pulseMsg": "The pulse is present.", 
            "pupilsMsg": "The pupils are pinpoint.", 
            "rateEbl": 0, 
            "rateUo": 1.5, 
            "recordMsg": "The operation is underway.", 
            "rhythm": "Sinus1", 
            "skinMsg": "The skin is warm and dry with normal capillary refill.", 
            "skipAheadHours": 0, 
            "skipAheadMsg": "", 
            "sodium": 142, 
            "sat20": 97, 
            "sat40": 99, 
            "sat100": 100, 
            "spSignal": 2, 
            "spontRr": 0, 
            "spontTv": 0, 
            "sputumAmount": 0, 
            "stSegII": 0.2, 
            "stSegV5": -0.3, 
            "temperature": 36.9, 
            "trans": [
                {
                    "nextState": "MANNITOL", 
                    "comment": "You administered mannitol (12.5-25 gms) appropriately. (+200 points)", 
                    "conditions": [
                        {
                            "drug": "Mannitol", 
                            "op": "GT", 
                            "type": "bDrug", 
                            "value": 12.3
                        }, 
                        {
                            "drug": "Mannitol", 
                            "op": "LT", 
                            "type": "bDrug", 
                            "value": 26
                        }
                    ], 
                    "points": 200
                }, 
                {
                    "nextState": "MANNITOL", 
                    "comment": "You administered an inadequate dose of mannitol. (Lost points)", 
                    "conditions": [
                        {
                            "drug": "Mannitol", 
                            "op": "LT", 
                            "type": "bDrug", 
                            "value": 12.4
                        }
                    ], 
                    "points": -100
                }, 
                {
                    "nextState": "MANNITOL", 
                    "comment": "You administered an excessive dose of mannitol. (Lost points)", 
                    "conditions": [
                        {
                            "drug": "Mannitol", 
                            "op": "GT", 
                            "type": "bDrug", 
                            "value": 25.9
                        }
                    ], 
                    "points": -100
                }, 
                {
                    "nextState": "MANNITOL", 
                    "comment": "You did not administer mannitol to this patient with high intracranial pressure. (Lost points)", 
                    "conditions": [
                        {
                            "op": "GT", 
                            "type": "time", 
                            "value": 180
                        }
                    ], 
                    "points": -500
                }, 
                {
                    "nextState": "DESATBRADY1", 
                    "comment": "You allowed the patient to become severely hypoxic. (-1000 points)", 
                    "conditions": [
                        {
                            "op": "LT", 
                            "type": "o2Sat", 
                            "value": 63
                        }
                    ], 
                    "points": -1000
                }
            ]
        }, 
        {
            "name": "MANNITOL", 
            "whatNextMsg": "Maintain adequate anesthesia for surgery with 1 MAC or less inhalation agent.", 
			"airwayStr": "nl",
            "aspirateCvpMsg": "10 mL blood was aspirated from the CVP catheter.", 
            "baseAbpD": 42, 
            "baseAbpM": 52, 
            "baseAbpS": 72, 
            "baseBicarb": 24, 
            "baseHr": 144, 
            "basePot": 4.2, 
            "breathSoundsMsg": "The breath sounds are equal bilaterally.", 
            "cardiacOutput": 2.2, 
            "contPip": 28, 
            "contPlateau": 26, 
            "cvp": 8, 
            "finalState": 0, 
            "glucose": 122, 
            "hct": 38, 
            "heartSoundsMsg": "Regular rate and rhythm, without murmurs.", 
            "hiCo2ProdFlag": false, 
            "laryTubeSuccess": 1, 
            "lidReflexMsg": "The lid reflex is absent.", 
            "lmaSuccessFlag": true, 
            "mentalStatusMsg": "The patient is unresponsive.", 
            "papD": 4, 
            "papM": 7, 
            "papS": 12, 
            "papW": 4, 
            "pulseMsg": "The pulse is present.", 
            "pupilsMsg": "The pupils are pinpoint.", 
            "rateEbl": 0, 
            "rateUo": 1.5, 
            "recordMsg": "The operation is underway. Mannitol administered?", 
            "rhythm": "Sinus1", 
            "skinMsg": "The skin is warm and dry with normal capillary refill.", 
            "skipAheadHours": 0, 
            "skipAheadMsg": "", 
            "sodium": 142, 
            "sat20": 97, 
            "sat40": 99, 
            "sat100": 100, 
            "spSignal": 2, 
            "spontRr": 0, 
            "spontTv": 0, 
            "sputumAmount": 0, 
            "stSegII": 0.2, 
            "stSegV5": -0.3, 
            "temperature": 36.9, 
            "trans": [
                {
                    "nextState": "FINAL", 
                    "comment": "You maintained adequate anesthesia with < 1 MAC inhalation agent. (+200 points)", 
                    "conditions": [
                        {
                            "op": "GT", 
                            "type": "doa", 
                            "value": 1.4
                        }, 
                        {
                            "op": "LT", 
                            "type": "mac", 
                            "value": 1.1
                        }
                    ], 
                    "points": 200
                }, 
                {
                    "nextState": "FINAL", 
                    "comment": "You failed to maintain adequate anesthesia with < 1 MAC inhalation agent. (Lost points)", 
                    "conditions": [
                        {
                            "op": "GT", 
                            "type": "time", 
                            "value": 180
                        }
                    ], 
                    "points": -200
                }, 
                {
                    "nextState": "DESATBRADY1", 
                    "comment": "You allowed the patient to become severely hypoxic. (-1000 points)", 
                    "conditions": [
                        {
                            "op": "LT", 
                            "type": "o2Sat", 
                            "value": 63
                        }
                    ], 
                    "points": -1000
                }
            ]
        }, 
        {
            "name": "FINAL", 
            "whatNextMsg": "You reached the end of the simulation. Review the debriefing.", 
			"airwayStr": "nl",
            "aspirateCvpMsg": "10 mL blood was aspirated from the CVP catheter.", 
            "baseAbpD": 50, 
            "baseAbpM": 62, 
            "baseAbpS": 88, 
            "baseBicarb": 24, 
            "baseHr": 132, 
            "basePot": 4.2, 
            "breathSoundsMsg": "The breath sounds are equal bilaterally.", 
            "cardiacOutput": 5.2, 
            "contPip": 28, 
            "contPlateau": 26, 
            "cvp": 8, 
            "finalState": 1, 
            "glucose": 122, 
            "hct": 38, 
            "heartSoundsMsg": "Regular rate and rhythm, without murmurs.", 
            "hiCo2ProdFlag": false, 
            "laryTubeSuccess": 1, 
            "lidReflexMsg": "The lid reflex is absent.", 
            "lmaSuccessFlag": true, 
            "mentalStatusMsg": "The patient is unresponsive.", 
            "papD": 4, 
            "papM": 7, 
            "papS": 12, 
            "papW": 4, 
            "pulseMsg": "The pulse is present.", 
            "pupilsMsg": "The pupils are pinpoint.", 
            "rateEbl": 0, 
            "rateUo": 1.5, 
            "recordMsg": "End of simulation.", 
            "rhythm": "Sinus1", 
            "skinMsg": "The skin is warm and dry with normal capillary refill.", 
            "skipAheadHours": 0, 
            "skipAheadMsg": "", 
            "sodium": 142, 
            "sat20": 97, 
            "sat40": 99, 
            "sat100": 100, 
            "spSignal": 2, 
            "spontRr": 0, 
            "spontTv": 0, 
            "sputumAmount": 0, 
            "stSegII": 0.2, 
            "stSegV5": -0.3, 
            "temperature": 36.9
        }, 
        {
            "name": "HURT1", 
            "whatNextMsg": "Deepen the anesthetic.", 
			"airwayStr": "nl",
            "aspirateCvpMsg": "10 mL blood was aspirated from the CVP catheter.", 
            "baseAbpD": 50, 
            "baseAbpM": 66, 
            "baseAbpS": 96, 
            "baseBicarb": 24, 
            "baseHr": 162, 
            "basePot": 4.2, 
            "breathSoundsMsg": "The breath sounds are equal bilaterally.", 
            "cardiacOutput": 2.4, 
            "contPip": 28, 
            "contPlateau": 26, 
            "cvp": 8, 
            "finalState": 0, 
            "glucose": 122, 
            "hct": 38, 
            "heartSoundsMsg": "Regular rate and rhythm, without murmurs.", 
            "hiCo2ProdFlag": false, 
            "laryTubeSuccess": 0, 
            "lidReflexMsg": "The lid reflex is reduced.", 
            "lmaSuccessFlag": false, 
            "mentalStatusMsg": "The patient is unresponsive.", 
            "papD": 6, 
            "papM": 10, 
            "papS": 16, 
            "papW": 6, 
            "pulseMsg": "The pulse is strong.", 
            "pupilsMsg": "The pupils are equal, round, and react to light.", 
            "rateEbl": 8, 
            "rateUo": 1.5, 
            "recordMsg": "Lightly anesthetized but autonomic response to painful stimulus.", 
            "rhythm": "Sinus1", 
            "skinMsg": "The skin is warm and dry with normal capillary refill.", 
            "skipAheadHours": 0, 
            "skipAheadMsg": "", 
            "sodium": 142, 
            "sat20": 97, 
            "sat40": 99, 
            "sat100": 100, 
            "spSignal": 2, 
            "spontRr": 26, 
            "spontTv": 90, 
            "sputumAmount": 0, 
            "stSegII": 0.2, 
            "stSegV5": -0.3, 
            "temperature": 36.9, 
            "trans": [
                {
                    "nextState": "GA1", 
                    "comment": "The autonomic response is abating.", 
                    "conditions": [
                        {
                            "op": "GT", 
                            "type": "time", 
                            "value": 30
                        }
                    ], 
                    "points": 0
                }, 
                {
                    "nextState": "GA2", 
                    "comment": "You deepened the anesthetic.", 
                    "conditions": [
                        {
                            "op": "GT", 
                            "type": "doa", 
                            "value": 2.2
                        }
                    ], 
                    "points": 0
                }, 
                {
                    "nextState": "DESATBRADY1", 
                    "comment": "You allowed the patient to become severely hypoxic. (-1000 points)", 
                    "conditions": [
                        {
                            "op": "LT", 
                            "type": "o2Sat", 
                            "value": 63
                        }
                    ], 
                    "points": -1000
                }
            ]
        }, 
        {
            "name": "DESATBRADY1", 
            "whatNextMsg": "Must reverse hypoxia immediately and treat bradycardia.", 
			"airwayStr": "nl",
            "aspirateCvpMsg": "10 mL blood was aspirated from the CVP catheter.", 
            "baseAbpD": 36, 
            "baseAbpM": 44, 
            "baseAbpS": 58, 
            "baseBicarb": 24, 
            "baseHr": 62, 
            "basePot": 4.2, 
            "breathSoundsMsg": "The breath sounds are equal bilaterally.", 
            "cardiacOutput": 1.2, 
            "contPip": 28, 
            "contPlateau": 26, 
            "cvp": 4, 
            "finalState": 0, 
            "glucose": 122, 
            "hct": 38, 
            "heartSoundsMsg": "Slow, regular rhythm, without murmurs.", 
            "hiCo2ProdFlag": false, 
            "laryTubeSuccess": 1, 
            "lidReflexMsg": "The lid reflex is absent.", 
            "lmaSuccessFlag": true, 
            "mentalStatusMsg": "The patient is unresponsive.", 
			"overdoseFlag": false,
            "papD": 10, 
            "papM": 12, 
            "papS": 16, 
            "papW": 8, 
            "pulseMsg": "The pulse is weak and slow.", 
            "pupilsMsg": "The pupils are small.", 
            "rateEbl": 0, 
            "rateUo": 1.5, 
            "recordMsg": "Hypoxic and bradycardic.", 
            "rhythm": "Sinus1", 
            "skinMsg": "The skin is cyanotic with poor capillary refill.", 
            "skipAheadHours": 0, 
            "skipAheadMsg": "", 
            "sodium": 142, 
            "sat20": 60, 
            "sat40": 61, 
            "sat100": 62, 
            "spSignal": 1, 
            "spontRr": 0, 
            "spontTv": 0, 
            "sputumAmount": 0, 
            "stSegII": 0.2, 
            "stSegV5": -0.3, 
            "temperature": 36.9, 
            "trans": [
                {
                    "nextState": "DESATBRADY2", 
                    "comment": "", 
                    "conditions": [
                        {
                            "op": "GT", 
                            "type": "time", 
                            "value": 30
                        }
                    ], 
                    "points": 0
                }
            ]
        }, 
        {
            "name": "DESATBRADY2", 
            "whatNextMsg": "Must reverse hypoxia immediately and treat bradycardia.", 
			"airwayStr": "nl",
            "aspirateCvpMsg": "10 mL blood was aspirated from the CVP catheter.", 
            "baseAbpD": 32, 
            "baseAbpM": 38, 
            "baseAbpS": 46, 
            "baseBicarb": 24, 
            "baseHr": 22, 
            "basePot": 4.2, 
            "breathSoundsMsg": "The breath sounds are equal bilaterally.", 
            "cardiacOutput": 0.8, 
            "contPip": 28, 
            "contPlateau": 26, 
            "cvp": 4, 
            "finalState": 0, 
            "glucose": 122, 
            "hct": 38, 
            "heartSoundsMsg": "Very slow, regular rhythm, without murmurs.", 
            "hiCo2ProdFlag": false, 
            "laryTubeSuccess": 1, 
            "lidReflexMsg": "The lid reflex is absent.", 
            "lmaSuccessFlag": true, 
            "mentalStatusMsg": "The patient is unresponsive.", 
			"overdoseFlag": false,
            "papD": 10, 
            "papM": 12, 
            "papS": 16, 
            "papW": 8, 
            "pulseMsg": "The pulse is weak and very slow.", 
            "pupilsMsg": "The pupils are large.", 
            "rateEbl": 0, 
            "rateUo": 1.5, 
            "recordMsg": "Hypoxic and severely bradycardic.", 
            "rhythm": "Sinus1", 
            "skinMsg": "The skin is cyanotic with poor capillary refill.", 
            "skipAheadHours": 0, 
            "skipAheadMsg": "", 
            "sodium": 142, 
            "sat20": 60, 
            "sat40": 61, 
            "sat100": 62, 
            "spSignal": 1, 
            "spontRr": 0, 
            "spontTv": 0, 
            "sputumAmount": 0, 
            "stSegII": 0.2, 
            "stSegV5": -0.3, 
            "temperature": 36.9, 
            "trans": [
                {
                    "nextState": "DESATASYST", 
                    "comment": "", 
                    "conditions": [
                        {
                            "op": "GT", 
                            "type": "time", 
                            "value": 20
                        }
                    ], 
                    "points": 0
                }
            ]
        }, 
        {
            "name": "DESATASYST", 
            "whatNextMsg": "CPR, epinephrine, atropine.", 
			"airwayStr": "nl",
            "aspirateCvpMsg": "10 mL blood was aspirated from the CVP catheter.", 
            "baseAbpD": 18, 
            "baseAbpM": 18, 
            "baseAbpS": 18, 
            "baseBicarb": 24, 
            "baseHr": 0, 
            "basePot": 4.2, 
            "breathSoundsMsg": "The breath sounds are equal bilaterally.", 
            "cardiacOutput": 0.2, 
            "contPip": 28, 
            "contPlateau": 26, 
            "cvp": 18, 
            "finalState": 0, 
            "glucose": 122, 
            "hct": 38, 
            "heartSoundsMsg": "Heart sounds are absent.", 
            "hiCo2ProdFlag": false, 
            "laryTubeSuccess": 1, 
            "lidReflexMsg": "The lid reflex is absent.", 
            "lmaSuccessFlag": true, 
            "mentalStatusMsg": "The patient is unresponsive.", 
			"overdoseFlag": false,
            "papD": 18, 
            "papM": 18, 
            "papS": 18, 
            "papW": 18, 
            "pulseMsg": "The pulse is absent.", 
            "pupilsMsg": "The pupils are large.", 
            "rateEbl": 0, 
            "rateUo": 1.5, 
            "recordMsg": "Hypoxic and asystolic.", 
            "rhythm": "Asystole1", 
            "skinMsg": "The skin is cyanotic with poor capillary refill.", 
            "skipAheadHours": 0, 
            "skipAheadMsg": "", 
            "sodium": 142, 
            "sat20": 60, 
            "sat40": 61, 
            "sat100": 62, 
            "spSignal": 0, 
            "spontRr": 0, 
            "spontTv": 0, 
            "sputumAmount": 0, 
            "stSegII": 0.2, 
            "stSegV5": -0.3, 
            "temperature": 36.9, 
            "trans": [
                {
                    "nextState": "DESATDEAD", 
                    "comment": "", 
                    "conditions": [
                        {
                            "op": "GT", 
                            "type": "time", 
                            "value": 30
                        }
                    ], 
                    "points": 0
                }
            ]
        }, 
        {
            "name": "DESATDEAD", 
            "whatNextMsg": "Notify the family.", 
			"airwayStr": "nl",
            "aspirateCvpMsg": "10 mL blood was aspirated from the CVP catheter.", 
            "baseAbpD": 18, 
            "baseAbpM": 18, 
            "baseAbpS": 18, 
            "baseBicarb": 24, 
            "baseHr": 0, 
            "basePot": 4.2, 
            "breathSoundsMsg": "The breath sounds are equal bilaterally.", 
            "cardiacOutput": 0.2, 
            "contPip": 28, 
            "contPlateau": 26, 
            "cvp": 18, 
            "finalState": -2, 
            "glucose": 122, 
            "hct": 38, 
            "heartSoundsMsg": "Heart sounds are absent.", 
            "hiCo2ProdFlag": false, 
            "laryTubeSuccess": 1, 
            "lidReflexMsg": "The lid reflex is absent.", 
            "lmaSuccessFlag": true, 
            "mentalStatusMsg": "The patient is unresponsive.", 
			"overdoseFlag": false,
            "papD": 18, 
            "papM": 18, 
            "papS": 18, 
            "papW": 18, 
            "pulseMsg": "The pulse is absent.", 
            "pupilsMsg": "The pupils are fixed and dilated.", 
            "rateEbl": 0, 
            "rateUo": 1.5, 
            "recordMsg": "The patient cannot be resuscitated.", 
            "rhythm": "Asystole1", 
            "skinMsg": "The skin is cyanotic.", 
            "skipAheadHours": 0, 
            "skipAheadMsg": "", 
            "sodium": 142, 
            "sat20": 60, 
            "sat40": 61, 
            "sat100": 62, 
            "spSignal": 0, 
            "spontRr": 0, 
            "spontTv": 0, 
            "sputumAmount": 0, 
            "stSegII": 0.2, 
            "stSegV5": -0.3, 
            "temperature": 36.9
        }
    ]
}