This case was written by Dr. Brandon Evtushevski. Dr. Evtushevski is an Emergency Medicine resident at the University of British Columbia, Vancouver Island Site. Prior to this, he completed a BSc in Neuroscience at McGill University followed by his MD at the University of British Columbia. He has interests in neurologic emergencies, critical care and … Continue reading Tracheoinnominate Artery Fistula
Cocaine-induced Aortic Dissection
This 49-year old male had abdominal and chest pain that start while smoking cocaine. This is on top of a history of untreated hypertension. On exam, he has signs of aortic dissection and requires stabilization before going to the CT scanner. Upon arrival back from the CT scan (which confirms the diagnosis of Type A aortic dissection) the patient is altered and in shock. Assessment reveals the patient to be in cardiac tamponade requiring emergent pericardiocentesis.
Pediatric Polytrauma
A 2.5 year old child falls from the 3rd floor balcony and presents to a community hospital. The team is expected to coordinate a thorough trauma survey. The patient will initially demonstrate compensated shock requiring aggressive resuscitation. After this initial phase, findings of severe head injury will become apparent. The team must optimize the patient for transfer to definitive care.
Pediatric Asthma Exacerbation
Acute asthma exacerbations in children are extremely common. Most asthmatic exacerbations respond quickly to basic treatment with beta-agonists, anticholinergics, and steroids. This case highlights the management of those patients who need treatment that goes beyond the basics.
Beta Blocker Toxicity
A 44-year-old male presents to the emergency department following the ingestion of an entire bottle of metoprolol. Decontamination strategies should be utilized alongside consultation with poison control. Patient clinically deteriorates as the drug reaches peak effects, requiring IV fluids, atropine, calcium, glucagon, multi-dose vasopressors, high dose insulin, and a discussion around potential salvage therapies.
COVID-19: Pediatric Multisystem Inflammatory Syndrome
Elliot, a seven-year old boy, is brought to the emergency department after six days of fever and lethargy. He has a rash, diarrhea and decreased urine output. Both his parents are healthcare workers with possible COVID-19 exposures.
Agitation and Aortic Dissection
A 53 year old male with untreated hypertension presents with a history of vomiting, back pain and acute agitation. Once he is sedated, assessment will reveal an acute aortic dissection. He will require prompt treatment, intubation and disposition planning.
COPDE with Pneumothorax
A 68-year old man with COPD requiring home oxygen presents with respiratory failure. He is hypoxic, hypercarbic and agitated and will require intubation. Dissociative-dosed ketamine and BiPAP can facilitate pre-oxygenation. After a successful intubation, the high pressure alarms on the ventilator will go off. The team leader must troubleshoot the high ventilation pressures until they find and treat a tension pneumothorax.
TB Pericarditis
A 38 year-old man (Ethiopian refugee) with untreated HIV and past history of TB, presents to the emergency department (ED) with anterior chest pain, shortness of breath and hypotension. He was seen 3 days prior by a walk-in clinic and referred to the ED with chest pain and ECG showing pericarditis, but did not attend the ED until symptoms were severe. In the ED, patient quickly progresses to profound shock and has a PEA arrest. POCUS will show a large pericardial effusion and tamponade. Team members are to initiate CPR, manage the arrest and treat the effusion using bedside pericardiocentesis in order to obtain return of spontaneous circulation (ROSC).
Urologic Sepsis
Denise is a 59-year-old female who presents with a 7-day history of urinary symptoms, fever, and left flank pain. She has a history of STEMI 5 years ago with chronic left-sided heart failure. She becomes unstable in the ER, requiring judicious fluid resuscitation, vasopressors, and empiric antibiotic treatment. The team leader needs to consider the history and arrange renal imaging to discover the severe sepsis is secondary to an infected ureteric calculus. From there, emergent urologic consultation and admission to hospital is warranted.
