Stable VT with ICD Firing

This case is written by Dr. Kyla Caners. She is a staff emergency physician in Hamilton, Ontario and the Simulation Director of McMaster University’s FRCP-EM program. She is also one of the Editors-in-Chief here at EmSimCases.

Why it Matters

This case tackles several components of ICD management that can make emergency physicians a little nervous. Most notably, it highlights:

  • The discomfort that staff members may have with touching a patient whose ICD is firing, and the need to reassure them of safety
  • The role of a magnet in terminating the inappropriate or ineffective shocks delivered by an ICD
  • The various anti-dysrhythmic options that are available to treat ventricular tachycardia (and the need to ask for expert opinion!)
  • The way a sympathetic response or anxiety may exacerbate dysrhythmias

Clinical Vignette

A 40-year-old male to presents to your tertiary care ED complaining that his ICD keeps firing. He keeps yelling “ow” and jumping/jerking every couple minutes during his triage. He has an ICD in place because he had previous myocarditis that left him with a poor EF.

Case Summary

A 40-year-old male presents to the ED complaining that his ICD keeps firing. He will have a HR of 180 and VT on the monitor. He will occasionally yell “ow.” The team will need to work through medical management of VT, while considering magnet placement for patient comfort. The patient will remain stable but will trigger VT with his agitation.

Download the case here: Stable VT with ICD firing

ECG for the case found here:

VT

(ECG source: http://lifeinthefastlane.com/ecg-library/ventricular-tachycardia/)

CXR for the case found here:

CXR with normal ICD

(CXR source: https://commons.wikimedia.org/wiki/File:Implantable_cardioverter_defibrillator_chest_X-ray.jpg)

 

Newborn Resuscitation

This case is written by Dr. Kyla Caners. She is a staff emergency physician in Hamilton, Ontario and the Simulation Director of McMaster University’s FRCP-EM program. She is also one of the Editors-in-Chief here at EmSimCases.

Why it Matters

Approximately 10% of newborns require some degree of resuscitation upon delivery, with less than 1% requiring active resuscitation.1 Given that deliveries in the ED are relatively rare, this means that performing NRP in the ED is quite uncommon. On the other hand, the ED team must be able to respond quickly and efficiently to a flat neonate. This means that practising NRP is paramount – and what better way to do so than with simulation! This case highlights three key pieces of NRP, including:

  • The need to warm, dry, and stimulate immediately
  • The quick progression to positive pressure ventilation if stimulation doesn’t work
  • When to initiate CPR, the necessary 3:1 compression:ventilation ratio, and how to place hands for performing CPR on a neonate

Clinical Vignette

You are working in the minor area of your ED and have been called by the physician on the major side to assist with a precipitous delivery. He is managing the mother and wants you to be ready to resuscitate the infant if needed. The mom thinks she’s term. She’s had no prenatal care and is an IV drug user. She used earlier today. There no meconium staining noted in the amniotic fluid. Baby has just been delivered and is handed to your team.

Case Summary

The team has been called to help in the ED where a woman just precipitously gave birth to a baby now requiring resuscitation. The mom thinks she’s at term. She has had no prenatal care and is an iv drug user. The baby will be flat. After stimulation and drying, the baby will have a HR <100 and PPV will be required. After 60 seconds, the HR will still be <60 and CPR will need to be started. This will be short lived. The team will also need to intubate and obtain IV access.

Download the case here: NRP Case

References

  1. Barber CA, Wyckoff MH. Use and efficacy of endotracheal versus intravenous epinephrine during neonatal cardiopulmonary resuscitation in the delivery room. Pediatrics2006;118:10281034doi: 10.1542/peds.2006-0416

Simulation Design

This critique on simulation design was written by Alice Gray, a PGY 4 in Emergency Medicine at The University of Toronto and 2017 SHRED [Simulation, Health Sciences, Resuscitation for the Emergency Department] Fellow.

Have you ever designed a simulation case for learners? If so, did you create your sim on a “cool case” that you saw?  I think we have all been guilty of this; I know I have. Obviously a unique, interesting case should make for a good sim, right?  And learning objectives can be created after the case creation?

Recently, during my Simulation, Health Sciences and Resuscitation in the ED fellowship (SHRED), I have come to discover some theory and methods behind the madness of creating sim cases. And I have pleasantly discovered that rather than making things more complicated, having an approach to sim creation can not only help to guide meaningful educational goals but also makes life a whole lot easier!

I find it helpful to think of sim development in the PRE-sim, DURING-sim, and POST-sim phases.

In a systematic review of simulation-based education, Issenberg et al, describe the 10 aspects of simulation interventions that lead to effective learning, which I will incorporate these the different phases of sim design.1

PRE-sim

 Like many things, the bulk of the work and planning are required in the PRE phase.

When deciding to use sim or not as a learning tool, the first step should be to ask what modality is most appropriate based on the stated learning objectives?1 A one-sized fits all approach is not optimal for learning. This is stated well in a paper by Lioce et al about simulation design that the “modality is the platform of the experience”.2 For me, one of the most important things to take into consideration is the following: can the learning objectives be appropriately attained though simulation, and if so, what type of simulation?  For example, if the goal is to learn about advanced airway adjuncts, this may be best suited by repetitive training on an airway mannequin or a focused task trainer. If the goal is to work through a difficult airway algorithm, perhaps learners should progress through cases requiring increasingly difficult airway management using immersive, full-scale simulation.  You can try in-situ inter-professional team training to explore systems-based processes.  Basically, a needs assessment is key. The paper by Lioce et al. describe guidelines when working through a needs assessment.2

 Next, simulation should be integrated into an overall curriculum to provide the opportunity to engage in repetitive (deliberate) practice:1 Simulation in isolation may not produce effective sustainable results.3  An overall curriculum development, while time consuming to develop and implement, is a worthy task.  Having one simulation build upon others may improve learning through spaced repetition, varying context, delivery and level of difficulty.

This can be difficult to achieve given constrained time, space and financial resources.  Rather than repeat the same cases multiple times, Adler et al created cases that had overlapping themes; the content and learning objectives differed between the cases but they had similar outcome measures. 3 This strategy could be employed in curriculum design to enhance repeated exposure while limiting the number of total sessions required.

Effective programmatic design should facilitate individualized learning and provide clinical variation: 1 Lioce et al, refer to a needs assessment as the foundation for any well-designed simulation.2 Simulation has addressed certain competencies residents are supposed to master – airway, toxicology, trauma, pediatrics, etc – without seeking input a priori on the learning needs of the residents. It may be valuable to survey participants and design simulations based on perceived curriculum gaps or learning objectives or try to assess baseline knowledge with structured assessment techniques prior to designing cases and curricula. (NB: Such a project is currently underway, led by simulation investigators at Sunnybrook Hospital in Toronto).

 Learners should have the opportunity to practice with increasing levels of difficulty:1 It is logical that learners at different stages of their training require different gradations of difficultly. Dr. Martin Kuuskne breaks down the development of simulation cases into their basic elements.  He advocates for thinking of each sim objective in terms of both knowledge and cognitive process.4

The knowledge components can divided into the medical and critical resource management (CRM), or more preferably, non-technical skills. 5 Medical knowledge objectives are self-explanatory and should be based on the level of trainee. Non-technical skills objectives typically relate to team-based communication, leadership, resource utilization, situational awareness and problem solving.6  Kuuskne’s post makes the very salient point that we need to limit the number of objectives in both these domains as this can quickly overwhelm learners and decreased absorption of knowledge.

The cognitive processes objectives can also be developed with increasing complexity, depending on the level of the trainee.4  For example, at the lowest level of learning is “remembering” – describing, naming, repeating, etc.   At the highest levels of learning is “creating” – formulate, integrate, modify, etc.  A case could be made to involve senior learners in creating and implementing their own sim cases.

DURING-sim

 As part of creating scripts and cases, case designers should try to anticipate learner actions and pitfalls.  There will always be surprises and unexpected actions (a good reason to trial, beta test and revise before deploying). On EMSimCases.com, Kuuskne outlines his approach to creating the case progression, and how can it be standardized.6  The patient in the simulation has a set of definite states: i.e. the condition of the patient created by vital signs and their clinical status.6  We can think of progression to different states through learner modifiers and triggers: Modifiers are actions that make a change in the patient, whereas triggers are actions that changes the state of the patient.  I found this terminology helpful when outlining case progression.

Simulation allows for standardization of learning in a controlled environment: 11 The truth of residency training is that even in the same program, residents will all have uniquely different experience.  One resident ahead of me, at graduation, had taken part in 10 resuscitative thoracotomies.  Many residents in the same class had not seen any.  We cannot predict what walks through our doors but we can try to give residents the same baseline skills and knowledge to deal with whatever does.

POST-sim

 Feedback is provided during the learning experience1 unless in an exam-type setting, where it should be given after.  It is important again to note the necessity of limiting the number of learning objectives, so you have room for scripted and unscripted topics of conversation.  Debriefing the case should be a breeze, as it should flow from the case objectives created at the beginning.

Going further than “the debrief” is the idea of how we evaluate the value of sim. To me, this is the most difficult and rarely done.  Evaluation of each sim case should be sought from participants and stakeholders, in addition to the pilot testing.  That information needs to be fed forward to make meaningful improvements in case design and implementation.

Outcomes or benchmarks should be clearly defined and measured.  The randomized study by Adler et al created clearly defined critical rating checklists during the development and needs assessment of their sim cases. 3 They then tested each case twice on residents to get feedback.

In summary, although a “cool case” is always interesting, it doesn’t always make the best substrate for teaching and learning in the simulator.  Thoughtful case creation for simulation needs to go beyond that, breaking down the design process into basic, known components and using a structured theory-based approach in order to achieve meaningful educational outcomes.

REFERENCES:

1               Issenberg et al. Features and uses of high-fidelity medical simulations that lead to effective learning: A BEME systematic review. Med Teach. 2005;27:10 –28.

2               Lioce et al. Standards of Best Practice: Simulation Standard IX: Simulation Design.  Clinical Stimulation in Nursing. 2015;11:309-315.

3               Adler et al. Development and Evaluation of a Simulation-Based Pediatric Emergency Medicine Curriculum. Academic Medicine. 2009;84:935-941.

4               Kuuskne M. How to develop targeted simulation learning objectives – Part 1: The Theory. April 21, 2015 https://emsimcases.com/2015/04/21/how-to-develop-targeted-simulation-learning-objectives-part-1-the-theory/

5               Kuuskne M. How to develop targeted simulation learning objectives – Part 2: The Practice. June 15, 2015. https://emsimcases.com/2015/06/16/how-to-develop-targeted-simulation-learning-objectives-part-2-the-practice/

6               Kuuskne M. Case Progression: states, modifiers and triggers. May 19, 2015. ​https://emsimcases.com/2015/05/19/case-progression-states-modifiers-and-triggers/

 

 

 

Burn with CO/CN Toxicity

This case is written by Dr. Kyla Caners. She is a staff emergency physician in Hamilton, Ontario and the Simulation Director of McMaster University’s FRCP-EM program. She is also one of the Editors-in-Chief here at EmSimCases.

Why it Matters

The management of patients with significant burns obtained in an enclosed space involves several important components. This case nicely highlights three key management considerations:

  • The need to intubate early in anticipation of airway edema that may develop
  • The possibility of cyanide toxicity in the context of hypotension and a high lactate, and the need to treat early with hydroxycobalamin
  • The importance of recognizing and testing for possible CO toxicity (and initiating 100% oxygen upon patient arrival)

Clinical Vignette

A 33-year-old female has just been brought into your tertiary care ED. She was dragged out of a house fire and is unresponsive. The etiology of the fire is unclear, but the home was severely damaged. The EMS crew that transported her noted significant burns across her chest, abdomen, arm, and leg.

Case Summary

A 33 year-old female is dragged out of a burning house and presents to the ED unresponsive. She has soot on her face, singed eyebrows, and burns to her entire chest, the front of her right arm, and part of her right leg. She is hypotensive and tachycardic with a GCS of 3. The team should proceed to intubate and fluid resuscitate. After this, the team will receive a critical VBG result that reveals profound metabolic acidosis, carboxyhemoglobin of 25 and a lactate of 11. If the potential for cyanide toxicity is recognized and treated, the case will end. If it is not, the patient will proceed to VT arrest.

Download the case here: Burn CO CN Case

ECG for the case found here:

sinus-tachycardia

ECG source: https://lifeinthefastlane.com/ecg-library/sinus-tachycardia/

CXR for the case found here:

CXR source: https://emcow.files.wordpress.com/2012/11/normal-intubation2.jpg

MVC with Tension Pneumothorax

This case is written by Dr. Kyla Caners. She is a staff emergency physician in Hamilton, Ontario and the Simulation Director of McMaster University’s FRCP-EM program. She is also one of the Editors-in-Chief here at EmSimCases.

Why it Matters

This case is a great example of challenging junior learners to a place that is just outside their comfort zone. Becoming comfortable with a primary and secondary survey is an important part of training in Emergency Medicine. Further, this case highlights the following:

  • The need to clinically recognize a possible tension pneumothorax and intervene immediately with needle decompression or finger thoracostomy
  • The challenge of performing/delegating multiple simultaneous interventions in a trauma patient
  • The importance of reassessing the patient and searching for multiple possible causes of hypotension

Clinical Vignette

EMS arrives with a 44-year-old male to your tertiary care ED. The trauma team has been activated. He was the driver in a single vehicle MVC at highway speed. There was extensive damage to the car. He is currently screaming and moaning.

Case Summary

A 44 year-old male arrives by EMS to a tertiary care ED where the trauma team has been activated. He was the driver in a single-vehicle MVC. He presents screaming and moaning with a GCS of 13. He has an obvious open fracture of his right forearm. He also has decreased air entry to the right side of his chest. The team will need to recognize the tension pneumothorax as part of their primary survey. They will then need to irrigate and splint the right arm after they have completed their secondary survey. As the secondary survey is being completed, the patient will become hypotensive again. This time, the team will find free fluid in the RUQ.

Download the case here: MVC with Tension PTX

ECG for the case found here:

sinus-tachycardia

(ECG source: https://lifeinthefastlane.com/ecg-library/sinus-tachycardia/)

Initial CXR for the case found here:

Tension PTX

(CXR source: https://radiopaedia.org/cases/tension-pneumothorax-9)

PXR for the case found here:

normal-pelvis-male

(PXR source: http://radiopaedia.org/articles/pelvis-1)

Second CXR for the case (post chest-tube insertion) found here:

R chest tube post PTX

(CXR source: http://jtd.amegroups.com/article/view/663/html)

FAST showing free fluid in the RUQ found here:

RUQ FF

U/S showing no PCE found here:

(All U/S images are courtesy of McMaster PoCUS Subspecialty Training Program)

Anaphylaxis (+/- Laryngospasm)

This case is written by Dr. Donika Orlich. She is a staff physician practising in the Greater Toronto Area. She completed her Emergency Medicine training at McMaster University and also completed a fellowship in Simulation and Medical Education.

Why it Matters

Anaphylaxis is a fairly frequent presentation to the ED. However, severe anaphylaxis requiring multiple epinephrine doses and airway management is quite rare. This case is challenging on its own merit simply due to the stress of intubating an impending airway obstruction. However, if learners are faced with laryngospasm as a complication of anaphylaxis, this case takes on even more important lessons, including:

  • The surprising and unexpected nature of laryngospasm
  • The role of Larson’s point in trying to resolve laryngospasm
  • How quickly children desaturate, and develop resultant bradycardia, as a consequence of laryngospasm

For an excellent review of the management of laryngospasm, click here.

Clinical Vignette

A 7-year-old boy arrives via EMS with increased work of breathing. He has a known allergy to peanuts and developed symptoms after eating birthday cake at a party. He has been given 0.15mg IM epinephrine 10 minutes ago by his mother. Current vital are: HR 140, BP 85/60, RR 40, O2 98% on NRB. He has some ongoing wheeze noted by EMS.

Case Summary

A 7-year-old male presents with wheeze, rash and increased WOB after eating a birthday cake. He has a known allergy to peanuts. The team must initiate usual anaphylaxis treatment including salbutamol for bronchospasm. The patient will then develop worsened hypotension, requiring the start of an epinephrine infusion. After this the patient will experience increased angioedema, prompting the team to consider intubation. If no paralytic is used for intubation (or if intubation is delayed), the patient will experience laryngospasm. The team will be unable to bag-mask ventilate the patient until they ask for either deeper sedation or a paralytic. If a paralytic is used, the team will be able to successfully intubate the child.

Download the case here: Anaphylaxis

Initial CXR for the case found here:

normal pediatric CXR

(CXR source: http://radiology-information.blogspot.ca/2015/04/normal-chest-x-ray.html)

Post-intubation CXR for the case found here:

Normal Pediatric Post-Intubation CXR

(CXR source: http://jetem.org/ettcxr/)

STEMI with Cardiogenic Shock

This case is written by Dr. Kyla Caners. She is a staff emergency physician in Hamilton, Ontario and the Simulation Director of McMaster University’s FRCP-EM program. She is also one of the Editors-in-Chief here at EmSimCases.

Why it Matters

The majority of STEMI presentations to the ED are quite straight-forward to manage: expediency and protocolization are of the utmost importance. However, when a patient presents with cardiogenic shock as a result of their STEMI, more nuanced care is required. In particular, the patient must be stabilized in order to facilitate the definitive treatment of cardiac catheterization. This case highlights some of those nuances, including:

  • The need for vasopressor support and possibly inotropic support in patients with cardiogenic shock
  • The challenges associated with intubating a hypotensive and hypoxic patient
  • The importance of optimizing the patient’s status as best as possible prior to intubation (whether via BiPAP, PEEP valve, push-dose pressors, or otherwise)

Clinical Vignette

A 55-year-old male presents to the ED with EMS as a STEMI activation. He arrives being bagged by EMS for hypoxia. His initial EMS call was for chest pain and he has significantly deteriorated en route. He has a history of smoking, hypertension, diabetes, and hypercholesterolemia. No prior cardiac history.

Case Summary

A 55-year-old man presents to the ED as a STEMI call. He is profoundly hypotensive with low O2 sats and obvious CHF. The patient’s blood pressure will transiently respond to fluid resuscitation. The ECG will show anterolateral ST elevation. The team will need to prepare for intubation while activating the cath lab. They will also need to start vasopressors. The patient will remain hypotensive until an inotrope like dobutamine is initiated. If unsafe medications are chosen for intubation, the patient will have a VT arrest.

Download the case here: STEMI with Cardiogenic Shock

ECG for the case found here:

anterolateral STEMI

(ECG source: https://lifeinthefastlane.com/ecg-library/lateral-stemi/)

Pre-intubation CXR for the case found here:

CHF

(CXR source: https://www.med-ed.virginia.edu/courses/rad/cxr/pathology2Bchest.html)

Post-intubation CXR for the case found here:

CHF post intubtation

(CXR source: https://heart-conditions.knoji.com/learning-about-and-coping-with-congestive-heart-failure/)

Lung U/S for the case found here:

 

 

Cashing out by buying in – How expensive does a mannequin have to be to call a simulation “high fidelity?”

This critique on simulation fidelity was written by Alia Dharamsi, a PGY 4 in Emergency Medicine at The University of Toronto and 2017 SHRED [Simulation, Health Sciences, Resuscitation for the Emergency Department] Fellow.

How expensive does a mannequin have to be to call a simulation “high fidelity?”

mannequin

That was the question I was pondering this week, as our SHRED theme this month is simulation in medical education. In my 4th year of residency at University of Toronto, most of my simulation training has been in one of our two simulation labs, using one of our three “high fidelity” mannequins. However, even though the simulation labs and equipment have been very consistent over the past few years, I have found a fluctuating attentiveness and “buy-in” to these simulation sessions: some have felt very real and have resulted in a measurable level of stress and urgency to improve the patient’s (read: mannequin’s) outcome while others have felt like a mandatory hoop through which to jump in order to pass a rotation.

It should not come to anyone’s surprise to note that in Emergency Medicine, simulation is a necessary part of our development as residents. Simulation based medical education allows trainees to meet standards of care and training, mitigates risks to patients, develops clinical competencies, improves patient safety, aids in managing complex patient encounters, and protects patients [1]. Furthermore, in emergency medicine, simulation has allowed me to practice rare and life-saving critical skills like cricothyroidotomies and thoracotomies before employing them in real-time resuscitations. Those who know me will tell you when it comes to simulation I fully support its use as an educational tool, but there does still seem to be an ebb and flow to how much I commit to each sim case that I participate in as a learner.

During a CCU rotation,  I was involved in a relatively simple “chest pain” simulation exercise. As the circulating resident, I was tasked with giving the patient ASA to chew. In that moment I didn’t just simulate giving ASA; I took the yellow lid from an epinephrine kit (it looked like a small circular tablet) and put it in the mannequin’s mouth asking him to chew it. I did not think much of it until our airway resident was preparing to intubate, and the whole case derailed into an “ airway foreign body” scenario—to the confusion of the simulationists sitting behind the window who didn’t know how that foreign body got into the airway in the first place. Why did I do that? I believe it’s because I bought into the scenario, and in my eyes that mannequin was my patient, and my patient needed the ASA to chew. The case of a chest pain—although derailed into a difficult airway case by my earnest delivery of medications—was in the context of a residency rotation where I was expected to manage the CCU independently overnight. That context allowed me to buy-into the case because I knew these skills were transferrable to my role as a CCU resident. My buy-in has had less to do with the mannequin and the physical space and everything to do with how the simulation fit into the greater context of my current training.

There has been discussion amongst simulationists that there should be a frame shift away from fidelity and towards educational effectiveness: helping to engage learners, providing framework and context to aid them in suspending their disbelief, and providing structure to apply the simulation to real-time resuscitations in order to enhance learner engagement [2]. The notion of functional fidelity is one that resonates with me as a budding simulationist; if a learner has an educational goal and is oriented to how the simulation will provide the context and platform to learn that goal, the learner may more easily “project fidelity onto the simulation scenario.” That is, the learner will buy-into the simulation [2].

 So how do we facilitate buy-in?

We can start by orienting learners meaningfully and intentionally to the simulation exercises. [3] This can be accomplished by demonstrating how the concepts from the simulation are transferrable to other contexts which can allow the learners to engage on a deeper level with the simulation and see the greater applicability of what they are learning [2].  We can’t assume learners understand why or how this exercise is applicable to them. A chest pain case for a senior resident in emergency medicine has very different learning outcomes than the same case for an off service junior resident rotating through the ER; the same can be said for a resident primarily working in the hospital or working in an outpatient clinic. Tailoring case objectives to learners specifically provides an opportunity to provide relevant skills to learners in the context of their training, giving them a reason to buy-in to the scenario session. Moving beyond “to learn…” or “to outline the management of…”, I would advocate that specifically outlining objectives for the level and specialties of participating learners will help them see the employability of the skills they gain in the simulation.

We can also use those specific objectives and context we start the simulation session with to foster a more directed debrief. The post-simulation discussion should not only cover medical management principles but also specific discussion about what learners would do if they encountered a similar situation in their specific work environment (clinic, ward, etc), transferring the learning out of the simulation lab and into real world medical practice.

If we are going to see simulation as a tool, let’s see it as one of those fancy screwdrivers with multiple bits, and stop trying to use the screwdriver handle as a hammer for every nail. No one mannequin, regardless of how expensive and how many fancy features it has, can replace the role of a thoughtful facilitator who can help learners buy-into the simulation. If facilitators take the time to orient the learner to their specific learning objectives and then reinforce that context in the debrief discussion, they can increase the functional fidelity of the session and aid learners in maximizing their benefit from each simulation experience.

 

Citations 

  1. Ziv, A., Wolpe, P. R., Small, S. D., & Glick, S. (2003). Simulation-Based Medical Education. Academic Medicine, 78(8), 783-788. doi:10.1097/00001888-200308000-00006
  2. Hamstra, S. J., Brydges, R., Hatala, R., Zendejas, B., & Cook, D. A. (2014). Reconsidering Fidelity in Simulation-Based Training. Academic Medicine, 89(3), 387-392. doi:10.1097/acm.0000000000000130
  3. Issenberg, S. B., Mcgaghie, W. C., Petrusa, E. R., Gordon, D. L., & Scalese, R. J. (2005). Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Medical Teacher, 27(1), 10-28. doi:10.1080/01421590500046924

 

ASA Toxicity

This case is written by Dr. Donika Orlich. She is a staff physician practising in the Greater Toronto Area. She completed her Emergency Medicine training at McMaster University and also obtained a fellowship in Simulation and Medical Education.

Why it Matters

Salicylate toxicity, while relatively rare, has fairly nuanced management. It is important for physicians to be aware of presenting features of the toxicity and also of key management steps. Some pearls from this case include:

  • That hypoglycemia (and neuroglycopenia) is a manifestation of ASA toxicity.
  • Urine alkalinization (and correction of hypokalemia) is an important initial treatment for suspected toxicity.
  • Should a patient require intubation, it is paramount to set the ventilator to match the patient’s pre-intubation respiratory rate as best as possible.
  • Dialysis is indicated in intubated patients and also in patients with profoundly altered mental status, high measured ASA levels, and renal failure.

Clinical Vignette

You are working at a community hospital. The triage nurse comes to tell you that they have just put an 82 year-old male in a resuscitation room. He was found unresponsive by his daughter and was brought in by EMS. In triage he was profoundly altered, febrile and hypotensive. His daughter is in the room with him.

Case Summary

The learner will be presented with an altered febrile patient, requiring an initial broad work-up and management plan. The learner will receive a critical VBG report of severe acidosis, hypoglycemia and hypokalemia, requiring management. Following this, the rest of the blood work and investigations will come back, giving the diagnosis of salicylate overdose. The patient’s mental status will continue to decline and learners should proceed to intubate the patient, anticipating issues given the acid-base status. The learner should also initiate urinary alkalinization and make arrangements for urgent dialysis.

Download the case here: ASA Toxicity

ECG for the case found here:

Hypokalemia ECG

(ECG source: https://lifeinthefastlane.com/ecg-library/basics/hypokalaemia/)

Initial CXR for the case found here:

ards pre intubation

(CXR source: http://www.radiology.vcu.edu/programs/residents/quiz/pulm_cotw/PulmonConf/09-03-04/68yM%2008-03-04%20CXR.jpg)

Post-intubation CXR for the case found here:

ARDS post intubation

(CXR source: http://courses.washington.edu/med620/images/mv_c3fig1.jpg)

FAST showing no free fluid found here:

no FF

Pericardial U/S showing no PCE found here:

Abdominal U/S showing no AAA found here:

no AAA

All U/S images are courtesy of McMaster PoCUS Subspecialty Training Program.

Aortic Stenosis with A Fib and CHF

This case is written by Dr. Donika Orlich. She is a staff physician practising in the Greater Toronto Area. She completed her Emergency Medicine training at McMaster University along with a fellowship in Simulation and Medical Education.

Why it Matters

The management of patients with aortic stenosis can be tenuous at the best of times. When these patients present with CHF or dysrhythmias, their management is much more nuanced than the typical patient presenting with the same complaints. This case nicely highlights the following management differences:

  • The need for expedient rate control in a patient with aortic stenosis (in this case, most safely accomplished via cardioversion)
  • The need for judicious treatment of CHF, including careful diuresis and avoiding nitroglycerin use
  • The importance of early consultation with both cardiac surgery and cardiology

Clinical Vignette

A 78-year-old male presents via EMS with 4 days of increased SOB. The triage nurse comes to tell you she has put him in the resuscitation bay due to unstable vitals. HR was in the 150s. The O2SAT was 86% on RA when EMS arrived, but is now 95% on a NRB.

Case Summary

A 78-year-old male presents with increased SOB over the past 4 days. A recent ECHO will be presented showing severe AS. The ECG will demonstrate new A Fib with a HR of 150 and the CXR will show CHF. The patient will be normotensive at first but will become hypotensive shortly after. The team will then need to decide whether to cardiovert the patient or attempt rate control. If these are done safely, the patient will respond and then develop worsening CHF. Definitive management should be sought with early cardiology/cardiac surgery consult. If management is not carried out judiciously, the patient will become profoundly hypotensive.

Download the case here: Aortic Stenosis with A Fib and CHF

Initial ECG for the case found here:

ECG- A.fib + LVH

(ECG source: http://www.wikidoc.org/index.php/Atrial_fibrillation_EKG_examples)

Second ECG for the case (after cardioversion) found here:

ECG- LVH

(ECG source: http://bestpractice.bmj.com/best-practice/monograph/409/resources/image/bp/5.html)

CXR for the case found here:

CHF

(CXR source: https://www.med-ed.virginia.edu/courses/rad/cxr/pathology2Bchest.html)

Lung ultrasound for the case found here: