Postpartum Hemorrhage and NRP

This case is written by Dr. Donika Orlich. She is a PGY5 Emergency Medicine resident at McMaster University who also completed a fellowship in Simulation and Medical Education last year.

Why it Matters

Deliveries in the Emergency Department are, by definition, high risk deliveries. However, they are relatively rare. This case highlights some of the “worst case scenarios” that one may face after a delivery in the ED. In particular, it showcases:

  • The key first steps required for NRP in the 60 seconds after delivery
  • The later stages of NRP, including CPR and intubation
  • The approach to a patient with postpartum hemorrhage, including transfusion, fundal massage, administration of uterotonics, and a search for retained products

Clinical Vignette

EMS Patch: “We have a 26 year-old female who is 38 weeks pregnant and appears to be in active labor. She is complaining of severe abdominal pain and has had some vaginal bleeding. We don’t see any crowing yet, but the patient feels the baby’s head is about to come out. Patient’s Vitals as follows: HR 120, BP 140/85, RR 20, O2 100% on room air. ETA 2 minutes.”

Case Summary

The team receives advanced notification from EMS about a woman who is imminently delivering. Upon arrival, delivery will be uncomplicated, but the neonate will appear lifeless. Neonatal resuscitation should be initiated. Eight minutes into the neonatal resuscitation, the team leader will be notified that the mother continues to hemorrhage and is becoming hypotensive. They must begin concurrent workup and management of the mother while continuing to run the neonatal resuscitation. Second & third line medical therapies for uterine atony will be needed, and also manual uterine exploration and packing. Early consultation should be made to NICU, ICU, OB, and Interventional Radiology.

Download the case here: PPH and NRP Combined Case

Toxic Alcohol Ingestion

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

While toxic alcohol ingestions requiring treatment are relatively rare, patients presenting with a profoundly altered mental status are not. This case highlights key features of each, including:

  • The need for a broad differential in patients with an altered mental status (especially when there is absolutely no relevant history available!)
  • The importance of identifying and working through causes of an anion gap metabolic acidosis
  • The empiric and definitive treatments of a toxic alcohol overdose

Clinical Vignette

EMS has just brought you to a patient with a GCS of 3. He was found in the back alley behind a drug store with no identifying information. He is not known to EMS or to your department. He appears to be in his 30s or 40s.

Case Summary

A 46 year-old male presents with a GCS of 3 after being found in the back alley behind a drug store. The team will need to work through a broad differential diagnosis and recognize the need to intubate the patient. If they try naloxone, it will have no effect. After intubation, the team will receive critical VBG results showing a profound metabolic acidosis with a significant anion gap. The goal is to trigger the team to work through the possible causes of an elevated anion gap, including toxic alcohols.

Download the case here: Toxic Alcohol Case

ECG for the case found here:

Sinus tachycardia

(ECG source: http://i0.wp.com/lifeinthefastlane.com/wp-content/uploads/2011/12/sinus-tachycardia.jpg)

Post-intubation CXR for the case found here:

Post-Intubation

Post Intubation

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

Thyroid Storm

This case is written by Dr. Cheryl ffrench, a staff Emergency Physician at the Health Sciences Centre in Winnipeg. She is the Associate Program Director and the Director of Simulation for the University of Manitoba’s FRCP-EM residency program; she is also on the Advisory Board of emsimcases.com.

Why it Matters

Thyrotoxicosis is a rare presentation to the ED that can masquerade as many other conditions. This case nicely reviews the following:

  • The importance of maintaining a broad differential diagnosis in any patient who presents with an altered level of consciousness and a fever
  • The nuances associated with managing atrial fibrillation in the context of thyrotoxicosis
  • The multiple medications required in order to treat thyroid storm

Clinical Vignette

You are working the evening shift at a tertiary care hospital. A 31-year-old female two weeks postpartum is brought in by EMS accompanied by her husband. He is concerned because she is delirious and somewhat difficult to rouse.

Case Summary

A 31 year-old-female presents by EMS with altered LOC and fever due to thyroid storm precipitated by recent parturition. The patient is tachycardic and hypoxic on arrival. Her level of consciousness will continue to deteriorate despite IV fluids and antibiotics and will require intubation. The husband will be at the bedside, and the team will need to discuss the need for intubation with him. After intubation, lab results will come back indicating possible thyrotoxicosis. The patient’s rhythm will change to atrial fibrillation at this time. The team will be expected to manage the thyroid storm in consultation with Endocrinology and ICU.

Download the case here: Thyroid Storm Case

Sinus tachycardia ECG for the case found here:

Sinus tachycardia

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

Atrial fibrillation ECG for the case found here:

rapid-a-fib

(ECG source: http://lifeinthefastlane.com/ecg-library/atrial-fibrillation/)

CHF CXR for the case found here:

severe-chf

(CXR source: http://www.radiologyassistant.nl/en/p4c132f36513d4/chest-x-ray-heart-failure.html)

Status Epilepticus

This case is written by Dr. Donika Orlich. She is a PGY5 Emergency Medicine resident at McMaster University who also completed a fellowship in simulation and medical education last year.

Why it Matters

This case is an excellent review of the management of status epilepticus and includes 2nd, 3rd, and 4th line agents for treatment. This case also highlights a few unique practice challenges, including:

  • The hemodynamic effects of administering phenytoin too quickly
  • Disclosing medical error to families
  • Special agents to be considered in refractory seizure, such as magnesium sulfate, hypertonic saline, and pyridoxine

Clinical Vignette

A 38 year-old female is brought in by EMS with active seizure. She was last seen normal about 45 minutes ago by her husband, and has been witnessed seizing now for about 20 minutes. She is known to have epilepsy. EMS have 1 line in place, and 5mg IV midazolam was given en route.

Case Summary

A 38 year-old female presents actively seizing with EMS. She will fail to respond to repeat doses of IV benzodiazepines, and will require escalating medial management. Following phenytoin infusion, the patient will become hypotensive (because the phenytoin was given as a “push dose”, which the nurse will mention). The patient will then stop her GTC seizure, but will remain unresponsive with eye deviation. The team should recognize this as subclinical status, and proceed to intubate the patient.   The patient will continue to seize following phenobarbital and propofol infusion. Urgent consults to radiology and ICU should be made to expedite care out of the ED. The team will be expected to debrief the phenytoin medication error and disclose the error to the husband.

Download the case here: Status Epilepticus

ECG for the case found here:

normal-sinus-rhythm

(ECG source: http://i0.wp.com/lifeinthefastlane.com/wp-content/uploads/2011/12/normal-sinus-rhythm.jpg)

Post-intubation CXR for the case found here:

normal-intubation2

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

VSA Megacode

This case is written by Dr. Cheryl ffrench, a staff Emergency Physician at the Health Sciences Centre in Winnipeg. She is the Associate Program Director and the Director of Simulation for the University of Manitoba’s FRCP-EM residency program; she is also on the Advisory Board of emsimcases.com.

Why it Matters

Leading a resuscitation is a core skill of an Emergency Physician. More often than not, we know very little about the patient’s history before orchestrating a team of nurses, respiratory technicians, residents and other team members to provide resuscitative care. Assessment of the cardiac rhythm and pulse allows us to start with ACLS algorithms in order to hopefully obtain return of spontaneous circulation (ROSC), initiate post-ROSC care and arrange for the appropriate disposition of the patient This case, which is geared toward junior learners, highlights the following:

  • The importance of resource allocation during a prolonged resuscitation
  • Managing the resuscitation team, ensuring effective communication and recognizing compression fatigue.
  • Providing high quality ACLS and post-ROSC care
  • Recognizing STEMI as the cause of the cardiac arrest and initiating disposition for percutaneous coronary intervention (PCI)

Clinical Vignette

A 54-year-old male police officer presents to the ED with chest pain. He played his normal weekend hockey game about two hours ago. He has been having retrosternal chest pain since the game ended. It improved with rest, but has not resolved completely. It is worse after walking into the department. He now feels dizzy, short of breath, and nauseous.

Case Summary

A 54-year-old male police officer presents to the ED complaining of chest pain for two hours that started after his weekend hockey game. He is feeling dizzy and short of breath upon presentation. He will have a VT arrest as he is placed on the monitor. He will require two shocks and rounds of CPR before he has ROSC. He will then loose his pulse again while the team is trying to initiate post-arrest care; this will happen several times. Finally, the team will maintain ROSC. When an ECG is performed, it is revealed that the patient has a STEMI and the team will need to call for emergent PCI.

Download the case here: VSA Megacode

ECG for the case found here:

anterolateral

(ECG source: http://cdn.lifeinthefastlane.com/wp-content/uploads/2011/10/anterolateral.jpg)

Post Intubation-CXR for the case found here:

normal-intubation2

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

Tumour Lysis Syndrome

This case is written by Dr. Donika Orlich. She is a PGY5 Emergency Medicine resident at McMaster University who completed a fellowship in Simulation and Medical Education last year.

Why it Matters

Tumor Lysis Syndrome is a constellation of metabolic disturbances that can occur as a potentially fatal complication of treating cancers, most notably leukemias or solid rapidly-proliferating tumours. This case highlights the following:

  • The identification and management of severe hyperkalemia
  • The need to consider Tumour Lysis Syndrome as a diagnosis and order appropriate metabolic tests
  • Recognizing and initiating the treatment of severe hyperuricemia
  • Communicating with family members effectively during the treatment of a critically ill patient.

Clinical Vignette

A 72-year-old male presents to the emergency department complaining of general weakness for 2 days.  His wife called EMS and he was a STEMI patch to your hospital. He has been placed in the resuscitation bay.

Case Summary

A 72-year-old male is brought in as a “code STEMI” to the resuscitation bay. He was recently diagnosed with ALL and had chemotherapy 3 days ago for the first time. The patient is severely hyperkalemic, which must be initially recognized and treated, hypocalcemic and hyperuricemic as a result of Tumour Lysis Syndrome and the metabolic derangements must be stabilized until emergent hemodialysis is arranged.

Download the case here: Tumour Lysis Syndrome

ECGs for the case found here:

ecg90406-hyperkalaemia-pr-lengthens

(Source:  http://lifeinthefastlane.com/ecg-library/basics/hyperkalaemia/)

normal-sinus-rhythm

(Source:  http://cdn.lifeinthefastlane.com/wp-content/uploads/2011/12/normal-sinus-rhythm.jpg)

CXR for the case found here:

CXR

Obstetrical Trauma

This case is written by Dr. Donika Orlich. She is a PGY5 Emergency Medicine resident at McMaster University who completed a fellowship in Simulation and Medical Education last year.

Why it Matters

The management of a late-term pregnant trauma patient poses unique challenges. In particular, this case highlights the following:

  • The need for manual uterine displacement
  • The importance of considering uterine rupture or abruption as part of the primary or secondary survey (and how this necessitates a pelvic exam)
  • The challenge associated with controlling the noise and chaos in the trauma bay when multiple consultants are present
  • How difficult it is to break bad news about two patients at once to the father

**Special note: please be aware that this case has the potentially to be distressing to learners. As such, if you are to run it, please have resources available to help learners should they be affected by the weight of this case.

Clinical Vignette

You are working in a tertiary care emergency department and receive an EMS Patch: “33F who appears quite pregnant coming to you from an MVC. Belted driver. Prolonged extrication at the scene (30mins). Altered LOC and hypotensive on scene. Current vitals: HR 150, BP 80/50, RR 40, O2 90% on NRB, CBG 6. 1L NS bolus going. ETA 5 minutes.”

Case Summary

A 33 year old G2P1 female at 32 weeks GA presents with blunt trauma following an MVC. She will be hypotensive due to both hypovolemic shock from a pelvic fracture and obstructive shock from a tension pneumothorax. Fetal monitoring will show the fetus in distress with tachycardia and late decelerations. Early airway intervention should be employed, with thoughtful selection of drugs for sedation and paralysis given the pregnancy. After intubation, the patient will remain hypotensive. She will require massive transfusion and coordination of care between orthopedics, general surgery, and obstetrics. The patient’s husband will also arrive after intubation and the team must give him the bad news.

Download the case here: Obstetrical trauma case

ECG for the case found here:

Sinus tachycardia

(ECG source: http://i0.wp.com/lifeinthefastlane.com/wp-content/uploads/2011/12/sinus-tachycardia.jpg)

CXR for the case found here:

CXR Tension ptx

(CXR source: http://cdem.phpwebhosting.com/ssm/pulm/pneumothorax/images/cxr_ptx_3.png)

Pelvic XR for the case found here:

Pelvic X-ray post binder

(PXR source: https://drhem.files.wordpress.com/2011/11/5-4-6.jpg)

Normal pericardial U/S for the case found here: 

Left lung U/S with no lung sliding found here: 

RUQ U/S showing FF found here: RUQ FF

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

Pancreatitis with ARDS

This case is written by Dr. Kyla Caners. She is an 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

Pancreatitis is a common diagnosis made in the ED. However, severe pancreatitis with shock is relatively rare. As such, this case highlights several important points about the management of a hypotensive patient with abdominal pain:

  • The importance of maintaining a broad differential diagnosis and employing beside imaging in one’s assessment
  • The need for aggressive fluid resuscitation in an acutely hypotensive patient
  • The risk of ARDS with pancreatitis
  • The importance of developing a safe approach to the intubation of a patient who is simultaneously hypoxic and hypotensive

Clinical Vignette

Patricia is a 50 year old female who presents with epigastric abdominal pain. It’s been persistent for the last 24 hours and radiates through to her back. She has been nauseous all day and has been vomiting so much she “can’t keep anything down.” She was “on a bender” this weekend drinking beer and whiskey.

Case Summary

A 50 year-old female who was “on a bender” over the weekend now presents with diffuse abdominal pain and persistent nausea and vomiting. She will have a diffusely tender abdomen, a BP of 80/40, and be tachycardic. The team will need to work through a broad differential diagnosis and should fluid resuscitate aggressively. Once the patient has received 6L of fluid, she will become tachypneic and hypoxic and require intubation. The team will be given a lipase result just prior.

Download the case here: Pancreatitis with ARDS

ECG for the case found here:

Sinus tachycardia

(ECG source: http://cdn.lifeinthefastlane.com/wp-content/uploads/2011/12/sinus-tachycardia.jpg)

Initial CXR for the case found here:

normal female CXR radiopedia

(CXR source: http://radiopaedia.org/articles/normal-position-of-diaphragms-on-chest-radiography)

ARDS CXR for when patient is hypoxic found here:

Pre-intuabtion

(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:

Post intubation

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

FAST showing no free fluid found here:

no FF

U/S aorta showing no AAA found here:

no AAA

Pericardial U/S showing no effusion found here:

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

Acute Chest Syndrome

This case is written by Dr. Carla Angelski. She has completed both a PEM fellowship at Dalhousie and a MEd in Health Sciences Education. She now works in the Pediatric Emergency Department at the Royal University Hospital in Saskatchewan and is intimately involved in the delivery of high-fidelity simulation at the their sim centre. She is currently working on a curriculum to deliver in-situ simulation for ongoing faculty CME within the division and department.

Why it Matters

Patients with sickle cell disease are subject to a host of crises that can be difficult to manage. This case highlights the unique management of acute chest syndrome. In particular:

  • Recognition of acute chest syndrome as a possibility in the sickle cell patient with respiratory distress
  • Judicious use of fluids in patients with possible acute chest syndrome
  • The possible need for exchange transfusion in patients with severe acute chest syndrome

Clinical Vignette

You are working the day shift at a tertiary children’s hospital. A mother brings in her son, James, a four-year old boy with known sickle cell disease (HbSS). She is concerned since he’s had low energy and a cough for two days. Now he’s had a fever since this afternoon.

Case Summary

A 4-year-old boy with known sick cell disease presents with two days of cough and a one afternoon of fever. The patient is initially saturating at 88%, looks unwell and is in moderate-severe distress. During the case, the patient’s oxygenation with drop and the emergency team is expected to provide airway support. They will also need to pick appropriate induction agents for intubation. The case will end with ICU admission. During the case, the mother will also be challenging/questioning the team until a team member is delegated to help keep the mother calm.

Download the case here: Acute Chest Syndrome

CXR for the case found here:

sickle cell CXR

(CXR source: http://reference.medscape.com/features/slideshow/sickle-cell#8)

Post-intubation CXR for the case found here:

Post-intubation R-sided infiltrate

(CXR source: http://www.swjpcc.com/critical-care/?currentPage=4)

Gearing up to restart!

After an exam-writing hiatus, we’re gearing up to restart our regular case publications.

Have a case you’d love to see featured on the site? Send it to us at cases@emsimcases.com. We’re always happy to collaborate and feature the great work of our peers.

Stay tuned for new cases coming soon – we’ve got great things planned!