COVID-19: STEMI with VF Arrest

This is the third COVID-19 case that we are publishing to provide simulation tools to healthcare providers during the 2020 Coronavirus pandemic. It involves an unexpected cardiac arrest in a suspected COVID positive patient.

This case was written by Drs. Krista Dowhos and Alim Nagji for use to assess and improve team preparedness to care for a COVID positive patient in cardiac arrest.

Dr. Krista Dowhos is a 2nd year Family Medicine resident at McMaster’s Kitchener-Waterloo distributed campus. She is passionate about medical education, especially simulation-based medical education and the production of infographics for knowledge translation in Emergency Medicine.

Dr. Alim Nagji is an ER staff physician at Joseph Brant Hospital (JBH) and St. Joseph Healthcare Hamilton. He is the Director of Emergency Medicine Clerkship for McMaster University and the Director of Simulation Learning and Clinical Teaching Unit for JBH. He has interests in medical education, simulation and global health. Send him your favourite meme on twitter (@alimnagji)

Why It Matters

Outbreaks of novel respiratory illnesses occur with some regularity (e.g. Severe Acute Respiratory Syndrome (SARS) and Middle-East Respiratory Syndrome (MERS)). With world travel being a modern reality, disease spread can happen quickly requiring careful infection control practices. COVID-19 (aka 2019-nCoV) was first detected in Wuhan, China in December 2019 and has since been declared a pandemic by the WHO (see this link for further information).

The COVID-19 worldwide pandemic has overwhelmed healthcare systems in many countries and led to catastrophic loss of life. Many healthcare providers have been exposed and infected in the course of their work and protocols to protect providers have been rapidly evolving. Simulation is being used to test and improve systems in place for infection control, PPE, and management of exposure to COVID-19.

This simulation case tests the response to an unexpected cardiac arrest, and the ability of the staff to stay safe while caring for a critically ill patient. At the time of publishing, there is not a single consensus approach to code blue in the suspected or confirmed COVID-19 patient. However, in this case, we explore an approach that maximizes the protection of healthcare providers.

Clinical Vignette

A 50-year old woman presents to the emergency department with 1.5 hours of chest pain and left arm heaviness. She works at a long term care facility where she has been caring for COVID-19 positive patients. She has had two days of mild URTI symptoms. She looks moderately unwell and has been placed in a resuscitation room with droplet/contact precautions.

Case Summary

This 50-year old woman presents with typical cardiac chest pain and high suspicion for COVID-19. Her ECG shows an anterior STEMI. The team will start performing the initial work-up and management of a patient with STEMI. While this is occurring, the patient suffers a VF arrest. The team will need to go through the ACLS algorithm while taking all precautions required in caring for a patient with suspected COVID.

Download the case here: COVID STEMI and VF Arrest

ECG for the Case

Source: https://litfl.com/anterior-myocardial-infarction-ecg-library/

Pediatric Airway Obstruction

This case was written by Drs. Rob Woods and Gautam Sinha. Rob is an Associate Professor of Emergency Medicine at the University of Saskatchewan.  He works clinically in Adult & Pediatric EM, as well as doing Transport Medicine with STARS.  He is the FRCPC Residency Program Director as well as the Program Director for the Clinician Educator Diploma Program at the University of Saskatchewan.

Why It Matters

Acute airway obstruction is a time sensitive and anxiety inducing presentation. For most providers this is even more true with pediatric patients. When a patient presents to the emergency department with airway compromise, having a methodical and timely approach can be life saving. This case gives a chance to practice recognition and management of the upper airway obstruction.

Clinical Vignette

An 8-year-old boy (30kg) has been brought to the ED by ambulance. He was eating a sausage about 30 minutes earlier and choked.  He lost consciousness with the ambulance crew and they were unable to visualize or remove the foreign body.  He is peri-arrest on ED arrival with O2 saturations in the 40s. 

Case Summary

This case involves an 8 year-old boy with upper airway obstruction from sausage. When indirect treatment fails, removal with Magill forceps under direct visualization is required. The patient slowly recovers after removal of foreign body but will require admission for monitoring.

Download the case here: Pediatric Airway Obstruction

CXR for the case found here:

Picture1

(CXR sourced from authors of case)

 

COVID-19: Ambulatory Care

Last week’s case featured a critically ill patient with COVID-19. However, not all patients will present that sick, and not always to a tertiary care centre. In a follow-up case, this patient presents moderately unwell and is a good case to use in an ambulatory care setting such as an urgent care or clinic.

This case was written by Dr. Alex Chorley, a staff emergency physician at Hamilton Health Sciences in Hamilton, Ontario. The case is part of the ongoing in situ simulation project designed to discover and fix or mitigate latent safety threats in the Emergency Department. (To learn more about using in situ simulation for quality improvement, read our previous two-part blog post.)

Why It Matters

Outbreaks of novel respiratory illnesses occur with some regularity (e.g. Severe Acute Respiratory Syndrome (SARS) and Middle-East Respiratory Syndrome (MERS)). With world travel being a modern reality, disease spread can happen quickly requiring careful infection control practices. COVID-19 (aka 2019-nCoV) was first detected in Wuhan, China in December 2019 and has since been declared an outbreak by the WHO (see this link for further information).

This simulation case, designed for a moderately unwell patient presenting to an ambulatory clinic, provides a way to test and improve systems in place for infection control, PPE, and management of exposure to COVID-19 or any high risk communicable respiratory illness.

Clinical Vignette

A 38-year old male has returned from a business trip in Asia last week.  Over the last 48 hours, he has developed fever, rigors, myalgias as well as nausea, vomiting and upper respiratory symptoms.  He initially was trying to ride it out at home, but is feeling increasingly short of breath and fatigued. He has now presented to your ambulatory care clinic.

Case Summary

This case was designed during the January 2020 COVID-19 outbreak in order to assess and improve team preparedness for safely and effectively caring for a moderately ill coronavirus patient from triage through to EMS transfer out of an ambulatory care setting.

Download the case here: Ambulatory COVID-19

CXR for the case found here:

Courtesy of Dr Henry Knipe, Radiopaedia.org, rID: 31352

COVID-19: Respiratory Failure

We are interrupting our regular q2weeks cases with this bonus case for use in an in situ simulation setting for testing your emergency department’s response to acutely unwell patient’s with suspected COVID-19. This case was written by Drs. Alia Dharamsi, SooJin Yi and Kate Hayman who are academic staff emergency physicians in Toronto. This case has been used widely at a variety of community and academic EDs in the Greater Toronto Area to facilitate departmental preparedness.

Twitter – @alia_dh + @soojinder + @hayman_kate

Featured image used under creative commons licence by Pete Linforth via Pixabay.

Why It Matters

Outbreaks of novel respiratory illnesses occur with some regularity (e.g. Severe Acute Respiratory Syndrome (SARS) and Middle-East Respiratory Syndrome (MERS)). With world travel being a modern reality, disease spread can happen quickly requiring careful infection control practices. COVID-19 (aka 2019-nCoV) was first detected in Wuhan, China in December 2019 and has since been declared an outbreak by the WHO (see THIS link for further information).

This well developed simulation case provides a way to test and improve systems in place for infection control, PPE, and management of exposure to COVID-19 or any high risk communicable respiratory illness.

Clinical Vignette

A 35-year-old woman became febrile last night with coryza and woke up acutely short of breath with productive cough, rhinorrhea, and a subjective fever. She presents to triage where she screens positive for potential coronavirus exposure due to fever, respiratory symptoms and a high-risk travel history.

Case Summary

This case was designed during the January 2020 COVID-19 outbreak in order to assess and improve team preparedness for safely and effectively caring for a critically ill coronavirus patient from triage through to intubation.

Download the case here: COVID-19

Find the directions for the props here: Props for COVID-19

Video of the nasal secretion prop:

ECG for the case found here:

1600px-Sinustachycardia

(ECG Source: https://en.ecgpedia.org/wiki/Sinus_Tachycardia)

CXR for the case found here:

acute-respiratory-distress-syndrome-ards

(CXR Source: https://radiopaedia.org/cases/35985)

POCUS for the case found here:

ezgif.com-optimize

(POCUS Source: http://www.thepocusatlas.com/pulmonary)

Resuscitative Hysterotomy

This weeks’ case was written by Dr. Amy Hildreth who is an emergency physician and assistant program director for the EM residency at Naval Medical Centre in San Diego.

Why it Matters

Resuscitative hysterotomy is fortunately a rare procedure, however, as with other high impact, low occurrence procedures in emergency medicine, it can be life saving! Equally as important as the procedure itself are the crisis resource management (CRM) components involved in managing two critically ill patients; the mother and the baby.

This case was designed to highlight the management of a pregnant trauma patient, the procedure of resuscitative hysterotomy, and the CRM principles involved. It is not for the faint of heart!

Clinical Vignette

A 30 y/o female was found unresponsive in an SUV that rolled over after being side swiped on the highway going approximately 70 mph (~110kph). The patient has a large, gravid abdomen and, as she was wheeled into the resuscitation bay, the pulse was lost.

Case Summary

The team receives advance notification from EMS about a 30 year-old female who is visibly pregnant and was in a car accident. Upon arrival to the ED the patient loses pulses and CPR begins. The team must begin ACLS/ATLS and proceed to resuscitative hysterotomy. After delivery they should begin neonatal resuscitation and continue management of the mother.  Early consultation should be made to trauma surgery, NICU, and OB. 

Download the case here: Resuscitative Hysterotomy

Nightmares Case 8: Sepsis/Cholangitis

This is the eighth and final case in a series we will be publishing that make up “The Nightmares Course”.

The Nightmares Course at Queen’s University (Kingston, Ontario) was developed in 2011 by Drs. Dan Howes and Mike O’Connor. The course emerged organically in response to requests from first year residents wanting more training in the response to acutely unwell patients. In 2014, Dr. Tim Chaplin took over as the course director and has expanded the course to include first year residents from 14 programs and to provide both formative feedback and summative assessment. The course involves 4 sessions between August and November and a summative OSCE in December. Each session involves 4-5 residents and covers 3 simulated scenarios that are based on common calls to the floor. The course has been adapted for use at the University of Saskatchewan, the University of Manitoba, and the University of Calgary.

Why it Matters

The first few months of residency can be a stressful time with long nights on call and the adjustment to a new level of responsibility. While help should always be available, the first few minutes of managing a decompensating patient is something all junior residents must be competent at. This case series will help to accomplish that through simulation.

Clinical Vignette

You are covering an in-patient surgical floor. Its 2300 and you are called to assess a 47-year old man who has been admitted for cholecystitis and is currently awaiting a cholecystectomy. The nurse called because she is worried about new confusion and fever that has developed over the last 3 hours.

Case Summary

This case involves the approach to severe sepsis, more specifically acute cholangitis. If treated aggressively (IV fluids, early broad spectrum antibiotics and source control) the patient will stabilize. If not, the patient will deteriorate into a PEA arrest.

Download Here

Nightmares Sepsis

Media for the Case

No imaging or ultrasound required for this case. If they are asked for:
– X-rays will be normal
– Ultrasound unavailable overnight
– EKG shows sinus tach

Nightmares Case 7: Hyperkalemia

This is the seventh in a case series we will be publishing that make up “The Nightmares Course”.

The Nightmares Course at Queen’s University (Kingston, Ontario) was developed in 2011 by Drs. Dan Howes and Mike O’Connor. The course emerged organically in response to requests from first year residents wanting more training in the response to acutely unwell patients. In 2014, Dr. Tim Chaplin took over as the course director and has expanded the course to include first year residents from 14 programs and to provide both formative feedback and summative assessment. The course involves 4 sessions between August and November and a summative OSCE in December. Each session involves 4-5 residents and covers 3 simulated scenarios that are based on common calls to the floor. The course has been adapted for use at the University of Saskatchewan, the University of Manitoba, and the University of Calgary.

Why it Matters

The first few months of residency can be a stressful time with long nights on call and the adjustment to a new level of responsibility. While help should always be available, the first few minutes of managing a decompensating patient is something all junior residents must be competent at. This case series will help to accomplish that through simulation.

Clinical Vignette

You’ve been called to assess a 67M on the general medical floor. He was admitted 3 days ago for a community acquired pneumonia and is now awaiting discharge home once out-patient services can be put in place. He was noted to be hypokalemic on labs this morning (3.2 mEq/L) and the daytime resident ordered KCl 10mEq in 100cc NS bolus, to be given once. On her initial assessment, the overnight nurse found that he was actually placed on an infusion over the last 10 hours and the patient is now confused and bradycardic.

Case Summary

This case involves the diagnosis and management of hyperkalemia. If not treated appropriately the patient will progress to ventricular fibrillation arrest.

Download here

Nightmares Hyperkalemia

EKG for the Case

ECG-Hyperkalemia-junctional-bradycardia-potassium-8

ECG-Hyperkalemia-sine-wave-serum-potassium-9.9

Source for both ECGs: https://litfl.com/hyperkalaemia-ecg-library/

Nightmares Case 6: Ventricular Tachycardia

This is the sixth in a case series we will be publishing that make up “The Nightmares Course”.

The Nightmares Course at Queen’s University (Kingston, Ontario) was developed in 2011 by Drs. Dan Howes and Mike O’Connor. The course emerged organically in response to requests from first year residents wanting more training in the response to acutely unwell patients. In 2014, Dr. Tim Chaplin took over as the course director and has expanded the course to include first year residents from 14 programs and to provide both formative feedback and summative assessment. The course involves 4 sessions between August and November and a summative OSCE in December. Each session involves 4-5 residents and covers 3 simulated scenarios that are based on common calls to the floor. The course has been adapted for use at the University of Saskatchewan, the University of Manitoba, and the University of Calgary.

Why it Matters

The first few months of residency can be a stressful time with long nights on call and the adjustment to a new level of responsibility. While help should always be available, the first few minutes of managing a decompensating patient is something all junior residents must be competent at. This case series will help to accomplish that through simulation.

Clinical Vignette

You are called by the ward nurse to assess a 65-year old male with a new onset of a “rapid heart rate”. This patient was admitted early yesterday and is awaiting a coronary angiogram for an NSTEMI.

Case Summary

In this scenario, the learner is called to the ward to assess a 65-year old male with new VT. The learner must recognize the rhythm and institute appropriate work-up and management including electrical cardioversion.

Download here

Ventricular Tachycardia

EKG for the Case

Source: https://litfl.com/ventricular-tachycardia-monomorphic-ecg-library/

Nightmares Case 5: Pulmonary Edema

This is the fifth in a case series we will be publishing that make up “The Nightmares Course”.

The Nightmares Course at Queen’s University (Kingston, Ontario) was developed in 2011 by Drs. Dan Howes and Mike O’Connor. The course emerged organically in response to requests from first year residents wanting more training in the response to acutely unwell patients. In 2014, Dr. Tim Chaplin took over as the course director and has expanded the course to include first year residents from 14 programs and to provide both formative feedback and summative assessment. The course involves 4 sessions between August and November and a summative OSCE in December. Each session involves 4-5 residents and covers 3 simulated scenarios that are based on common calls to the floor. The course has been adapted for use at the University of Saskatchewan, the University of Manitoba, and the University of Calgary.

Why it Matters

The first few months of residency can be a stressful time with long nights on call and the adjustment to a new level of responsibility. While help should always be available, the first few minutes of managing a decompensating patient is something all junior residents must be competent at. This case series will help to accomplish that through simulation.

Clinical Vignette

A patient is seen by the emergency team, diagnosed with a hip fracture after he slipped and fell, and admitted by the orthopedics service. His medications have been held and he has been made NPO and started on maintenance fluids in anticipation of an operation tomorrow. He is boarding in the emergency department when he wakes up with shortness of breath and hypoxia secondary pulmonary edema.

Case Summary

This case involves the approach to the patient with acute dyspnea. The patient is tachypneic, hypoxic, and hypertensive. The team should consider multiple possibilities but recognize pulmonary edema as the most likely cause.

The team is expected to appropriately call for help while initiating management. The patient will respond to supplemental oxygen, nitrates, and non-invasive positive pressure ventilation after which the internal medicine team will be consulted.

Download here

Pulmonary Edema

Chest X-ray for the Case

Screen Shot 2019-12-10 at 11.19.40 AM.png

Reference = https://radiologyassistant.nl/chest/chest-x-ray-heart-failure

EKG for the Case

LBBB ECG.png

Reference = http://hqmeded-ecg.blogspot.com/2012/10/hyperkalemia-in-setting-of-left-bundle.html

Ultrasounds for the Case

Find it HERE.

Nightmares Case 4: Pulmonary Embolism

This is the fourth in a case series we will be publishing that make up “The Nightmares Course”.

The Nightmares Course at Queen’s University (Kingston, Ontario) was developed in 2011 by Drs. Dan Howes and Mike O’Connor. The course emerged organically in response to requests from first year residents wanting more training in the response to acutely unwell patients. In 2014, Dr. Tim Chaplin took over as the course director and has expanded the course to include first year residents from 14 programs and to provide both formative feedback and summative assessment. The course involves 4 sessions between August and November and a summative OSCE in December. Each session involves 4-5 residents and covers 3 simulated scenarios that are based on common calls to the floor. The course has been adapted for use at the University of Saskatchewan, the University of Manitoba, and the University of Calgary.

Why it Matters

The first few months of residency can be a stressful time with long nights on call and the adjustment to a new level of responsibility. While help should always be available, the first few minutes of managing a decompensating patient is something all junior residents must be competent at. This case series will help to accomplish that through simulation.

Clinical Vignette

It’s 1:00 AM and you’ve been called to assess a 69 year old woman admitted to the Gyne Oncology unit. She was recently diagnosed with ovarian cancer and is actively receiving chemotherapy. Her repeat CT showed decreased tumor burden and the plan is for surgery tomorrow. She was admitted pre-op to receive a blood transfusion for a Hb of 72. The transfusion ended 4 hours ago and was tolerated well. Approximately 30 min ago, the patient started developing shortness of breath and central chest discomfort.

Case Summary

This case involves the approach to the patient with acute dyspnea. The patient is tachypneic but with an otherwise normal respiratory exam. ECG shows new right heart strain. The team should consider multiple possibilities but recognize PE as the most likely cause.

The team is expected to appropriately call for help while initiating management. The patient will decompensate and arrest – thrombolytics should be discussed. After the patient achieves ROSC, the resident will provide handover to the code blue team.

Download here

Nightmare Care #4 – PE

Chest X-ray for the Case

Source: https://openpress.usask.ca/undergradimaging/chapter/pulmonary-thromboembolism/

EKG for the Case

Source: https://litfl.com/ecg-changes-in-pulmonary-embolism/