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: 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:

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

CXR for the case found here:

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

POCUS for the case found here:

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(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 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 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

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

EKG for the Case

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

Ultrasounds for the Case

Find it HERE.

Nightmares Case 3: Seizure

This is the third 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 is 01:00 and you are on call covering the thoracic surgery service. You have been called to assess Mr. Wright for a seizure episode.

Case Summary

The resident is called to the ward to manage a patient who may have had a seizure. The patient is somnolent when the resident arrives. Shortly afterward, the patient seizes again. Two doses of anti-epileptic will be required to terminate the seizure. Finally, when the patient has been stabilized, the resident will be required to discuss the case with their staff on call.

Download here

Seizure

Nightmares Case 1: Bradycardia

This is the first 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

The triage note states – Patient “fainted” while returning from the bathroom at home. He was found to be slightly more confused by his wife and complained of right elbow pain.

Case Summary

This is a case of an elderly patient with syncope. He is found to be in third degree heart block.  The team is expected to perform an initial assessment and obtain an ECG. Upon recognizing the heart block, they should ensure IV access and place pacer pads while calling for help.

Download the case here:

Bradycardia

ECG for the case found here:

Brady.jpg

Source: https://www.ecgquest.net/ecg/complete-heart-block-3/

Geriatric Case 5: Trauma with Head Injury

This case is the fifth in a six-part mini-series focusing on the management of geriatric patients in the ED. This series of cases was written by Drs. Rebecca Shaw, Nemat Alsaba, and Victoria Brazil.

Dr. Rebecca Shaw is an emergency physician currently working as a medical education fellow within the Emergency Department of the Gold Coast Hospital and Health Service in Queensland, Australia. Dr. Nemat Alsaba (@talk2nemat) is an emergency physician with a special interest in geriatric emergency medicine, medical education and simulation. She is trying her best to combine these interests to improve geriatric patient care across all health sectors. She is also an assistant professor in medical education and simulation at Bond university. Dr. Victoria Brazil is an emergency physician and medical educator. She is Professor of Emergency Medicine and Director of Simulation at the Gold Coast Health Service, and at Bond University medical program. Victoria’s main interests are in connecting education with patient care – through healthcare simulation, technology enabled learning, faculty development activities, and talking at conferences. Victoria is an enthusiast in the social media and #FOAMed world (@SocraticEM), and she is co-producer of Simulcast (Simulationpodcast.com).

Why It Matters

Elderly patients who have sustained trauma are frequently encountered in the ED. These patients have unique physiology and are often complex due to frailty and polypharmacy concerns. Care of the elderly trauma patient requires attention to these complexities, to goals of care, and to communication with family members. This case gives the opportunity to learn and enhance these skills.

Clinical Vignette

The bedside nurse informs you that “EMS just off-loaded an elderly male to the resuscitation bay. He had a fall down the stairs and sustained a head injury. He was GCS 15 and hemodynamically stable when they picked him up, so they didn’t activate the trauma team, but he has deteriorated during transport. He has an obvious large, boggy scalp hematoma over the left parietal region. I am worried because he’s getting restless and won’t follow commands.”

Case Summary

An 81-year old man falls down the stairs at home. He is initially asymptomatic but his level of consciousness declines and he starts to show signs of raised ICP. Providers must recognize and treat this, as well as reverse his anticoagulation, provide neuroprotective RSI and safely transport to the CT scanner. Providers must then talk with the patient’s wife, to provide information on his condition and prognosis and discuss the patient’s goals of care.

Download the case here:

Geriatric Trauma with Head Injury

ECG for the case found here:

Geriatric Trauma ECG

ECG Source: https://en.ecgpedia.org/index.php?title=Atrial_Fibrillation

CXR for the case found here:

Geriatric Trauma CXR

Image courtesy of Dr Jeremy Jones, Radiopaedia.org, rID: 6410

Pelvic XR for the case found here:

Geriatric Trauma Pelvic XR

Image courtesy of Dr Jeremy Jones, Radiopaedia.org, rID: 28928

Learner-Consultant Communication

This case was written by Dr. Jared Baylis. Jared is currently a PGY-4 in emergency medicine at UBC (Interior Site – Kelowna, BC) and is completing a simulation fellowship in Vancouver, BC.

Twitter – @baylis_jared + @KelownaEM

Why It Matters

Referral-consultant interactions occur with regularity in the emergency department. These interactions are critically important to safe and effective patient care. Several frameworks have been developed for teaching learners how to communicate during a consultation including the 5C, PIQUED, and CONSULT models. This case allows simulation educators to incorporate whichever consultation framework they prefer into a simulation scenario that allows deliberate practice of the consultation process.

Clinical Vignette

You are a junior resident working in a tertiary care centre and you are asked to see a 58-year-old female patient who was sent in from the cancer centre. She is known to have metastatic non-small-cell lung cancer and has been increasingly dyspneic with postural pre-syncope over the last few days. Her history is significant for a previous malignant pericardial effusion that was drained therapeutically a few months ago.

Case Summary

In this case, learners will be expected to recognize that this 58-year-old female patient with metastatic non-small-cell lung cancer has tamponade physiology secondary to a malignant pericardial effusion. The patient will stabilize somewhat with a gentle fluid bolus but the learners will be expected to urgently consult cardiology or cardiac/thoracic surgery (depending on the centre) for a pericardiocentesis and/or pericardial window.

Download the case here: Learner-Consultant Communication

Checklists for 5C, PIQUED, and CONSULT frameworks: Consult Framework Checklists

FOAMed article on 5C framework: 5C CanadiEM

FOAMed article on PIQUED framework: PIQUED CanadiEM

ECG for the case found here:

ECG

(ECG Source: https://lifeinthefastlane.com/ecg-library/basics/low-qrs-voltage/)

CXR for the case found here:

CXR

(CXR Source: https://radiopaedia.org)

POCUS for the case found here:

 

(Ultrasound Source: https://www.youtube.com/watch?v=qAlU8qhC1cU)