GSW Vascular Injury

Adult male with penetrating extremity and chest trauma (gun shot wounds) with peripheral vascular compromise. The patient needs a thorough and systematic approach despite distracting injuries. For both junior and senior learners, the patient progresses from threatened limb (requiring emergent investigation) to a pulseless limb (requiring emergent OR). For senior learners, there will be an additional element of instability from the penetrating chest injury requiring chest tube.

Critical Care 1 – Subarachnoid Hemorrhage

This is the first case in a series looking at critical care medicine. Patients under the care of the critical care team may develop delayed complications of their illness or injuries. This patient with a spontaneous subarachnoid hemorrhage develops progressive hydrocephalus with need for hyperosmotic therapy and airway management.

Bronchiolitis

Four days ago, an older sibling who recently started pre-school had a cold. The next day, Zarah fell sick. She has had a runny nose and cough but seemed to be doing fine until yesterday when she did not eat or drink very much. This morning, she had some noisy breathing, and her chest looked funny while she was breathing. When it did not go away after a couple of hours, Zarah’s parents called 811 for advice. They were directed to go to the emergency department. The patient will progress through escalating respiratory support and eventually require intubation and transfer to higher level of care.

Ending a resuscitation

The medical aspect of this case is a relatively straight-forward out-of-hospital cardiac arrest where the team must recognize futility and make the decision to stop resuscitation efforts. The primary goal is simulating the experience of making a termination of resuscitation decision, and managing the impacts of a patient’s death. Other goals could also be scaffolded onto this scenario as deemed appropriate by the simulation instructor, including breaking bad news to family member or a simulated hot debrief with the team. 

Accidental Hypothermia

A 24-year-old previously healthy male presents to the ED with absent vital signs. He is out for a trail run when he becomes trapped in waist deep cold water. When he is found by search and rescue, he is awake with altered mental status. He has a cardiac arrest on retrieval and is found to be severely hypothermic. CPR and ACLS is initiated and he is transferred to the nearest community ED. The resuscitation team is expected to perform ACLS specific to hypothermic arrest. The patient will require intubation, active rewarming, defibrillation and discussion with the ECMO physician on call for transport and ECMO assisted rewarming.  

Tracheostomy Emergency

48-year-old male with a recent tracheostomy presents with sudden onset respiratory distress. The patient is unable to be oxygenated or ventilated through the tracheostomy tube. The team must recognize that the tracheostomy tube is either obstructed or displaced. Attempts to correct tracheostomy obstruction with suctioning and cuff deflation are not successful. Removal of the tracheostomy tube is required, followed by either oral intubation or placement of a new tracheostomy tube. The patient improves once oral or stomal intubation is performed. If tracheostomy tube is not removed, the patient worsens and goes into cardiac arrest secondary to respiratory failure.