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.

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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.

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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.

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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.

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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/

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.

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Seizure

Nightmares Case 2: Pneumonia

This is the second 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

Mr. Jim Smith is a 64 year old male that was admitted 3 days ago. He was diagnosed with a community acquired pneumonia and started on daily Moxifloxacin. The nurse is concerned about his increasing shortness of breath since she started the night shift 4 hours ago.

Case Summary

In this case, the patient has been admitted for pneumonia and treated with the usual antibiotics. However, the team has not yet recognized that the causative bacteria is resistant to this antibiotic. The pneumonia has progressed and the team must manage the patient’s respiratory distress and sepsis. The patient requires a change in antibiotics, non-invasive ventilatory support and IV fluid resuscitation.

Download the Case Here

Nightmares Course #2: Pneumonia

EKG for the Case

Pulmonary disease pattern COPD ECG
EKG: https://litfl.com/ecg-in-chronic-obstructive-pulmonary-disease/

Chest X-ray for the Case

Chest X-ray: https://radiopaedia.org/cases/right-upper-lobe-pneumonia-8

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 6: Elder Abuse

This is the sixth and final case 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

Elder abuse and neglect is under-recognized, under-reported and under-treated. The emergency department provides an opportunity to identify and intervene in cases of elder abuse. Often, the signs of abuse may be subtle. This case gives participants the chance to improving their skill in identifying elder abuse and to practice their approach to this emotionally challenging issue.

Clinical Vignette

A bedside RN comes to you and says, “Nora has been brought into ED after a fall at home 3 days ago. She is a bit tachycardic and complaining of some pain in her abdomen. She has a few bruises on the rest of her body. Could you please assess her?”

Case Summary

An 80-year old woman presents after a fall at home. She is complaining of right sided upper abdominal pain since the fall. She is also complaining of intermittent palpitations and dizziness prior to the fall. Participants are expected to identify that the cause of the fall is due to elder abuse and to manage this along with her concurrent medical issues and abdominal injury.

Key to a Successful Simulation

This case uses a standardized patient who has an extensive script and back story. This patient needs to be familiar with the story and respond in character to the participants questions and empathy (or lack of empathy). There should be a slow unfolding of the story as the participants gain the patient’s trust.

Download the case here:

ECG for the case:

ECG Source: Dr Ed Burns, LITFL.com

Chest x-ray for the case:

Pelvis x-ray for the case:

RUQ ultrasound for the case:

U/S source: McMaster PoCUS Subspecialty Training Program

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

Geriatric Case 4: End of Life Care

This case is the fourth 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 requiring resuscitation are frequently encountered in the ED. When patients are non-communicative, close family members are regularly required to act as substitute decision makers and represent their family member’s wishes. Engaging and communicating effectively with SDMs in end-of-life and goals-of-care discussions is necessary to provide the most appropriate care for the elderly patient. This case gives the opportunity to learn and enhance these skills.

Clinical Vignette

The charge nurse informs you “I just put a very unwell looking patient into resus. She’s from a nursing home facility and the paramedics think she is septic. She’s hypotensive and barely responsive. Honestly, she looks like she might be dying. Her granddaughter is on her way. I don’t think she has a known advanced care directive or code status.”

Case Summary

An 89-year-old patient is brought in to the ED by ambulance from their nursing home. Staff found her unresponsive and hypotensive at morning handover. She had been treated for UTI by her family physician over the last few days. Participants identify severe sepsis and realize that critical care interventions may be inappropriate. This should prompt a goals of care discussion including potential for initiating end-of-life care.

Download the case here:

ECG for the case found here:

ECG source: https://litfl.com/hyperkalaemia-ecg-library/

CXR for the case found here:

CXR source: https://emrems.com/2013/01/30/how-to-you-tell-its-a-right-middle-lobe-infiltrate/