A 62-year-old man presents to the ED with palpitations and general malaise. On initial assessment, the team finds out he had an LVAD placed within the last 1 month. The team will need to work through how to assess the patient’s vital signs appropriately and will discover the patient has a low MAP and a low-grade fever. On inspection, the patient’s drive line site will appear infected. The initial ECG will show features of hyperkalemia. After the initial assessment, the patient will progress to a PEA arrest requiring resuscitation by ACLS protocols. Labs will reveal an acute kidney injury and hyperkalemia. The patient will obtain ROSC when the hyperkalemia is treated.

Pregnant Cardiomyopathy

A 38-year-old female G2P1 at 36 weeks GA presents with acute on chronic respiratory distress in addition to chronic peripheral edema. She undergoes respiratory fatigue and hypoxia requiring intubation. She then becomes hypotensive which the team discovers is secondary to cardiogenic shock, requiring vasopressor infusion and consultation with Cardiology/ ICU.

Pediatric SVT

The team has been called to the ED after a 12-month old is brought in with a rapid heart rate. The team will realize the patient is in a stable SVT rhythm, with no response to either vagal maneuvers or adenosine. The patient will then progress to having an unstable SVT. If the SVT is defibrillated (i.e. – shocked without synchronization), the patient will progress to VT arrest. If the SVT is cardioverted, the patient will clinically improve.

Learner-Consultant Communication

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.

Electrical Storm

A 55 year-old male is brought to the emergency department with absent vital signs. He collapsed at his office after complaining of feeling unwell. CPR was started by a colleague and continued by EMS. He received 3 shocks by an AED. His downtime is approximately 10 minutes. The team is expected to perform routine ACLS care. When the patient remains in VF despite ACLS management, the team will need to consider specific therapies, such as iv beta blockade or dual sequential shock, in order to abort the electrical storm.

Chest Pain on the Ward

The case will begin with a phone call from the bedside nurse for a patient on the ward that the resident on call is covering. The resident will then arrive at the bedside to find a patient complaining of significant chest pain. The patient will be in some respiratory distress due to CHF. The patient’s initial ECG will show new T-wave inversion. The patient will prompt regarding ongoing chest pain and his ECG will evolve to show an anterolateral STEMI. The team is expected to recognize the evolving STEMI and initiate treatment and cath lab activation.

Stable VT with ICD Firing

A 40-year-old male presents to the ED complaining that his ICD keeps firing. He will have a HR of 180 and VT on the monitor. He will occasionally yell “ow.” The team will need to work through medical management of VT, while considering magnet placement for patient comfort. The patient will remain stable but will trigger VT with his agitation.

STEMI with Cardiogenic Shock

A 55-year-old man presents to the ED as a STEMI call. He is profoundly hypotensive with low O2 sats and obvious CHF. The patient’s blood pressure will transiently respond to fluid resuscitation. The ECG will show anterolateral ST elevation. The team will need to prepare for intubation while activating the cath lab. They will also need to start vasopressors. The patient will remain hypotensive until an inotrope like dobutamine is initiated. If unsafe medications are chosen for intubation, the patient will have a VT arrest.

Aortic Stenosis with A Fib and CHF

A 78-year-old male presents with increased SOB over the past 4 days. A recent ECHO will be presented showing severe AS. The ECG will demonstrate new A Fib with a HR of 150 and the CXR will show CHF. The patient will be normotensive at first but will become hypotensive shortly after. The team will then need to decide whether to cardiovert the patient or attempt rate control. If these are done safely, the patient will respond and then develop worsening CHF. Definitive management should be sought with early cardiology/cardiac surgery consult. If management is not carried out judiciously, the patient will become profoundly hypotensive.