The learners receive a call from a peripheral hospital about transferring an unwell 8-year-old girl with new DKA. She has been incorrectly managed, receiving a 20cc/kg bolus for initial hypotension as well as an insulin bolus of 8 units (adult sliding scale dose for glucose of >20). The learner must perform a telephone consultation and dictate new orders. On arrival, EMS will state that they lost the IV en route, and the patient will become more somnolent in the ED. The learner should begin empiric treatment for likely cerebral edema and concurrently manage the DKA. Physical exam will show a peritonitic abdomen with guarding in the RLQ. Empiric Abx should be started for likely appendicitis. Due to decreasing neurologic status and vomiting, the patient will eventually require an advanced airway. The challenge is to optimize the peri-intubation course and ventilation to allow for compensation of her metabolic acidosis.
Category: Endocrine
Adrenal Crisis
A 46-year-old female presents to the ED complaining of fatigue, anorexia, and weight loss over the last two weeks. She had the “stomach flu” a couple weeks ago and thought she was getting over it. But now she feels very weak and seems to be vomiting again. On presentation, the patient will have mild hypothermia, hypoglycemia, and hypotension. The team will have to initiate fluid resuscitation and an initial workup. The patient’s blood pressure won’t respond to 4 L of IV fluids, forcing the residents to work through the differential diagnosis of shock. Eventually, they will receive critical VBG results that indicate a mild metabolic acidosis, hyperkalemia, and hyponatremia. The team will need to treat the hyperkalemia and initiate hydrocortisone therapy.
Thyroid Storm
A 31 year-old-female presents by EMS with altered LOC and fever due to thyroid storm precipitated by recent parturition. The patient is tachycardic and hypoxic on arrival. Her level of consciousness will continue to deteriorate despite IV fluids and antibiotics and will require intubation. The husband will be at the bedside, and the team will need to discuss the need for intubation with him. After intubation, lab results will come back indicating possible thyrotoxicosis. The patient's rhythm will change to atrial fibrillation at this time. The team will be expected to manage the thyroid storm in consultation with Endocrinology and ICU.
Tumour Lysis Syndrome
A 72-year-old male is brought in as a “code STEMI” to the resuscitation bay. He was recently diagnosed with ALL and had chemotherapy 3 days ago for the first time. The patient is severely hyperkalemic, which must be initially recognized and treated, hypocalcemic and hyperuricemic as a result of Tumour Lysis Syndrome and the metabolic derangements must be stabilized until emergent hemodialysis is arranged.
Hypothermia with Trauma
30 year-old female is brought into the ED at 4 AM by a man who found her lying at the side of the road with no coat or shoes. It is minus 30 degrees Celsius outside. On arrival she has a reduced LOC, laboured breathing, a right-sided pneumothorax, cyanotic extremities, a left radius & ulna fracture, and a right tib-fib fracture. The team is required to use both active and passive rewarming strategies. Regardless of the team’s efforts, the patient in this case will arrest. Upon ROSC, they are required to continue rewarming as well as to address the other traumatic injuries.
Hyponatremic Seizure
A 93 year old woman comes in with family. They are concerned about general weakness, worsening PO intake over the last few months, and new confusion. As the team takes a history and starts the initial workup, the patient will begin to seize. She will seize continuously until hypertonic saline or a paralytic is given. After two doses of benzodiazepine, a critical result showing severe hyponatremia will come back. The team is expected to administer hypertonic saline, which will stop the seizure. The patient will remain somnolent after this dosing, and as the team prepares to intubate, she will seize again, requiring a repeated dose of hypertonic saline.
DKA
An 8 year old girl who has been tired and “unwell” for several days presents to the ED with an acute decline in her mental status. She is confused and lethargic. It becomes quickly apparent that the child is in DKA and requires immediate treatment. Due to decreasing neurologic status and vomiting, she eventually requires an advanced airway. The challenge is to optimize the peri-intubation course and to appropriately ventilate to allow for compensation of her metabolic acidosis.
CAH with adrenal crisis
A lethargic 1 week old presents from home after recurrent emesis and progressive sleepiness. He is hypovolemic, hypothermic, and hypoglycemic. If his hypoglycemia is not quickly corrected, he begins to seize and will continue to do so until the team gives glucose. If they do not, the patient will go on to have a VF arrest. If the team identifies and treats the hypoglycemia, orders blood work, and fluid resuscitates the child, they receive blood results demonstrating hyperkalemia and hyponatremia. If they correctly identify and treat the patient as a possible adrenal crisis, the neonate is safely transferred to the PICU. If they fail to treat the hyperkalemia or fail to administer steroids, the patient will have a VF arrest.
EM Sim Cases 