Adrenal Crisis

This case is written by Dr. Kyla Caners. She is a staff emergency physician in Hamilton, Ontario and the Simulation Director of McMaster University’s FRCP-EM program. She is also one of the Editors-in-Chief here at EmSimCases.

Why it Matters

While adrenal crisis is a relatively rare presentation, shock is not. This case highlights several important points, including:

  • The importance of having an approach to fluid non-responsive shock
  • How difficult it can be to shift cognitive frames and resist diagnostic anchoring
  • The electrolyte abnormalities associated with adrenal crisis (hyponatremia, hyperkalemia, and hypoglycemia)
  • The need to treat an adrenal crisis with corticosteroids

Clinical Vignette

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. Her blood pressure is 80/40, so she was triaged straight to the resuscitation bay.

Case Summary

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.

Download the case here: Adrenal Crisis Case

ECG for the case found here:

peaked-t-waves

(ECG source: http://lifeinthefastlane.com/ecg-library/basics/hyperkalaemia/)

CXR for the case found here:

normal female CXR radiopedia

(CXR source: https://radiopaedia.org/cases/normal-chest-radiograph-female-1)

Pericardial U/S for the case found here:

(U/S courtesy of the McMaster PoCUS Subspecialty Training Program)

FAST image for the case found here:

no FF

(U/S courtesy of the McMaster PoCUS Subspecialty Training Program)

Thyroid Storm

This case is written by Dr. Cheryl ffrench, a staff Emergency Physician at the Health Sciences Centre in Winnipeg. She is the Associate Program Director and the Director of Simulation for the University of Manitoba’s FRCP-EM residency program; she is also on the Advisory Board of emsimcases.com.

Why it Matters

Thyrotoxicosis is a rare presentation to the ED that can masquerade as many other conditions. This case nicely reviews the following:

  • The importance of maintaining a broad differential diagnosis in any patient who presents with an altered level of consciousness and a fever
  • The nuances associated with managing atrial fibrillation in the context of thyrotoxicosis
  • The multiple medications required in order to treat thyroid storm

Clinical Vignette

You are working the evening shift at a tertiary care hospital. A 31-year-old female two weeks postpartum is brought in by EMS accompanied by her husband. He is concerned because she is delirious and somewhat difficult to rouse.

Case Summary

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.

Download the case here: Thyroid Storm Case

Sinus tachycardia ECG for the case found here:

Sinus tachycardia

(ECG source: http://lifeinthefastlane.com/ecg-library/hyperthyroidism/)

Atrial fibrillation ECG for the case found here:

rapid-a-fib

(ECG source: http://lifeinthefastlane.com/ecg-library/atrial-fibrillation/)

CHF CXR for the case found here:

severe-chf

(CXR source: http://www.radiologyassistant.nl/en/p4c132f36513d4/chest-x-ray-heart-failure.html)

Tumour Lysis Syndrome

This case is written by Dr. Donika Orlich; a PGY5 Emergency Medicine resident at McMaster University who completed a fellowship in Simulation and Medical Education last year.

Why it Matters

Tumor Lysis Syndrome is a constellation of metabolic disturbances that can occur as a potentially fatal complication of treating cancers, most notably leukemias or solid rapidly-proliferating tumours. This case highlights the following:

  • The identification and management of severe hyperkalemia
  • The need to consider Tumour Lysis Syndrome as a diagnosis and order appropriate metabolic tests
  • Recognizing and initiating the treatment of severe hyperuricemia
  • Communicating with family members effectively during the treatment of a critically ill patient.

Clinical Vignette

A 72-year-old male presents to the emergency department complaining of general weakness for 2 days.  His wife called EMS and he was a STEMI patch to your hospital. He has been placed in the resuscitation bay.

Case Summary

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.

Download the case here: Tumour Lysis Syndrome

ECGs for the case found here:

ecg90406-hyperkalaemia-pr-lengthens

(Source:  http://lifeinthefastlane.com/ecg-library/basics/hyperkalaemia/)

normal-sinus-rhythm

(Source:  http://cdn.lifeinthefastlane.com/wp-content/uploads/2011/12/normal-sinus-rhythm.jpg)

CXR for the case found here:

CXR

Hypothermia with Trauma

This case is written by Dr. Stephen Miller. He is an emergency physician in Halifax. He is also the former medical director of EM Simulation and the current director of the Skilled Clinician Program for UGME at Dalhousie University. He developed his interest in simulation while obtaining his Masters of Health Professions Education.

Why it Matters

Moderate to severe hypothermia can be quite challenging to correct. This case highlights several important features of hypothermia management:

  • The importance of searching for concurrent illness that may be causing the hypothermia or working against rewarming efforts
  • The effect of hypothermia on trauma management
  • Modifications to ACLS as required during hypothermic resuscitation
  • The multitude of ways in which one can attempt to actively re-warm a patient

Clinical Vignette

An approximately 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. It is minus 30 degrees Celsius outside and she has no coat or shoes. The man does not know her and is unable to provide any additional history except that she was blue and having trouble breathing when he found her. She is noted to have a decreased LOC and laboured breathing. She has obvious deformities of her left forearm and right leg.

Case Summary

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.

Download the case here: Hypothermia

CXR for the case found here:

PTX R with rib fractures

(CXR source: http://radiopaedia.org/cases/pneumothorax-due-to-rib-fractures-1)

ECG for the case found here:

hypothermia-shiver-artefact

(ECG source: : http://cdn.lifeinthefastlane.com/wp-content/uploads/2011/03/hypothermia-shiver-artefact.jpg)

Right lung U/S found here:

Left lung U/S found here:

RUQ FAST image found here:

RUQ FF

Pericardial U/S found here:

(All U/S images are courtesy of McMaster PoCUS Subspecialty Training Program.)

Hyponatremic Seizure

This case is written by Dr. Kyla Caners. She is a PGY5 Emergency Medicine resident at McMaster University and is also one of the Editors-in-Chief here at EMSimCases.

Why it Matters

This case allows educators to review the approach to a common condition while also pushing learners to think outside conventional treatments. In particular, it demonstrates:

  • The importance of a broad differential diagnosis in the elderly patient with weakness
  • The typical management pathway for a patient with status epilepticus
  • The treatment of symptomatic hyponatremia and the urgency with which it must be given.

Clinical Vignette

Agnes Jones is a 93 year old female who has been brought to the ED by her daughter. The family has noticed that Agnes is not eating well over the last few months. She seems weak. Now, over the last day or so, she seems confused.

Case Summary

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.

Download the case here: Hyponatremic Seizure

ECG for case found here:

normal-sinus-rhythm

(ECG source: http://cdn.lifeinthefastlane.com/wp-content/uploads/2011/12/normal-sinus-rhythm.jpg)

Pre-intubation CXR for the case found here:

normal-female-chest

(CXR source: http://radiologypics.com/2013/01/25/normal-female-chest-radiograph/)

Post-intubation CXR for the case found here:

Normal Post-Intubation CXR

(CXR source: https://emcow.files.wordpress.com/2012/11/normal-intubation2.jpg)

DKA

This case is written by Dr. Lindsey McMurray. She is a PGY4 Emergency Medicine resident from the University of Toronto who is currently doing a Resuscitation and Reanimation fellowship at Queen’s University.

Why it Matters

DKA is a physiologically complex disorder. Thanks to excellent research and protocolization of care, certain components of DKA care have been clearly delineated. However, in the profoundly unwell DKA, it can be harder to account for complex physiology. This case highlights a few important management pearls:

  • The importance of re-assessing glucose in an altered patient with DKA on an insulin infusion
  • The consideration of cerebral edema in a DKA patient who becomes altered
  • The importance of expertly managing acidosis in the peri-intubation period by considering pre and post intubation respiratory rate

Our reviewers had quite the debate about what is considered optimal peri-intubation management in this patient. This case serves as an excellent starting point for a high-level discussion about the intubation of a severely acidotic patient. In particular:

  • Pre-intubation bicarbonate is relatively contraindicated in Peds DKA. Balancing the increased acidosis peri-intubation against the increased risk of cerebral edema is challenging.
  • A second IV fluid bolus pre-intubation is also controversial. Would it increase the risk of cerebral edema?
  • Is intubation with or without a paralytic the best choice? Using a paralytic optimizes time to intubation and first pass success, as well as minimizing aspiration risk. But it also eliminates the patient’s respiratory drive, which could potentially worsen acidosis and precipitate arrest. Not using a paralytic runs the risk of increased time to intubation and a resultant desaturation. It also adds an aspiration risk.

For this, and so many other reasons, this case will trigger plenty of discussion during debriefing!

Clinical Vignette

You have been called to the resuscitation bay to assess an 8 year old girl who has been brought in by her mother for lethargy and confusion. She has been unwell for 3 days with excessive fatigue, a few episodes of vomiting, and mild abdominal pain.

Case Summary

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.

Download the case here: DKA Case

CXR for case found here:

Normal Post-Intubation CXR

(CXR source: https://emcow.files.wordpress.com/2012/11/normal-intubation2.jpg)

CAH with adrenal crisis

This case is written by Dr. Quang Ngo from McMaster University. Dr. Ngo is a pediatric emergency physician in Hamilton, ON and one of the advisory board members at EMSimCases.

Why it Matters

This cases highlights three crucial management steps for a toxic neonate:

  • Maintaining a broad differential diagnosis (including hypoglycemia, sepsis, metabolic/cardiac conditions)
  • Consideration of hypoglycemia as a cause or consequence of a toxic neonate
  • Treatment of hypoglycemia in a neonate

This case also reviews management specific to congenital adrenal hyperplasia:

  • Recognition of laboratory abnormalities associated with adrenal crisis and initiation of steroid treatment

Clinical Vignette

A 1 week old neonate is brought to the emergency department because his parents are worried that he’s been vomiting and not keeping his feeds down. After he vomited his last feed, his parents noted he was quite lethargic and felt cold. His mom states he’s been increasingly sleepy since discharge and she’s been needing to wake him to feed. In between feeding, he sleeps and doesn’t “act like my other 2 kids did at that age.” The team is called to assess this patient urgently after being triaged because the nurse felt the patient looked unwell.

Case Summary

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.

Download the case here: CAH Case

ECG for case found here:

Hyperkalemia peaked T waves

(ECG source: http://lifeinthefastlane.com/ecg-library/basics/hyperkalaemia/)