Geriatric Case 1: Delirium

This case is the first in a six-part mini-series focusing on the management of geriatric patients in the ED. This series of cases was written by Drs. Victoria Brazil, Nemat Alsaba, and Rebecca Shaw.

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). 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. 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.

Why it Matters

As our global patient population ages, it is increasingly important that emergency physicians have specialized knowledge in the care of elderly patients. This is particularly true when managing patients with baseline dementia or presenting to the ED with delirium. This case highlights specific challenges in these patients, including:

  • The need to recognize delirium as symptom of a large array of potential medical illnesses
  • The importance of a medical work-up in patients with delirium (including blood work, urine, and possible imaging)
  • The need for health care workers to have a toolbox of de-escalation techniques at their disposal

Clinical Vignette

Patient is sitting on the edge of the ED bed, looking perplexed. She/he is fidgeting and not concentrating on the questions being asked, she/he is staring around the room, looking in his/her bag and picking at the BP cuff and bed sheet. The ED nurse is attempting to do some baseline vital signs on the patient.

Participants asked by ED RN “Could you please go and assess this patient? She/he has just been brought in to the ED by ambulance after a friend found her/him confused at home”

Case Summary

An 81-year-old (wo)man is brought to the ED by her/his friend as she/he is confused and agitated. In the ED, her/his confusion worsens. Initially she/he is fidgety but as the case progresses she/he becomes more agitated and confused. She/he will be fairly uncooperative, moving around and not able to follow many commands. The participants should be looking for a source of infection and evidence of any recent trauma.  They are expected to use both non-pharmacological and safe pharmacological options in order to control the situation, ensure patient safety, and facilitate investigations.

Download the case here: Geri EM Delirium

Elderly Psychosis and Agitation

This case is written by Drs. Nicole Kester-Green and Jen Riley. Dr. Kester-Greene is a staff physician at Sunnybrook Health Sciences Centre in the Department of Emergency Services and an assistant professor in the Department of Medicine, Division of Emergency Medicine. She has completed a simulation educators training course at Harvard Centre for Medical Simulation and is currently Director of Emergency Medicine Simulation at Sunnybrook. Dr. Riley is a staff emergency physician at St. Michael’s Hospital and assistant professor at the University of Toronto.  Her areas of interest are in simulation and medical technology, with a focus on developing programs and curriculum for trainees and faculty both in medicine and allied health professions.

Why it Matters

Patients who present to the ED with agitation can be very challenging to manage. It is particularly difficult when the patient clearly lacks capacity and is unable to respond appropriately to any simple commands. In these situations, ensuring the safety of both the patient and staff members becomes the primary goal. This case highlights, specifically:

  • That chemical restraint should always be used if physical restraints are to be used
  • The challenges to assessing a patient who is clearly unwell when that patient is not cooperative
  • The role security plays in ensuring a safe patient care experience

A Note on Safety

Pre-briefing is always an important component of simulation. For this case, it is essential that the pre-briefing takes a little extra time so that the safety of everyone involved is reviewed. The case is designed so that physical restraints are only placed once the standardized patient is traded for a mannequin. Regardless, both the standardized patient and the sim participants should be briefed on the use of simulated restraint. It is essential that a safe word like “time out” is pre-determined in case any participants are feeling unsafe at any point in the case. This would immediately halt the case. Similarly, instructors must be watching closely for safety and cut the scenario if they feel anyone may be harmed. We advocate for having security participate in this case as learners. However, briefing security that they should not use the restraints on the standardized patient would also help ensure safety.

Clinical Vignette

The charge nurse comes to you: “There is a 68 year old woman in the seclusion room. She was observed pacing and acting bizarre at the bus stop. EMS managed to talk her into ambulance. On route she told them her neighbour is trying to poison her. Initially, she was calm but now she is starting to get agitated. She doesn’t have any previous psych admissions in the system. We couldn’t get any vital signs.

Case Summary

A 68-year old woman is found at a bus stop exhibiting bizarre behaviour. She is brought to the ED by paramedics. In the ED, she is expressing paranoid delusions. Her agitation escalates and does not respond to verbal de-escalation or an overwhelming show of force. She will require physical and chemical sedation to facilitate the work-up for her new onset psychosis.

Download the case here: Elderly psychosis and agitation

ECG for the case found here:

normal-sinus-rhythm

(ECG source: https://lifeinthefastlane.com/ecg-library/normal-sinus-rhythm/)

Multi-trauma (Kicked off a Horse)

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

Management of trauma patients with multiple intercurrent injuries can be challenging. This case provides an opportunity for junior learners to stretch themselves beyond their comfort zones. In particular, this case highlights the following:

  • The need for a systematic approach to the initial assessment and ongoing re-assessment of any complex trauma patient
  • The importance of prioritizing tasks and adjusting priorities as patient status changes
  • The complexity of managing a hypotensive, head-injured patient

Clinical Vignette

A 32-year-old female presents as a trauma activation with EMS after being bucked off of her horse. Her mom witnessed the episode and called EMS because she seemed groggy. She has had a low BP with EMS on route. Her current BP is 80/40.

Case Summary

A 32-year-old female presents after being bucked off of her horse. She is brought in as a trauma team activation because of a low BP. Her primary survey will reveal a boggy hematoma over her right temporal area as well as an unstable pelvis. Her initial GCS will be 8. The team will proceed through airway management in a hypotensive, head-injured trauma patient while also binding her pelvis. The patient eventually shows signs of brain herniation, which the team will need to manage prior to consultant arrival.

Download the case here: Pelvic Fracture and SDH

ECG for the case found here:

Sinus tachycardia

(ECG source: https://i0.wp.com/lifeinthefastlane.com/wp-content/uploads/2011/12/sinus-tachycardia.jpg)

Pre-intubation CXR for the case found here:

normal female CXR radiopedia

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

PXR for the case found here:

Pelvic fracture

(PXR source: https://littlemedic.files.wordpress.com/2013/01/pelvis_0_1.jpg)

Post-intubation CXR for the case found here:

normal-intubation2

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

Ultrasound showing free fluid in RUQ found here:

RUQ FF

Ultrasound showing normal lung sliding found here:

Ultrasound showing no pericardial effusion found here:

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

Status Epilepticus

This case is written by Dr. Donika Orlich. She is a PGY5 Emergency Medicine resident at McMaster University who also completed a fellowship in simulation and medical education last year.

Why it Matters

This case is an excellent review of the management of status epilepticus and includes 2nd, 3rd, and 4th line agents for treatment. This case also highlights a few unique practice challenges, including:

  • The hemodynamic effects of administering phenytoin too quickly
  • Disclosing medical error to families
  • Special agents to be considered in refractory seizure, such as magnesium sulfate, hypertonic saline, and pyridoxine

Clinical Vignette

A 38 year-old female is brought in by EMS with active seizure. She was last seen normal about 45 minutes ago by her husband, and has been witnessed seizing now for about 20 minutes. She is known to have epilepsy. EMS have 1 line in place, and 5mg IV midazolam was given en route.

Case Summary

A 38 year-old female presents actively seizing with EMS. She will fail to respond to repeat doses of IV benzodiazepines, and will require escalating medial management. Following phenytoin infusion, the patient will become hypotensive (because the phenytoin was given as a “push dose”, which the nurse will mention). The patient will then stop her GTC seizure, but will remain unresponsive with eye deviation. The team should recognize this as subclinical status, and proceed to intubate the patient.   The patient will continue to seize following phenobarbital and propofol infusion. Urgent consults to radiology and ICU should be made to expedite care out of the ED. The team will be expected to debrief the phenytoin medication error and disclose the error to the husband.

Download the case here: Status Epilepticus

ECG for the case found here:

normal-sinus-rhythm

(ECG source: http://i0.wp.com/lifeinthefastlane.com/wp-content/uploads/2011/12/normal-sinus-rhythm.jpg)

Post-intubation CXR for the case found here:

normal-intubation2

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

Altered LOC

This case was 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

It’s easy as a simulation case writer to get excited about complex cases with rare presentations. But it’s also important to remember to teach to the level of the resident. This case highlights some very important lessons for junior learners:

  • The importance of a broad differential diagnosis in the altered patient
  • How to prioritize and coordinate an extensive work-up for a relatively ill patient
  • Recognizing when an altered patient needs to be intubated

We take these skills for granted as experienced clinicians. But it’s amazing how many excellent teaching conversations come from running this very simple case.

Case Summary

An 82 year old man arrives to the ED by EMS with a GCS of 7. He smells of urine and feces, and apparently has not been seen in 4 days. He is hypotensive and tachycardic. With simple fluid resuscitation (1-2L), the BP will improve. Learners are to organize a broad diagnostic work-up and coverage with broad-spectrum antibiotics. They must also recognize the need to intubate. If they do not, the patient will vomit and have a resultant desaturation. The case ends after successful workup and intubation.

Clinical Vignette

You are working in a community ED. Mr. Alito Bizzaro is brought in by EMS into a resuscitation room with altered LOC. He is known to be reclusive, but always picks up his paper at 10am. His neighbours had not seen him pick up his paper in 4 days, and so they called. The patient was found on the floor in his apartment near the doorway to the bathroom. He is 82 years old and lives alone. His apartment was unkempt. The patient is covered in urine and feces.

Download the case here: aLOC Case

ECG for the case found here:

Sinus tachycardia

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

CXR for the case found here:

Post Intubation

Post Intubation

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

Subarachnoid Hemorrhage with Increased Intracranial Pressure

This case was written by Dr. Martin Kuuskne from McGill University. Dr. Kuuskne is a PGY4 Emergency Medicine resident and one of the editors-in-chief at EMSimCases.

Why it Matters

This case highlights three important aspects of the management of a subarachnoid hemorrhage:

  • Blood pressure control in an undifferentiated neurologic catastrophe
  • Safe approaches to intubating a patient with possible acute hydrocephalus
  • Management of a patient demonstrating signs of increased intracranial pressure

Clinical Vignette

You are working an evening shift at a tertiary care centre emergency department with full surgical capabilities. A patient is brought into the resuscitation area by ambulance with decreased mental status. The patient was at the gym lifting weights; he complained of an acute headache to his friend and suddenly fell to the ground. The patient remained unconscious with sonorous breathing. The ambulance was called.

Case Summary

A 45-year-old male who suffered an aneurysmal subarachnoid hemorrhage while weightlifting presents to the emergency department requiring intubation for airway protection and develops acute hydrocephalus requiring ICP lowering maneuvers before definitive surgical management.

Download the case here: SAH Case

ECG for case found here:

Deep cerebral t-wave inversions

(ECG source: http://cdn.lifeinthefastlane.com/wp-content/uploads/2011/12/SAH1.jpg)

CXR for case found here:

Post Intubation

Post Intubation CXR

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