Anaphylaxis (+/- Laryngospasm)

This case is written by Dr. Donika Orlich. She is a staff physician practising in the Greater Toronto Area. She completed her Emergency Medicine training at McMaster University and also completed a fellowship in Simulation and Medical Education.

Why it Matters

Anaphylaxis is a fairly frequent presentation to the ED. However, severe anaphylaxis requiring multiple epinephrine doses and airway management is quite rare. This case is challenging on its own merit simply due to the stress of intubating an impending airway obstruction. However, if learners are faced with laryngospasm as a complication of anaphylaxis, this case takes on even more important lessons, including:

  • The surprising and unexpected nature of laryngospasm
  • The role of Larson’s point in trying to resolve laryngospasm
  • How quickly children desaturate, and develop resultant bradycardia, as a consequence of laryngospasm

For an excellent review of the management of laryngospasm, click here.

Clinical Vignette

A 7-year-old boy arrives via EMS with increased work of breathing. He has a known allergy to peanuts and developed symptoms after eating birthday cake at a party. He has been given 0.15mg IM epinephrine 10 minutes ago by his mother. Current vital are: HR 140, BP 85/60, RR 40, O2 98% on NRB. He has some ongoing wheeze noted by EMS.

Case Summary

A 7-year-old male presents with wheeze, rash and increased WOB after eating a birthday cake. He has a known allergy to peanuts. The team must initiate usual anaphylaxis treatment including salbutamol for bronchospasm. The patient will then develop worsened hypotension, requiring the start of an epinephrine infusion. After this the patient will experience increased angioedema, prompting the team to consider intubation. If no paralytic is used for intubation (or if intubation is delayed), the patient will experience laryngospasm. The team will be unable to bag-mask ventilate the patient until they ask for either deeper sedation or a paralytic. If a paralytic is used, the team will be able to successfully intubate the child.

Download the case here: Anaphylaxis

Initial CXR for the case found here:

normal pediatric CXR

(CXR source: http://radiology-information.blogspot.ca/2015/04/normal-chest-x-ray.html)

Post-intubation CXR for the case found here:

Normal Pediatric Post-Intubation CXR

(CXR source: http://jetem.org/ettcxr/)

Pediatric DKA

This case is written by Dr. Donika Orlich. She is an Emergency physician practising in the Greater Toronto Area. She completed her Emergency Medicine training at McMaster University and also obtained a fellowship in simulation and medical education during her training.

Why it Matters

DKA is a reasonably common presentation to the ED. However, it requires several important steps in its management in order to prevent harm. This is especially true in children, where the rates of cerebral edema are higher. This case highlights several important features in the management of Pediatric DKA, including:

  • That there is no role for an insulin bolus.
  • That the precipitant of DKA must always be considered (in this case, it is appendicitis)
  • That cerebral edema is a known complication of DKA and must be managed immediately with a reduction in the insulin and fluid rates as well as with either mannitol or hypertonic saline

We have previously published a case of Pediatric DKA on emsimcases. Today’s case is unique in that it begins with the learners providing advice over the phone to a physician who is less comfortable managing DKA.  We have chosen to publish on this topic a second time as a way to emphasizes how cases on the same topic can be designed with different objectives in mind. The objectives (and therefore the case design) can lead to very different learning experiences. We have no doubt that this new case will also lead to excellent debriefing and evidence review with learners – it certainly does when we run it for our senior residents at McMaster University!

Case Summary

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.

Clinical Vignette

Outside Patch: We have an 8-year-old female we want to send for DKA. She presented after feeling generally “unwell” for 3 days, with some accompanying abdominal pain and vomiting. Her blood glucose came back at 24 with a pH of 7.15 and HCO3 of 12, so we made the diagnosis of DKA. She received a 20mL/kg bolus for hypotension (BP 90/60) and Humulin R 8 unit bolus (as per our hospital sliding scale). What do you want for insulin and fluids before we send her?

Download the case here: Pediatric DKA

Post-intubation CXR for the case found here:

normal-intubation2

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

Breech Delivery + NRP

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

All deliveries in the Emergency Department are considered high risk. Further, in most departments, both delivery and neonatal resuscitation are rare events. However, Emergency physicians must be prepared to manage all presentations – including breech delivery! This case highlights several important components of managing these rare presentations, including:

  • The need to adequately prepare the room (if time permits)
  • The importance of calling for a second physician to be available to manage the neonate upon delivery
  • How to safely perform a breech delivery
  • The step-wise progression of neonatal resuscitation post-delivery

Clinical Vignette

EMS Patch: “We have a 19 F complaining of severe abdominal pain onset 1 hour ago. She denies being pregnant, but looks almost full term to us. Contractions seem to be about 1 minute apart. Patient’s Vitals as follows: HR 120, BP 140/85, RR 20, O2 100% on RA. ETA 2 minutes.”

Case Summary

A 19-year-old female presents with EMS in active labour. She denies any history of pregnancy and has had no prenatal care. On examination, infant will be in breech position. The learner must deliver the infant from breech presentation. Following this, the neonate will will present lifeless, and require resuscitation.

Download the case here: Breech + NRP

 

Newborn Sepsis with Apneas

This case is written by Dr. Rob Woods. He works in both the adult and pediatric emergency departments in Saskatoon and has been working in New Zealand for the past year. He is the founder and director of the FRCP EM residency program in Saskatchewan.

Why it Matters

This case highlights important manifestations of sepsis in a neonate. In particular, it reinforces that:

  • Apneas, hypoglycemia, and hypothermia are commonly seen as a result of systemic illness in neonates
  • Prolonged or persistent apneas with associated desaturations require management with either high-flow oxygen or intubation
  • Fluid resuscitation and broad-spectrum antibiotics are important early considerations when managing toxic neonates

Clinical Vignette

To be stated by the Paramedic with the Resus Nurse at bedside: “We picked up this term 3-day old male infant at their GPs office. Mom reports poor feeding for the past 12 hours, and two episodes of vomiting. They took him to the GPs office this morning and they found the temperature to be quite low at 33.1°C. They called us concerned about sepsis. We were only 5 minutes away so we have not obtained IV access. We did obtain a glucose level of 2.7. The child is lethargic and has very poor perfusion – peripheral cap refill is 7 seconds. We don’t have a cuff to get an accurate BP but the HR is 190.”

Case Summary

A 3-day-old term male infant is brought to the ED by EMS after being seen at their Family Physician’s office with a low temperature (33.1oC). The child has been feeding poorly for about 12 hours, and has vomited twice. He is lethargic on examination and poorly perfused with intermittent apneas lasting ~ 20 seconds. He requires immediate fluid resuscitation and broad-spectrum antibiotics. His perfusion will improve after IVF boluses, however the apneas will persist and necessitate intubation.

Download the case here: Newborn Sepsis with Apneas

Initial CXR for the case found here:

Normal neonatal CXR

(CXR source: http://emedicine.medscape.com/article/414608-overview)

Post-intubation CXR for the case found here:

Post-intubation CXR neonate

(CXR source: https://radiopaedia.org/articles/neonatal-pneumonia)

Pediatric Septic Shock

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

Children with true septic shock are, thankfully, a rare presentation in the ED. However, recognition of early shock is an essential skill. This case highlights several important features of managing the critically ill child, including:

  • The need for early vascular access (whether that be intravenous or intraosseous, it must be obtained expediently)
  • The importance of monitoring for and treating resultant hypoglycemia
  • The need for early antibiotics

Clinical Vignette

A 4-year-old girl presents to your pediatric ED. Her mother states she is “not herself” and seems “lethargic.” She’s had a fever and a cough for the last three days. Today she just seems different. She was brought straight into a resus room and the charge nurse came to find you to tell you the child looks unwell.

Case Summary

A 4 year-old girl is brought to the ED because she is “not herself.” She has had 3 days of fever and cough and is previously healthy. She looks toxic on arrival with delayed capillary refill, a glazed stare, tachypnea and tachycardia. The team will be unable to obtain IV access and will need to insert an IO. Once they have access, they will need to resuscitate by pushing fluids. If they do not, the patient’s BP will drop. If a cap sugar is not checked, the patient will seize. The patient will remain listless after fluid resuscitation and will require intubation.

Download the case here: Pediatric Septic Shock

ECG for the case found here:

sinus-tachycardia

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

CXR for the case found here:

pediatric-pneumonia

(CXR source: http://radiopaedia.org/articles/round-pneumonia-1)

Coarctation of the Aorta

This case is written by Drs. Quang Ngo and Donika Orlich. Dr. Ngo is an attending emergency physician at McMaster Children’s Hospital and also serves as the Associate Program Director for the Department of Pediatrics. He is also a member of the advisory board here at EMSimCases. Dr. Orlich is a PGY5 Emergency Medicine resident at McMaster University who also completed a fellowship in Simulation and Medical Education last year.

Why it Matters

Having an approach to the toxic neonate is essential. More importantly, emergency physicians must be able to recognize subtle historical clues and physical exam features that point toward congenital heart disease in order to begin critical treatment rapidly. This case highlights the following:

  • The presentation of neonates with congenital heart disease including features like difficulty feeding, CHF, and tachypnea without increased work of breathing
  • The clinical features that may be present in a coarctation of the aorta, one specific type of congenital heart disease, and the resultant need to include four-limb BP’s as part of the work-up of toxic-appearing neonates
  • The importance of beginning a prostaglandin infusion in patients with suspected ductal-dependent congenital heart disease
  • One of the most common side effects of a prostaglandin infusion – apnea

Clinical Vignette

Your triage nurse comes to tell you about an infant she just put in the resuscitation room who she feels looks quite unwell. He is a 2 week old neonate brought to the ED by his mother. Mom was worried because he hasn’t been feeding very well and seems to just get sleepy when feeding. Now he just vomited his last feed and seems really lethargic. She thinks he just “doesn’t look the right colour”.

Case Summary

A 2-week-old neonate presents in shock requiring the learner to implement an initial broad work-up. The patient will also be hypoglycemic, and will seize if this is not promptly recognized. Physical exam and CXR findings will suggest coarctation of the aorta as the likely cause, and the learner should recognize the need for gentle fluid boluses and a prostaglandin infusion. Unless learners anticipate appropriately and intubate the patient prior to beginning the prostaglandins, the infant will become apneic after starting the infusion and require intubation.

Download the case here: Coarctation of the Aorta Case

ECG for the case found here:

coarc-ecg

(ECG source: http://www.omjournal.org/IssueText.aspx?issId=380)

Initial CXR for the case found here:

chf-neonate

(CXR source: http://www.adhb.govt.nz/newborn/TeachingResources/Radiology/CXR/HLHS/CXR-HLHS-congested.jpg)

Post-intubation CXR for the case found here:

chf-neonate-post-intubation

(CXR source: http://www.adhb.govt.nz/newborn/TeachingResources/Radiology/CXR/OtherCHF/NonstructuralCHF.jpg)

For more information on the management of Congenital Heart Disease Emergencies, see the excellent review by Emergency Medicine Cases found here.

Postpartum Hemorrhage and NRP

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

Deliveries in the Emergency Department are, by definition, high risk deliveries. However, they are relatively rare. This case highlights some of the “worst case scenarios” that one may face after a delivery in the ED. In particular, it showcases:

  • The key first steps required for NRP in the 60 seconds after delivery
  • The later stages of NRP, including CPR and intubation
  • The approach to a patient with postpartum hemorrhage, including transfusion, fundal massage, administration of uterotonics, and a search for retained products

Clinical Vignette

EMS Patch: “We have a 26 year-old female who is 38 weeks pregnant and appears to be in active labor. She is complaining of severe abdominal pain and has had some vaginal bleeding. We don’t see any crowing yet, but the patient feels the baby’s head is about to come out. Patient’s Vitals as follows: HR 120, BP 140/85, RR 20, O2 100% on room air. ETA 2 minutes.”

Case Summary

The team receives advanced notification from EMS about a woman who is imminently delivering. Upon arrival, delivery will be uncomplicated, but the neonate will appear lifeless. Neonatal resuscitation should be initiated. Eight minutes into the neonatal resuscitation, the team leader will be notified that the mother continues to hemorrhage and is becoming hypotensive. They must begin concurrent workup and management of the mother while continuing to run the neonatal resuscitation. Second & third line medical therapies for uterine atony will be needed, and also manual uterine exploration and packing. Early consultation should be made to NICU, ICU, OB, and Interventional Radiology.

Download the case here: PPH and NRP Combined Case

Acute Chest Syndrome

This case is written by Dr. Carla Angelski. She has completed both a PEM fellowship at Dalhousie and a MEd in Health Sciences Education. She now works in the Pediatric Emergency Department at the Royal University Hospital in Saskatchewan and is intimately involved in the delivery of high-fidelity simulation at the their sim centre. She is currently working on a curriculum to deliver in-situ simulation for ongoing faculty CME within the division and department.

Why it Matters

Patients with sickle cell disease are subject to a host of crises that can be difficult to manage. This case highlights the unique management of acute chest syndrome. In particular:

  • Recognition of acute chest syndrome as a possibility in the sickle cell patient with respiratory distress
  • Judicious use of fluids in patients with possible acute chest syndrome
  • The possible need for exchange transfusion in patients with severe acute chest syndrome

Clinical Vignette

You are working the day shift at a tertiary children’s hospital. A mother brings in her son, James, a four-year old boy with known sickle cell disease (HbSS). She is concerned since he’s had low energy and a cough for two days. Now he’s had a fever since this afternoon.

Case Summary

A 4-year-old boy with known sick cell disease presents with two days of cough and a one afternoon of fever. The patient is initially saturating at 88%, looks unwell and is in moderate-severe distress. During the case, the patient’s oxygenation with drop and the emergency team is expected to provide airway support. They will also need to pick appropriate induction agents for intubation. The case will end with ICU admission. During the case, the mother will also be challenging/questioning the team until a team member is delegated to help keep the mother calm.

Download the case here: Acute Chest Syndrome

CXR for the case found here:

sickle cell CXR

(CXR source: http://reference.medscape.com/features/slideshow/sickle-cell#8)

Post-intubation CXR for the case found here:

Post-intubation R-sided infiltrate

(CXR source: http://www.swjpcc.com/critical-care/?currentPage=4)

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)

Procedural Sedation with Laryngospasm

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

Why it Matters

Laryngospasm is a rare complication of procedural sedation (typically with ketamine). Patients desaturate quickly and require immediate, life-saving interventions. It is important for physicians to practice and be familiar with this management. This case highlights:

  • The surprising and unexpected nature of laryngospasm
  • How rapidly a patient deteriorates
  • That it is critical to know interventions beyond BVM

Clinical Vignette

A 7-year-old boy has a fracture through the distal radius and ulna that requires reduction. The emergency physician treating him has just asked you to come provide procedural sedation for the reduction.

Case Summary

The emergency team is preparing to perform a conscious sedation on a 7-year-old boy to facilitate the reduction of a fracture of the radius and ulna. They will be expected to do an airway assessment and pick an appropriate agent for sedation. In the middle of sedation, the patient’s oxygen saturation will suddenly drop and the patient will stop breathing. The team will be unable to bag the patient until they ask for either deeper sedation or a paralytic. If they administer succinylcholine, the patient will become bradycardic and require atropine.

Download the case here: Procedural Sedation with Laryngospasm