Non-Accidental Trauma

March 27, 2018March 26, 2018 / kcaners / Leave a comment

This case is written by Dr. Suzan Schneeweiss. She is a staff physician at Sick Kids Hospital in Toronto and is the Director of Education for the Division of Pediatric Emergency Medicine at the University of Toronto.

Why it Matters

The differential diagnosis for any sick neonate is always broad. This case, in particular, addresses the differential diagnosis and management of a seizing neonate. It highlights the following:

The need for anti-epileptics in a neonate with seizures in the context of trauma
The importance of including a septic work-up and broad antibiotic/antiviral coverage in the management of a seizing neonate
The need to consider non-accidental injury

Clinical Vignette

A 1 month-old male is brought into the ED due to poor feeding and lethargy. The baby was apparently well until this morning, when his mom noticed it was difficult to wake and feed him. There has been no fever. The baby vomited once this morning, and is voiding and stooling normally.

The nurse in triage notices abnormal movements and brings the baby in to your team in the resuscitation room.

Case Summary

The team has been called to help in the ED after a 1 month-old male is brought in seizing. The team is expected to manage the seizure, but then will subsequently realize on examination there are concerning signs for non-accidental trauma, specifically head injury. The team will be expected to establish definitive airway management and consult with PICU and local child protection services.

Download the case here: Non-Accidental Trauma

CXR for the case found here:

neonatal pneumonia

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

Pediatric Viral Myocarditis

March 13, 2018March 12, 2018 / kcaners / Leave a comment

This case is written by Dr. Adam Cheng. Adam Cheng, MD, FRCPC is Associate Professor, Departments of Paediatrics and Emergency Medicine at the Cumming School of Medicine, University of Calgary. He is also Scientist, Alberta Children’s Hospital Research Institute and Director, KidSIM-ASPIRE Simulation Research Program, Alberta Children’s Hospital. Adam is passionate about cardiac arrest, resuscitation, simulation-based education and debriefing. The case has been modified by Drs. Dawn Lim, Andrea Somers, and Nadia Farooki for use at the University of Toronto.

Why it Matters

Myocarditis is a presentation that can be challenging to recognize early. It is often mistaken simply for septic shock. This case highlights some important features of the recognition and management of myocarditis, including:

The need to re-evaluate the differential in a patient with persistent hypotension
The role of bedside tests in aiding the diagnosis (ECG, POCUS, CXR)
The importance of re-evaluating and re-assessing a patient and adjusting the differential diagnosis and management accordingly

Clinical Vignette

You are working in a large community ED. The charge nurse tells you: “EMS have just arrived with a 15-year old boy with shortness of breath and chest pain. His O2 sat is low. EMS have administered oxygen and IVF en route. He looks unwell so I put him in a resuscitation room. Can you see him immediately?”

Case Summary

A 15 year-old male with no prior medical history is brought to the ED by his parents for lethargy, shortness of breath and chest pain. He was feeling run down for the past 4 days with URTI symptoms.

His initial presentation looks like sepsis with a secondary bacterial pneumonia. He becomes hypoxic requiring intubation. He develops hypotension that does not respond as expected to fluids and vasopressors, which should prompt more diagnostics from the team.

Further testing reveals cardiomyopathy with reduced EF and acute CHF. He finally stabilizes with inotropes and diuresis.

Download the case here: Pediatric Viral Myocarditis

ECG for the case found here:

sinus-tachy-non-specific-ST-changes

(ECG source: https://lifeinthefastlane.com/ecg-library/myocarditis/)

CXR for the case found here:

cardiomegaly CHF

(CXR source: https://www.med-ed.virginia.edu/courses/rad/cxr/postquestions/posttest.html)

Cardiac U/S for the case found here:

Parasternal Long

(U/S source: http://www.thepocusatlas.com/echo/xg2awokhx1zx8q3ndwjju5cu4t1adq)

Lung U/S for the case found here:

B lines

(U/S source: https://www.thoracic.org/professionals/clinical-resources/critical-care/clinical-education/quick-hits/orthopnea-in-a-patient-with-doxorubicin-exposure.php)

Pediatric Difficult Airway

February 27, 2018February 25, 2018 / kcaners / Leave a comment

This case is written by Dr. Jonathan Pirie. He is a staff physician in the Division of Pediatric Emergency Medicine and Associate Professor at the University of Toronto. Dr. Pirie is also the Director of Simulation for Pediatric Emergency Medicine and the Simulation Fellowship program. His simulation interests include development of core curricula for postgraduate training programs, in-situ team training, and mastery learning with competency based simulation for trainees and faculty in pediatric technical skills and resuscitation.

Why it Matters

While croup makes stridor a relatively common presentation in the Pediatric ED, today it is quite rare to have a child with stridor who requires definitive airway management. It is exceedingly rare for an Emergency physician to need to proceed to cricothyroidotomy on a child. This case highlights the following:

The initial management steps for a child with undifferentiated, severe stridor
The need to call for help early
The steps required for a needle cricothyroidotomy and the equipment necessary to ventilate a child after this procedure is performed

Clinical Vignette

You are working in the ED, and your team has been called urgently to see a 2-year-old old boy with difficulty breathing. The patient was brought in by his mother, who states he’s had a 2-day history of runny nose. Today he developed a barking cough with fever, and is “breathing with a funny noise.”

Case Summary

The ED team is called to manage a 2-year-old boy in severe respiratory distress with stridor and hypoxia. Initial management steps (humidified O2, nebulized epinephrine and dexamethasone) fail to improve the patient’s respiratory status, and the team must prepare for a difficult intubation. They will encounter difficulties with both bagging and passing the endotracheal tube due to airway edema, which will necessitate an emergency needle cricothyroidotomy.

Download the case here: Pediatric Difficult Airway

Newborn Resuscitation

October 24, 2017October 21, 2017 / kcaners / Leave a comment

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

Approximately 10% of newborns require some degree of resuscitation upon delivery, with less than 1% requiring active resuscitation.¹ Given that deliveries in the ED are relatively rare, this means that performing NRP in the ED is quite uncommon. On the other hand, the ED team must be able to respond quickly and efficiently to a flat neonate. This means that practising NRP is paramount – and what better way to do so than with simulation! This case highlights three key pieces of NRP, including:

The need to warm, dry, and stimulate immediately
The quick progression to positive pressure ventilation if stimulation doesn’t work
When to initiate CPR, the necessary 3:1 compression:ventilation ratio, and how to place hands for performing CPR on a neonate

Clinical Vignette

You are working in the minor area of your ED and have been called by the physician on the major side to assist with a precipitous delivery. He is managing the mother and wants you to be ready to resuscitate the infant if needed. The mom thinks she’s term. She’s had no prenatal care and is an IV drug user. She used earlier today. There no meconium staining noted in the amniotic fluid. Baby has just been delivered and is handed to your team.

Case Summary

The team has been called to help in the ED where a woman just precipitously gave birth to a baby now requiring resuscitation. The mom thinks she’s at term. She has had no prenatal care and is an iv drug user. The baby will be flat. After stimulation and drying, the baby will have a HR <100 and PPV will be required. After 60 seconds, the HR will still be <60 and CPR will need to be started. This will be short lived. The team will also need to intubate and obtain IV access.

Download the case here: NRP Case

References

Barber CA, Wyckoff MH. Use and efficacy of endotracheal versus intravenous epinephrine during neonatal cardiopulmonary resuscitation in the delivery room. Pediatrics. 2006;118:1028–1034. doi: 10.1542/peds.2006-0416

Anaphylaxis (+/- Laryngospasm)

September 12, 2017June 27, 2017 / kcaners / Leave a comment

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

July 18, 2017June 21, 2017 / kcaners / Leave a comment

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

April 25, 2017April 24, 2017 / kcaners / Leave a comment

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

April 11, 2017April 10, 2017 / kcaners / 1 Comment

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 (33.1^oC). 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

February 28, 2017February 18, 2017 / kcaners / Leave a comment

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

January 31, 2017January 30, 2017 / kcaners / Leave a comment

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.