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.
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.
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.
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.
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.
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.
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.
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.
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.
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.