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
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”.
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.
ECG for the case found here:
(ECG source: http://www.omjournal.org/IssueText.aspx?issId=380)
Initial CXR for the case found here:
(CXR source: http://www.adhb.govt.nz/newborn/TeachingResources/Radiology/CXR/HLHS/CXR-HLHS-congested.jpg)
Post-intubation CXR for the case found here:
(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.
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
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.”
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.
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
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.
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.
CXR for the case found here:
(CXR source: http://reference.medscape.com/features/slideshow/sickle-cell#8)
Post-intubation CXR for the case found here:
(CXR source: http://www.swjpcc.com/critical-care/?currentPage=4)
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!
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.
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:
(CXR source: https://emcow.files.wordpress.com/2012/11/normal-intubation2.jpg)
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
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.
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.
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
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.
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:
(ECG source: http://lifeinthefastlane.com/ecg-library/basics/hyperkalaemia/)