This is the fourth case in a series looking at critical care medicine. A 59-year old man in your ICU was just extubated 30 minutes ago. He is four days post blunt polytrauma and has ongoing agitation but no other requirement for intubation. Since extubation, he has required several sedatives and has now developed stridor at rest.
Category: Respiratory
Organophosphate Poisoning
A 60-year old farmer presents to the ED with a runny nose, vomiting and diarrhea. He feels short of breath and dizzy. He looks so unwell that he is placed into the resuscitation bay. Initial vital sign show tachypnea, hypoxia, and bradycardia. You are immediately concerned about the copious nasal and oral secretions.
LVAD Pump Thrombosis
A 70 y/o male post LVAD implantation presents to the emergency department with a chief complaint of shortness of the breath. The team will need to progress through the initial assessment of an LVAD patient, ultimately leading to a diagnosis of pump thrombosis. They will initiate anticoagulation, consult cardiothoracic surgery, and admit to CTICU.
Asthma in Pregnancy
A third trimester patient presents with a severe asthma exacerbation that deteriorates and requires BiPAP/ICU admission. The learner will need to identify severe asthma and manage accordingly accounting for differences in physiology during pregnancy.
Pediatric Drowning
A three-year-old child was swimming with their family, when they wandered into the deep end and submerged under water. The parents noticed the child was below the surface. When the child was brought to the surface, they were unconscious and coughing up foam. EHS arrived, provided oxygen supplementation, and brought them to your tertiary emergency department, with access to PICU. In the ED, the child is unconscious with increasing respiratory distress, requiring intubation. Despite intubation, the child remains hypoxemic and the team works through an approach to post-intubation hypoxemia. Unfortunately, the child becomes bradycardic. The team should begin CPR and follow the PALS pediatric bradycardia algorithm. PICU should be called if not already involved. After one round of CPR, the patient’s heart rate will increase and the consulting team should arrive.
Critical Care 2 – Myasthenic Crisis
This is the second case in a series looking at critical care medicine. A 57-year-old female with history of thymoma and myasthenia gravis is currently admitted to a general medical ward for pneumonia develops respiratory distress 48 hours after admission. A respiratory therapist (RT) was paged to assess the patient and then called you urgently because the patient appears unwell.
Massive Hemoptysis
This is a case of a breathless 57-year-old male coming into a community emergency department with symptoms consistent with COPD exacerbation. During his ED stay, however, the patient will develop massive hemoptysis with airway compromise, requiring learners to secure the airway, reverse anticoagulation, and manage massive hemoptysis.
Bronchiolitis
Four days ago, an older sibling who recently started pre-school had a cold. The next day, Zarah fell sick. She has had a runny nose and cough but seemed to be doing fine until yesterday when she did not eat or drink very much. This morning, she had some noisy breathing, and her chest looked funny while she was breathing. When it did not go away after a couple of hours, Zarah’s parents called 811 for advice. They were directed to go to the emergency department. The patient will progress through escalating respiratory support and eventually require intubation and transfer to higher level of care.
Tracheostomy Emergency
48-year-old male with a recent tracheostomy presents with sudden onset respiratory distress. The patient is unable to be oxygenated or ventilated through the tracheostomy tube. The team must recognize that the tracheostomy tube is either obstructed or displaced. Attempts to correct tracheostomy obstruction with suctioning and cuff deflation are not successful. Removal of the tracheostomy tube is required, followed by either oral intubation or placement of a new tracheostomy tube. The patient improves once oral or stomal intubation is performed. If tracheostomy tube is not removed, the patient worsens and goes into cardiac arrest secondary to respiratory failure.
Airway Obstruction from FB
This case involves a 60-year-old male patient who arrives VSA in PEA after collapsing while eating dinner with family. The collateral history included that he was suspected to be intoxicated. The patient is difficult to bag with EMS. The learner will have to work through the can’t ventilate/can’t oxygenate scenario once they identify that BVM is ineffective.
EM Sim Cases 