Respiratory

Anaphylaxis (+/- Laryngospasm)

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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/)

Anaphylaxis with Angioedema

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This case is written by Dr. Ahmed Taher. He is an Emergency Medicine resident at the University of Toronto and a Masters of Public Health Student at Johns Hopkins University. He developed his appreciation and excitement for simulation while previously employed as a Primary Care Paramedic for York Region EMS.

Why it Matters

Anaphylaxis is a fairly common presentation to the ED. However, it is rare to see truly severe anaphylaxis. This case exposes learners to the most feared complication of anaphylaxis – angioedema requiring surgical airway management. In particular, it highlights:

  • The importance of initiating early treatment for anaphylaxis with epinephrine (and removing ongoing allergen exposure, if possible)
  • The need to intubate early in patients with signs of airway compromise not immediately responding to epinephrine
  • The fact that the “decision to cut” is crucial (and arguably the most challenging part of a surgical airway)
  • The steps required for a successful cricothyrotomy

Clinical Vignette

You are working a night shift at your local Emergency Department. You are called STAT to the bedside of a patient in the department who was seen by your colleague earlier and has recently been started on IV ceftriaxone for a pyelonephritis. You recall from handover that this is a 45-year-old previously healthy female patient with a diagnosis of a UTI two weeks ago, who returned after failing treatment and was diagnosed with pyelonephritis today. The nurse tells you she started the IV antibiotics and fluids 20 min ago, and then started to experience respiratory distress and a full body rash.

Case Summary

A 45-year-old patient who has already been seen in the ED begins treatment for pyelonephritis with IV antibiotics. Soon after initiated, she develops stridor and respiratory distress, as part of an anaphylactic reaction. The team is called into the room to assess the patient. After standard anaphylaxis treatment is given, the airway is still of concern. Intubation attempts are not successful and the patient will need a surgical airway.

Download the case here: Anaphylaxis with Angioedema

ECG for the case found here:

sinus-tachycardia

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

CXR for the case found here:

normal female CXR radiopedia

(CXR source: https://radiopaedia.org/cases/normal-chest-radiograph-female)

Newborn Sepsis with Apneas

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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)

Massive Pulmonary Embolism

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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

The management of massive pulmonary embolism is one that requires rapid action and decisive decision-making, often based on less information than one would like. This case highlights several key features of the management of a massive PE, including:

  • The importance of recognizing the signs of PE and using basic bedside investigations to aid in diagnosis when a patient is too unstable for confirmatory CT
  • The need to maintain quality ACLS care when a patient arrests, regardless of arrest etiology
  • The use of thrombolytics during cardiac arrest to treat a suspected pulmonary embolism

Clinical Vignette

A 46 year old male presents to the ED complaining of shortness of breath and pleuritic chest pain. He broke his ankle a week ago and has been in a cast since. He was just discharged home after operative repair 2 days ago.

Case Summary

A 46 year old male with a cast on his left leg from a bad ankle fracture presents to the ED complaining of pleuritic chest pain and shortness of breath. The team will take a history and start workup when the patient will suddenly state he’s “not feeling well” and then arrest. The team will perform ACLS consistent with the PEA algorithm and should consider IV thrombolytics. If IV thrombolytics are administered, the patient will have ROSC.

Download the case here: Pulmonary Embolism

ECG for the case found here:

ecg-massive-pte

(ECG source: http://cdn.lifeinthefastlane.com/wp-content/uploads/2011/12/ECG-Massive-PTE.jpg)

Post-intubation CXR for the case found here:

Post-Intubation

Post Intubation

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

Cardiac U/S showing right heart strain found here:

(U/S courtesy of the McMaster PoCUS Subspecialty Training Program)

Cardiac U/S showing cardiac standstill found here:

(U/S courtesy of the McMaster PoCUS Subspecialty Training Program)

Pancreatitis with ARDS

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This case is written by Dr. Kyla Caners. She is an 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

Pancreatitis is a common diagnosis made in the ED. However, severe pancreatitis with shock is relatively rare. As such, this case highlights several important points about the management of a hypotensive patient with abdominal pain:

  • The importance of maintaining a broad differential diagnosis and employing beside imaging in one’s assessment
  • The need for aggressive fluid resuscitation in an acutely hypotensive patient
  • The risk of ARDS with pancreatitis
  • The importance of developing a safe approach to the intubation of a patient who is simultaneously hypoxic and hypotensive

Clinical Vignette

Patricia is a 50 year old female who presents with epigastric abdominal pain. It’s been persistent for the last 24 hours and radiates through to her back. She has been nauseous all day and has been vomiting so much she “can’t keep anything down.” She was “on a bender” this weekend drinking beer and whiskey.

Case Summary

A 50 year-old female who was “on a bender” over the weekend now presents with diffuse abdominal pain and persistent nausea and vomiting. She will have a diffusely tender abdomen, a BP of 80/40, and be tachycardic. The team will need to work through a broad differential diagnosis and should fluid resuscitate aggressively. Once the patient has received 6L of fluid, she will become tachypneic and hypoxic and require intubation. The team will be given a lipase result just prior.

Download the case here: Pancreatitis with ARDS

ECG for the case found here:

Sinus tachycardia

(ECG source: http://cdn.lifeinthefastlane.com/wp-content/uploads/2011/12/sinus-tachycardia.jpg)

Initial CXR for the case found here:

normal female CXR radiopedia

(CXR source: http://radiopaedia.org/articles/normal-position-of-diaphragms-on-chest-radiography)

ARDS CXR for when patient is hypoxic found here:

Pre-intuabtion

(CXR source: http://www.radiology.vcu.edu/programs/residents/quiz/pulm_ cotw/PulmonConf/09-03-04/68yM%2008-03-04%20CXR.jpg)

Post-intubation CXR for the case found here:

Post intubation

(CXR source: http://courses.washington.edu/med620/images/mv_c3fig1.jpg)

FAST showing no free fluid found here:

no FF

U/S aorta showing no AAA found here:

no AAA

Pericardial U/S showing no effusion found here:

(All U/S images are courtesy of McMaster PoCUS Subspecialty Training Program)

Acute Chest Syndrome

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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)

Acute Respiratory Distress

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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

When the cause of acute respiratory distress is clear, its management can feel routine. However, as many senior physicians can attest, sometimes the cause is quite uncertain. It is important for junior learners to work through this differential because:

  • Acute respiratory distress is a relatively common patient presentation
  • Simultaneous initiation of investigations and treatment requires significant resource management skills
  • Delays to treatment in the critically ill patient can lead to poor outcomes

Clinical Vignette

You are on the Gynecology service and have been paged by the ward nurse to attend to a 78 year old woman who is having trouble breathing. She is POD #0 from a 4 hour TAH+BSO operation for ovarian CA. She just got to the ward about 1 hour ago. You enter the patient’s room she is hooked up to an IV with NS running at 150cc/hr.

Case Summary

A 78 year old woman post-op from a TAH+ BSO for ovarian CA has just been transferred to the ward when she develops acute shortness of breath. When the resident arrives, the patient is in significant respiratory distress saturating 80% on RA. Oxygen and medical therapy will not adequately relieve the patient’s distress. The resident will need to recognize that the patient has a Grade 3-4 LV and received 2L of fluid intra-operatively. When BiPAP is called for, it will be unavailable. Ultimately, the patient will require intubation.

Download the case here: Acute Respiratory Distress

ECG for case found here:

ECG lateral changes

(ECG source: https://thejarvik7.files.wordpress.com/2012/02/inferior-wall-stemi-2005-05-27-08.jpg)

CXR for case found here:

CHF CXR

(CXR source: https://www.med-ed.virginia.edu/courses/rad/cxr/pathology2chest.html)

Severe Asthma Exacerbation

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This week’s case is written by Dr. Andrew Hall. He is an Assistant Professor in the Department of Emergency Medicine at Queen’s University where he is a Simulation-based Resuscitation Rounds Instructor and runs the Simulation-based OSCE Assessment Program for EM residents. He’s also one of the advisory board members here at EMSimCases.

Why it Matters

Acute asthma exacerbations are extremely common. Most asthmatics improve quickly after basic treatment with beta-agonists, anticholinergics, and steroids. This case highlights the management of those patients who don’t respond to the basics, including the following important points:

  • Severe asthma requires immediate, continuous treatment
  • Adjuncts to treatment such as magnesium sulfate, iv epinephrine, and bipap may be required
  • Ventilation in a severe asthmatic is extremely challenging due to air trapping and the need for prolonged expiratory time

Clinical Vignette

(vignette delivered by ER RN) A patient has been brought in by EMS and triaged to a Resuscitation Room in the Emergency Department with shortness of breath. He has had an upper respiratory tract infection with cough for 4 days. He’s now been having increasing SOB and chest tightness for 12 hours. He may have had a fever yesterday. EMS was called by a housemate who found him struggling to breathe at home. He is no longer responding to ventolin (using 4 puffs q30 min) and has rapidly worsened over the last hour. EMS reported vitals are HR 140, RR 41, O2Sat 85% on 100% O2 with face mask.

Case Summary

22 y.o. male is brought by EMS to the emergency department with increasing SOB and chest tightness x12 hours with rapid deterioration over the last hour resulting from a severe asthma exacerbation. He will require multiple pharmaceutical treatments, rapid sequence intubation and proper ventilation.

Download the case here: Asthma Exacerbation

CXR for the case found here:

Hyperinflation CXR

(CXR source: http://www.mypacs.net/cases/ACUTE-SEVERE-ASTHMA-ON-31-YO-CXR-3547838.html)