Palliative Respiratory Case

This case is written by Dr. Alexandra Stefan. Dr. Stefan is an emergency medicine physician and the Postgraduate Site Director for Emergency Medicine at Sunnybrook Health Sciences Centre in Toronto. She is also an assistant professor in the Division of Emergency Medicine at the University of Toronto. Her areas of interest are postgraduate medical education, simulation (has completed the Harvard Centre for Medical Simulation training course) and global health  education (has participated in teaching trips with Toronto Addis Ababa Academic Collaboration).

Why it Matters

Emergency medicine training is often focused on the many interventions we can make when a patient arrives in distress. This case highlights that sometimes, one of the most important interventions is to determine a patient’s goals of care. It specifically highlights:

  • The importance of pain management as a part of end of life care
  • The need to speak clearly and without medical jargon to establish a patient’s wishes
  • That goals of care conversations often happen in the ED through a substitute decision maker, rather than with the patient directly.

Clinical Vignette

“A 72 year old man from home with acute shortness of breath has just been placed in the resuscitation room. He has a history of lung cancer and is on 2L home oxygen. His daughter Cindy called 911 because he has been getting worse since this morning. He just finished a course of antibiotics for presumed pneumonia. He is on hydromorph contin and prochlorperazine. No allergies. Here is his most recent oncology clinic note.”

Case Summary

A 72-year old male with small cell lung cancer and bony metastases presents with acute shortness of breath. Curative treatment has been stopped and palliative care assessment is pending. He is on home oxygen and has come to the ED as his symptoms could not be controlled at home.

The patient initially improves with oxygen and pain control. He is too confused to engage in discussion about advanced directives. No previous advanced directives or level of care have been documented but, Cindy, the patient’s daughter is available to act as decision maker. She will have a number of questions about her father’s care.

The patient’s respiratory status will deteriorate. Cindy will confirm her father’s wish for comfort measures, to be started by the treating team.

Download the case here: Palliative Resp Case

Download the clinic note required for the case here: Med Onc Note

ECG for the case found here:

ecg sob case

(ECG source: http://www.thecrashcart.org/case-2-post-partum-palpitations/)

CXR for the case found here:

pleural effusion

(CXR source: https://radiopaedia.org/cases/pleural-effusion-7)

Cardiac Ultrasound for the case found here:

 

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

Pediatric Difficult Airway

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

Intubation with Missing BVM

This case is written by Drs. Andrew Petrosoniak and Nicole Kester-Greene. Dr. Andrew Petrosoniak is an emergency physician and trauma team leader at St. Michael’s Hospital. He’s an assistant professor at the University of Toronto and an associate scientist at the Li Ka Shing Knowledge Institute.  Dr. Nicole Kester-Greene is a staff physician at Sunnybrook Health Sciences Centre in the Department of Emergency Services and an assistant professor in the Department of Medicine, Division of Emergency Medicine. She has completed a simulation educators training course at Harvard Centre for Medical Simulation and is currently Director of Emergency Medicine Simulation at Sunnybrook.

Why it Matters

Emergency medicine is about anticipating the worst and preparing for it . This case highlights this perfectly. In particular, it emphasizes:

  • The need to have a mental (or physical) checklist to ensure all necessary equipment is available at the bedside before starting a procedure
  • The complex nature of managing an immunocompromised patient with respiratory illness
  • The role for intubation in a hypoxic patient

Clinical Vignette

You are working in a large community ED. The triage nurse tells you that she has just put a patient in the resuscitation room. He is a 41-year old man with HIV. He is known to be non-compliant with his anti-retrovirals. He noticed progressive shortness of breath over 3-4 days and has had a dry cough for 10 days. His O2 sat was in the 80s at triage.

Case Summary

A 41-year old male with HIV (not on treatment) presents to the ED with a cough for 10 days, progressive dyspnea and fever. He is hypoxic at triage and brought immediately to the resuscitation room. He has transient improvement on oxygen but then has progressive worsening of his hypoxia and dyspnea. Intubation is required. The team needs to prepare for RSI and identify that the BVM is missing from the room prior to intubation.

Download the case here: Intubation with Missing BVM

CXR for the case found here:

PJP pneumonia

(CXR source: https://radiopaedia.org/cases/35823)

 

PE with Bleeding

This case is written by Dr. Donika Orlich. She is a staff physician practising in the Greater Toronto Area. She completed both her Emergency Medicine training and Clinician Educator Diploma at McMaster University.

Why it Matters

Many simulation cases that deal with pulmonary embolism seem to focus on the decision to administer thrombolytics (usually upon a patient’s arrest). This case is different. While the team must administer thrombolytics to a patient with known pulmonary embolism, the catch is that they must then also recognize shock as a result of intra-abdominal bleeding. As a result, the case highlights the following:

  • The dose of thrombolytics to be used in the context of cardiac arrest
  • The importance of an approach to undifferentiated shock after ROSC. (It’s not all cardiogenic!)
  • That bleeding is a complication of thrombolysis. This is drilled into our brains as the major complication, but somehow it is diagnostically challenging to recognize.

Clinical Vignette

You are called urgently to the bedside of a patient who is in the Emergency Department awaiting medicine consultation. Your colleague saw her earlier. She is 63 years old and has a CT-confirmed pulmonary embolism. She had presented with shortness of breath on exertion in the context of a recent hysterectomy 4 weeks ago. She has been stable in the ED until she got up to go to the bathroom and suddenly developed severe shortness of breath.

Case Summary

A 63-year-old female is in the Emergency Department awaiting internal medicine consultation for a diagnosed pulmonary embolism. She suddenly becomes very short of breath while walking to the bathroom and the team is called to assess. The patent will then arrest, necessitating thrombolysis. After ROSC, she will stabilize briefly but then develop increasing vasopressor requirements. The team will need to work through the shock differential diagnosis and recognize free fluid in the abdomen as a complication of thrombolysis requiring surgical consultation and transfusion.

Download the case here: PE with Bleeding

ECG for the case found here:

Massive PE ECG

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

Initial CXR for the case found here:

normal female CXR radiopedia

(CXR source: https://radiopaedia.org/cases/normal-chest-radiograph-female-1)

Post-intubation CXR for the case found here:

normal-intubation2

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

Pericardial ultrasound for the case found here:

Normal lung ultrasound for the case found here:

Abdominal free fluid ultrasound for the case found here:

RUQ FF

(All ultrasound images are courtesy of McMaster PoCUS Subspecialty Training Program.)

Anaphylaxis (+/- Laryngospasm)

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

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

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

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

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

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)