Nightmares Case 4: Pulmonary Embolism

This is the fourth in a case series we will be publishing that make up “The Nightmares Course”.

The Nightmares Course at Queen’s University (Kingston, Ontario) was developed in 2011 by Drs. Dan Howes and Mike O’Connor. The course emerged organically in response to requests from first year residents wanting more training in the response to acutely unwell patients. In 2014, Dr. Tim Chaplin took over as the course director and has expanded the course to include first year residents from 14 programs and to provide both formative feedback and summative assessment. The course involves 4 sessions between August and November and a summative OSCE in December. Each session involves 4-5 residents and covers 3 simulated scenarios that are based on common calls to the floor. The course has been adapted for use at the University of Saskatchewan, the University of Manitoba, and the University of Calgary.

Why it Matters

The first few months of residency can be a stressful time with long nights on call and the adjustment to a new level of responsibility. While help should always be available, the first few minutes of managing a decompensating patient is something all junior residents must be competent at. This case series will help to accomplish that through simulation.

Clinical Vignette

It’s 1:00 AM and you’ve been called to assess a 69 year old woman admitted to the Gyne Oncology unit. She was recently diagnosed with ovarian cancer and is actively receiving chemotherapy. Her repeat CT showed decreased tumor burden and the plan is for surgery tomorrow. She was admitted pre-op to receive a blood transfusion for a Hb of 72. The transfusion ended 4 hours ago and was tolerated well. Approximately 30 min ago, the patient started developing shortness of breath and central chest discomfort.

Case Summary

This case involves the approach to the patient with acute dyspnea. The patient is tachypneic but with an otherwise normal respiratory exam. ECG shows new right heart strain. The team should consider multiple possibilities but recognize PE as the most likely cause.

The team is expected to appropriately call for help while initiating management. The patient will decompensate and arrest – thrombolytics should be discussed. After the patient achieves ROSC, the resident will provide handover to the code blue team.

Download here

Nightmare Care #4 – PE

Chest X-ray for the Case

Source: https://openpress.usask.ca/undergradimaging/chapter/pulmonary-thromboembolism/

EKG for the Case

Source: https://litfl.com/ecg-changes-in-pulmonary-embolism/

Nightmares Case 1: Bradycardia

This is the first in a case series we will be publishing that make up “The Nightmares Course”.

The Nightmares Course at Queen’s University (Kingston, Ontario) was developed in 2011 by Drs. Dan Howes and Mike O’Connor. The course emerged organically in response to requests from first year residents wanting more training in the response to acutely unwell patients. In 2014, Dr. Tim Chaplin took over as the course director and has expanded the course to include first year residents from 14 programs and to provide both formative feedback and summative assessment. The course involves 4 sessions between August and November and a summative OSCE in December. Each session involves 4-5 residents and covers 3 simulated scenarios that are based on common calls to the floor. The course has been adapted for use at the University of Saskatchewan, the University of Manitoba, and the University of Calgary.

Why It Matters

The first few months of residency can be a stressful time with long nights on call and the adjustment to a new level of responsibility. While help should always be available, the first few minutes of managing a decompensating patient is something all junior residents must be competent at. This case series will help to accomplish that through simulation.

Clinical Vignette

The triage note states – Patient “fainted” while returning from the bathroom at home. He was found to be slightly more confused by his wife and complained of right elbow pain.

Case Summary

This is a case of an elderly patient with syncope. He is found to be in third degree heart block.  The team is expected to perform an initial assessment and obtain an ECG. Upon recognizing the heart block, they should ensure IV access and place pacer pads while calling for help.

Download the case here:

Bradycardia

ECG for the case found here:

Brady.jpg

Source: https://www.ecgquest.net/ecg/complete-heart-block-3/

Geriatric Case 5: Trauma with Head Injury

This case is the fifth in a six-part mini-series focusing on the management of geriatric patients in the ED. This series of cases was written by Drs. Rebecca Shaw, Nemat Alsaba, and Victoria Brazil.

Dr. Rebecca Shaw is an emergency physician currently working as a medical education fellow within the Emergency Department of the Gold Coast Hospital and Health Service in Queensland, Australia. Dr. Nemat Alsaba (@talk2nemat) is an emergency physician with a special interest in geriatric emergency medicine, medical education and simulation. She is trying her best to combine these interests to improve geriatric patient care across all health sectors. She is also an assistant professor in medical education and simulation at Bond university. Dr. Victoria Brazil is an emergency physician and medical educator. She is Professor of Emergency Medicine and Director of Simulation at the Gold Coast Health Service, and at Bond University medical program. Victoria’s main interests are in connecting education with patient care – through healthcare simulation, technology enabled learning, faculty development activities, and talking at conferences. Victoria is an enthusiast in the social media and #FOAMed world (@SocraticEM), and she is co-producer of Simulcast (Simulationpodcast.com).

Why It Matters

Elderly patients who have sustained trauma are frequently encountered in the ED. These patients have unique physiology and are often complex due to frailty and polypharmacy concerns. Care of the elderly trauma patient requires attention to these complexities, to goals of care, and to communication with family members. This case gives the opportunity to learn and enhance these skills.

Clinical Vignette

The bedside nurse informs you that “EMS just off-loaded an elderly male to the resuscitation bay. He had a fall down the stairs and sustained a head injury. He was GCS 15 and hemodynamically stable when they picked him up, so they didn’t activate the trauma team, but he has deteriorated during transport. He has an obvious large, boggy scalp hematoma over the left parietal region. I am worried because he’s getting restless and won’t follow commands.”

Case Summary

An 81-year old man falls down the stairs at home. He is initially asymptomatic but his level of consciousness declines and he starts to show signs of raised ICP. Providers must recognize and treat this, as well as reverse his anticoagulation, provide neuroprotective RSI and safely transport to the CT scanner. Providers must then talk with the patient’s wife, to provide information on his condition and prognosis and discuss the patient’s goals of care.

Download the case here:

Geriatric Trauma with Head Injury

ECG for the case found here:

Geriatric Trauma ECG

ECG Source: https://en.ecgpedia.org/index.php?title=Atrial_Fibrillation

CXR for the case found here:

Geriatric Trauma CXR

Image courtesy of Dr Jeremy Jones, Radiopaedia.org, rID: 6410

Pelvic XR for the case found here:

Geriatric Trauma Pelvic XR

Image courtesy of Dr Jeremy Jones, Radiopaedia.org, rID: 28928

Geriatric Case 3: Termination of Resuscitation

This case is the third in a six-part mini-series focusing on the management of geriatric patients in the ED. This series of cases was written by Drs. Rebecca Shaw, Nemat Alsaba, and Victoria Brazil.

Dr. Rebecca Shaw is an emergency physician currently working as a Medical Education Fellow within the Emergency department of the Gold Coast Hospital and Health Service in Queensland, Australia. Dr. Nemat Alsaba (@talk2nemat) is an Emergency physician with a special interest in Geriatric Emergency Medicine, medical education and simulation. She is trying her best to combine these interests to improve Geriatric patient care across all health sectors. She is also an Assistant professor in medical education and simulation at Bond university. Dr. Victoria Brazil is an emergency physician and medical educator. She is Professor of Emergency Medicine and Director of Simulation at the Gold Coast Health Service, and at Bond University medical program. Victoria’s main interests are in connecting education with patient care – through healthcare simulation, technology enabled learning, faculty development activities, and talking at conferences. Victoria is an enthusiast in the social media and #FOAMed world (@SocraticEM), and she is co-producer of Simulcast (Simulationpodcast.com).

Why it Matters

Deciding when to terminate CPR is a very delicate moment in a patient’s care. It is literally the determination of possible life vs. certain death. There are clear guidelines for when to terminate resuscitation in certain contexts, but for patients who are brought to the ED by EMS, there is no true objective measure of when to terminate CPR. This is where determination of quality of life is important. In the elderly, the likelihood of a meaningful quality of life after a CPR-requiring event is quite low. Recognizing this futility is an important and challenging skill to learn. Being able to debrief with your team and discuss these events further is another essential skill that is often not practiced. This case gives the opportunity to learn and enhance these skills.

Clinical Vignette

ED RN to inform team prior to patient’s arrival: “We have an out of hospital cardiac arrest coming in with an unknown downtime and unknown past medical history. He is an 89-year-old male coming from home. He has had no shocks and CPR is in progress. They are one minute away.”

Case Summary

An elderly male is brought in by ambulance from home with CPR in progress. He collapsed in front of his son/daughter who commenced CPR. His rhythm has been PEA throughout and his downtime is 20 minutes. Participants should assess the patient, gather information about his background and determine that CPR is futile. They should decide to cease CPR and inform his son/daughter in a sensitive manner that their father has died. They will also debrief the team following the termination of resuscitation.

Download the case here: Geri EM Termination of Resuscitation

U/S for the case found here:

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

Geriatric Case 2: Chronic Digoxin Toxicity

This case is the second in a six-part mini-series focusing on the management of geriatric patients in the ED. This series of cases was written by Drs. Rebecca Shaw, Nemat Alsaba, and Victoria Brazil.

Dr. Rebecca Shaw is an emergency physician currently working as a Medical Education Fellow within the Emergency department of the Gold Coast Hospital and Health Service in Queensland, Australia.Dr. Nemat Alsaba (@talk2nemat) is an Emergency physician with a special interest in Geriatric Emergency Medicine, medical education and simulation. She is trying her best to combine these interests to improve Geriatric patient care across all health sectors. She is also an Assistant professor in medical education and simulation at Bond university. Dr. Victoria Brazil is an emergency physician and medical educator. She is Professor of Emergency Medicine and Director of Simulation at the Gold Coast Health Service, and at Bond University medical program. Victoria’s main interests are in connecting education with patient care – through healthcare simulation, technology enabled learning, faculty development activities, and talking at conferences. Victoria is an enthusiast in the social media and #FOAMed world (@SocraticEM), and she is co-producer of Simulcast (Simulationpodcast.com).

Why it Matters

This case demonstrates several diagnostic challenges that can occur with the bradycardic patient on digoxin including:

  • The need to resuscitate the patient appropriately (and thus, empirically treat) while waiting on labs to confirm whether hyperkalemia or digoxin is the culprit
  • The theoretical concern of administering calcium for correction of hyperkalemia (because we usually have a potassium result back before the digoxin level)
  • The need to consider precipitating causes of a patient’s presentation

Clinical Vignette

To be stated by the bedside nurse: “Bertie is an 85-year-old man who has been brought in after a fall at home. He says he is feeling dizzy and has a HR of 30 on the monitor. I haven’t had much of a chance to take more of a history from him but he has a list of medications with him and seems ok from the fall other than a bruise on his head.”

Case Summary

An 85-year-old man presents after a fall at home. He is complaining of dizziness and has a HR of 30. Further assessment reveals chronic digoxin toxicity and a concurrent UTI with acute renal failure. The patient requires management of his bradycardia and acute renal failure with specific management of chronic digoxin toxicity including a discussion with toxicology and administration of Digibind.

Download the case here: Geri EM Chronic Digoxin Toxicity

ECG for the case found here:

(ECG source: http://www.ems12lead.com/wp-content/uploads/sites/42/2014/01/digitalis_ECG.jpg)

CXR for the case found here:

normal cxr

(CXR source: https://radiopaedia.org/images/220869)

 

LVAD Case

This week’s case is written by Drs. Ashley Lubberdink and Sameer Sharif. Dr. Lubberdink is a PGY4 Emergency Medicine resident at McMaster University and is just beginning her fellowship in simulation and medical education. Dr. Sharif is a PGY5 Emergency Medicine resident at McMaster University who has just completed his fellowship in simulation and medical education.

Why it Matters

LVADs are pretty uncommon devices! If your practice location is not a hospital that inserts LVADs, then it is likely that you have never come across a patient with an LVAD. Without prior knowledge of these devices, it can be quite distressing trying to assess these patients. This case is designing to highlight the following:

  • LVAD patients do not have a pulse, a measurable blood pressure, or a detectable heart rate on the sat probe
  • To assess for blood pressure, one must insert an arterial line or use a blood pressure cuff and doppler U/S to obtain the MAP
  • Early after LVAD placement, drive line infection and bleeding are common complications
  • Call for help early! These patients generally have care providers who are available to help trouble shoot by phone at all hours of the day

More Reading

For more information on an approach to LVADs, we suggest the following sources:

https://emcrit.org/emcrit/left-ventricular-assist-devices-lvads-2/

https://canadiem.org/lvads-approach-ed/

Clinical Vignette

A 62-year-old male presents to your large community ED with a 1 day history of generalized malaise and nausea and a 2-hour history of palpitations. He is particularly concerned about his symptoms because last month he had an LVAD placed at your provinces’ major cardiac center (3 hours away) for stage 4 CHF. His wife is accompanying him but is currently parking the car.

Case Summary

A 62-year-old man presents to the ED with palpitations and general malaise. On initial assessment, the team finds out he had an LVAD placed within the last 1 month. The team will need to work through how to assess the patient’s vital signs appropriately and will discover the patient has a low MAP and a low-grade fever. On inspection, the patient’s drive line site will appear infected. The initial ECG will show features of hyperkalemia. After the initial assessment, the patient will progress to a PEA arrest requiring resuscitation by ACLS protocols. Labs will reveal an acute kidney injury and hyperkalemia. The patient will obtain ROSC when the hyperkalemia is treated.

Download the case here: LVAD Case

Initial ECG for the case found here:

hyperkalemia

(ECG source: https://lifeinthefastlane.com/ecg-library/basics/hyperkalaemia/)

Second ECG for the case found here:

hyperkalemia narrow QRS

(ECG source: https://lifeinthefastlane.com/ecg-library/basics/hyperkalaemia/)

CXR for the case found here:

LVAD-CXR

(CXR source: https://edecmo.org/additional-technologies/ventricular-assist-devices-vads/lvads/)

Picture of drive line site infection found here:

driveline infection A

(Picture source: http://journals.sagepub.com/doi/full/10.1177/1179065217714216)

Echo for case found here:

(Echo source: https://www.youtube.com/watch?v=-4ThAo4m2UI)

Polytrauma for Team Communication

This case is written by Dr. Chris Heyd. He is a PGY4 Emergency Medicine resident at McMaster University and has spent the last year completing a sub-specialty focus in disaster medicine and simulation. He is also one of our resident editors here at EmSimCases.

Why it Matters

This case highlights some of the challenges that can be associated with activating a trauma team. While the intent is to have many expert hands available to help at once, sometimes the team members arrive in a staggered fashion. This case reviews:

  • The challenges of managing an unstable trauma patient when there are interruptions to the flow of communication
  • The need to expediently place a chest tube in a hypoxic trauma patient
  • The fact that near simultaneous intubation and chest tube placement is often necessary in an unstable trauma patient

Clinical Vignette

To be read aloud by simulation facilitator at start of case:

“You are working as an Emergency physician at a tertiary care trauma centre and have been called overhead to your trauma bay. A paramedic team has just arrived with a 64-year old trauma patient. He was involved in a highway speed head-on MVC. He was restrained and air bags deployed. He was the driver and the other drive died on scene. There were no other passengers. EMS extricated the patient easily. They have placed one IV line and started running normal saline. He has been placed on a non-rebreather mask but has remained tachycardic, hypoxic and altered. GCS has been consistently 14. The trauma team was activated based on injury mechanism but so far only the orthopedic resident has arrived at the bedside.”

Case Summary

A 64-year old man is involved in a high-speed car crash. The trauma team is activated and he is brought directly to the ED. On arrival, he is hypoxic, tachycardic and altered. CXR reveals multiple rib fractures with a right-sided hemopneumothorax.

The team leader will need to effectively communicate with the team to ensure the tasks of intubation, chest tube placement and blood product administration are performed in a safe and quickly. The patient will stabilize after these treatments.

Members of the trauma team will have a staggered entry into the room. The team leader will need to balance communication with the new team members and the urgent interventions needed by the patient.

Download the case here: Polytrauma for Team Communication

CXR for the case found here:

CXR trauma

(CXR source: https://radiopaedia.org/cases/large-traumatic-haemothorax)

PXR for the case found here:

Normal PXR

(PXR source: https://radiopaedia.org/cases/normal-pelvis-x-ray-trauma-supine-1)

Lung U/S showing hemothorax found here:

 

(U/S source: McMaster PoCUS Subspecialty Training Program)

Normal RUQ FAST image found here:

no FF

(U/S source: McMaster PoCUS Subspecialty Training Program)

Pregnant Cardiomyopathy

This case is written by Drs. Nadia Primiani and Sev Perelman. They are both emergency physicians at Mount Sinai Hospital in Toronto. Dr. Primiani is the postgraduate education coordinator at the Schwartz/Reisman Emergency Centre. Dr. Perelman is the director of SIMSinai.

Why it Matters

Most emergency physicians have some degree of discomfort when a woman in her third trimester presents to the ED for any complaint. When that woman presents in acute distress, the discomfort is increased even further! This case takes learners through the management of a patient with a pregnancy-induced cardiomyopathy, reviewing:

  • The importance of calling for help early
  • The fact that all pregnant patients at term must be presumed to have difficult airways
  • That the treatment of the underlying medical condition is still the primary focus – in this case, BiPap, definitive airway management, and ultimately, inotropic support

Clinical Vignette

You are working in a community ED and your team has been called urgently by the nurse to see a 38 year old female who is G2P1 at 36 weeks gestational age. She was brought in by her sister, who is quite agitated and upset, saying “everybody has been ignoring her symptoms for the last 4 weeks.” The patient has just experienced a syncopal episode at home.

Case Summary

A 38-year-old female G2P1 at 36 weeks GA presents with acute on chronic respiratory distress in addition to chronic peripheral edema. She undergoes respiratory fatigue and hypoxia requiring intubation. She then becomes hypotensive which the team discovers is secondary to cardiogenic shock, requiring vasopressor infusion and consultation with Cardiology/ ICU.

Download the case here: Pregnant Cardiomyopathy

ECG for the case found here:

(ECG source: https://lifeinthefastlane.com/ecg-library/dilated-cardiomyopathy/)

 CXR for case found here:

posttestQ2pulmonaryedema

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

Cardiac Ultrasound for the case found here:

ezgif.com-optimize+(6)

(U/S source: http://www.thepocusatlas.com/echo/2hj4yjl0bcpxxokzzzoyip9mnz1ck5)

Lung U/S for the case found here:

Confluent+B+Lines

(U/S source: http://www.thepocusatlas.com/pulmonary/)

RUQ FAST U/S Image found here:

usruqneg

(U/S source: http://sinaiem.us/tutorials/fast/us-ruq-normal/)

OB U/S found here:

(U/S source: https://www.youtube.com/watch?v=SKKnTLqI_VM)

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 Viral Myocarditis

This case is written by Dr. Adam Cheng. Adam Cheng, MD, FRCPC is Associate Professor, Departments of Paediatrics and Emergency Medicine at the Cumming School of Medicine, University of Calgary.  He is also Scientist, Alberta Children’s Hospital Research Institute and Director, KidSIM-ASPIRE Simulation Research Program, Alberta Children’s Hospital.  Adam is passionate about cardiac arrest, resuscitation, simulation-based education and debriefing. The case has been modified by Drs. Dawn Lim, Andrea Somers, and Nadia Farooki for use at the University of Toronto.

Why it Matters

Myocarditis is a presentation that can be challenging to recognize early. It is often mistaken simply for septic shock. This case highlights some important features of the recognition and management of myocarditis, including:

  • The need to re-evaluate the differential in a patient with persistent hypotension
  • The role of bedside tests in aiding the diagnosis (ECG, POCUS, CXR)
  • The importance of re-evaluating and re-assessing a patient and adjusting the differential diagnosis and management accordingly

Clinical Vignette

You are working in a large community ED. The charge nurse tells you: “EMS have just arrived with a 15-year old boy with shortness of breath and chest pain. His O2 sat is low. EMS have administered oxygen and IVF en route. He looks unwell so I put him in a resuscitation room. Can you see him immediately?”

Case Summary

A 15 year-old male with no prior medical history is brought to the ED by his parents for lethargy, shortness of breath and chest pain. He was feeling run down for the past 4 days with URTI symptoms.

His initial presentation looks like sepsis with a secondary bacterial pneumonia. He becomes hypoxic requiring intubation. He develops hypotension that does not respond as expected to fluids and vasopressors, which should prompt more diagnostics from the team.

Further testing reveals cardiomyopathy with reduced EF and acute CHF. He finally stabilizes with inotropes and diuresis.

 

Download the case here: Pediatric Viral Myocarditis

ECG for the case found here:

sinus-tachy-non-specific-ST-changes

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

CXR for the case found here:

cardiomegaly CHF

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

Cardiac U/S for the case found here:

Parasternal Long

(U/S source: http://www.thepocusatlas.com/echo/xg2awokhx1zx8q3ndwjju5cu4t1adq)

Lung U/S for the case found here:

B lines

(U/S source: https://www.thoracic.org/professionals/clinical-resources/critical-care/clinical-education/quick-hits/orthopnea-in-a-patient-with-doxorubicin-exposure.php)