Stable VT with ICD Firing

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

This case tackles several components of ICD management that can make emergency physicians a little nervous. Most notably, it highlights:

  • The discomfort that staff members may have with touching a patient whose ICD is firing, and the need to reassure them of safety
  • The role of a magnet in terminating the inappropriate or ineffective shocks delivered by an ICD
  • The various anti-dysrhythmic options that are available to treat ventricular tachycardia (and the need to ask for expert opinion!)
  • The way a sympathetic response or anxiety may exacerbate dysrhythmias

Clinical Vignette

A 40-year-old male to presents to your tertiary care ED complaining that his ICD keeps firing. He keeps yelling “ow” and jumping/jerking every couple minutes during his triage. He has an ICD in place because he had previous myocarditis that left him with a poor EF.

Case Summary

A 40-year-old male presents to the ED complaining that his ICD keeps firing. He will have a HR of 180 and VT on the monitor. He will occasionally yell “ow.” The team will need to work through medical management of VT, while considering magnet placement for patient comfort. The patient will remain stable but will trigger VT with his agitation.

Download the case here: Stable VT with ICD firing

ECG for the case found here:

VT

(ECG source: http://lifeinthefastlane.com/ecg-library/ventricular-tachycardia/)

CXR for the case found here:

CXR with normal ICD

(CXR source: https://commons.wikimedia.org/wiki/File:Implantable_cardioverter_defibrillator_chest_X-ray.jpg)

 

Newborn Resuscitation

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

Approximately 10% of newborns require some degree of resuscitation upon delivery, with less than 1% requiring active resuscitation.1 Given that deliveries in the ED are relatively rare, this means that performing NRP in the ED is quite uncommon. On the other hand, the ED team must be able to respond quickly and efficiently to a flat neonate. This means that practising NRP is paramount – and what better way to do so than with simulation! This case highlights three key pieces of NRP, including:

  • The need to warm, dry, and stimulate immediately
  • The quick progression to positive pressure ventilation if stimulation doesn’t work
  • When to initiate CPR, the necessary 3:1 compression:ventilation ratio, and how to place hands for performing CPR on a neonate

Clinical Vignette

You are working in the minor area of your ED and have been called by the physician on the major side to assist with a precipitous delivery. He is managing the mother and wants you to be ready to resuscitate the infant if needed. The mom thinks she’s term. She’s had no prenatal care and is an IV drug user. She used earlier today. There no meconium staining noted in the amniotic fluid. Baby has just been delivered and is handed to your team.

Case Summary

The team has been called to help in the ED where a woman just precipitously gave birth to a baby now requiring resuscitation. The mom thinks she’s at term. She has had no prenatal care and is an iv drug user. The baby will be flat. After stimulation and drying, the baby will have a HR <100 and PPV will be required. After 60 seconds, the HR will still be <60 and CPR will need to be started. This will be short lived. The team will also need to intubate and obtain IV access.

Download the case here: NRP Case

References

  1. Barber CA, Wyckoff MH. Use and efficacy of endotracheal versus intravenous epinephrine during neonatal cardiopulmonary resuscitation in the delivery room. Pediatrics2006;118:10281034doi: 10.1542/peds.2006-0416

Burn with CO/CN Toxicity

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 patients with significant burns obtained in an enclosed space involves several important components. This case nicely highlights three key management considerations:

  • The need to intubate early in anticipation of airway edema that may develop
  • The possibility of cyanide toxicity in the context of hypotension and a high lactate, and the need to treat early with hydroxycobalamin
  • The importance of recognizing and testing for possible CO toxicity (and initiating 100% oxygen upon patient arrival)

Clinical Vignette

A 33-year-old female has just been brought into your tertiary care ED. She was dragged out of a house fire and is unresponsive. The etiology of the fire is unclear, but the home was severely damaged. The EMS crew that transported her noted significant burns across her chest, abdomen, arm, and leg.

Case Summary

A 33 year-old female is dragged out of a burning house and presents to the ED unresponsive. She has soot on her face, singed eyebrows, and burns to her entire chest, the front of her right arm, and part of her right leg. She is hypotensive and tachycardic with a GCS of 3. The team should proceed to intubate and fluid resuscitate. After this, the team will receive a critical VBG result that reveals profound metabolic acidosis, carboxyhemoglobin of 25 and a lactate of 11. If the potential for cyanide toxicity is recognized and treated, the case will end. If it is not, the patient will proceed to VT arrest.

Download the case here: Burn CO CN Case

ECG for the case found here:

sinus-tachycardia

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

CXR for the case found here:

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

STEMI with Cardiogenic Shock

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 majority of STEMI presentations to the ED are quite straight-forward to manage: expediency and protocolization are of the utmost importance. However, when a patient presents with cardiogenic shock as a result of their STEMI, more nuanced care is required. In particular, the patient must be stabilized in order to facilitate the definitive treatment of cardiac catheterization. This case highlights some of those nuances, including:

  • The need for vasopressor support and possibly inotropic support in patients with cardiogenic shock
  • The challenges associated with intubating a hypotensive and hypoxic patient
  • The importance of optimizing the patient’s status as best as possible prior to intubation (whether via BiPAP, PEEP valve, push-dose pressors, or otherwise)

Clinical Vignette

A 55-year-old male presents to the ED with EMS as a STEMI activation. He arrives being bagged by EMS for hypoxia. His initial EMS call was for chest pain and he has significantly deteriorated en route. He has a history of smoking, hypertension, diabetes, and hypercholesterolemia. No prior cardiac history.

Case Summary

A 55-year-old man presents to the ED as a STEMI call. He is profoundly hypotensive with low O2 sats and obvious CHF. The patient’s blood pressure will transiently respond to fluid resuscitation. The ECG will show anterolateral ST elevation. The team will need to prepare for intubation while activating the cath lab. They will also need to start vasopressors. The patient will remain hypotensive until an inotrope like dobutamine is initiated. If unsafe medications are chosen for intubation, the patient will have a VT arrest.

Download the case here: STEMI with Cardiogenic Shock

ECG for the case found here:

anterolateral STEMI

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

Pre-intubation CXR for the case found here:

CHF

(CXR source: https://www.med-ed.virginia.edu/courses/rad/cxr/pathology2Bchest.html)

Post-intubation CXR for the case found here:

CHF post intubtation

(CXR source: https://heart-conditions.knoji.com/learning-about-and-coping-with-congestive-heart-failure/)

Lung U/S for the case found here:

 

 

ASA Toxicity

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 obtained a fellowship in Simulation and Medical Education.

Why it Matters

Salicylate toxicity, while relatively rare, has fairly nuanced management. It is important for physicians to be aware of presenting features of the toxicity and also of key management steps. Some pearls from this case include:

  • That hypoglycemia (and neuroglycopenia) is a manifestation of ASA toxicity.
  • Urine alkalinization (and correction of hypokalemia) is an important initial treatment for suspected toxicity.
  • Should a patient require intubation, it is paramount to set the ventilator to match the patient’s pre-intubation respiratory rate as best as possible.
  • Dialysis is indicated in intubated patients and also in patients with profoundly altered mental status, high measured ASA levels, and renal failure.

Clinical Vignette

You are working at a community hospital. The triage nurse comes to tell you that they have just put an 82 year-old male in a resuscitation room. He was found unresponsive by his daughter and was brought in by EMS. In triage he was profoundly altered, febrile and hypotensive. His daughter is in the room with him.

Case Summary

The learner will be presented with an altered febrile patient, requiring an initial broad work-up and management plan. The learner will receive a critical VBG report of severe acidosis, hypoglycemia and hypokalemia, requiring management. Following this, the rest of the blood work and investigations will come back, giving the diagnosis of salicylate overdose. The patient’s mental status will continue to decline and learners should proceed to intubate the patient, anticipating issues given the acid-base status. The learner should also initiate urinary alkalinization and make arrangements for urgent dialysis.

Download the case here: ASA Toxicity

ECG for the case found here:

Hypokalemia ECG

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

Initial CXR for the case found here:

ards pre intubation

(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:

ARDS post intubation

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

FAST showing no free fluid found here:

no FF

Pericardial U/S showing no PCE found here:

Abdominal U/S showing no AAA found here:

no AAA

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

Aortic Stenosis with A Fib and CHF

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 along with a fellowship in Simulation and Medical Education.

Why it Matters

The management of patients with aortic stenosis can be tenuous at the best of times. When these patients present with CHF or dysrhythmias, their management is much more nuanced than the typical patient presenting with the same complaints. This case nicely highlights the following management differences:

  • The need for expedient rate control in a patient with aortic stenosis (in this case, most safely accomplished via cardioversion)
  • The need for judicious treatment of CHF, including careful diuresis and avoiding nitroglycerin use
  • The importance of early consultation with both cardiac surgery and cardiology

Clinical Vignette

A 78-year-old male presents via EMS with 4 days of increased SOB. The triage nurse comes to tell you she has put him in the resuscitation bay due to unstable vitals. HR was in the 150s. The O2SAT was 86% on RA when EMS arrived, but is now 95% on a NRB.

Case Summary

A 78-year-old male presents with increased SOB over the past 4 days. A recent ECHO will be presented showing severe AS. The ECG will demonstrate new A Fib with a HR of 150 and the CXR will show CHF. The patient will be normotensive at first but will become hypotensive shortly after. The team will then need to decide whether to cardiovert the patient or attempt rate control. If these are done safely, the patient will respond and then develop worsening CHF. Definitive management should be sought with early cardiology/cardiac surgery consult. If management is not carried out judiciously, the patient will become profoundly hypotensive.

Download the case here: Aortic Stenosis with A Fib and CHF

Initial ECG for the case found here:

ECG- A.fib + LVH

(ECG source: http://www.wikidoc.org/index.php/Atrial_fibrillation_EKG_examples)

Second ECG for the case (after cardioversion) found here:

ECG- LVH

(ECG source: http://bestpractice.bmj.com/best-practice/monograph/409/resources/image/bp/5.html)

CXR for the case found here:

CHF

(CXR source: https://www.med-ed.virginia.edu/courses/rad/cxr/pathology2Bchest.html)

Lung ultrasound for the case found here:

STEMI with Bradycardia

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 requires learners to coordinate multiple components of care at once. A patient presenting with a STEMI requires urgent PCI, however they must also be stable enough to safely travel to the cardiac catheterization lab. This case emphasizes important adjuncts to STEMI management in an unstable patient, including:

  • The utility of transcutaneous pacing and epinephrine infusion in the context of symptomatic bradycardia
  • The importance of recognizing complete heart block as a complication of a STEMI
  • The need for intubation in order to facilitate medication administration and safe transport in a PCI-requiring patient who presents with severe CHF or altered LOC

Clinical Vignette

To be stated by the bedside nurse: “This 65-year-old woman came in with 1 hour of chest pressure and SOB. Her O2 sats were 84% on RA at triage, and they are now 90% with a non-rebreather mask. She’s also bradycardic at 30 and hypotensive at 77/40.”

Case Summary

A 65-year-old female is brought to the ED with chest tightness and SOB. On arrival, she will be found to have an inferior STEMI with resultant 3rd degree heart block and hypotension. The team will be expected to initiate vasopressor support and transcutaneous pacing. However, prior to doing so, the patient will develop a VT arrest requiring ACLS care. After ROSC, the team will need to initiate transcutaneous pacing and activate the cath lab for definitive management.

Download the case here: STEMI with Bradycardia

ECG for the case found here:

Inferior STEMI with CHB

(ECG source: http://lifeinthefastlane.com/ecg-library/basics/inferior-stemi/)

CXR for the case found here:

CHF

(CXR source: https://www.med-ed.virginia.edu/courses/rad/cxr/pathology2Bchest.html)

Multi-Trauma: Blunt VSA and Burn

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

This case is an excellent example of the challenges faced in Emergency Medicine. Not only are learners faced with a worst-case airway scenario, but they must also manage two critically ill patients at once. In particular, it draws attention to the following:

  • The need to plan for and manage resources appropriately when faced with two critically ill patients simultaneously
  • The importance of recognizing and adequately preparing for a difficult airway
  • The acknowledgement of a failed intubation/ventilation scenario requiring expedient placement of a surgical airway

Case Summary

The case will start with an EMS patch indicating that they are 2 minutes out with multi-trauma from a 2 car MVC. Two patients will then arrive within 1 minute of each other. The first will have gone VSA en route from presumed blunt trauma. This patient will not regain a pulse. The second patient will arrive with significant burns from a car fire, and will have GCS of 3 necessitating intubation. All attempts at intubation will be unsuccessful, and a surgical airway must be performed. The team will need to prioritize resources between the two patients and realize that an ED thoracotomy is not reasonable in the first patient.

Clinical Vignette

Before first patient:

You are working in a tertiary care trauma center. EMS patch: We have a 50ish M unbelted driver in a head-on MCV at about 60km/hr. He was ejected from the vehicle and found about 30m from the crash site with a GCS of 3. He has an obvious head injury, torso injury and unstable pelvis, which we’ve bound. Initially had RR 40, O2 85% on NRB, HR 150 and a questionable femoral pulse. Since then, he’s been pulseless. We’ve been en route about 5 minutes and should be there in about 2 min. He’s received 1mg Epi so far with no shocks advised x2. Smells of EtOH, but no other known history. There was one other car involved that caught on fire, so you’ll probably get them, too, if they survive. Please prepare for this patient.

Upon arrival of second patient:

EMS Handover: This 30ish male belted driver was in a head on MVC with both cars going ~60km/hr. His car was on fire when we got there, and he’s got 2nd/3rd degree burns everywhere. We found him outside the car, so he must have self-extricated. His GCS has been 3 the entire time with us. He’s tolerating an oral airway. His last vitals were HR 120, BP 130/80, RR 30, O2 95% NRB

How to Run the Case

At McMaster University, we successfully ran this case with our PGY4 residents. To do so, we had two confederate nurses at the bedside (one nurse per patient). We also had dedicated sim techs running each mannequin. Finally, we had three faculty instructors. One instructor to observe the management of each patient, and one instructor to play the role of the arriving paramedic and to coordinate between the two instructors and sim techs. We are able to run the case with four of our emergency medicine resident learners playing the roles of a trauma team (one team leader, one senior emerg resident, one senior anesthesia resident, and one surgical resident). It went very well and received positive feedback from the learners. Of note, this case is ripe with opportunity for incorporating other learners. In particular, inter-professional education using ED nurses, RT’s, and learners from other services could work as well.

 

Download the case here: Multitrauma Cric and Blunt VSA Case

Cardiac U/S for Patient 1 found here*:

FAST for Patient 1 found here:

RUQ FF

ECG for Patient 2 found here:

sinus-tachycardia

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

Pre-intubation CXR for Patient 2 found here:

Normal CXR Male

(CXR source: https://radiopaedia.org/cases/normal-chest-x-ray)

PXR for Patient 2 found here:

normal-pelvis-male

(PXR source: http://radiopaedia.org/articles/pelvis-1)

Post-intubation CXR for Patient 2 found here:

Normal Post-Intubation CXR

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

Cardiac U/S for Patient 2 found here*:

FAST for Patient 2 found here*:

no FF

Lung U/S for Patient 2 found here*:

*All U/S images are courtesy of McMaster PoCUS Subspecialty Training Program.

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)

Breech Delivery + NRP

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

All deliveries in the Emergency Department are considered high risk. Further, in most departments, both delivery and neonatal resuscitation are rare events. However, Emergency physicians must be prepared to manage all presentations – including breech delivery! This case highlights several important components of managing these rare presentations, including:

  • The need to adequately prepare the room (if time permits)
  • The importance of calling for a second physician to be available to manage the neonate upon delivery
  • How to safely perform a breech delivery
  • The step-wise progression of neonatal resuscitation post-delivery

Clinical Vignette

EMS Patch: “We have a 19 F complaining of severe abdominal pain onset 1 hour ago. She denies being pregnant, but looks almost full term to us. Contractions seem to be about 1 minute apart. Patient’s Vitals as follows: HR 120, BP 140/85, RR 20, O2 100% on RA. ETA 2 minutes.”

Case Summary

A 19-year-old female presents with EMS in active labour. She denies any history of pregnancy and has had no prenatal care. On examination, infant will be in breech position. The learner must deliver the infant from breech presentation. Following this, the neonate will will present lifeless, and require resuscitation.

Download the case here: Breech + NRP