A 38 year-old man (Ethiopian refugee) with untreated HIV and past history of TB, presents to the emergency department (ED) with anterior chest pain, shortness of breath and hypotension. He was seen 3 days prior by a walk-in clinic and referred to the ED with chest pain and ECG showing pericarditis, but did not attend the ED until symptoms were severe. In the ED, patient quickly progresses to profound shock and has a PEA arrest. POCUS will show a large pericardial effusion and tamponade. Team members are to initiate CPR, manage the arrest and treat the effusion using bedside pericardiocentesis in order to obtain return of spontaneous circulation (ROSC).
Denise is a 59-year-old female who presents with a 7-day history of urinary symptoms, fever, and left flank pain. She has a history of STEMI 5 years ago with chronic left-sided heart failure. She becomes unstable in the ER, requiring judicious fluid resuscitation, vasopressors, and empiric antibiotic treatment. The team leader needs to consider the history and arrange renal imaging to discover the severe sepsis is secondary to an infected ureteric calculus. From there, emergent urologic consultation and admission to hospital is warranted.
A femoral nerve block has just been performed on a 65-year-old male who sustained a right femoral neck fracture. The patient also sustained a laceration to the scalp which was repaired by the medical student. The patient is now complaining of blurry vision, paresthesias, and “twitchiness”. The patient progresses on to seizure followed by cardiac arrest and will need high quality ACLS care along with lipid emulsion therapy.
A 70-year old female is brought to the ED after lighting herself on fire while trying to light a cigarette. She will have a 15% TBSA burn (upper anterior chest and neck only) with inhalational injury. Preparation for intubation should be an early priority. Her prognosis is poor but survivable and it will be key to discuss goals of care with the family before proceeding with intubation and further burn care. A difficult intubation should be anticipated but is not encountered in this case.
A 70 year old man who had an unwitnessed cardiac arrest is brought to the ED via EMS from his local Tennis Club. Despite multiple rounds of appropriate resuscitative measures, the patient does not gain return of spontaneous circulation (ROSC). Learners will need to discuss the termination of resuscitation with team members and communicate with the patient’s wife.
This patient is in respiratory failure and requires intubation. Participants must prepare for her arrival, organize the care team, communicate effectively and secure the patient's airway according to the principles of a protected intubation.
The patient is found by a friend unresponsive after a 7 day history of cough and shortness of breath. He immediately receives bystander CPR. An advanced care paramedic crew attends the scene and manages a ventricular fibrillation arrest prior to transporting to hospital. The patient goes into cardiac arrest again shortly before arriving in the emergency department. The team will need to prepare for the patient's arrival and then manage a cardiac arrest using appropriate precautions for suspected COVID-19.
This 50-year old woman presents with typical cardiac chest pain and high suspicion for COVID-19. Her ECG shows an anterior STEMI. The team will start performing the initial work-up and management of a patient with STEMI. While this is occurring, the patient suffers a VF arrest. The team will need to go through the ACLS algorithm while taking all precautions required in caring for a patient with suspected COVID.
This case involves an 8 year-old boy with upper airway obstruction from sausage. When indirect treatment fails, removal with Magill forceps under direct visualization is required. The patient slowly recovers after removal of foreign body but will require admission for monitoring.
This case was designed during the January 2020 COVID-19 outbreak in order to assess and improve team preparedness for safely and effectively caring for a critically ill coronavirus patient from triage through to intubation.