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

 

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)

Multi-trauma (Kicked off a Horse)

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

Management of trauma patients with multiple intercurrent injuries can be challenging. This case provides an opportunity for junior learners to stretch themselves beyond their comfort zones. In particular, this case highlights the following:

  • The need for a systematic approach to the initial assessment and ongoing re-assessment of any complex trauma patient
  • The importance of prioritizing tasks and adjusting priorities as patient status changes
  • The complexity of managing a hypotensive, head-injured patient

Clinical Vignette

A 32-year-old female presents as a trauma activation with EMS after being bucked off of her horse. Her mom witnessed the episode and called EMS because she seemed groggy. She has had a low BP with EMS on route. Her current BP is 80/40.

Case Summary

A 32-year-old female presents after being bucked off of her horse. She is brought in as a trauma team activation because of a low BP. Her primary survey will reveal a boggy hematoma over her right temporal area as well as an unstable pelvis. Her initial GCS will be 8. The team will proceed through airway management in a hypotensive, head-injured trauma patient while also binding her pelvis. The patient eventually shows signs of brain herniation, which the team will need to manage prior to consultant arrival.

Download the case here: Pelvic Fracture and SDH

ECG for the case found here:

Sinus tachycardia

(ECG source: https://i0.wp.com/lifeinthefastlane.com/wp-content/uploads/2011/12/sinus-tachycardia.jpg)

Pre-intubation CXR for the case found here:

normal female CXR radiopedia

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

PXR for the case found here:

Pelvic fracture

(PXR source: https://littlemedic.files.wordpress.com/2013/01/pelvis_0_1.jpg)

Post-intubation CXR for the case found here:

normal-intubation2

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

Ultrasound showing free fluid in RUQ found here:

RUQ FF

Ultrasound showing normal lung sliding found here:

Ultrasound showing no pericardial effusion found here:

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

Multi-drug Overdose

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

Calcium channel blocker overdoses are one of the most difficult overdoses for emergency physicians to manage. Even with excellent care, these patients often progress to cardiac arrest or to needing ECMO. This case highlights some key features in management, including:

  • The use of calcium gluconate and high-d0se insulin infusions to assist with blood pressure support (in isolation or in addition to other vasopressors)
  • The use of intralipid as an end of the line rescue treatment
  • The need to consider co-ingestions and their effects on management (in this case, clonazepam that slows the patient’s respiratory rate enough to require intubation)

Clinical Vigenette

A 48-year-old female presents to the ED with an unknown overdose. She was out drinking with friends until an hour ago. Her daughter came home and found her with vomit around her, empty pill bottles, and bits of pills in her vomit.

Case Summary

A 48-year-old female presents with a possible multi-drug overdose including glyburide, clonazepam and nifedipine. She will remain hypotensive throughout the case, despite treatment with calcium, high dose insulin, and other vasopressors. She will also have progressive respiratory depression and will eventually require intubation. She will then proceed to arrest. The team will be expected to give intralipid once the patient has arrested.

Download the case here: Multi-drug (CCB) OD

ECG for the case found here:

sinus brady with 1st degree hb

(ECG source: http://lifeinthefastlane.com/ecg-library/beta-blocker-and-calcium-channel-blocker-toxicity/sb-1hb/)

Post-intubation CXR for the case found here:

normal-intubation2

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

Pediatric Septic 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

Children with true septic shock are, thankfully, a rare presentation in the ED. However, recognition of early shock is an essential skill. This case highlights several important features of managing the critically ill child, including:

  • The need for early vascular access (whether that be intravenous or intraosseous, it must be obtained expediently)
  • The importance of monitoring for and treating resultant hypoglycemia
  • The need for early antibiotics

Clinical Vignette

A 4-year-old girl presents to your pediatric ED. Her mother states she is “not herself” and seems “lethargic.” She’s had a fever and a cough for the last three days. Today she just seems different. She was brought straight into a resus room and the charge nurse came to find you to tell you the child looks unwell.

Case Summary

A 4 year-old girl is brought to the ED because she is “not herself.” She has had 3 days of fever and cough and is previously healthy. She looks toxic on arrival with delayed capillary refill, a glazed stare, tachypnea and tachycardia. The team will be unable to obtain IV access and will need to insert an IO. Once they have access, they will need to resuscitate by pushing fluids. If they do not, the patient’s BP will drop. If a cap sugar is not checked, the patient will seize. The patient will remain listless after fluid resuscitation and will require intubation.

Download the case here: Pediatric Septic Shock

ECG for the case found here:

sinus-tachycardia

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

CXR for the case found here:

pediatric-pneumonia

(CXR source: http://radiopaedia.org/articles/round-pneumonia-1)

Adrenal Crisis

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

While adrenal crisis is a relatively rare presentation, shock is not. This case highlights several important points, including:

  • The importance of having an approach to fluid non-responsive shock
  • How difficult it can be to shift cognitive frames and resist diagnostic anchoring
  • The electrolyte abnormalities associated with adrenal crisis (hyponatremia, hyperkalemia, and hypoglycemia)
  • The need to treat an adrenal crisis with corticosteroids

Clinical Vignette

A 46-year-old female presents to the ED complaining of fatigue, anorexia, and weight loss over the last two weeks. She had the “stomach flu” a couple weeks ago and thought she was getting over it. But now she feels very weak and seems to be vomiting again. Her blood pressure is 80/40, so she was triaged straight to the resuscitation bay.

Case Summary

A 46-year-old female presents to the ED complaining of fatigue, anorexia, and weight loss over the last two weeks. She had the “stomach flu” a couple weeks ago and thought she was getting over it. But now she feels very weak and seems to be vomiting again. On presentation, the patient will have mild hypothermia, hypoglycemia, and hypotension. The team will have to initiate fluid resuscitation and an initial workup. The patient’s blood pressure won’t respond to 4 L of IV fluids, forcing the residents to work through the differential diagnosis of shock. Eventually, they will receive critical VBG results that indicate a mild metabolic acidosis, hyperkalemia, and hyponatremia. The team will need to treat the hyperkalemia and initiate hydrocortisone therapy.

Download the case here: Adrenal Crisis Case

ECG for the case found here:

peaked-t-waves

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

CXR for the case found here:

normal female CXR radiopedia

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

Pericardial U/S for the case found here:

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

FAST image for the case found here:

no FF

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

Coarctation of the Aorta

This case is written by Drs. Quang Ngo and Donika Orlich. Dr. Ngo is an attending emergency physician at McMaster Children’s Hospital and also serves as the Associate Program Director for the Department of Pediatrics. He is also a member of the advisory board here at EMSimCases. Dr. Orlich is a PGY5 Emergency Medicine resident at McMaster University who also completed a fellowship in Simulation and Medical Education last year.

Why it Matters

Having an approach to the toxic neonate is essential. More importantly, emergency physicians must be able to recognize subtle historical clues and physical exam features that point toward congenital heart disease in order to begin critical treatment rapidly. This case highlights the following:

  • The presentation of neonates with congenital heart disease including features like difficulty feeding, CHF, and tachypnea without increased work of breathing
  • The clinical features that may be present in a coarctation of the aorta, one specific type of congenital heart disease, and the resultant need to include four-limb BP’s as part of the work-up of toxic-appearing neonates
  • The importance of beginning a prostaglandin infusion in patients with suspected ductal-dependent congenital heart disease
  • One of the most common side effects of a prostaglandin infusion – apnea

Clinical Vignette

Your triage nurse comes to tell you about an infant she just put in the resuscitation room who she feels looks quite unwell. He is a 2 week old neonate brought to the ED by his mother. Mom was worried because he hasn’t been feeding very well and seems to just get sleepy when feeding. Now he just vomited his last feed and seems really lethargic. She thinks he just “doesn’t look the right colour”.

Case Summary

A 2-week-old neonate presents in shock requiring the learner to implement an initial broad work-up. The patient will also be hypoglycemic, and will seize if this is not promptly recognized. Physical exam and CXR findings will suggest coarctation of the aorta as the likely cause, and the learner should recognize the need for gentle fluid boluses and a prostaglandin infusion. Unless learners anticipate appropriately and intubate the patient prior to beginning the prostaglandins, the infant will become apneic after starting the infusion and require intubation.

Download the case here: Coarctation of the Aorta Case

ECG for the case found here:

coarc-ecg

(ECG source: http://www.omjournal.org/IssueText.aspx?issId=380)

Initial CXR for the case found here:

chf-neonate

(CXR source: http://www.adhb.govt.nz/newborn/TeachingResources/Radiology/CXR/HLHS/CXR-HLHS-congested.jpg)

Post-intubation CXR for the case found here:

chf-neonate-post-intubation

(CXR source: http://www.adhb.govt.nz/newborn/TeachingResources/Radiology/CXR/OtherCHF/NonstructuralCHF.jpg)

For more information on the management of Congenital Heart Disease Emergencies, see the excellent review by Emergency Medicine Cases found here.

Multi-trauma case: burn and head injury

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

Too often in the Emergency Department, we are faced with the challenge of simultaneously managing two patients who each require immediate care. This case does an excellent job of highlighting the following issues that often arise as a result:

  • The importance of delegating any tasks that may be delegated
  • The need to clarify who is taking ownership of a patient’s management when there is help available from others (such as another ED MD or a trauma team leader)
  • How essential it is to call for help early

In addition, this case also features some key medical content, including:

  • The recognition and treatment of cyanide toxicity in the context of a house fire
  • The preparation and management of a potentially difficult airway
  • The need to perform an escharotomy in a patient with circumferential chest burns and high ventilation pressures
  • The importance of checking a blood glucose on all patients with an altered level of consciousness

Clinical Vignette

Patient A: “You are working in a tertiary care ED. A 33 year old male has just been brought in by EMS after being dragged out of a house fire. He has been unresponsive with EMS and has significant burns to his chest, arm, and leg. The etiology of the fire is unclear, but the home was severely damaged.”

Midway through the case, Patient B will arrive.

Patient B (To be stated by EMS in handover): “We have a 55 year old male here who was repeatedly kicked during an altercation outside a bar. His GCS was 15 on arrival, but it just decreased to 13 in the ambulance bay, and he has become combative. We put him in C-spine collar at the scene. He has lots of bruising to face and head, but no other obvious injuries. When he was more cooperative, the patient denied other medical history or allergies initially.”

Case Summary

The case will begin with the arrival of patient from a house fire who has 30%TBSA burns. The team will be expected to recognize the need for intubation and fluid resuscitation. After successful intubation, a second patient will arrive from an altercation outside a bar. He appears to have a blunt traumatic head injury after being repeatedly kicked. The team is expected to recognize hypoglycemia in the context of a minor head injury and provide immediate glucose replacement. During the management of the head injured patient, the burn patient will continue to by hypotensive. The team will need to recognize the possibility of CN toxicity. The patient will also become more difficult to ventilate and will require an escharotomy.

A Note on Technical Requirements

At McMaster, we recently ran this case for our senior residents. It was a huge success! It did, however, require many resources. We used one high fidelity mannequin and one standardized patient actor. We also had two confederate nurses (one per patient). We had three staff physicians as instructors. One instructor was assigned to observing each patient’s management. The third instructor briefly played the paramedic and also coordinated between the two instructors and the sim tech to ensure the case ran smoothly. We ran the case with five residents participating. We had them pre-assigned to roles of trauma team leader, senior emerg resident, senior anesthesia resident, senior general surgery resident, and senior orthopedic resident. (This is often the make-up of our trauma team.)

Download the case here: Multi-trauma Case: Burn and Head Injury

CXR for Patient B found here:

normal-cxr-patient-b

(CXR source: http://www.pharmacology2000.com/respiratory_anesthesiology/pulmonary_assessment/pulmonary_assessment2.htm)

PXR for Patient B found here:

normal-pelvis-male

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

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)