Mr. Johnson, a 60-year old man was found at the bottom of 3 steps at home by his wife. He is obtunded with obvious bruising to head. EMS has placed him in a C-spine collar and provided supplemental oxygen. He was swabbed for COVID yesterday due to a new cough and fever and the results are still pending.
A 44-year-old male presents to the emergency department following the ingestion of an entire bottle of metoprolol. Decontamination strategies should be utilized alongside consultation with poison control. Patient clinically deteriorates as the drug reaches peak effects, requiring IV fluids, atropine, calcium, glucagon, multi-dose vasopressors, high dose insulin, and a discussion around potential salvage therapies.
Elliot, a seven-year old boy, is brought to the emergency department after six days of fever and lethargy. He has a rash, diarrhea and decreased urine output. Both his parents are healthcare workers with possible COVID-19 exposures.
A 53 year old male with untreated hypertension presents with a history of vomiting, back pain and acute agitation. Once he is sedated, assessment will reveal an acute aortic dissection. He will require prompt treatment, intubation and disposition planning.
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.