A three-year-old child was swimming with their family, when they wandered into the deep end and submerged under water. The parents noticed the child was below the surface. When the child was brought to the surface, they were unconscious and coughing up foam. EHS arrived, provided oxygen supplementation, and brought them to your tertiary emergency department, with access to PICU. In the ED, the child is unconscious with increasing respiratory distress, requiring intubation. Despite intubation, the child remains hypoxemic and the team works through an approach to post-intubation hypoxemia. Unfortunately, the child becomes bradycardic. The team should begin CPR and follow the PALS pediatric bradycardia algorithm. PICU should be called if not already involved. After one round of CPR, the patient’s heart rate will increase and the consulting team should arrive.
Category: Resuscitation
GSW Vascular Injury
Adult male with penetrating extremity and chest trauma (gun shot wounds) with peripheral vascular compromise. The patient needs a thorough and systematic approach despite distracting injuries. For both junior and senior learners, the patient progresses from threatened limb (requiring emergent investigation) to a pulseless limb (requiring emergent OR). For senior learners, there will be an additional element of instability from the penetrating chest injury requiring chest tube.
Bronchiolitis
Four days ago, an older sibling who recently started pre-school had a cold. The next day, Zarah fell sick. She has had a runny nose and cough but seemed to be doing fine until yesterday when she did not eat or drink very much. This morning, she had some noisy breathing, and her chest looked funny while she was breathing. When it did not go away after a couple of hours, Zarah’s parents called 811 for advice. They were directed to go to the emergency department. The patient will progress through escalating respiratory support and eventually require intubation and transfer to higher level of care.
Ending a resuscitation
The medical aspect of this case is a relatively straight-forward out-of-hospital cardiac arrest where the team must recognize futility and make the decision to stop resuscitation efforts. The primary goal is simulating the experience of making a termination of resuscitation decision, and managing the impacts of a patient’s death. Other goals could also be scaffolded onto this scenario as deemed appropriate by the simulation instructor, including breaking bad news to family member or a simulated hot debrief with the team.
Accidental Hypothermia
A 24-year-old previously healthy male presents to the ED with absent vital signs. He is out for a trail run when he becomes trapped in waist deep cold water. When he is found by search and rescue, he is awake with altered mental status. He has a cardiac arrest on retrieval and is found to be severely hypothermic. CPR and ACLS is initiated and he is transferred to the nearest community ED. The resuscitation team is expected to perform ACLS specific to hypothermic arrest. The patient will require intubation, active rewarming, defibrillation and discussion with the ECMO physician on call for transport and ECMO assisted rewarming.
Tracheostomy Emergency
48-year-old male with a recent tracheostomy presents with sudden onset respiratory distress. The patient is unable to be oxygenated or ventilated through the tracheostomy tube. The team must recognize that the tracheostomy tube is either obstructed or displaced. Attempts to correct tracheostomy obstruction with suctioning and cuff deflation are not successful. Removal of the tracheostomy tube is required, followed by either oral intubation or placement of a new tracheostomy tube. The patient improves once oral or stomal intubation is performed. If tracheostomy tube is not removed, the patient worsens and goes into cardiac arrest secondary to respiratory failure.
Pediatric Status Epilepticus
Pre-notification is sent about an 8-year-old with known seizure disorder coming in via EMS who has been seizing for 7 minutes and is persistently seizing despite intramuscular midazolam. The case will involve managing pediatric status epilepticus and including escalating anti-epileptics, intubation, and handing over to pediatrics.
Trauma Airway Management
Securing the airway of a severely traumatized patient is fraught with difficulties. There can be anatomic difficulties associated with facial and neck injuries. There are often physiologic difficulties from uncommon causes of shock (like pericardial tamponade). But emergency physicians have all the skills needed to safely handle any trauma airway!
Nightmares Case 10: Anaphylaxis
This is the tenth case in a series we are publishing that make up “The Nightmares Course” - a Sim Bootcamp for new residents. 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 … Continue reading Nightmares Case 10: Anaphylaxis
Undifferentiated Abdominal Pain + Shock
A 67yr old male with multiple comorbidities is brought by ambulance with a 3-day history of diffuse abdominal pain. The history is vague and the differential of his symptoms remains very broad. He develops significantly worsening pain and hypotension and becomes obtunded. As the patient’s condition deteriorates, the team must initiate management of abdominal pain plus shock and support the hemodynamics with vasopressors/inotropes. The team will need to intubate to facilitate advanced imaging and definitive care.
EM Sim Cases 