Resuscitation

LVAD Case

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This week’s case is written by Drs. Ashley Lubberdink and Sameer Sharif. Dr. Lubberdink is a PGY4 Emergency Medicine resident at McMaster University and is just beginning her fellowship in simulation and medical education. Dr. Sharif is a PGY5 Emergency Medicine resident at McMaster University who has just completed his fellowship in simulation and medical education.

Why it Matters

LVADs are pretty uncommon devices! If your practice location is not a hospital that inserts LVADs, then it is likely that you have never come across a patient with an LVAD. Without prior knowledge of these devices, it can be quite distressing trying to assess these patients. This case is designing to highlight the following:

  • LVAD patients do not have a pulse, a measurable blood pressure, or a detectable heart rate on the sat probe
  • To assess for blood pressure, one must insert an arterial line or use a blood pressure cuff and doppler U/S to obtain the MAP
  • Early after LVAD placement, drive line infection and bleeding are common complications
  • Call for help early! These patients generally have care providers who are available to help trouble shoot by phone at all hours of the day

More Reading

For more information on an approach to LVADs, we suggest the following sources:

https://emcrit.org/emcrit/left-ventricular-assist-devices-lvads-2/

https://canadiem.org/lvads-approach-ed/

Clinical Vignette

A 62-year-old male presents to your large community ED with a 1 day history of generalized malaise and nausea and a 2-hour history of palpitations. He is particularly concerned about his symptoms because last month he had an LVAD placed at your provinces’ major cardiac center (3 hours away) for stage 4 CHF. His wife is accompanying him but is currently parking the car.

Case Summary

A 62-year-old man presents to the ED with palpitations and general malaise. On initial assessment, the team finds out he had an LVAD placed within the last 1 month. The team will need to work through how to assess the patient’s vital signs appropriately and will discover the patient has a low MAP and a low-grade fever. On inspection, the patient’s drive line site will appear infected. The initial ECG will show features of hyperkalemia. After the initial assessment, the patient will progress to a PEA arrest requiring resuscitation by ACLS protocols. Labs will reveal an acute kidney injury and hyperkalemia. The patient will obtain ROSC when the hyperkalemia is treated.

Download the case here: LVAD Case

Initial ECG for the case found here:

hyperkalemia

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

Second ECG for the case found here:

hyperkalemia narrow QRS

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

CXR for the case found here:

LVAD-CXR

(CXR source: https://edecmo.org/additional-technologies/ventricular-assist-devices-vads/lvads/)

Picture of drive line site infection found here:

driveline infection A

(Picture source: http://journals.sagepub.com/doi/full/10.1177/1179065217714216)

Echo for case found here:

(Echo source: https://www.youtube.com/watch?v=-4ThAo4m2UI)

Polytrauma for Team Communication

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This case is written by Dr. Chris Heyd. He is a PGY4 Emergency Medicine resident at McMaster University and has spent the last year completing a sub-specialty focus in disaster medicine and simulation. He is also one of our resident editors here at EmSimCases.

Why it Matters

This case highlights some of the challenges that can be associated with activating a trauma team. While the intent is to have many expert hands available to help at once, sometimes the team members arrive in a staggered fashion. This case reviews:

  • The challenges of managing an unstable trauma patient when there are interruptions to the flow of communication
  • The need to expediently place a chest tube in a hypoxic trauma patient
  • The fact that near simultaneous intubation and chest tube placement is often necessary in an unstable trauma patient

Clinical Vignette

To be read aloud by simulation facilitator at start of case:

“You are working as an Emergency physician at a tertiary care trauma centre and have been called overhead to your trauma bay. A paramedic team has just arrived with a 64-year old trauma patient. He was involved in a highway speed head-on MVC. He was restrained and air bags deployed. He was the driver and the other drive died on scene. There were no other passengers. EMS extricated the patient easily. They have placed one IV line and started running normal saline. He has been placed on a non-rebreather mask but has remained tachycardic, hypoxic and altered. GCS has been consistently 14. The trauma team was activated based on injury mechanism but so far only the orthopedic resident has arrived at the bedside.”

Case Summary

A 64-year old man is involved in a high-speed car crash. The trauma team is activated and he is brought directly to the ED. On arrival, he is hypoxic, tachycardic and altered. CXR reveals multiple rib fractures with a right-sided hemopneumothorax.

The team leader will need to effectively communicate with the team to ensure the tasks of intubation, chest tube placement and blood product administration are performed in a safe and quickly. The patient will stabilize after these treatments.

Members of the trauma team will have a staggered entry into the room. The team leader will need to balance communication with the new team members and the urgent interventions needed by the patient.

Download the case here: Polytrauma for Team Communication

CXR for the case found here:

CXR trauma

(CXR source: https://radiopaedia.org/cases/large-traumatic-haemothorax)

PXR for the case found here:

Normal PXR

(PXR source: https://radiopaedia.org/cases/normal-pelvis-x-ray-trauma-supine-1)

Lung U/S showing hemothorax found here:

 

(U/S source: McMaster PoCUS Subspecialty Training Program)

Normal RUQ FAST image found here:

no FF

(U/S source: McMaster PoCUS Subspecialty Training Program)

Pregnant Cardiomyopathy

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This case is written by Drs. Nadia Primiani and Sev Perelman. They are both emergency physicians at Mount Sinai Hospital in Toronto. Dr. Primiani is the postgraduate education coordinator at the Schwartz/Reisman Emergency Centre. Dr. Perelman is the director of SIMSinai.

Why it Matters

Most emergency physicians have some degree of discomfort when a woman in her third trimester presents to the ED for any complaint. When that woman presents in acute distress, the discomfort is increased even further! This case takes learners through the management of a patient with a pregnancy-induced cardiomyopathy, reviewing:

  • The importance of calling for help early
  • The fact that all pregnant patients at term must be presumed to have difficult airways
  • That the treatment of the underlying medical condition is still the primary focus – in this case, BiPap, definitive airway management, and ultimately, inotropic support

Clinical Vignette

You are working in a community ED and your team has been called urgently by the nurse to see a 38 year old female who is G2P1 at 36 weeks gestational age. She was brought in by her sister, who is quite agitated and upset, saying “everybody has been ignoring her symptoms for the last 4 weeks.” The patient has just experienced a syncopal episode at home.

Case Summary

A 38-year-old female G2P1 at 36 weeks GA presents with acute on chronic respiratory distress in addition to chronic peripheral edema. She undergoes respiratory fatigue and hypoxia requiring intubation. She then becomes hypotensive which the team discovers is secondary to cardiogenic shock, requiring vasopressor infusion and consultation with Cardiology/ ICU.

Download the case here: Pregnant Cardiomyopathy

ECG for the case found here:

(ECG source: https://lifeinthefastlane.com/ecg-library/dilated-cardiomyopathy/)

 CXR for case found here:

posttestQ2pulmonaryedema

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

Cardiac Ultrasound for the case found here:

ezgif.com-optimize+(6)

(U/S source: http://www.thepocusatlas.com/echo/2hj4yjl0bcpxxokzzzoyip9mnz1ck5)

Lung U/S for the case found here:

Confluent+B+Lines

(U/S source: http://www.thepocusatlas.com/pulmonary/)

RUQ FAST U/S Image found here:

usruqneg

(U/S source: http://sinaiem.us/tutorials/fast/us-ruq-normal/)

OB U/S found here:

(U/S source: https://www.youtube.com/watch?v=SKKnTLqI_VM)

Palliative Respiratory Case

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This case is written by Dr. Alexandra Stefan. Dr. Stefan is an emergency medicine physician and the Postgraduate Site Director for Emergency Medicine at Sunnybrook Health Sciences Centre in Toronto. She is also an assistant professor in the Division of Emergency Medicine at the University of Toronto. Her areas of interest are postgraduate medical education, simulation (has completed the Harvard Centre for Medical Simulation training course) and global health  education (has participated in teaching trips with Toronto Addis Ababa Academic Collaboration).

Why it Matters

Emergency medicine training is often focused on the many interventions we can make when a patient arrives in distress. This case highlights that sometimes, one of the most important interventions is to determine a patient’s goals of care. It specifically highlights:

  • The importance of pain management as a part of end of life care
  • The need to speak clearly and without medical jargon to establish a patient’s wishes
  • That goals of care conversations often happen in the ED through a substitute decision maker, rather than with the patient directly.

Clinical Vignette

“A 72 year old man from home with acute shortness of breath has just been placed in the resuscitation room. He has a history of lung cancer and is on 2L home oxygen. His daughter Cindy called 911 because he has been getting worse since this morning. He just finished a course of antibiotics for presumed pneumonia. He is on hydromorph contin and prochlorperazine. No allergies. Here is his most recent oncology clinic note.”

Case Summary

A 72-year old male with small cell lung cancer and bony metastases presents with acute shortness of breath. Curative treatment has been stopped and palliative care assessment is pending. He is on home oxygen and has come to the ED as his symptoms could not be controlled at home.

The patient initially improves with oxygen and pain control. He is too confused to engage in discussion about advanced directives. No previous advanced directives or level of care have been documented but, Cindy, the patient’s daughter is available to act as decision maker. She will have a number of questions about her father’s care.

The patient’s respiratory status will deteriorate. Cindy will confirm her father’s wish for comfort measures, to be started by the treating team.

Download the case here: Palliative Resp Case

Download the clinic note required for the case here: Med Onc Note

ECG for the case found here:

ecg sob case

(ECG source: http://www.thecrashcart.org/case-2-post-partum-palpitations/)

CXR for the case found here:

pleural effusion

(CXR source: https://radiopaedia.org/cases/pleural-effusion-7)

Cardiac Ultrasound for the case found here:

 

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

Pediatric Viral Myocarditis

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This case is written by Dr. Adam Cheng. Adam Cheng, MD, FRCPC is Associate Professor, Departments of Paediatrics and Emergency Medicine at the Cumming School of Medicine, University of Calgary.  He is also Scientist, Alberta Children’s Hospital Research Institute and Director, KidSIM-ASPIRE Simulation Research Program, Alberta Children’s Hospital.  Adam is passionate about cardiac arrest, resuscitation, simulation-based education and debriefing. The case has been modified by Drs. Dawn Lim, Andrea Somers, and Nadia Farooki for use at the University of Toronto.

Why it Matters

Myocarditis is a presentation that can be challenging to recognize early. It is often mistaken simply for septic shock. This case highlights some important features of the recognition and management of myocarditis, including:

  • The need to re-evaluate the differential in a patient with persistent hypotension
  • The role of bedside tests in aiding the diagnosis (ECG, POCUS, CXR)
  • The importance of re-evaluating and re-assessing a patient and adjusting the differential diagnosis and management accordingly

Clinical Vignette

You are working in a large community ED. The charge nurse tells you: “EMS have just arrived with a 15-year old boy with shortness of breath and chest pain. His O2 sat is low. EMS have administered oxygen and IVF en route. He looks unwell so I put him in a resuscitation room. Can you see him immediately?”

Case Summary

A 15 year-old male with no prior medical history is brought to the ED by his parents for lethargy, shortness of breath and chest pain. He was feeling run down for the past 4 days with URTI symptoms.

His initial presentation looks like sepsis with a secondary bacterial pneumonia. He becomes hypoxic requiring intubation. He develops hypotension that does not respond as expected to fluids and vasopressors, which should prompt more diagnostics from the team.

Further testing reveals cardiomyopathy with reduced EF and acute CHF. He finally stabilizes with inotropes and diuresis.

 

Download the case here: Pediatric Viral Myocarditis

ECG for the case found here:

sinus-tachy-non-specific-ST-changes

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

CXR for the case found here:

cardiomegaly CHF

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

Cardiac U/S for the case found here:

Parasternal Long

(U/S source: http://www.thepocusatlas.com/echo/xg2awokhx1zx8q3ndwjju5cu4t1adq)

Lung U/S for the case found here:

B lines

(U/S source: https://www.thoracic.org/professionals/clinical-resources/critical-care/clinical-education/quick-hits/orthopnea-in-a-patient-with-doxorubicin-exposure.php)

Pediatric Difficult Airway

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This case is written by Dr. Jonathan Pirie. He is a staff physician in the Division of Pediatric Emergency Medicine and Associate Professor at the University of Toronto. Dr. Pirie is also the Director of Simulation for Pediatric Emergency Medicine and the Simulation Fellowship program. His simulation interests include development of core curricula for postgraduate training programs, in-situ team training, and mastery learning with competency based simulation for trainees and faculty in pediatric technical skills and resuscitation.

Why it Matters

While croup makes stridor a relatively common presentation in the Pediatric ED, today it is quite rare to have a child with stridor who requires definitive airway management. It is exceedingly rare for an Emergency physician to need to proceed to cricothyroidotomy on a child. This case highlights the following:

  • The initial management steps for a child with undifferentiated, severe stridor
  • The need to call for help early
  • The steps required for a needle cricothyroidotomy and the equipment necessary to ventilate a child after this procedure is performed

Clinical Vignette

You are working in the ED, and your team has been called urgently to see a 2-year-old old boy with difficulty breathing. The patient was brought in by his mother, who states he’s had a 2-day history of runny nose. Today he developed a barking cough with fever, and is “breathing with a funny noise.”

Case Summary

The ED team is called to manage a 2-year-old boy in severe respiratory distress with stridor and hypoxia. Initial management steps (humidified O2, nebulized epinephrine and dexamethasone) fail to improve the patient’s respiratory status, and the team must prepare for a difficult intubation. They will encounter difficulties with both bagging and passing the endotracheal tube due to airway edema, which will necessitate an emergency needle cricothyroidotomy.

Download the case here: Pediatric Difficult Airway

Iron Overdose in a Pregnant Patient

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This case is written by Dr. Kate Hayman (@hayman_kate) and Dr. Dawn Lim (@curious doc). Dr. Hayman (MD MPH FRCPC) is an emergency physician at University Health Network and an Assistant Professor at the University of Toronto. Her interests are in health equity, advocacy education, and the use of simulation in low-resource settings.

Why it Matters

Iron toxicity is a relatively rare presentation to the ED. Familiarity with its presentation can be vital to recognizing this potentially lethal overdose. This case highlights the following:

  • The presenting features of moderate to severe iron toxicity
  • The fact that prenatal vitamins contain ferrous fumarate
  • When chelation therapy is indicated for an iron overdose

Clinical Vignette

You are working in a large community ED. You are called to a resuscitation room where EMS has just brought in a 29-year woman with altered mental status. Her boyfriend called 9-1-1 when he found her confused this morning. She is 10 weeks pregnant and had some vomiting and diarrhea yesterday. Her boyfriend is in the waiting room.

Case Summary

A 29-year old woman with a history of depression and an early unplanned pregnancy is found at home with decreased level of consciousness. She comes to the ED with EMS and her boyfriend. She remains altered in the resuscitation room and declines despite aggressive resuscitation.

After gathering history from the boyfriend, it seems likely that she has ingested a large quantity of pre-natal vitamins resulting in iron toxicity. This is confirmed on bloodwork and imaging. She will require airway management, hemodynamic support and specific chelation therapy.

Download the case here: Pregnant Iron OD

AXR for the case found here:

Toxicology_Iron_Tablets-936x1024

(AXR source: https://lifeinthefastlane.com/top-ten-foreign-bodies/)

CXR for the case found here:

post-ETT-CXR

(CXR source: http://jetem.org/ettcxr/)

Abdominal U/S showing IUP for the case found here:

IUP

(U/S source: https://radiologykey.com/first-trimester-pregnancy/)

FAST for the case found here:

Untitled

(U/S source: http://www.emergencyultrasoundteaching.com)

Pelvic U/S for the case found here:

Untitled2

(U/S source: http://www.emergencyultrasoundteaching.com)

Electrical Storm

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This case is written by Dr. Peter Dieckmann and Dr. Marcus Rall of the TuPASS Centre for Safety and Patient Simulation in Germany.

Why it Matters

Electrical Storm is a rare complication of a cardiac arrest. When it is present, the typical therapies for aborting VF are not sufficient. This case reviews the tailored management of this situation, including:

Clinical Vignette

“Arrest arriving in 1 minute. Doctor to resuscitation room STAT.

Paramedic report: “This is a 55 year old male we picked up at an office tower down the street. Apparently he was complaining of feeling unwell all morning and then collapsed at lunch. A colleague started CPR and we were called. The AED delivered 3 shocks. His colleagues say he’s healthy and they’re unsure about meds or allergies. His boss called his wife and she’s on her way.” CPR is ongoing.”

Case Summary

A 55 year-old male is brought to the emergency department with absent vital signs. He collapsed at his office after complaining of feeling unwell. CPR was started by a colleague and continued by EMS. He received 3 shocks by an AED. His downtime is approximately 10 minutes. The team is expected to perform routine ACLS care. When the patient remains in VF despite ACLS management, the team will need to consider specific therapies, such as iv beta blockade or dual sequential shock, in order to abort the electrical storm.

Download the case here: Electrical Storm

Cardiac U/S for the case found here:

(Ultrasound image courtesy of McMaster PoCUS Subspecialty Training Program)

ECG for the case found here:

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

CXR for the case found here:

Normal Post-Intubation CXR

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

Intubation with Missing BVM

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This case is written by Drs. Andrew Petrosoniak and Nicole Kester-Greene. Dr. Andrew Petrosoniak is an emergency physician and trauma team leader at St. Michael’s Hospital. He’s an assistant professor at the University of Toronto and an associate scientist at the Li Ka Shing Knowledge Institute.  Dr. Nicole Kester-Greene is a staff physician at Sunnybrook Health Sciences Centre in the Department of Emergency Services and an assistant professor in the Department of Medicine, Division of Emergency Medicine. She has completed a simulation educators training course at Harvard Centre for Medical Simulation and is currently Director of Emergency Medicine Simulation at Sunnybrook.

Why it Matters

Emergency medicine is about anticipating the worst and preparing for it . This case highlights this perfectly. In particular, it emphasizes:

  • The need to have a mental (or physical) checklist to ensure all necessary equipment is available at the bedside before starting a procedure
  • The complex nature of managing an immunocompromised patient with respiratory illness
  • The role for intubation in a hypoxic patient

Clinical Vignette

You are working in a large community ED. The triage nurse tells you that she has just put a patient in the resuscitation room. He is a 41-year old man with HIV. He is known to be non-compliant with his anti-retrovirals. He noticed progressive shortness of breath over 3-4 days and has had a dry cough for 10 days. His O2 sat was in the 80s at triage.

Case Summary

A 41-year old male with HIV (not on treatment) presents to the ED with a cough for 10 days, progressive dyspnea and fever. He is hypoxic at triage and brought immediately to the resuscitation room. He has transient improvement on oxygen but then has progressive worsening of his hypoxia and dyspnea. Intubation is required. The team needs to prepare for RSI and identify that the BVM is missing from the room prior to intubation.

Download the case here: Intubation with Missing BVM

CXR for the case found here:

PJP pneumonia

(CXR source: https://radiopaedia.org/cases/35823)

 

Anaphylaxis and Medication Error

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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

Anaphylaxis is a very common presentation to the ED. Knowing how to treat it expediently is essential. This case is designed to review common errors made by junior learners in the emergency department. In particular, it reviews:

  • The need to prioritize epinephrine above all other medications
  • The IM dosing of epinephrine
  • The need to understand the different concentrations of epinephrine available and how to avoid medication errors that occur as a result

Clinical Vignette

Report from EMS:

“This patient was recently prescribed Levofloxacin for a presumed pneumonia by his family MD. Approximately one hour after his first dose he developed a diffuse pruritic rash and felt acutely dyspneic. He denies any chest pain, syncope, fever or diaphoresis. He has not had Levofloxacin prior and there is no previous history of this. The highest SBP we could get was 90 by palp. Heart rate has been around 100. We’ve been unable to get an IV. Epi 0.5 IM x 1 has been given.”

Case Summary

A 59-year-old male presents to the ED with anaphylaxis. He has already received a dose of epinephrine by EMS. On arrival, he will be wheezing and hypotensive with angioedema. Learners will be expected to provide repeat dosing of epinephrine as well as to start an epinephrine infusion in order for the patient to improve. They will also be expected to prepare for intubation. To highlight common errors in anaphylaxis treatment, a nurse will delay giving epinephrine unless specifically instructed to give it before other medications. The nurse will also attempt to give the cardiac epinephrine, requiring the team leader to clarify proper dosing. Once an epinephrine infusion has started, the patient’s angioedema and breathing will improve.

Download the case here: Anaphylaxis