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.
Category: Resuscitation
Polytrauma for Team Communication
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.
Pregnant Cardiomyopathy
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.
Palliative Respiratory Case
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.
Pediatric Viral Myocarditis
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.
Pediatric Difficult Airway
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.
Iron Overdose in a Pregnant Patient
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.
Electrical Storm
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.
Intubation with Missing BVM
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.
Anaphylaxis and Medication Error
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.
EM Sim Cases 