A 63-year-old female is in the Emergency Department awaiting internal medicine consultation for a diagnosed pulmonary embolism. She suddenly becomes very short of breath while walking to the bathroom and the team is called to assess. The patent will then arrest, necessitating thrombolysis. After ROSC, she will stabilize briefly but then develop increasing vasopressor requirements. The team will need to work through the shock differential diagnosis and recognize free fluid in the abdomen as a complication of thrombolysis requiring surgical consultation and transfusion.
Category: Resuscitation
Stable VT with ICD Firing
A 40-year-old male presents to the ED complaining that his ICD keeps firing. He will have a HR of 180 and VT on the monitor. He will occasionally yell “ow.” The team will need to work through medical management of VT, while considering magnet placement for patient comfort. The patient will remain stable but will trigger VT with his agitation.
Newborn Resuscitation
The team has been called to help in the ED where a woman just precipitously gave birth to a baby now requiring resuscitation. The mom thinks she’s at term. She has had no prenatal care and is an iv drug user. The baby will be flat. After stimulation and drying, the baby will have a HR <100 and PPV will be required. After 60 seconds, the HR will still be <60 and CPR will need to be started. This will be short lived. The team will also need to intubate and obtain IV access.
Burn with CO/CN Toxicity
A 33 year-old female is dragged out of a burning house and presents to the ED unresponsive. She has soot on her face, singed eyebrows, and burns to her entire chest, the front of her right arm, and part of her right leg. She is hypotensive and tachycardic with a GCS of 3. The team should proceed to intubate and fluid resuscitate. After this, the team will receive a critical VBG result that reveals profound metabolic acidosis, carboxyhemoglobin of 25 and a lactate of 11. If the potential for cyanide toxicity is recognized and treated, the case will end. If it is not, the patient will proceed to VT arrest.
STEMI with Cardiogenic Shock
A 55-year-old man presents to the ED as a STEMI call. He is profoundly hypotensive with low O2 sats and obvious CHF. The patient’s blood pressure will transiently respond to fluid resuscitation. The ECG will show anterolateral ST elevation. The team will need to prepare for intubation while activating the cath lab. They will also need to start vasopressors. The patient will remain hypotensive until an inotrope like dobutamine is initiated. If unsafe medications are chosen for intubation, the patient will have a VT arrest.
ASA Toxicity
The learner will be presented with an altered febrile patient, requiring an initial broad work-up and management plan. The learner will receive a critical VBG report of severe acidosis, hypoglycemia and hypokalemia, requiring management. Following this, the rest of the blood work and investigations will come back, giving the diagnosis of salicylate overdose. The patient’s mental status will continue to decline and learners should proceed to intubate the patient, anticipating issues given the acid-base status. The learner should also initiate urinary alkalinization and make arrangements for urgent dialysis.
Aortic Stenosis with A Fib and CHF
A 78-year-old male presents with increased SOB over the past 4 days. A recent ECHO will be presented showing severe AS. The ECG will demonstrate new A Fib with a HR of 150 and the CXR will show CHF. The patient will be normotensive at first but will become hypotensive shortly after. The team will then need to decide whether to cardiovert the patient or attempt rate control. If these are done safely, the patient will respond and then develop worsening CHF. Definitive management should be sought with early cardiology/cardiac surgery consult. If management is not carried out judiciously, the patient will become profoundly hypotensive.
STEMI with Bradycardia
A 65-year-old female is brought to the ED with chest tightness and SOB. On arrival, she will be found to have an inferior STEMI with resultant 3rd degree heart block and hypotension. The team will be expected to initiate vasopressor support and transcutaneous pacing. However, prior to doing so, the patient will develop a VT arrest requiring ACLS care. After ROSC, the team will need to initiate transcutaneous pacing and activate the cath lab for definitive management.
Multi-Trauma: Blunt VSA and Burn
The case will start with an EMS patch indicating that they are 2 minutes out with multi-trauma from a 2 car MVC. Two patients will then arrive within 1 minute of each other. The first will have gone VSA en route from presumed blunt trauma. This patient will not regain a pulse. The second patient will arrive with significant burns from a car fire, and will have GCS of 3 necessitating intubation. All attempts at intubation will be unsuccessful, and a surgical airway must be performed. The team will need to prioritize resources between the two patients and realize that an ED thoracotomy is not reasonable in the first patient.
Anaphylaxis with Angioedema
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.
EM Sim Cases 