A 46 year-old male presents with a GCS of 3 after being found in the back alley behind a drug store. The team will need to work through a broad differential diagnosis and recognize the need to intubate the patient. If they try naloxone, it will have no effect. After intubation, the team will receive critical VBG results showing a profound metabolic acidosis with a significant anion gap. The goal is to trigger the team to work through the possible causes of an elevated anion gap, including toxic alcohols.
Category: Resuscitation
Thyroid Storm
A 31 year-old-female presents by EMS with altered LOC and fever due to thyroid storm precipitated by recent parturition. The patient is tachycardic and hypoxic on arrival. Her level of consciousness will continue to deteriorate despite IV fluids and antibiotics and will require intubation. The husband will be at the bedside, and the team will need to discuss the need for intubation with him. After intubation, lab results will come back indicating possible thyrotoxicosis. The patient's rhythm will change to atrial fibrillation at this time. The team will be expected to manage the thyroid storm in consultation with Endocrinology and ICU.
Status Epilepticus
A 38 year-old female presents actively seizing with EMS. She will fail to respond to repeat doses of IV benzodiazepines, and will require escalating medial management. Following phenytoin infusion, the patient will become hypotensive (because the phenytoin was given as a “push dose”, which the nurse will mention). The patient will then stop her GTC seizure, but will remain unresponsive with eye deviation. The team should recognize this as subclinical status, and proceed to intubate the patient. The patient will continue to seize following phenobarbital and propofol infusion. Urgent consults to radiology and ICU should be made to expedite care out of the ED. The team will be expected to debrief the phenytoin medication error and disclose the error to the husband.
VSA Megacode
A 54-year-old male police officer presents to the ED complaining of chest pain for two hours that started after his weekend hockey game. He is feeling dizzy and short of breath upon presentation. He will have a VT arrest as he is placed on the monitor. He will require two shocks and rounds of CPR before he has ROSC. He will then loose his pulse again while the team is trying to initiate post-arrest care; this will happen several times. Finally, the team will maintain ROSC. When an ECG is performed, it is revealed that the patient has a STEMI and the team will need to call for emergent PCI.
Tumour Lysis Syndrome
A 72-year-old male is brought in as a “code STEMI” to the resuscitation bay. He was recently diagnosed with ALL and had chemotherapy 3 days ago for the first time. The patient is severely hyperkalemic, which must be initially recognized and treated, hypocalcemic and hyperuricemic as a result of Tumour Lysis Syndrome and the metabolic derangements must be stabilized until emergent hemodialysis is arranged.
Obstetrical Trauma
A 33 year old G2P1 female at 32 weeks GA presents with blunt trauma following an MVC. She will be hypotensive due to both hypovolemic shock from a pelvic fracture and obstructive shock from a tension pneumothorax. Fetal monitoring will show the fetus in distress with tachycardia and late decelerations. Early airway intervention should be employed, with thoughtful selection of drugs for sedation and paralysis given the pregnancy. After intubation, the patient will remain hypotensive. She will require massive transfusion and coordination of care between orthopedics, general surgery, and obstetrics. The patient’s husband will also arrive after intubation and the team must give him the bad news.
Pancreatitis with ARDS
A 50 year-old female who was “on a bender” over the weekend now presents with diffuse abdominal pain and persistent nausea and vomiting. She will have a diffusely tender abdomen, a BP of 80/40, and be tachycardic. The team will need to work through a broad differential diagnosis and should fluid resuscitate aggressively. Once the patient has received 6L of fluid, she will become tachypneic and hypoxic and require intubation. The team will be given a lipase result just prior.
Digoxin Overdose
This case is written by Dr. Kyla Caners. She is a PGY5 Emergency Medicine resident at McMaster University and is also one of the Editors-in-Chief here at EMSimCases. Why it Matters Digoxin toxicity is of critical importance to recognize. There are many subtleties to its management, which means that the concepts of digoxin toxicity are important … Continue reading Digoxin Overdose
Ruptured Ectopic
26 year-old female, recently immigrated from Cambodia, presents after a syncopal episode at home. At the case outset, she complains of feeling “a little dizzy” and has a HR of 100 and a BP of 90/60. Once the team initiates care, the patient will say she has to vomit and then become poorly responsive and more hypotensive. The patient does not know that she is pregnant, so the team will have to consider the diagnosis early and use bedside U/S to point them in the right direction. The team will then need to initiate a massive transfusion and arrange for surgery. If the ectopic pregnancy is not recognized, the patient will become persistently more hypotensive until she has a PEA arrest.
Hypothermia with Trauma
30 year-old female is brought into the ED at 4 AM by a man who found her lying at the side of the road with no coat or shoes. It is minus 30 degrees Celsius outside. On arrival she has a reduced LOC, laboured breathing, a right-sided pneumothorax, cyanotic extremities, a left radius & ulna fracture, and a right tib-fib fracture. The team is required to use both active and passive rewarming strategies. Regardless of the team’s efforts, the patient in this case will arrest. Upon ROSC, they are required to continue rewarming as well as to address the other traumatic injuries.
EM Sim Cases 