A 60-year old farmer presents to the ED with a runny nose, vomiting and diarrhea. He feels short of breath and dizzy. He looks so unwell that he is placed into the resuscitation bay. Initial vital sign show tachypnea, hypoxia, and bradycardia. You are immediately concerned about the copious nasal and oral secretions.
Category: Toxicology
Alcohol and opioid use
These cases come to us from Drs. Jessica Pelletier and Anne Ickes. Jessica Pelletier, DO is an Emergency Medicine Education Fellow at Washington University School of Medicine in St. Louis. Her interests include harm reduction, the use of simulation for difficult conversations and procedural preparedness, and the use of osteopathic manipulation for pain control in … Continue reading Alcohol and opioid use
Nightmares Case 11: Opioid Overdose
This is the eleventh case in a series we are publishing that make up “The Nightmares Course” – a Sim Bootcamp for new residents. It’s 23:00 and you’re called to assess a 42-year old man who is difficult to rouse on evening rounds.
Armed Overdose
In this case a 44 y/o M is brought in via EMS after receiving 0.4mg of naloxone for what is suspected to be an opioid overdose. He remains GCS 7 upon arrival in the resuscitation bay. The team will need to work through the differential for altered LoC and will find drug paraphernalia and a loaded weapon on the patient upon inspection. The case will end with successful treatment and consultation with local police with regard to weapon and contraband protocols.
Beta Blocker Toxicity
A 44-year-old male presents to the emergency department following the ingestion of an entire bottle of metoprolol. Decontamination strategies should be utilized alongside consultation with poison control. Patient clinically deteriorates as the drug reaches peak effects, requiring IV fluids, atropine, calcium, glucagon, multi-dose vasopressors, high dose insulin, and a discussion around potential salvage therapies.
Local Anesthetic Systemic Toxicity
A femoral nerve block has just been performed on a 65-year-old male who sustained a right femoral neck fracture. The patient also sustained a laceration to the scalp which was repaired by the medical student. The patient is now complaining of blurry vision, paresthesias, and “twitchiness”. The patient progresses on to seizure followed by cardiac arrest and will need high quality ACLS care along with lipid emulsion therapy.
COVID-19: Respiratory Failure
This case was designed during the January 2020 COVID-19 outbreak in order to assess and improve team preparedness for safely and effectively caring for a critically ill coronavirus patient from triage through to intubation.
Geriatric Case 2: Chronic Digoxin Toxicity
An 85-year-old man presents after a fall at home. He is complaining of dizziness and has a HR of 30. Further assessment reveals chronic digoxin toxicity and a concurrent UTI with acute renal failure. The patient requires management of his bradycardia and acute renal failure with specific management of chronic digoxin toxicity including a discussion with toxicology and administration of Digibind.
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.
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.
EM Sim Cases 