ASA Toxicity

This case is written by Dr. Donika Orlich. She is a staff physician practising in the Greater Toronto Area. She completed her Emergency Medicine training at McMaster University and also obtained a fellowship in Simulation and Medical Education.

Why it Matters

Salicylate toxicity, while relatively rare, has fairly nuanced management. It is important for physicians to be aware of presenting features of the toxicity and also of key management steps. Some pearls from this case include:

  • That hypoglycemia (and neuroglycopenia) is a manifestation of ASA toxicity.
  • Urine alkalinization (and correction of hypokalemia) is an important initial treatment for suspected toxicity.
  • Should a patient require intubation, it is paramount to set the ventilator to match the patient’s pre-intubation respiratory rate as best as possible.
  • Dialysis is indicated in intubated patients and also in patients with profoundly altered mental status, high measured ASA levels, and renal failure.

Clinical Vignette

You are working at a community hospital. The triage nurse comes to tell you that they have just put an 82 year-old male in a resuscitation room. He was found unresponsive by his daughter and was brought in by EMS. In triage he was profoundly altered, febrile and hypotensive. His daughter is in the room with him.

Case Summary

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.

Download the case here: ASA Toxicity

ECG for the case found here:

Hypokalemia ECG

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

Initial CXR for the case found here:

ards pre intubation

(CXR source: http://www.radiology.vcu.edu/programs/residents/quiz/pulm_cotw/PulmonConf/09-03-04/68yM%2008-03-04%20CXR.jpg)

Post-intubation CXR for the case found here:

ARDS post intubation

(CXR source: http://courses.washington.edu/med620/images/mv_c3fig1.jpg)

FAST showing no free fluid found here:

no FF

Pericardial U/S showing no PCE found here:

Abdominal U/S showing no AAA found here:

no AAA

All U/S images are courtesy of McMaster PoCUS Subspecialty Training Program.

Serotonin Syndrome

This case is written by Dr. Donika Orlich. She is a PGY5 Emergency Medicine resident at McMaster University who also completed a fellowship in Simulation and Medical Education last year.

Why it Matters

This case is an example of why it is important to keep a broad differential in our patients. It would be easy to assume this patient has sepsis and to form cognitive biases around only this as a possible presentation. Instead, by maintaining a broad differential diagnosis, a relatively rare presentation is recognized. This case highlights the following:

  • The presenting features of serotonin syndrome: agitation, confusion, clonus, and hyperthermia
  • The management priorities in serotonin syndrome include both minimizing patient agitation with benzodiazepines and aggressive cooling
  • The potential for sodium channel blockade (and a resultant wide QRS pattern on ECG) with cocaine use
  • The potential for patients with a prolonged QT interval to develop Torsades de Pointes
  • The need to treat Torsades de Pointes with magnesium sulfate and defibrillation

Case Summary

A 27-year-old female presents hot and altered to the ED with EMS. Likely cause is serotonin syndrome, precipitated by being on citalopram and methadone in the setting of a recent cocaine binge (all increase serotonin levels). She will develop Torsades de Pointes as a complication which must be treated with MgSO4. She will become increasingly agitated and febrile, requiring IV benzodiazepines, active cooling, and consideration of intubation with paralysis to achieve normothermia.

Clinical Vignette

A 27-year-old female was found by her boyfriend this morning seeming confused and warm. He called EMS. She has a history of opioid abuse and is on methadone, but he swears that she has takes this as prescribed and has not done any prescription pain meds lately. They did “party a lot yesterday,” but she was otherwise well, with no complaints of fever before today. With EMS the patient was noted to be diaphoretic, febrile and quite agitated. She has been placed in a resuscitation bay.

Download the case here: Serotonin Syndrome

1st ECG for the case (long QT and wide QRS) found here:

Wide QRS

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

2nd ECG for the case (long QT) found here:

Long QT ECG

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

3rd ECG for the case (Torsades de Pointes) found here:

Torsades ECG

(ECG source: https://en.wikipedia.org/wiki/Torsades_de_pointes)

Normal CXR found here:

normal female CXR radiopedia

(CXR source: https://radiopaedia.org/cases/normal-chest-radiograph-female-1)

Post-intubation CXR found here:

normal-intubation2

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

Multi-drug Overdose

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

Calcium channel blocker overdoses are one of the most difficult overdoses for emergency physicians to manage. Even with excellent care, these patients often progress to cardiac arrest or to needing ECMO. This case highlights some key features in management, including:

  • The use of calcium gluconate and high-d0se insulin infusions to assist with blood pressure support (in isolation or in addition to other vasopressors)
  • The use of intralipid as an end of the line rescue treatment
  • The need to consider co-ingestions and their effects on management (in this case, clonazepam that slows the patient’s respiratory rate enough to require intubation)

Clinical Vigenette

A 48-year-old female presents to the ED with an unknown overdose. She was out drinking with friends until an hour ago. Her daughter came home and found her with vomit around her, empty pill bottles, and bits of pills in her vomit.

Case Summary

A 48-year-old female presents with a possible multi-drug overdose including glyburide, clonazepam and nifedipine. She will remain hypotensive throughout the case, despite treatment with calcium, high dose insulin, and other vasopressors. She will also have progressive respiratory depression and will eventually require intubation. She will then proceed to arrest. The team will be expected to give intralipid once the patient has arrested.

Download the case here: Multi-drug (CCB) OD

ECG for the case found here:

sinus brady with 1st degree hb

(ECG source: http://lifeinthefastlane.com/ecg-library/beta-blocker-and-calcium-channel-blocker-toxicity/sb-1hb/)

Post-intubation CXR for the case found here:

normal-intubation2

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

Multi-trauma case: burn and head injury

This case is written by Dr. Donika Orlich. She is a PGY5 Emergency Medicine resident at McMaster University who also completed a fellowship in Simulation and Medical Education last year.

Why it Matters

Too often in the Emergency Department, we are faced with the challenge of simultaneously managing two patients who each require immediate care. This case does an excellent job of highlighting the following issues that often arise as a result:

  • The importance of delegating any tasks that may be delegated
  • The need to clarify who is taking ownership of a patient’s management when there is help available from others (such as another ED MD or a trauma team leader)
  • How essential it is to call for help early

In addition, this case also features some key medical content, including:

  • The recognition and treatment of cyanide toxicity in the context of a house fire
  • The preparation and management of a potentially difficult airway
  • The need to perform an escharotomy in a patient with circumferential chest burns and high ventilation pressures
  • The importance of checking a blood glucose on all patients with an altered level of consciousness

Clinical Vignette

Patient A: “You are working in a tertiary care ED. A 33 year old male has just been brought in by EMS after being dragged out of a house fire. He has been unresponsive with EMS and has significant burns to his chest, arm, and leg. The etiology of the fire is unclear, but the home was severely damaged.”

Midway through the case, Patient B will arrive.

Patient B (To be stated by EMS in handover): “We have a 55 year old male here who was repeatedly kicked during an altercation outside a bar. His GCS was 15 on arrival, but it just decreased to 13 in the ambulance bay, and he has become combative. We put him in C-spine collar at the scene. He has lots of bruising to face and head, but no other obvious injuries. When he was more cooperative, the patient denied other medical history or allergies initially.”

Case Summary

The case will begin with the arrival of patient from a house fire who has 30%TBSA burns. The team will be expected to recognize the need for intubation and fluid resuscitation. After successful intubation, a second patient will arrive from an altercation outside a bar. He appears to have a blunt traumatic head injury after being repeatedly kicked. The team is expected to recognize hypoglycemia in the context of a minor head injury and provide immediate glucose replacement. During the management of the head injured patient, the burn patient will continue to by hypotensive. The team will need to recognize the possibility of CN toxicity. The patient will also become more difficult to ventilate and will require an escharotomy.

A Note on Technical Requirements

At McMaster, we recently ran this case for our senior residents. It was a huge success! It did, however, require many resources. We used one high fidelity mannequin and one standardized patient actor. We also had two confederate nurses (one per patient). We had three staff physicians as instructors. One instructor was assigned to observing each patient’s management. The third instructor briefly played the paramedic and also coordinated between the two instructors and the sim tech to ensure the case ran smoothly. We ran the case with five residents participating. We had them pre-assigned to roles of trauma team leader, senior emerg resident, senior anesthesia resident, senior general surgery resident, and senior orthopedic resident. (This is often the make-up of our trauma team.)

Download the case here: Multi-trauma Case: Burn and Head Injury

CXR for Patient B found here:

normal-cxr-patient-b

(CXR source: http://www.pharmacology2000.com/respiratory_anesthesiology/pulmonary_assessment/pulmonary_assessment2.htm)

PXR for Patient B found here:

normal-pelvis-male

(PXR source: http://radiopaedia.org/articles/pelvis-1)

Toxic Alcohol Ingestion

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

While toxic alcohol ingestions requiring treatment are relatively rare, patients presenting with a profoundly altered mental status are not. This case highlights key features of each, including:

  • The need for a broad differential in patients with an altered mental status (especially when there is absolutely no relevant history available!)
  • The importance of identifying and working through causes of an anion gap metabolic acidosis
  • The empiric and definitive treatments of a toxic alcohol overdose

Clinical Vignette

EMS has just brought you to a patient with a GCS of 3. He was found in the back alley behind a drug store with no identifying information. He is not known to EMS or to your department. He appears to be in his 30s or 40s.

Case Summary

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.

Download the case here: Toxic Alcohol Case

ECG for the case found here:

Sinus tachycardia

(ECG source: http://i0.wp.com/lifeinthefastlane.com/wp-content/uploads/2011/12/sinus-tachycardia.jpg)

Post-intubation CXR for the case found here:

Post-Intubation

Post Intubation

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

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 to review. This case highlights some key features of chronic digoxin toxicity. In particular:

  • The importance of considering digoxin toxicity in essentially all patients who take digoxin (due to its vague symptomatology)
  • The classic ECG rhythm seen in toxicity: bidirectional VT
  • The importance of treating digoxin toxicity early (and before a level is back) in the unstable patient with suspected toxicity
  • How to dose digibind for management of toxicity

This case is likely to push the knowledge capacity of junior learners. For senior learners, the case could be modified to include a less pathognomonic rhythm at the case onset. For example, a slow a fib could be used. Rapidly alternating between fast and slow rhythms would be another excellent alternative.

Clinical Vignette

Mildred Funk is a 90 year old woman who is brought to the ED by her daughter because of confusion. She had some vomiting and diarrhea recently and hasn’t been eating or drinking much since. Today, she seems confused and keeps complaining that she’s dizzy to her daughter

Case Summary

A 90 year-old woman is brought to ED by her daughter because of confusion. She recently had a bought of vomiting and diarrhea and hasn’t been taking much PO since. Today, she is less responsive, seems confused, and is complaining of being dizzy. The team will be given a copy of the patient’s medication list, which will include digoxin. On arrival, the patient will be hypotensive and her rhythm will be bi-directional VT. Ideally, the team should give digibind. If they do not, they will receive blood work back with a high level to trigger administration.

Download the case here: Digoxin Overdose

ECG #1 for the case found here:

Bidirectional-VT

(ECG source: http://cdn.lifeinthefastlane.com/wp-content/uploads/2011/04/Bidirectional-VT.jpg)

ECG #2 for the case found here:

afib.jpg

(ECG source: http://cdn.lifeinthefastlane.com/wp-content/uploads/2011/08/af1.jpg)

CXR for the case found here:

normal-female-chest

(CXR source: http://radiopaedia.org/articles/normal-position-of-diaphragms-on-chest-radiography)

ASA 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

Aspirin toxicity causes a complex array of direct and indirect physiologic effects. There are several key factors in the management of aspirin toxicity that this case reviews:

  • Urinary alkalinization is important to help renal clearance and to reduce the CNS effects of ASA
  • Altered LOC is an ominous sign that can be due to either neuroglycopenia or cerebral edema
  • Intubation of a patient with ASA toxicity is high-risk due to their requirement for a high respiratory rate. In fact, in the context of ASA overdose, intubation is an indication for dialysis.

Clinical Vignette

A 22 year-old female presents to the ED saying she just ingested 60 tablets of ASA because she wants to die. Her mom found her while she was finishing the bottle of 325mg tabs approximately 60 minutes ago and called EMS. The patient is complaining of nausea and tinnitus.

Case Summary

22 year-old female presents saying she just ingested 60 tablets of ASA because she wants to die. Her mom found her while she was finishing the bottle of 325mg tabs approximately 60 minutes ago and called EMS. The patient is complaining of nausea and tinnitus and is tachypneic. The team should consider activated charcoal and alkalinize the urine. If they do not initiate treatments, they will receive a critical VBG showing a mixed respiratory alkalosis and metabolic acidosis. The patient will then become somnolent. The team will be expected to check her blood sugar and call for dialysis. They will also need to intubate and recognize the need to hyperventilate and dialyze.

Download the case here: ASA Overdose

ECG for case found here:

Sinus tachycardia 115

(ECG source: http://en.ecgpedia.org/wiki/File:Sinustachycardia.jpg)

CXR for case found here:

normal-female-chest

(CXR source: http://radiologypics.com/2013/01/25/normal-female-chest-radiograph/)

Post-intubation CXR for case found here:

Post Intubation

Post Intubation

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

Opioid Overdose with ARDS

This case was written by Dr. Martin Kuuskne from McGill University. Dr. Kuuskne is a PGY4 Emergency Medicine resident and one of the editors-in-chief at EMSimCases.

Why it Matters

Opioid toxicity is a clinical diagnosis that should be rapidly recognized and managed. This case highlights four important aspects of a patient presenting after an opioid overdose:

  • Maintaining and addressing a wide differential diagnosis for the comatose patient.
  • Indications for and dosing of naloxone in the treatment of opioid toxicity.
  • Preoxygenation and intubation of a patient in the setting of significant hypoxemia.
  • Recognition of heroin associated acute respiratory distress syndrome (ARDS), a rare complication of opioid toxicity.

Clinical Vignette 

You are working in a community centre emergency department. A 34-year-old male is being brought into the resuscitation bay by EMS after being found unconscious in an alley-way by bystanders who called 911. The patient was given O2 by facemask and no other therapies en-route.

Case Summary

A 34-year-old male was found unconscious in an alleyway by bystanders who called EMS. The patient presents with a clinical opioid intoxication requiring naloxone administration. The patient also presents with acute respiratory distress syndrome (ARDS) secondary to heroin use requiring airway support, intubation and mechanical ventilation.

Download the case here: Opioid Overdose with ARDS

Preintubation CXR for case found here: 

Pre-intuabtion

(CXR source: http://www.radiology.vcu.edu/programs/residents/quiz/pulm_cotw/PulmonConf/09-03-04/68yM%2008-03-04%20CXR.jpg)

Postintubation CXR for case found here:

Post intubation

(CXR source: http://courses.washington.edu/med620/images/mv_c3fig1.jpg)

ECG for case found here: 

EKG

(ECG source: http://www.emedu.org/ecg/images/sb_1a.jpg)

Lung ultrasound for case found here: 

Tricyclic Antidepressant Overdose

This case was written by Dr. Martin Kuuskne from McGill University. Dr. Kuuskne is a PGY4 Emergency Medicine resident and one of the editors-in-chief at EMSimCases.

Why it Matters

Although largely replaced by newer and safer agents for the treatment of depression, tricyclic antidepressants are still routinely prescribed, especially for chronic pain. This case highlights three important aspects of the management of a tricyclic overdose:

  • The generous use of intravenous sodium bicarbonate therapy for sodium-channel blockade
  • The maintenance of a broad differential diagnosis for a patient with altered mental status and fever
  • The application of a rhythm-based or traditional approach to pulseless electrical activity (PEA)

Clinical Vignette

You are working an evening shift in a tertiary care hospital emergency department. A 27-year-old male is brought to the resuscitation bay with a decreased mental status.

Case Summary

A 27-year-old male presents to the emergency department with altered mental status after an intentional Amitriptyline overdose. He is found to have a wide QRS complex and an anticholinergic toxidrome. The patient deteriorates into PEA arrest necessitating advanced cardiac life support (ACLS) and intravenous sodium bicarbonate therapy.

Download the case here: TCA Case

First ECG for case found here:

Second ECG for case found here:

(ECG source: http://lifeinthefastlane.com/ecg-library/basics/tca-overdose/)

CXR for case found here:

Post Intubation

Post Intubation

(CXR source: http://radiopaedia.org/images/220869)

 

Ultrasound Source: Dr. Laurie Robichaud, PGY4 FRCP(C) Emergency Medicine, Ultrasound Fellow, McGill University