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.
Category: Toxicology
Serotonin Syndrome
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.
Multi-drug Overdose
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.
Multi-trauma case: burn and head injury
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.
Toxic Alcohol Ingestion
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.
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
ASA Overdose
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.
Opioid Overdose with ARDS
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.
Tricyclic Antidepressant Overdose
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.
EM Sim Cases 