Obstetrical Trauma

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

Why it Matters

The management of a late-term pregnant trauma patient poses unique challenges. In particular, this case highlights the following:

  • The need for manual uterine displacement
  • The importance of considering uterine rupture or abruption as part of the primary or secondary survey (and how this necessitates a pelvic exam)
  • The challenge associated with controlling the noise and chaos in the trauma bay when multiple consultants are present
  • How difficult it is to break bad news about two patients at once to the father

**Special note: please be aware that this case has the potentially to be distressing to learners. As such, if you are to run it, please have resources available to help learners should they be affected by the weight of this case.

Clinical Vignette

You are working in a tertiary care emergency department and receive an EMS Patch: “33F who appears quite pregnant coming to you from an MVC. Belted driver. Prolonged extrication at the scene (30mins). Altered LOC and hypotensive on scene. Current vitals: HR 150, BP 80/50, RR 40, O2 90% on NRB, CBG 6. 1L NS bolus going. ETA 5 minutes.”

Case Summary

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.

Download the case here: Obstetrical trauma 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)

CXR for the case found here:

CXR Tension ptx

(CXR source: http://cdem.phpwebhosting.com/ssm/pulm/pneumothorax/images/cxr_ptx_3.png)

Pelvic XR for the case found here:

Pelvic X-ray post binder

(PXR source: https://drhem.files.wordpress.com/2011/11/5-4-6.jpg)

Normal pericardial U/S for the case found here: 

Left lung U/S with no lung sliding found here: 

RUQ U/S showing FF found here: RUQ FF

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

Hypothermia with Trauma

This case is written by Dr. Stephen Miller. He is an emergency physician in Halifax. He is also the former medical director of EM Simulation and the current director of the Skilled Clinician Program for UGME at Dalhousie University. He developed his interest in simulation while obtaining his Masters of Health Professions Education.

Why it Matters

Moderate to severe hypothermia can be quite challenging to correct. This case highlights several important features of hypothermia management:

  • The importance of searching for concurrent illness that may be causing the hypothermia or working against rewarming efforts
  • The effect of hypothermia on trauma management
  • Modifications to ACLS as required during hypothermic resuscitation
  • The multitude of ways in which one can attempt to actively re-warm a patient

Clinical Vignette

An approximately 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. It is minus 30 degrees Celsius outside and she has no coat or shoes. The man does not know her and is unable to provide any additional history except that she was blue and having trouble breathing when he found her. She is noted to have a decreased LOC and laboured breathing. She has obvious deformities of her left forearm and right leg.

Case Summary

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.

Download the case here: Hypothermia

CXR for the case found here:

PTX R with rib fractures

(CXR source: http://radiopaedia.org/cases/pneumothorax-due-to-rib-fractures-1)

ECG for the case found here:


(ECG source: : http://cdn.lifeinthefastlane.com/wp-content/uploads/2011/03/hypothermia-shiver-artefact.jpg)

Right lung U/S found here:

Left lung U/S found here:

RUQ FAST image found here:


Pericardial U/S found here:

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

Two Patient Trauma

This case was written by Dr. Martin Kuuskne from McGill University. Dr. Kuuskne is a PGY5 Emergency Medicine resident and one of the editors-in-chief at EMSimCases.

Why it Matters

Emergency Medicine often requires care providers to be in multiple places at once. It is not uncommon to have two patients simultaneously require urgent or semi-urgent intervention. This case helps learners to develop this important skill by highlighting:

  • The challenges of triaging patients as immediately urgent or less urgent
  • The need to assign tasks to team members
  • The importance of adhering to the basics, even in a taxing situation

Clinical Vignette

Before entering the room: You are working the day shift in a tertiary care emergency department with full surgical capabilities. EMS is en-route to the hospital with two patients, a 37-year-old male and a 65 year old female, who were both drivers of a t-bone MVC of unknown speed. The ambulances will arrive in 2 minutes.

Upon entering the room: Each patient will be accompanied with a paramedic who will give this information and will be available to stay if asked.

Patient A: “37 year old male, belted driver, he got t-boned on the driver’s side. There was significant intrusion of his side door. We’re not sure if there was a loss of consciousness, we put him on a non-rebreather and his SAT was around 92%, tachy at 105 with an OK BP around 110 systolic during the ride.”

Patient B: “65 year old female, belted driver who t-boned the other car. The front of her car was totaled. Airbags were deployed and there was a brief loss of consciousness. We put on the collar ASAP. Vitals were stable en route but she was a bit confused during the ride. No vomiting.”

Case Summary

A young male and a middle-aged female are brought to the ED after a T-bone MVC at an unknown speed. Both patients were drivers. The emergency team is expected to triage the patients accordingly and to split the team so that both patients are treated.

Patient A: The team is expected to recognize respiratory compromise secondary to pneumothorax. Needle decompression and tube thoracostomy should be administered. The patient will in remain in respiratory compromise post-decompression and the team should consider intubation. If the pneumothorax is not recognized or treated, the patient will arrest. On secondary survey, the patient will complain of pelvic pain in addition to a positive eFAST evaluation. The team should activate the massive transfusion protocol (MTP) and activate the trauma/surgery team.

Patient B: The team is expected to recognize hypoglycemia in the context of a minor head injury. Immediate glucose replacement is required.

Download the case here:  Two for one MVC

CXR for Patient A found here:

left flail chest

(CXR source: http://learningradiology.com/archives2009/COW%20353-Flail%20Chest/caseoftheweek353page.htm)

Pelvic xray for Patient A found here:

open book # from radiopedia

(Xray source: http://radiopaedia.org/articles/open-book-fracture)

Left lung U/S for Patient A found here:

Right lung U/S for Patient A found here:

RUQ FAST image for Patient A found here:


Pericardial U/S for Patient A found here:

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

CXR for Patient B found here:

normal female CXR radiopedia

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

Stab Wound to the Neck with Neurogenic Shock

This week’s case is written by Dr. Cheryl ffrench. She is the Simulation Director for Emergency Medicine at the University of Manitoba and is one of the advisory board members here at EMSimCases.

Why it Matters

Neurogenic shock is an important manifestation of spinal trauma. This case highlights several important aspects of neurogenic shock:

  • It can be difficult to recognize (especially in a multi-trauma patient)
  • At its presentation, vasopressors are often required to manage blood pressure
  • It should be suspected in trauma cases where the patient is hypotensive without tachycardia

Clinical Vignette

To be stated by EMS: “This is Jamal James. He’s a 21 year-old male who was found in his house by police after being stabbed by a friend. There was a lot of blood at the scene. We found a stab wound on his neck so we initiated spinal precautions. Before we arrived, the police started CPR briefly because they thought he didn’t have a pulse. He had a pulse when we got there but his respiratory effort was poor and he had a decreased LOC. Several attempts to intubate were unsuccessful so we bagged him on the way here. We don’t know anything about his allergies, medications, or past medical history.

Case Summary

A 21 year old male is brought to your tertiary care ED by EMS after being stabbed by a friend. EMS initiated spinal precautions and failed several attempts to intubate en route. On arrival, the patient is being bagged and has a single stab wound to the right posterolateral neck. He requires emergent intubation for airway protection. After intubation, his blood pressure drops but his heart rate remains in the 70s. His blood pressure will stabilize only after appropriate fluid resuscitation and vasopressor initiation.

Download the case here: Stab Wound to Neck

ECG for the case found here:


(ECG source: http://lifeinthefastlane.com/ecg-library/normal-sinus-rhythm/)

CXR for the case found here:

Post Intubation

Post Intubation

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

U/S image showing no free fluid in the abdomen found here:

no FF

(U/S image courtesy of McMaster POCUS Subspecialty Training Program)

U/S showing no pericardial effusion found here:

(U/S courtesy of McMaster POCUS Subspecialty Training Program)