Pregnant Cardiomyopathy

This case is written by Drs. Nadia Primiani and Sev Perelman. They are both emergency physicians at Mount Sinai Hospital in Toronto. Dr. Primiani is the postgraduate education coordinator at the Schwartz/Reisman Emergency Centre. Dr. Perelman is the director of SIMSinai.

Why it Matters

Most emergency physicians have some degree of discomfort when a woman in her third trimester presents to the ED for any complaint. When that woman presents in acute distress, the discomfort is increased even further! This case takes learners through the management of a patient with a pregnancy-induced cardiomyopathy, reviewing:

  • The importance of calling for help early
  • The fact that all pregnant patients at term must be presumed to have difficult airways
  • That the treatment of the underlying medical condition is still the primary focus – in this case, BiPap, definitive airway management, and ultimately, inotropic support

Clinical Vignette

You are working in a community ED and your team has been called urgently by the nurse to see a 38 year old female who is G2P1 at 36 weeks gestational age. She was brought in by her sister, who is quite agitated and upset, saying “everybody has been ignoring her symptoms for the last 4 weeks.” The patient has just experienced a syncopal episode at home.

Case Summary

A 38-year-old female G2P1 at 36 weeks GA presents with acute on chronic respiratory distress in addition to chronic peripheral edema. She undergoes respiratory fatigue and hypoxia requiring intubation. She then becomes hypotensive which the team discovers is secondary to cardiogenic shock, requiring vasopressor infusion and consultation with Cardiology/ ICU.

Download the case here: Pregnant Cardiomyopathy

ECG for the case found here:

(ECG source: https://lifeinthefastlane.com/ecg-library/dilated-cardiomyopathy/)

 CXR for case found here:

posttestQ2pulmonaryedema

(CXR source: https://www.med-ed.virginia.edu/courses/rad/cxr/postquestions/posttest.html)

Cardiac Ultrasound for the case found here:

ezgif.com-optimize+(6)

(U/S source: http://www.thepocusatlas.com/echo/2hj4yjl0bcpxxokzzzoyip9mnz1ck5)

Lung U/S for the case found here:

Confluent+B+Lines

(U/S source: http://www.thepocusatlas.com/pulmonary/)

RUQ FAST U/S Image found here:

usruqneg

(U/S source: http://sinaiem.us/tutorials/fast/us-ruq-normal/)

OB U/S found here:

(U/S source: https://www.youtube.com/watch?v=SKKnTLqI_VM)

Simulation Solutions for Low Resource Settings

This review on simulation teaching in a low resource setting was written by Alia Dharamsi, a PGY 4 in Emergency Medicine at The University of Toronto and 2017 SHRED [Simulation, Health Sciences, Resuscitation for the Emergency Department] Fellow after her Toronto- Addis Ababa Academic Collaboration in Emergency Medicine (TAAAC-EM) elective. 

This past November I participated in an international elective in Addis Ababa, Ethiopia as a resident on the TAAAC-EM team. TAAAC-EM sends visiting faculty to teach and clinically mentor Ethiopian EM residents 3-4 times a year. Teaching trips cover a longitudinal, three-year curriculum through didactic teaching sessions, practical seminars, and bedside clinical supervision.

One of the areas of development identified by the residents was a yearning for more simulation exercises. As a budding simulationist and SHRED fellow, I was particularly keen to help contribute to the curriculum. Starting from the basics, we created two simulation curricula:

  • Rapid Cycle Deliberate Practice (RCDP) simulation exercises that covered basic Vfib, Vtach, PEA and asystolic arrests in short 5-minute simulation and debrief cycles and,
  • Managing airway exercises; a series of three cases addressing preparing for intubation, intubating a patient in respiratory extremis, and then troubleshooting an intubated and ventilated patient using the DOPES mnemonic

The local simulation centres were well relatively equipped however there were no high fidelity mannequins or elaborate set of monitors. We had to use an intubating mannequin head and torso for the airway simulation and a basic CPR mannequin for the RCDP exercise.

Picture1

Set up for the airway simulation exercises

For additional materials, we had to MacGyver some of the tools we needed to create these simulation scenarios, and from doing so we learned some valuable lessons. This post will outline some of the ways we created a higher sense of fidelity, even with low technology resources, and created high yield learning experiences for the residents.

Understand what actual resources are available to the trainees in the ED before you try to create a simulation exercise

It took a few weeks of working in the ED to really understand what resources are available to the staff and residents. For the most part there was no continuous saturation monitoring. X-rays are not typically done until after the patient is stabilized because the patient has to be taken out of the resuscitation room to the imaging department. Lastly, some medications that we use in Canada on a daily basis were simply not available. The first step to creating simulation in low resource settings is to understand the available resources.

Communication skills do not require a high technology environment; Neither do CPR or BVM skills!

Both simulation exercises focussed on team communication, closed loop communication, team preparation for interventions (like intubation), and team leadership. While our supplies were basic, the simulations lent themselves well to discussing improved communication methods in the ED during resuscitations. We also emphasized excellent quality CPR and reiterated basic bagging techniques. We can all use refreshers on the basics and this is one way me made the simulations fruitful for learners of all levels.

Picture2

GIFs make great rhythm generators

For these simulation sessions we did not consistently have access to a rhythm generator, so we downloaded GIFs to our phone of Vfib, Vtach, Aystole and normal sinus rhythm to display on our phones. This turned a partially functioning defibrillator into a monitor! We were also able to change the rhythm by picking a new GIF really easily.

Picture3.jpg

Wherever possible, add fidelity

While the technology was limited, the opportunity to bring human factors into the simulations were not. We used real bottles of medications, which helped the residents suspend some of their disbelief, and we encouraged them to verbalize the actual medication doses. We talked about safely labelling syringes so as not to mix which medication was in which syringe (sedation vs paralysis), and how to do a team time out before a critical intervention to ensure necessary supplies were available. We even simulated a broken laryngoscope by removing the battery to add a level of complexity to the case — if they didn’t check the laryngoscope ahead of time they wouldn’t have noticed.

Picture4

At its core, simulation should be fun

One of my most poignant memories from these simulation sessions is how much fun the residents had. We had to pause a few times because we were laughing so hard. These residents work extremely closely over their training, side by side and as a group for the majority of their on service time—they see more of each other than I feel like I’ve seen of my co-residents during my residency this far. I noticed that because of their extensive time together, they seem to have more personal relationships, and as such even in the ED they have more fun together. The residents all appreciated these sessions where they learned together, and really enjoyed each other’s company. Their joy refreshed and rejuvenated my love for simulation!

Simulation is an important teaching tool for learners in EM no matter where they are training. We take for granted our high tech sim labs, dedicated simulation curricula, and protected time to practice resuscitations and learn. Simulation offers the ability to make mistakes in a safe environment, to learn with our peers, and to develop an expertise that we can apply in the ED—something the residents in Addis Ababa really wanted to have as part of their ongoing curriculum. Applying my simulation training to a low resource setting has helped me grow as a simulationist and become pretty creative in how I approach resource limitations. I’m particularly grateful to the residents for not only being patient, keen, and enthusiastic as we worked through some of these challenges, but also for allowing me to take photos to post on this blog!

 

Thyroid Storm

This case is written by Dr. Cheryl ffrench, a staff Emergency Physician at the Health Sciences Centre in Winnipeg. She is the Associate Program Director and the Director of Simulation for the University of Manitoba’s FRCP-EM residency program; she is also on the Advisory Board of emsimcases.com.

Why it Matters

Thyrotoxicosis is a rare presentation to the ED that can masquerade as many other conditions. This case nicely reviews the following:

  • The importance of maintaining a broad differential diagnosis in any patient who presents with an altered level of consciousness and a fever
  • The nuances associated with managing atrial fibrillation in the context of thyrotoxicosis
  • The multiple medications required in order to treat thyroid storm

Clinical Vignette

You are working the evening shift at a tertiary care hospital. A 31-year-old female two weeks postpartum is brought in by EMS accompanied by her husband. He is concerned because she is delirious and somewhat difficult to rouse.

Case Summary

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.

Download the case here: Thyroid Storm Case

Sinus tachycardia ECG for the case found here:

Sinus tachycardia

(ECG source: http://lifeinthefastlane.com/ecg-library/hyperthyroidism/)

Atrial fibrillation ECG for the case found here:

rapid-a-fib

(ECG source: http://lifeinthefastlane.com/ecg-library/atrial-fibrillation/)

CHF CXR for the case found here:

severe-chf

(CXR source: http://www.radiologyassistant.nl/en/p4c132f36513d4/chest-x-ray-heart-failure.html)

Gearing up to restart!

After an exam-writing hiatus, we’re gearing up to restart our regular case publications.

Have a case you’d love to see featured on the site? Send it to us at cases@emsimcases.com. We’re always happy to collaborate and feature the great work of our peers.

Stay tuned for new cases coming soon – we’ve got great things planned!

Short Break

We’re going to be taking a short break here at EMSimCases. Our editors-in-chief have decided to pause until after their board exams in May. But don’t worry, we’ll be right back at it with new and interesting cases shortly thereafter.

Thanks for reading! We look forward to bringing you new content in May.

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)

Dysrhythmia Secondary to Hyperkalemia

This case is written by Dr. Kyla Caners. She is a PGY5 emergency medicine resident at McMaster University and has previously completed a fellowship in simulation and medical education. She is also one of the editors-in-chief here are EMSimCases.

Why it Matters

When studied in isolation, the ECG findings of hyperkalemia can seem straight-forward. However, placed out of context, the recognition of severe hyperkalemia on ECG can be quite challenging. This case highlights a few important points:

  • Hyperkalemia should be suspected as a possible cause of almost any symptom in a hemodialysis-dependent patient
  • Recognizing hyperkalemia on ECG allows for the critical intervention of administering calcium gluconate
  • ACLS should be modified in hyperkalemia to include aggressive calcium chloride and bicarbonate administration in an attempt to correct the underlying cause of cardiac arrest

Clinical Vignette

Geoff is a 52 year old male who is brought to the ED by EMS as a STEMI activation. He is not having chest pain, but has been feeling weak and dizzy today. He is diabetic and hypertensive and was started on hemodialysis 3 months ago for ESRD. He missed dialysis on the weekend for the first time so that he could attend his niece’s wedding.

Case Summary

A 52 year-old male with end-stage renal disease (requiring dialysis) is brought in by EMS feeling weak and dizzy. He missed dialysis for the first time over the weekend to attend his niece’s wedding. On presentation, his heart rate is 50 and his ECG demonstrates a wide complex rhythm with peaked T waves that EMS interprets as a STEMI. If the team recognizes the possibility of hyperkalemia and treats it appropriately, the patient’s QRS will narrow. If the hyperkalemia is not recognized, the patient will arrest.

Download the case here: Hyperkalemia Case

1st ECG for the case found here:

Hyperkalemia STEMI mimic

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

2nd ECG for the case found here:

normal-sinus-rhythm

(ECG source: : http://cdn.lifeinthefastlane.com/wp-content/uploads/2011/12/normal-sinus-rhythm.jpg)