Chest Pain on the Ward

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

When learners are transitioning to residency, they are often fearful of what feels like a sudden increase in responsibility. A big fear that is common among trainees is the idea that they might be left alone to treat something urgent or beyond their skill level. This case was designed to help alleviate some of those fears. The debriefing should focus on local resources available to learners when they feel alone in the middle of the night. The point of the case is to show them they’re not alone. In particular, this case highlights:

  • How to handle a call from the ward about a patient in distress (get things started while on your way to the ward!)
  • The work-up for an admitted patient with chest pain (and how treatment can change quickly!)
  • The senior-level resources available to learners overnight (ICU outreach, anesthesia, the senior resident, their attending over the phone, etc) and when learners should make certain to call their superiors

A Special Note

To make this case particularly realistic, we recommend using your local charting system to create a patient note that can be given to learners. If you use an EMR, then print out what an admission note would look like. If you use paper charting, then handwrite an admission note for learners to review!

Clinical Vignette

You are the junior medical resident on call overnight covering for a team of patients you do not know. You get a page from a nurse on the ward: “one of my patients is having chest pain…can you come and see him?”

*Note: the first part of this scenario is actually done best over the phone. Have the learner stand outside the room and call them on their cell phone.

Case Summary

The case will begin with a phone call from the bedside nurse for a patient on the ward that the resident on call is covering. The resident will then arrive at the bedside to find a patient complaining of significant chest pain. The patient will be in some respiratory distress due to CHF. The patient’s initial ECG will show new T-wave inversion. The patient will prompt regarding ongoing chest pain and his ECG will evolve to show an anterolateral STEMI. The team is expected to recognize the evolving STEMI and initiate treatment and cath lab activation.

Download the case here: Chest Pain on the Ward

“Old” ECG for the case found here:

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

Initial ECG on the ward found here:

001 Anterior TWI

(ECG source: http://hqmeded-ecg.blogspot.ca/2015/12/lvh-with-anterior-st-elevation-when-is.html)

Repeat ECG on the ward found here:

003 anterolateral STEMI

(ECG source: https://lifeinthefastlane.com/ecg-library/anterior-stemi/)

CXR for the case found here:

(CXR source: https://www.med-ed.virginia.edu/courses/rad/cxr/web%20images/into-chf.jpg)

STEMI with Cardiogenic Shock

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

The majority of STEMI presentations to the ED are quite straight-forward to manage: expediency and protocolization are of the utmost importance. However, when a patient presents with cardiogenic shock as a result of their STEMI, more nuanced care is required. In particular, the patient must be stabilized in order to facilitate the definitive treatment of cardiac catheterization. This case highlights some of those nuances, including:

  • The need for vasopressor support and possibly inotropic support in patients with cardiogenic shock
  • The challenges associated with intubating a hypotensive and hypoxic patient
  • The importance of optimizing the patient’s status as best as possible prior to intubation (whether via BiPAP, PEEP valve, push-dose pressors, or otherwise)

Clinical Vignette

A 55-year-old male presents to the ED with EMS as a STEMI activation. He arrives being bagged by EMS for hypoxia. His initial EMS call was for chest pain and he has significantly deteriorated en route. He has a history of smoking, hypertension, diabetes, and hypercholesterolemia. No prior cardiac history.

Case Summary

A 55-year-old man presents to the ED as a STEMI call. He is profoundly hypotensive with low O2 sats and obvious CHF. The patient’s blood pressure will transiently respond to fluid resuscitation. The ECG will show anterolateral ST elevation. The team will need to prepare for intubation while activating the cath lab. They will also need to start vasopressors. The patient will remain hypotensive until an inotrope like dobutamine is initiated. If unsafe medications are chosen for intubation, the patient will have a VT arrest.

Download the case here: STEMI with Cardiogenic Shock

ECG for the case found here:

anterolateral STEMI

(ECG source: https://lifeinthefastlane.com/ecg-library/lateral-stemi/)

Pre-intubation CXR for the case found here:

CHF

(CXR source: https://www.med-ed.virginia.edu/courses/rad/cxr/pathology2Bchest.html)

Post-intubation CXR for the case found here:

CHF post intubtation

(CXR source: https://heart-conditions.knoji.com/learning-about-and-coping-with-congestive-heart-failure/)

Lung U/S for the case found here: