LVAD Case

This week’s case is written by Drs. Ashley Lubberdink and Sameer Sharif. Dr. Lubberdink is a PGY4 Emergency Medicine resident at McMaster University and is just beginning her fellowship in simulation and medical education. Dr. Sharif is a PGY5 Emergency Medicine resident at McMaster University who has just completed his fellowship in simulation and medical education.

Why it Matters

LVADs are pretty uncommon devices! If your practice location is not a hospital that inserts LVADs, then it is likely that you have never come across a patient with an LVAD. Without prior knowledge of these devices, it can be quite distressing trying to assess these patients. This case is designing to highlight the following:

  • LVAD patients do not have a pulse, a measurable blood pressure, or a detectable heart rate on the sat probe
  • To assess for blood pressure, one must insert an arterial line or use a blood pressure cuff and doppler U/S to obtain the MAP
  • Early after LVAD placement, drive line infection and bleeding are common complications
  • Call for help early! These patients generally have care providers who are available to help trouble shoot by phone at all hours of the day

More Reading

For more information on an approach to LVADs, we suggest the following sources:

https://emcrit.org/emcrit/left-ventricular-assist-devices-lvads-2/

https://canadiem.org/lvads-approach-ed/

Clinical Vignette

A 62-year-old male presents to your large community ED with a 1 day history of generalized malaise and nausea and a 2-hour history of palpitations. He is particularly concerned about his symptoms because last month he had an LVAD placed at your provinces’ major cardiac center (3 hours away) for stage 4 CHF. His wife is accompanying him but is currently parking the car.

Case Summary

A 62-year-old man presents to the ED with palpitations and general malaise. On initial assessment, the team finds out he had an LVAD placed within the last 1 month. The team will need to work through how to assess the patient’s vital signs appropriately and will discover the patient has a low MAP and a low-grade fever. On inspection, the patient’s drive line site will appear infected. The initial ECG will show features of hyperkalemia. After the initial assessment, the patient will progress to a PEA arrest requiring resuscitation by ACLS protocols. Labs will reveal an acute kidney injury and hyperkalemia. The patient will obtain ROSC when the hyperkalemia is treated.

Download the case here: LVAD Case

Initial ECG for the case found here:

hyperkalemia

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

Second ECG for the case found here:

hyperkalemia narrow QRS

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

CXR for the case found here:

LVAD-CXR

(CXR source: https://edecmo.org/additional-technologies/ventricular-assist-devices-vads/lvads/)

Picture of drive line site infection found here:

driveline infection A

(Picture source: http://journals.sagepub.com/doi/full/10.1177/1179065217714216)

Echo for case found here:

(Echo source: https://www.youtube.com/watch?v=-4ThAo4m2UI)

Electrical Storm

This case is written by Dr. Peter Dieckmann and Dr. Marcus Rall of the TuPASS Centre for Safety and Patient Simulation in Germany.

Why it Matters

Electrical Storm is a rare complication of a cardiac arrest. When it is present, the typical therapies for aborting VF are not sufficient. This case reviews the tailored management of this situation, including:

Clinical Vignette

“Arrest arriving in 1 minute. Doctor to resuscitation room STAT.

Paramedic report: “This is a 55 year old male we picked up at an office tower down the street. Apparently he was complaining of feeling unwell all morning and then collapsed at lunch. A colleague started CPR and we were called. The AED delivered 3 shocks. His colleagues say he’s healthy and they’re unsure about meds or allergies. His boss called his wife and she’s on her way.” CPR is ongoing.”

Case Summary

A 55 year-old male is brought to the emergency department with absent vital signs. He collapsed at his office after complaining of feeling unwell. CPR was started by a colleague and continued by EMS. He received 3 shocks by an AED. His downtime is approximately 10 minutes. The team is expected to perform routine ACLS care. When the patient remains in VF despite ACLS management, the team will need to consider specific therapies, such as iv beta blockade or dual sequential shock, in order to abort the electrical storm.

Download the case here: Electrical Storm

Cardiac U/S for the case found here:

(Ultrasound image courtesy of McMaster PoCUS Subspecialty Training Program)

ECG for the case found here:

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

CXR for the case found here:

Normal Post-Intubation CXR

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

PE with Bleeding

This case is written by Dr. Donika Orlich. She is a staff physician practising in the Greater Toronto Area. She completed both her Emergency Medicine training and Clinician Educator Diploma at McMaster University.

Why it Matters

Many simulation cases that deal with pulmonary embolism seem to focus on the decision to administer thrombolytics (usually upon a patient’s arrest). This case is different. While the team must administer thrombolytics to a patient with known pulmonary embolism, the catch is that they must then also recognize shock as a result of intra-abdominal bleeding. As a result, the case highlights the following:

  • The dose of thrombolytics to be used in the context of cardiac arrest
  • The importance of an approach to undifferentiated shock after ROSC. (It’s not all cardiogenic!)
  • That bleeding is a complication of thrombolysis. This is drilled into our brains as the major complication, but somehow it is diagnostically challenging to recognize.

Clinical Vignette

You are called urgently to the bedside of a patient who is in the Emergency Department awaiting medicine consultation. Your colleague saw her earlier. She is 63 years old and has a CT-confirmed pulmonary embolism. She had presented with shortness of breath on exertion in the context of a recent hysterectomy 4 weeks ago. She has been stable in the ED until she got up to go to the bathroom and suddenly developed severe shortness of breath.

Case Summary

A 63-year-old female is in the Emergency Department awaiting internal medicine consultation for a diagnosed pulmonary embolism. She suddenly becomes very short of breath while walking to the bathroom and the team is called to assess. The patent will then arrest, necessitating thrombolysis. After ROSC, she will stabilize briefly but then develop increasing vasopressor requirements. The team will need to work through the shock differential diagnosis and recognize free fluid in the abdomen as a complication of thrombolysis requiring surgical consultation and transfusion.

Download the case here: PE with Bleeding

ECG for the case found here:

Massive PE ECG

(ECG source: https://lifeinthefastlane.com/ecg-library/pulmonary-embolism/)

Initial CXR for the case found here:

normal female CXR radiopedia

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

Post-intubation CXR for the case found here:

normal-intubation2

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

Pericardial ultrasound for the case found here:

Normal lung ultrasound for the case found here:

Abdominal free fluid ultrasound for the case found here:

RUQ FF

(All ultrasound images are courtesy of McMaster PoCUS Subspecialty Training Program.)

Massive Pulmonary Embolism

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 management of massive pulmonary embolism is one that requires rapid action and decisive decision-making, often based on less information than one would like. This case highlights several key features of the management of a massive PE, including:

  • The importance of recognizing the signs of PE and using basic bedside investigations to aid in diagnosis when a patient is too unstable for confirmatory CT
  • The need to maintain quality ACLS care when a patient arrests, regardless of arrest etiology
  • The use of thrombolytics during cardiac arrest to treat a suspected pulmonary embolism

Clinical Vignette

A 46 year old male presents to the ED complaining of shortness of breath and pleuritic chest pain. He broke his ankle a week ago and has been in a cast since. He was just discharged home after operative repair 2 days ago.

Case Summary

A 46 year old male with a cast on his left leg from a bad ankle fracture presents to the ED complaining of pleuritic chest pain and shortness of breath. The team will take a history and start workup when the patient will suddenly state he’s “not feeling well” and then arrest. The team will perform ACLS consistent with the PEA algorithm and should consider IV thrombolytics. If IV thrombolytics are administered, the patient will have ROSC.

Download the case here: Pulmonary Embolism

ECG for the case found here:

ecg-massive-pte

(ECG source: http://cdn.lifeinthefastlane.com/wp-content/uploads/2011/12/ECG-Massive-PTE.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)

Cardiac U/S showing right heart strain found here:

(U/S courtesy of the McMaster PoCUS Subspecialty Training Program)

Cardiac U/S showing cardiac standstill found here:

(U/S courtesy of the McMaster PoCUS Subspecialty Training Program)

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)