Pediatric Difficult Airway

This case is written by Dr. Jonathan Pirie. He is a staff physician in the Division of Pediatric Emergency Medicine and Associate Professor at the University of Toronto. Dr. Pirie is also the Director of Simulation for Pediatric Emergency Medicine and the Simulation Fellowship program. His simulation interests include development of core curricula for postgraduate training programs, in-situ team training, and mastery learning with competency based simulation for trainees and faculty in pediatric technical skills and resuscitation.

Why it Matters

While croup makes stridor a relatively common presentation in the Pediatric ED, today it is quite rare to have a child with stridor who requires definitive airway management. It is exceedingly rare for an Emergency physician to need to proceed to cricothyroidotomy on a child. This case highlights the following:

  • The initial management steps for a child with undifferentiated, severe stridor
  • The need to call for help early
  • The steps required for a needle cricothyroidotomy and the equipment necessary to ventilate a child after this procedure is performed

Clinical Vignette

You are working in the ED, and your team has been called urgently to see a 2-year-old old boy with difficulty breathing. The patient was brought in by his mother, who states he’s had a 2-day history of runny nose. Today he developed a barking cough with fever, and is “breathing with a funny noise.”

Case Summary

The ED team is called to manage a 2-year-old boy in severe respiratory distress with stridor and hypoxia. Initial management steps (humidified O2, nebulized epinephrine and dexamethasone) fail to improve the patient’s respiratory status, and the team must prepare for a difficult intubation. They will encounter difficulties with both bagging and passing the endotracheal tube due to airway edema, which will necessitate an emergency needle cricothyroidotomy.

Download the case here: Pediatric Difficult Airway

Multi-Trauma: Blunt VSA and Burn

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

Why it Matters

This case is an excellent example of the challenges faced in Emergency Medicine. Not only are learners faced with a worst-case airway scenario, but they must also manage two critically ill patients at once. In particular, it draws attention to the following:

  • The need to plan for and manage resources appropriately when faced with two critically ill patients simultaneously
  • The importance of recognizing and adequately preparing for a difficult airway
  • The acknowledgement of a failed intubation/ventilation scenario requiring expedient placement of a surgical airway

Case Summary

The case will start with an EMS patch indicating that they are 2 minutes out with multi-trauma from a 2 car MVC. Two patients will then arrive within 1 minute of each other. The first will have gone VSA en route from presumed blunt trauma. This patient will not regain a pulse. The second patient will arrive with significant burns from a car fire, and will have GCS of 3 necessitating intubation. All attempts at intubation will be unsuccessful, and a surgical airway must be performed. The team will need to prioritize resources between the two patients and realize that an ED thoracotomy is not reasonable in the first patient.

Clinical Vignette

Before first patient:

You are working in a tertiary care trauma center. EMS patch: We have a 50ish M unbelted driver in a head-on MCV at about 60km/hr. He was ejected from the vehicle and found about 30m from the crash site with a GCS of 3. He has an obvious head injury, torso injury and unstable pelvis, which we’ve bound. Initially had RR 40, O2 85% on NRB, HR 150 and a questionable femoral pulse. Since then, he’s been pulseless. We’ve been en route about 5 minutes and should be there in about 2 min. He’s received 1mg Epi so far with no shocks advised x2. Smells of EtOH, but no other known history. There was one other car involved that caught on fire, so you’ll probably get them, too, if they survive. Please prepare for this patient.

Upon arrival of second patient:

EMS Handover: This 30ish male belted driver was in a head on MVC with both cars going ~60km/hr. His car was on fire when we got there, and he’s got 2nd/3rd degree burns everywhere. We found him outside the car, so he must have self-extricated. His GCS has been 3 the entire time with us. He’s tolerating an oral airway. His last vitals were HR 120, BP 130/80, RR 30, O2 95% NRB

How to Run the Case

At McMaster University, we successfully ran this case with our PGY4 residents. To do so, we had two confederate nurses at the bedside (one nurse per patient). We also had dedicated sim techs running each mannequin. Finally, we had three faculty instructors. One instructor to observe the management of each patient, and one instructor to play the role of the arriving paramedic and to coordinate between the two instructors and sim techs. We are able to run the case with four of our emergency medicine resident learners playing the roles of a trauma team (one team leader, one senior emerg resident, one senior anesthesia resident, and one surgical resident). It went very well and received positive feedback from the learners. Of note, this case is ripe with opportunity for incorporating other learners. In particular, inter-professional education using ED nurses, RT’s, and learners from other services could work as well.

 

Download the case here: Multitrauma Cric and Blunt VSA Case

Cardiac U/S for Patient 1 found here*:

FAST for Patient 1 found here:

RUQ FF

ECG for Patient 2 found here:

sinus-tachycardia

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

Pre-intubation CXR for Patient 2 found here:

Normal CXR Male

(CXR source: https://radiopaedia.org/cases/normal-chest-x-ray)

PXR for Patient 2 found here:

normal-pelvis-male

(PXR source: http://radiopaedia.org/articles/pelvis-1)

Post-intubation CXR for Patient 2 found here:

Normal Post-Intubation CXR

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

Cardiac U/S for Patient 2 found here*:

FAST for Patient 2 found here*:

no FF

Lung U/S for Patient 2 found here*:

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

Anaphylaxis with Angioedema

This case is written by Dr. Ahmed Taher. He is an Emergency Medicine resident at the University of Toronto and a Masters of Public Health Student at Johns Hopkins University. He developed his appreciation and excitement for simulation while previously employed as a Primary Care Paramedic for York Region EMS.

Why it Matters

Anaphylaxis is a fairly common presentation to the ED. However, it is rare to see truly severe anaphylaxis. This case exposes learners to the most feared complication of anaphylaxis – angioedema requiring surgical airway management. In particular, it highlights:

  • The importance of initiating early treatment for anaphylaxis with epinephrine (and removing ongoing allergen exposure, if possible)
  • The need to intubate early in patients with signs of airway compromise not immediately responding to epinephrine
  • The fact that the “decision to cut” is crucial (and arguably the most challenging part of a surgical airway)
  • The steps required for a successful cricothyrotomy

Clinical Vignette

You are working a night shift at your local Emergency Department. You are called STAT to the bedside of a patient in the department who was seen by your colleague earlier and has recently been started on IV ceftriaxone for a pyelonephritis. You recall from handover that this is a 45-year-old previously healthy female patient with a diagnosis of a UTI two weeks ago, who returned after failing treatment and was diagnosed with pyelonephritis today. The nurse tells you she started the IV antibiotics and fluids 20 min ago, and then started to experience respiratory distress and a full body rash.

Case Summary

A 45-year-old patient who has already been seen in the ED begins treatment for pyelonephritis with IV antibiotics. Soon after initiated, she develops stridor and respiratory distress, as part of an anaphylactic reaction. The team is called into the room to assess the patient. After standard anaphylaxis treatment is given, the airway is still of concern. Intubation attempts are not successful and the patient will need a surgical airway.

Download the case here: Anaphylaxis with Angioedema

ECG for the case found here:

sinus-tachycardia

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

CXR for the case found here:

normal female CXR radiopedia

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