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
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.
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.
Cardiac U/S for Patient 1 found here*:
FAST for Patient 1 found here:
ECG for Patient 2 found here:
(ECG source: https://lifeinthefastlane.com/ecg-library/sinus-tachycardia/)
Pre-intubation CXR for Patient 2 found here:
(CXR source: https://radiopaedia.org/cases/normal-chest-x-ray)
PXR for Patient 2 found here:
(PXR source: http://radiopaedia.org/articles/pelvis-1)
Post-intubation CXR for Patient 2 found here:
(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*:
Lung U/S for Patient 2 found here*:
*All U/S images are courtesy of McMaster PoCUS Subspecialty Training Program.