ASA Toxicity

This case is written by Dr. Donika Orlich. She is a staff physician practising in the Greater Toronto Area. She completed her Emergency Medicine training at McMaster University and also obtained a fellowship in Simulation and Medical Education.

Why it Matters

Salicylate toxicity, while relatively rare, has fairly nuanced management. It is important for physicians to be aware of presenting features of the toxicity and also of key management steps. Some pearls from this case include:

  • That hypoglycemia (and neuroglycopenia) is a manifestation of ASA toxicity.
  • Urine alkalinization (and correction of hypokalemia) is an important initial treatment for suspected toxicity.
  • Should a patient require intubation, it is paramount to set the ventilator to match the patient’s pre-intubation respiratory rate as best as possible.
  • Dialysis is indicated in intubated patients and also in patients with profoundly altered mental status, high measured ASA levels, and renal failure.

Clinical Vignette

You are working at a community hospital. The triage nurse comes to tell you that they have just put an 82 year-old male in a resuscitation room. He was found unresponsive by his daughter and was brought in by EMS. In triage he was profoundly altered, febrile and hypotensive. His daughter is in the room with him.

Case Summary

The learner will be presented with an altered febrile patient, requiring an initial broad work-up and management plan. The learner will receive a critical VBG report of severe acidosis, hypoglycemia and hypokalemia, requiring management. Following this, the rest of the blood work and investigations will come back, giving the diagnosis of salicylate overdose. The patient’s mental status will continue to decline and learners should proceed to intubate the patient, anticipating issues given the acid-base status. The learner should also initiate urinary alkalinization and make arrangements for urgent dialysis.

Download the case here: ASA Toxicity

ECG for the case found here:

Hypokalemia ECG

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

Initial CXR for the case found here:

ards pre intubation

(CXR source: http://www.radiology.vcu.edu/programs/residents/quiz/pulm_cotw/PulmonConf/09-03-04/68yM%2008-03-04%20CXR.jpg)

Post-intubation CXR for the case found here:

ARDS post intubation

(CXR source: http://courses.washington.edu/med620/images/mv_c3fig1.jpg)

FAST showing no free fluid found here:

no FF

Pericardial U/S showing no PCE found here:

Abdominal U/S showing no AAA found here:

no AAA

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

Newborn Sepsis with Apneas

This case is written by Dr. Rob Woods. He works in both the adult and pediatric emergency departments in Saskatoon and has been working in New Zealand for the past year. He is the founder and director of the FRCP EM residency program in Saskatchewan.

Why it Matters

This case highlights important manifestations of sepsis in a neonate. In particular, it reinforces that:

  • Apneas, hypoglycemia, and hypothermia are commonly seen as a result of systemic illness in neonates
  • Prolonged or persistent apneas with associated desaturations require management with either high-flow oxygen or intubation
  • Fluid resuscitation and broad-spectrum antibiotics are important early considerations when managing toxic neonates

Clinical Vignette

To be stated by the Paramedic with the Resus Nurse at bedside: “We picked up this term 3-day old male infant at their GPs office. Mom reports poor feeding for the past 12 hours, and two episodes of vomiting. They took him to the GPs office this morning and they found the temperature to be quite low at 33.1°C. They called us concerned about sepsis. We were only 5 minutes away so we have not obtained IV access. We did obtain a glucose level of 2.7. The child is lethargic and has very poor perfusion – peripheral cap refill is 7 seconds. We don’t have a cuff to get an accurate BP but the HR is 190.”

Case Summary

A 3-day-old term male infant is brought to the ED by EMS after being seen at their Family Physician’s office with a low temperature (33.1oC). The child has been feeding poorly for about 12 hours, and has vomited twice. He is lethargic on examination and poorly perfused with intermittent apneas lasting ~ 20 seconds. He requires immediate fluid resuscitation and broad-spectrum antibiotics. His perfusion will improve after IVF boluses, however the apneas will persist and necessitate intubation.

Download the case here: Newborn Sepsis with Apneas

Initial CXR for the case found here:

Normal neonatal CXR

(CXR source: http://emedicine.medscape.com/article/414608-overview)

Post-intubation CXR for the case found here:

Post-intubation CXR neonate

(CXR source: https://radiopaedia.org/articles/neonatal-pneumonia)

Pediatric Septic 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

Children with true septic shock are, thankfully, a rare presentation in the ED. However, recognition of early shock is an essential skill. This case highlights several important features of managing the critically ill child, including:

  • The need for early vascular access (whether that be intravenous or intraosseous, it must be obtained expediently)
  • The importance of monitoring for and treating resultant hypoglycemia
  • The need for early antibiotics

Clinical Vignette

A 4-year-old girl presents to your pediatric ED. Her mother states she is “not herself” and seems “lethargic.” She’s had a fever and a cough for the last three days. Today she just seems different. She was brought straight into a resus room and the charge nurse came to find you to tell you the child looks unwell.

Case Summary

A 4 year-old girl is brought to the ED because she is “not herself.” She has had 3 days of fever and cough and is previously healthy. She looks toxic on arrival with delayed capillary refill, a glazed stare, tachypnea and tachycardia. The team will be unable to obtain IV access and will need to insert an IO. Once they have access, they will need to resuscitate by pushing fluids. If they do not, the patient’s BP will drop. If a cap sugar is not checked, the patient will seize. The patient will remain listless after fluid resuscitation and will require intubation.

Download the case here: Pediatric Septic Shock

ECG for the case found here:

sinus-tachycardia

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

CXR for the case found here:

pediatric-pneumonia

(CXR source: http://radiopaedia.org/articles/round-pneumonia-1)

Adrenal Crisis

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

While adrenal crisis is a relatively rare presentation, shock is not. This case highlights several important points, including:

  • The importance of having an approach to fluid non-responsive shock
  • How difficult it can be to shift cognitive frames and resist diagnostic anchoring
  • The electrolyte abnormalities associated with adrenal crisis (hyponatremia, hyperkalemia, and hypoglycemia)
  • The need to treat an adrenal crisis with corticosteroids

Clinical Vignette

A 46-year-old female presents to the ED complaining of fatigue, anorexia, and weight loss over the last two weeks. She had the “stomach flu” a couple weeks ago and thought she was getting over it. But now she feels very weak and seems to be vomiting again. Her blood pressure is 80/40, so she was triaged straight to the resuscitation bay.

Case Summary

A 46-year-old female presents to the ED complaining of fatigue, anorexia, and weight loss over the last two weeks. She had the “stomach flu” a couple weeks ago and thought she was getting over it. But now she feels very weak and seems to be vomiting again. On presentation, the patient will have mild hypothermia, hypoglycemia, and hypotension. The team will have to initiate fluid resuscitation and an initial workup. The patient’s blood pressure won’t respond to 4 L of IV fluids, forcing the residents to work through the differential diagnosis of shock. Eventually, they will receive critical VBG results that indicate a mild metabolic acidosis, hyperkalemia, and hyponatremia. The team will need to treat the hyperkalemia and initiate hydrocortisone therapy.

Download the case here: Adrenal Crisis Case

ECG for the case found here:

peaked-t-waves

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

CXR for the case found here:

normal female CXR radiopedia

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

Pericardial U/S for the case found here:

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

FAST image for the case found here:

no FF

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

Coarctation of the Aorta

This case is written by Drs. Quang Ngo and Donika Orlich. Dr. Ngo is an attending emergency physician at McMaster Children’s Hospital and also serves as the Associate Program Director for the Department of Pediatrics. He is also a member of the advisory board here at EMSimCases. Dr. Orlich is a PGY5 Emergency Medicine resident at McMaster University who also completed a fellowship in Simulation and Medical Education last year.

Why it Matters

Having an approach to the toxic neonate is essential. More importantly, emergency physicians must be able to recognize subtle historical clues and physical exam features that point toward congenital heart disease in order to begin critical treatment rapidly. This case highlights the following:

  • The presentation of neonates with congenital heart disease including features like difficulty feeding, CHF, and tachypnea without increased work of breathing
  • The clinical features that may be present in a coarctation of the aorta, one specific type of congenital heart disease, and the resultant need to include four-limb BP’s as part of the work-up of toxic-appearing neonates
  • The importance of beginning a prostaglandin infusion in patients with suspected ductal-dependent congenital heart disease
  • One of the most common side effects of a prostaglandin infusion – apnea

Clinical Vignette

Your triage nurse comes to tell you about an infant she just put in the resuscitation room who she feels looks quite unwell. He is a 2 week old neonate brought to the ED by his mother. Mom was worried because he hasn’t been feeding very well and seems to just get sleepy when feeding. Now he just vomited his last feed and seems really lethargic. She thinks he just “doesn’t look the right colour”.

Case Summary

A 2-week-old neonate presents in shock requiring the learner to implement an initial broad work-up. The patient will also be hypoglycemic, and will seize if this is not promptly recognized. Physical exam and CXR findings will suggest coarctation of the aorta as the likely cause, and the learner should recognize the need for gentle fluid boluses and a prostaglandin infusion. Unless learners anticipate appropriately and intubate the patient prior to beginning the prostaglandins, the infant will become apneic after starting the infusion and require intubation.

Download the case here: Coarctation of the Aorta Case

ECG for the case found here:

coarc-ecg

(ECG source: http://www.omjournal.org/IssueText.aspx?issId=380)

Initial CXR for the case found here:

chf-neonate

(CXR source: http://www.adhb.govt.nz/newborn/TeachingResources/Radiology/CXR/HLHS/CXR-HLHS-congested.jpg)

Post-intubation CXR for the case found here:

chf-neonate-post-intubation

(CXR source: http://www.adhb.govt.nz/newborn/TeachingResources/Radiology/CXR/OtherCHF/NonstructuralCHF.jpg)

For more information on the management of Congenital Heart Disease Emergencies, see the excellent review by Emergency Medicine Cases found here.

Multi-trauma case: burn and head injury

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

Too often in the Emergency Department, we are faced with the challenge of simultaneously managing two patients who each require immediate care. This case does an excellent job of highlighting the following issues that often arise as a result:

  • The importance of delegating any tasks that may be delegated
  • The need to clarify who is taking ownership of a patient’s management when there is help available from others (such as another ED MD or a trauma team leader)
  • How essential it is to call for help early

In addition, this case also features some key medical content, including:

  • The recognition and treatment of cyanide toxicity in the context of a house fire
  • The preparation and management of a potentially difficult airway
  • The need to perform an escharotomy in a patient with circumferential chest burns and high ventilation pressures
  • The importance of checking a blood glucose on all patients with an altered level of consciousness

Clinical Vignette

Patient A: “You are working in a tertiary care ED. A 33 year old male has just been brought in by EMS after being dragged out of a house fire. He has been unresponsive with EMS and has significant burns to his chest, arm, and leg. The etiology of the fire is unclear, but the home was severely damaged.”

Midway through the case, Patient B will arrive.

Patient B (To be stated by EMS in handover): “We have a 55 year old male here who was repeatedly kicked during an altercation outside a bar. His GCS was 15 on arrival, but it just decreased to 13 in the ambulance bay, and he has become combative. We put him in C-spine collar at the scene. He has lots of bruising to face and head, but no other obvious injuries. When he was more cooperative, the patient denied other medical history or allergies initially.”

Case Summary

The case will begin with the arrival of patient from a house fire who has 30%TBSA burns. The team will be expected to recognize the need for intubation and fluid resuscitation. After successful intubation, a second patient will arrive from an altercation outside a bar. He appears to have a blunt traumatic head injury after being repeatedly kicked. The team is expected to recognize hypoglycemia in the context of a minor head injury and provide immediate glucose replacement. During the management of the head injured patient, the burn patient will continue to by hypotensive. The team will need to recognize the possibility of CN toxicity. The patient will also become more difficult to ventilate and will require an escharotomy.

A Note on Technical Requirements

At McMaster, we recently ran this case for our senior residents. It was a huge success! It did, however, require many resources. We used one high fidelity mannequin and one standardized patient actor. We also had two confederate nurses (one per patient). We had three staff physicians as instructors. One instructor was assigned to observing each patient’s management. The third instructor briefly played the paramedic and also coordinated between the two instructors and the sim tech to ensure the case ran smoothly. We ran the case with five residents participating. We had them pre-assigned to roles of trauma team leader, senior emerg resident, senior anesthesia resident, senior general surgery resident, and senior orthopedic resident. (This is often the make-up of our trauma team.)

Download the case here: Multi-trauma Case: Burn and Head Injury

CXR for Patient B found here:

normal-cxr-patient-b

(CXR source: http://www.pharmacology2000.com/respiratory_anesthesiology/pulmonary_assessment/pulmonary_assessment2.htm)

PXR for Patient B found here:

normal-pelvis-male

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

Two Patient Trauma

This case was written by Dr. Martin Kuuskne from McGill University. Dr. Kuuskne is a PGY5 Emergency Medicine resident and one of the editors-in-chief at EMSimCases.

Why it Matters

Emergency Medicine often requires care providers to be in multiple places at once. It is not uncommon to have two patients simultaneously require urgent or semi-urgent intervention. This case helps learners to develop this important skill by highlighting:

  • The challenges of triaging patients as immediately urgent or less urgent
  • The need to assign tasks to team members
  • The importance of adhering to the basics, even in a taxing situation

Clinical Vignette

Before entering the room: You are working the day shift in a tertiary care emergency department with full surgical capabilities. EMS is en-route to the hospital with two patients, a 37-year-old male and a 65 year old female, who were both drivers of a t-bone MVC of unknown speed. The ambulances will arrive in 2 minutes.

Upon entering the room: Each patient will be accompanied with a paramedic who will give this information and will be available to stay if asked.

Patient A: “37 year old male, belted driver, he got t-boned on the driver’s side. There was significant intrusion of his side door. We’re not sure if there was a loss of consciousness, we put him on a non-rebreather and his SAT was around 92%, tachy at 105 with an OK BP around 110 systolic during the ride.”

Patient B: “65 year old female, belted driver who t-boned the other car. The front of her car was totaled. Airbags were deployed and there was a brief loss of consciousness. We put on the collar ASAP. Vitals were stable en route but she was a bit confused during the ride. No vomiting.”

Case Summary

A young male and a middle-aged female are brought to the ED after a T-bone MVC at an unknown speed. Both patients were drivers. The emergency team is expected to triage the patients accordingly and to split the team so that both patients are treated.

Patient A: The team is expected to recognize respiratory compromise secondary to pneumothorax. Needle decompression and tube thoracostomy should be administered. The patient will in remain in respiratory compromise post-decompression and the team should consider intubation. If the pneumothorax is not recognized or treated, the patient will arrest. On secondary survey, the patient will complain of pelvic pain in addition to a positive eFAST evaluation. The team should activate the massive transfusion protocol (MTP) and activate the trauma/surgery team.

Patient B: The team is expected to recognize hypoglycemia in the context of a minor head injury. Immediate glucose replacement is required.

Download the case here:  Two for one MVC

CXR for Patient A found here:

left flail chest

(CXR source: http://learningradiology.com/archives2009/COW%20353-Flail%20Chest/caseoftheweek353page.htm)

Pelvic xray for Patient A found here:

open book # from radiopedia

(Xray source: http://radiopaedia.org/articles/open-book-fracture)

Left lung U/S for Patient A found here:

Right lung U/S for Patient A found here:

RUQ FAST image for Patient A found here:

RUQ FF

Pericardial U/S for Patient A found here:

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

CXR for Patient B found here:

normal female CXR radiopedia

(CXR source: http://radiopaedia.org/articles/normal-position-of-diaphragms-on-chest-radiography)