Pregnant Cardiomyopathy

This case is written by Drs. Nadia Primiani and Sev Perelman. They are both emergency physicians at Mount Sinai Hospital in Toronto. Dr. Primiani is the postgraduate education coordinator at the Schwartz/Reisman Emergency Centre. Dr. Perelman is the director of SIMSinai.

Why it Matters

Most emergency physicians have some degree of discomfort when a woman in her third trimester presents to the ED for any complaint. When that woman presents in acute distress, the discomfort is increased even further! This case takes learners through the management of a patient with a pregnancy-induced cardiomyopathy, reviewing:

  • The importance of calling for help early
  • The fact that all pregnant patients at term must be presumed to have difficult airways
  • That the treatment of the underlying medical condition is still the primary focus – in this case, BiPap, definitive airway management, and ultimately, inotropic support

Clinical Vignette

You are working in a community ED and your team has been called urgently by the nurse to see a 38 year old female who is G2P1 at 36 weeks gestational age. She was brought in by her sister, who is quite agitated and upset, saying “everybody has been ignoring her symptoms for the last 4 weeks.” The patient has just experienced a syncopal episode at home.

Case Summary

A 38-year-old female G2P1 at 36 weeks GA presents with acute on chronic respiratory distress in addition to chronic peripheral edema. She undergoes respiratory fatigue and hypoxia requiring intubation. She then becomes hypotensive which the team discovers is secondary to cardiogenic shock, requiring vasopressor infusion and consultation with Cardiology/ ICU.

Download the case here: Pregnant Cardiomyopathy

ECG for the case found here:

(ECG source: https://lifeinthefastlane.com/ecg-library/dilated-cardiomyopathy/)

 CXR for case found here:

posttestQ2pulmonaryedema

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

Cardiac Ultrasound for the case found here:

ezgif.com-optimize+(6)

(U/S source: http://www.thepocusatlas.com/echo/2hj4yjl0bcpxxokzzzoyip9mnz1ck5)

Lung U/S for the case found here:

Confluent+B+Lines

(U/S source: http://www.thepocusatlas.com/pulmonary/)

RUQ FAST U/S Image found here:

usruqneg

(U/S source: http://sinaiem.us/tutorials/fast/us-ruq-normal/)

OB U/S found here:

(U/S source: https://www.youtube.com/watch?v=SKKnTLqI_VM)

Burn with CO/CN Toxicity

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 patients with significant burns obtained in an enclosed space involves several important components. This case nicely highlights three key management considerations:

  • The need to intubate early in anticipation of airway edema that may develop
  • The possibility of cyanide toxicity in the context of hypotension and a high lactate, and the need to treat early with hydroxycobalamin
  • The importance of recognizing and testing for possible CO toxicity (and initiating 100% oxygen upon patient arrival)

Clinical Vignette

A 33-year-old female has just been brought into your tertiary care ED. She was dragged out of a house fire and is unresponsive. The etiology of the fire is unclear, but the home was severely damaged. The EMS crew that transported her noted significant burns across her chest, abdomen, arm, and leg.

Case Summary

A 33 year-old female is dragged out of a burning house and presents to the ED unresponsive. She has soot on her face, singed eyebrows, and burns to her entire chest, the front of her right arm, and part of her right leg. She is hypotensive and tachycardic with a GCS of 3. The team should proceed to intubate and fluid resuscitate. After this, the team will receive a critical VBG result that reveals profound metabolic acidosis, carboxyhemoglobin of 25 and a lactate of 11. If the potential for cyanide toxicity is recognized and treated, the case will end. If it is not, the patient will proceed to VT arrest.

Download the case here: Burn CO CN Case

ECG for the case found here:

sinus-tachycardia

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

CXR for the case found here:

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

MVC with Tension Pneumothorax

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

This case is a great example of challenging junior learners to a place that is just outside their comfort zone. Becoming comfortable with a primary and secondary survey is an important part of training in Emergency Medicine. Further, this case highlights the following:

  • The need to clinically recognize a possible tension pneumothorax and intervene immediately with needle decompression or finger thoracostomy
  • The challenge of performing/delegating multiple simultaneous interventions in a trauma patient
  • The importance of reassessing the patient and searching for multiple possible causes of hypotension

Clinical Vignette

EMS arrives with a 44-year-old male to your tertiary care ED. The trauma team has been activated. He was the driver in a single vehicle MVC at highway speed. There was extensive damage to the car. He is currently screaming and moaning.

Case Summary

A 44 year-old male arrives by EMS to a tertiary care ED where the trauma team has been activated. He was the driver in a single-vehicle MVC. He presents screaming and moaning with a GCS of 13. He has an obvious open fracture of his right forearm. He also has decreased air entry to the right side of his chest. The team will need to recognize the tension pneumothorax as part of their primary survey. They will then need to irrigate and splint the right arm after they have completed their secondary survey. As the secondary survey is being completed, the patient will become hypotensive again. This time, the team will find free fluid in the RUQ.

Download the case here: MVC with Tension PTX

ECG for the case found here:

sinus-tachycardia

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

Initial CXR for the case found here:

Tension PTX

(CXR source: https://radiopaedia.org/cases/tension-pneumothorax-9)

PXR for the case found here:

normal-pelvis-male

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

Second CXR for the case (post chest-tube insertion) found here:

R chest tube post PTX

(CXR source: http://jtd.amegroups.com/article/view/663/html)

FAST showing free fluid in the RUQ found here:

RUQ FF

U/S showing no PCE found here:

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

Anaphylaxis (+/- Laryngospasm)

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 completed a fellowship in Simulation and Medical Education.

Why it Matters

Anaphylaxis is a fairly frequent presentation to the ED. However, severe anaphylaxis requiring multiple epinephrine doses and airway management is quite rare. This case is challenging on its own merit simply due to the stress of intubating an impending airway obstruction. However, if learners are faced with laryngospasm as a complication of anaphylaxis, this case takes on even more important lessons, including:

  • The surprising and unexpected nature of laryngospasm
  • The role of Larson’s point in trying to resolve laryngospasm
  • How quickly children desaturate, and develop resultant bradycardia, as a consequence of laryngospasm

For an excellent review of the management of laryngospasm, click here.

Clinical Vignette

A 7-year-old boy arrives via EMS with increased work of breathing. He has a known allergy to peanuts and developed symptoms after eating birthday cake at a party. He has been given 0.15mg IM epinephrine 10 minutes ago by his mother. Current vital are: HR 140, BP 85/60, RR 40, O2 98% on NRB. He has some ongoing wheeze noted by EMS.

Case Summary

A 7-year-old male presents with wheeze, rash and increased WOB after eating a birthday cake. He has a known allergy to peanuts. The team must initiate usual anaphylaxis treatment including salbutamol for bronchospasm. The patient will then develop worsened hypotension, requiring the start of an epinephrine infusion. After this the patient will experience increased angioedema, prompting the team to consider intubation. If no paralytic is used for intubation (or if intubation is delayed), the patient will experience laryngospasm. The team will be unable to bag-mask ventilate the patient until they ask for either deeper sedation or a paralytic. If a paralytic is used, the team will be able to successfully intubate the child.

Download the case here: Anaphylaxis

Initial CXR for the case found here:

normal pediatric CXR

(CXR source: http://radiology-information.blogspot.ca/2015/04/normal-chest-x-ray.html)

Post-intubation CXR for the case found here:

Normal Pediatric Post-Intubation CXR

(CXR source: http://jetem.org/ettcxr/)

Aortic Dissection

This case was written by Dr. Martin Kuuskne who is one of the editors-in-chief at EMSimCases and is an attending Emergency Medicine Physician at University Health Network in Toronto.

Why it Matters

Aortic Dissection is one of the most deadly causes of chest pain for the emergency physician. Its presentation, methods of diagnosis, management and complications are varied and demand critical thinking, clear communication and teamwork. This case highlights the following points:

  1. The key elements of the history, physical exam and initial investigations that support the diagnosis of aortic dissection.
  2. The importance of managing hypertension in the setting of aortic dissection, including specific blood pressure and heart rate targets.
  3. The need to set priorities dynamically as a patient becomes unstable and requires ACLS care.

Clinical Vignette 

You are working the day shift at a tertiary-care hospital. A 66-year-old female is being wheeled into the resuscitation bay with a history of a syncopal episode. No family members or friends are present with the patient.

Case Summary

A 66-year-old female with a history of smoking, HTN and T2DM presents with syncope while walking her dog. She complains of retrosternal chest pain radiating to her jaw. She will become increasingly bradycardic and hypotensive, requiring the team to mobilize resources in order to facilitate diagnosis and management of an aortic dissection.

Download the case here: Aortic Dissection

First EKG for the case: Sinus tachycardia

(EKG Source: http://i0.wp.com/lifeinthefastlane.com/wp-content/uploads/2011/12/sinus-tachycardia.jpg)

Second EKG for the case:

mobitz-1-stemi

(EKG Source: http://hqmeded-ecg.blogspot.ca/2012_09_01_archive.html)

CXR for the case:

(CXR Source: https://radiopaedia.org/articles/aortic-dissection)

Pancreatitis with ARDS

This case is written by Dr. Kyla Caners. She is an 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

Pancreatitis is a common diagnosis made in the ED. However, severe pancreatitis with shock is relatively rare. As such, this case highlights several important points about the management of a hypotensive patient with abdominal pain:

  • The importance of maintaining a broad differential diagnosis and employing beside imaging in one’s assessment
  • The need for aggressive fluid resuscitation in an acutely hypotensive patient
  • The risk of ARDS with pancreatitis
  • The importance of developing a safe approach to the intubation of a patient who is simultaneously hypoxic and hypotensive

Clinical Vignette

Patricia is a 50 year old female who presents with epigastric abdominal pain. It’s been persistent for the last 24 hours and radiates through to her back. She has been nauseous all day and has been vomiting so much she “can’t keep anything down.” She was “on a bender” this weekend drinking beer and whiskey.

Case Summary

A 50 year-old female who was “on a bender” over the weekend now presents with diffuse abdominal pain and persistent nausea and vomiting. She will have a diffusely tender abdomen, a BP of 80/40, and be tachycardic. The team will need to work through a broad differential diagnosis and should fluid resuscitate aggressively. Once the patient has received 6L of fluid, she will become tachypneic and hypoxic and require intubation. The team will be given a lipase result just prior.

Download the case here: Pancreatitis with ARDS

ECG for the case found here:

Sinus tachycardia

(ECG source: http://cdn.lifeinthefastlane.com/wp-content/uploads/2011/12/sinus-tachycardia.jpg)

Initial CXR for the case found here:

normal female CXR radiopedia

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

ARDS CXR for when patient is hypoxic found here:

Pre-intuabtion

(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:

Post intubation

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

FAST showing no free fluid found here:

no FF

U/S aorta showing no AAA found here:

no AAA

Pericardial U/S showing no effusion found here:

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

Intra-abdominal Sepsis

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

Although recent literature has challenged the use of protocolized care in the management of sepsis, this case highlights the key points that are crucial in early sepsis care, namely:

  • The recognition of sepsis and identifying a likely source of infection
  • The initiation of broad-spectrum antibiotics in the emergency department
  • Hemodynamic resuscitation with intravenous fluids and vasopressor therapy

Clinical Vignette 

You are working a day shift at a community hospital emergency department. You are handed a chart of a patient presenting with abdominal pain. You recognize the following vital signs: Heart rate 120, blood pressure 85/55, respiratory rate 20, and O2 Saturation 95%.

Case Summary

A 60-year-old male presents with a four-day history of abdominal pain secondary to cholangitis. The patient presents in septic shock requiring intravenous fluid resuscitation, empiric broad-spectrum antibiotics and vasopressor support and suffers a PEA arrest prior to disposition to advanced imaging or definitive management.

Download the case here: Cholangitis

ECG for case found here: 

Sinus tachycardia

(ECG source: http://cdn.lifeinthefastlane.com/wp-content/uploads/2011/12/sinus-tachycardia.jpg)

CXR for case found here: 

CXR

Ultrasound for case found here:

http://www.pocustoronto.com/wordpress/?p=264

Altered LOC

This case was written by Dr. Kyla Caners. She is a PGY5 Emergency Medicine resident at McMaster University and is also one of the Editors-in-Chief here at EMSimCases.

Why it Matters

It’s easy as a simulation case writer to get excited about complex cases with rare presentations. But it’s also important to remember to teach to the level of the resident. This case highlights some very important lessons for junior learners:

  • The importance of a broad differential diagnosis in the altered patient
  • How to prioritize and coordinate an extensive work-up for a relatively ill patient
  • Recognizing when an altered patient needs to be intubated

We take these skills for granted as experienced clinicians. But it’s amazing how many excellent teaching conversations come from running this very simple case.

Case Summary

An 82 year old man arrives to the ED by EMS with a GCS of 7. He smells of urine and feces, and apparently has not been seen in 4 days. He is hypotensive and tachycardic. With simple fluid resuscitation (1-2L), the BP will improve. Learners are to organize a broad diagnostic work-up and coverage with broad-spectrum antibiotics. They must also recognize the need to intubate. If they do not, the patient will vomit and have a resultant desaturation. The case ends after successful workup and intubation.

Clinical Vignette

You are working in a community ED. Mr. Alito Bizzaro is brought in by EMS into a resuscitation room with altered LOC. He is known to be reclusive, but always picks up his paper at 10am. His neighbours had not seen him pick up his paper in 4 days, and so they called. The patient was found on the floor in his apartment near the doorway to the bathroom. He is 82 years old and lives alone. His apartment was unkempt. The patient is covered in urine and feces.

Download the case here: aLOC Case

ECG for the case found here:

Sinus tachycardia

(ECG source: http://cdn.lifeinthefastlane.com/wp-content/uploads/2011/12/sinus-tachycardia.jpg)

CXR for the case found here:

Post Intubation

Post Intubation

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

Ruptured AAA

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

Rupture is the most common and critical complication of an abdominal aortic aneurysm (AAA). It usually occurs into the retroperitoneum where bleeding may be temporarily limited and allows an opportunity to intervene. This case highlights three important aspects of managing a patient with a AAA rupture.

  • The use of a targeted ultrasound protocol in undifferentiated shock.
  • The concept of permissive hypotension in the treatment of a critical hemorrhage.
  • Rapid stabilization with blood products and organization for the transfer of a critically ill patient to the operating room.

Clinical Vignette 

You are working an evening shift at a tertiary care emergency department. You receive a call from a paramedic to alert you to the arrival of a 70-year old male who had a syncopal episode and was then found to be obtunded by his daughter. The patient is now in the resuscitation bay.

Case Summary

A 70-year-old male presents to the emergency department after a syncopal episode and then found to be obtunded by his daughter. He is hypotensive and tachycardic on arrival secondary to a AAA rupture into the retroperitoneal space. He requires intubation and fluid resuscitation with blood products to avoid a PEA arrest secondary to hypovolemia.

Download the case here: Ruptured AAA

ECG for case found here: 

Preintubation CXR for case found here: 

CXR

http://radiopaedia.org/images/220869

Postintubation CXR for case found here: 

Ultrasounds for case found here: