Polytrauma for Team Communication

This case is written by Dr. Chris Heyd. He is a PGY4 Emergency Medicine resident at McMaster University and has spent the last year completing a sub-specialty focus in disaster medicine and simulation. He is also one of our resident editors here at EmSimCases.

Why it Matters

This case highlights some of the challenges that can be associated with activating a trauma team. While the intent is to have many expert hands available to help at once, sometimes the team members arrive in a staggered fashion. This case reviews:

  • The challenges of managing an unstable trauma patient when there are interruptions to the flow of communication
  • The need to expediently place a chest tube in a hypoxic trauma patient
  • The fact that near simultaneous intubation and chest tube placement is often necessary in an unstable trauma patient

Clinical Vignette

To be read aloud by simulation facilitator at start of case:

“You are working as an Emergency physician at a tertiary care trauma centre and have been called overhead to your trauma bay. A paramedic team has just arrived with a 64-year old trauma patient. He was involved in a highway speed head-on MVC. He was restrained and air bags deployed. He was the driver and the other drive died on scene. There were no other passengers. EMS extricated the patient easily. They have placed one IV line and started running normal saline. He has been placed on a non-rebreather mask but has remained tachycardic, hypoxic and altered. GCS has been consistently 14. The trauma team was activated based on injury mechanism but so far only the orthopedic resident has arrived at the bedside.”

Case Summary

A 64-year old man is involved in a high-speed car crash. The trauma team is activated and he is brought directly to the ED. On arrival, he is hypoxic, tachycardic and altered. CXR reveals multiple rib fractures with a right-sided hemopneumothorax.

The team leader will need to effectively communicate with the team to ensure the tasks of intubation, chest tube placement and blood product administration are performed in a safe and quickly. The patient will stabilize after these treatments.

Members of the trauma team will have a staggered entry into the room. The team leader will need to balance communication with the new team members and the urgent interventions needed by the patient.

Download the case here: Polytrauma for Team Communication

CXR for the case found here:

CXR trauma

(CXR source: https://radiopaedia.org/cases/large-traumatic-haemothorax)

PXR for the case found here:

Normal PXR

(PXR source: https://radiopaedia.org/cases/normal-pelvis-x-ray-trauma-supine-1)

Lung U/S showing hemothorax found here:

 

(U/S source: McMaster PoCUS Subspecialty Training Program)

Normal RUQ FAST image found here:

no FF

(U/S source: McMaster PoCUS Subspecialty Training Program)

Intubation with Missing BVM

This case is written by Drs. Andrew Petrosoniak and Nicole Kester-Greene. Dr. Andrew Petrosoniak is an emergency physician and trauma team leader at St. Michael’s Hospital. He’s an assistant professor at the University of Toronto and an associate scientist at the Li Ka Shing Knowledge Institute.  Dr. Nicole Kester-Greene is a staff physician at Sunnybrook Health Sciences Centre in the Department of Emergency Services and an assistant professor in the Department of Medicine, Division of Emergency Medicine. She has completed a simulation educators training course at Harvard Centre for Medical Simulation and is currently Director of Emergency Medicine Simulation at Sunnybrook.

Why it Matters

Emergency medicine is about anticipating the worst and preparing for it . This case highlights this perfectly. In particular, it emphasizes:

  • The need to have a mental (or physical) checklist to ensure all necessary equipment is available at the bedside before starting a procedure
  • The complex nature of managing an immunocompromised patient with respiratory illness
  • The role for intubation in a hypoxic patient

Clinical Vignette

You are working in a large community ED. The triage nurse tells you that she has just put a patient in the resuscitation room. He is a 41-year old man with HIV. He is known to be non-compliant with his anti-retrovirals. He noticed progressive shortness of breath over 3-4 days and has had a dry cough for 10 days. His O2 sat was in the 80s at triage.

Case Summary

A 41-year old male with HIV (not on treatment) presents to the ED with a cough for 10 days, progressive dyspnea and fever. He is hypoxic at triage and brought immediately to the resuscitation room. He has transient improvement on oxygen but then has progressive worsening of his hypoxia and dyspnea. Intubation is required. The team needs to prepare for RSI and identify that the BVM is missing from the room prior to intubation.

Download the case here: Intubation with Missing BVM

CXR for the case found here:

PJP pneumonia

(CXR source: https://radiopaedia.org/cases/35823)

 

Acute Chest Syndrome

This case is written by Dr. Carla Angelski. She has completed both a PEM fellowship at Dalhousie and a MEd in Health Sciences Education. She now works in the Pediatric Emergency Department at the Royal University Hospital in Saskatchewan and is intimately involved in the delivery of high-fidelity simulation at the their sim centre. She is currently working on a curriculum to deliver in-situ simulation for ongoing faculty CME within the division and department.

Why it Matters

Patients with sickle cell disease are subject to a host of crises that can be difficult to manage. This case highlights the unique management of acute chest syndrome. In particular:

  • Recognition of acute chest syndrome as a possibility in the sickle cell patient with respiratory distress
  • Judicious use of fluids in patients with possible acute chest syndrome
  • The possible need for exchange transfusion in patients with severe acute chest syndrome

Clinical Vignette

You are working the day shift at a tertiary children’s hospital. A mother brings in her son, James, a four-year old boy with known sickle cell disease (HbSS). She is concerned since he’s had low energy and a cough for two days. Now he’s had a fever since this afternoon.

Case Summary

A 4-year-old boy with known sick cell disease presents with two days of cough and a one afternoon of fever. The patient is initially saturating at 88%, looks unwell and is in moderate-severe distress. During the case, the patient’s oxygenation with drop and the emergency team is expected to provide airway support. They will also need to pick appropriate induction agents for intubation. The case will end with ICU admission. During the case, the mother will also be challenging/questioning the team until a team member is delegated to help keep the mother calm.

Download the case here: Acute Chest Syndrome

CXR for the case found here:

sickle cell CXR

(CXR source: http://reference.medscape.com/features/slideshow/sickle-cell#8)

Post-intubation CXR for the case found here:

Post-intubation R-sided infiltrate

(CXR source: http://www.swjpcc.com/critical-care/?currentPage=4)

Hypothermia with Trauma

This case is written by Dr. Stephen Miller. He is an emergency physician in Halifax. He is also the former medical director of EM Simulation and the current director of the Skilled Clinician Program for UGME at Dalhousie University. He developed his interest in simulation while obtaining his Masters of Health Professions Education.

Why it Matters

Moderate to severe hypothermia can be quite challenging to correct. This case highlights several important features of hypothermia management:

  • The importance of searching for concurrent illness that may be causing the hypothermia or working against rewarming efforts
  • The effect of hypothermia on trauma management
  • Modifications to ACLS as required during hypothermic resuscitation
  • The multitude of ways in which one can attempt to actively re-warm a patient

Clinical Vignette

An approximately 30 year old female is brought into the ED at 4 AM by a man who found her lying at the side of the road. It is minus 30 degrees Celsius outside and she has no coat or shoes. The man does not know her and is unable to provide any additional history except that she was blue and having trouble breathing when he found her. She is noted to have a decreased LOC and laboured breathing. She has obvious deformities of her left forearm and right leg.

Case Summary

30 year-old female is brought into the ED at 4 AM by a man who found her lying at the side of the road with no coat or shoes. It is minus 30 degrees Celsius outside. On arrival she has a reduced LOC, laboured breathing, a right-sided pneumothorax, cyanotic extremities, a left radius & ulna fracture, and a right tib-fib fracture. The team is required to use both active and passive rewarming strategies. Regardless of the team’s efforts, the patient in this case will arrest. Upon ROSC, they are required to continue rewarming as well as to address the other traumatic injuries.

Download the case here: Hypothermia

CXR for the case found here:

PTX R with rib fractures

(CXR source: http://radiopaedia.org/cases/pneumothorax-due-to-rib-fractures-1)

ECG for the case found here:

hypothermia-shiver-artefact

(ECG source: : http://cdn.lifeinthefastlane.com/wp-content/uploads/2011/03/hypothermia-shiver-artefact.jpg)

Right lung U/S found here:

Left lung U/S found here:

RUQ FAST image found here:

RUQ FF

Pericardial U/S found here:

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

Acute Respiratory Distress

This case is written by Dr. Lindsey McMurray. She is a PGY4 Emergency Medicine resident from the University of Toronto who is currently doing a Resuscitation and Reanimation fellowship at Queen’s University.

Why it Matters

When the cause of acute respiratory distress is clear, its management can feel routine. However, as many senior physicians can attest, sometimes the cause is quite uncertain. It is important for junior learners to work through this differential because:

  • Acute respiratory distress is a relatively common patient presentation
  • Simultaneous initiation of investigations and treatment requires significant resource management skills
  • Delays to treatment in the critically ill patient can lead to poor outcomes

Clinical Vignette

You are on the Gynecology service and have been paged by the ward nurse to attend to a 78 year old woman who is having trouble breathing. She is POD #0 from a 4 hour TAH+BSO operation for ovarian CA. She just got to the ward about 1 hour ago. You enter the patient’s room she is hooked up to an IV with NS running at 150cc/hr.

Case Summary

A 78 year old woman post-op from a TAH+ BSO for ovarian CA has just been transferred to the ward when she develops acute shortness of breath. When the resident arrives, the patient is in significant respiratory distress saturating 80% on RA. Oxygen and medical therapy will not adequately relieve the patient’s distress. The resident will need to recognize that the patient has a Grade 3-4 LV and received 2L of fluid intra-operatively. When BiPAP is called for, it will be unavailable. Ultimately, the patient will require intubation.

Download the case here: Acute Respiratory Distress

ECG for case found here:

ECG lateral changes

(ECG source: https://thejarvik7.files.wordpress.com/2012/02/inferior-wall-stemi-2005-05-27-08.jpg)

CXR for case found here:

CHF CXR

(CXR source: https://www.med-ed.virginia.edu/courses/rad/cxr/pathology2chest.html)