Status Epilepticus

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 review of the management of status epilepticus and includes 2nd, 3rd, and 4th line agents for treatment. This case also highlights a few unique practice challenges, including:

  • The hemodynamic effects of administering phenytoin too quickly
  • Disclosing medical error to families
  • Special agents to be considered in refractory seizure, such as magnesium sulfate, hypertonic saline, and pyridoxine

Clinical Vignette

A 38 year-old female is brought in by EMS with active seizure. She was last seen normal about 45 minutes ago by her husband, and has been witnessed seizing now for about 20 minutes. She is known to have epilepsy. EMS have 1 line in place, and 5mg IV midazolam was given en route.

Case Summary

A 38 year-old female presents actively seizing with EMS. She will fail to respond to repeat doses of IV benzodiazepines, and will require escalating medial management. Following phenytoin infusion, the patient will become hypotensive (because the phenytoin was given as a “push dose”, which the nurse will mention). The patient will then stop her GTC seizure, but will remain unresponsive with eye deviation. The team should recognize this as subclinical status, and proceed to intubate the patient.   The patient will continue to seize following phenobarbital and propofol infusion. Urgent consults to radiology and ICU should be made to expedite care out of the ED. The team will be expected to debrief the phenytoin medication error and disclose the error to the husband.

Download the case here: Status Epilepticus

ECG for the case found here:

normal-sinus-rhythm

(ECG source: http://i0.wp.com/lifeinthefastlane.com/wp-content/uploads/2011/12/normal-sinus-rhythm.jpg)

Post-intubation CXR for the case found here:

normal-intubation2

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

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)

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)

Hyponatremic Seizure

This case is 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

This case allows educators to review the approach to a common condition while also pushing learners to think outside conventional treatments. In particular, it demonstrates:

  • The importance of a broad differential diagnosis in the elderly patient with weakness
  • The typical management pathway for a patient with status epilepticus
  • The treatment of symptomatic hyponatremia and the urgency with which it must be given.

Clinical Vignette

Agnes Jones is a 93 year old female who has been brought to the ED by her daughter. The family has noticed that Agnes is not eating well over the last few months. She seems weak. Now, over the last day or so, she seems confused.

Case Summary

A 93 year old woman comes in with family. They are concerned about general weakness, worsening PO intake over the last few months, and new confusion. As the team takes a history and starts the initial workup, the patient will begin to seize. She will seize continuously until hypertonic saline or a paralytic is given. After two doses of benzodiazepine, a critical result showing severe hyponatremia will come back. The team is expected to administer hypertonic saline, which will stop the seizure. The patient will remain somnolent after this dosing, and as the team prepares to intubate, she will seize again, requiring a repeated dose of hypertonic saline.

Download the case here: Hyponatremic Seizure

ECG for case found here:

normal-sinus-rhythm

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

Pre-intubation CXR for the case found here:

normal-female-chest

(CXR source: http://radiologypics.com/2013/01/25/normal-female-chest-radiograph/)

Post-intubation CXR for the case found here:

Normal Post-Intubation CXR

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

DKA

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

DKA is a physiologically complex disorder. Thanks to excellent research and protocolization of care, certain components of DKA care have been clearly delineated. However, in the profoundly unwell DKA, it can be harder to account for complex physiology. This case highlights a few important management pearls:

  • The importance of re-assessing glucose in an altered patient with DKA on an insulin infusion
  • The consideration of cerebral edema in a DKA patient who becomes altered
  • The importance of expertly managing acidosis in the peri-intubation period by considering pre and post intubation respiratory rate

Our reviewers had quite the debate about what is considered optimal peri-intubation management in this patient. This case serves as an excellent starting point for a high-level discussion about the intubation of a severely acidotic patient. In particular:

  • Pre-intubation bicarbonate is relatively contraindicated in Peds DKA. Balancing the increased acidosis peri-intubation against the increased risk of cerebral edema is challenging.
  • A second IV fluid bolus pre-intubation is also controversial. Would it increase the risk of cerebral edema?
  • Is intubation with or without a paralytic the best choice? Using a paralytic optimizes time to intubation and first pass success, as well as minimizing aspiration risk. But it also eliminates the patient’s respiratory drive, which could potentially worsen acidosis and precipitate arrest. Not using a paralytic runs the risk of increased time to intubation and a resultant desaturation. It also adds an aspiration risk.

For this, and so many other reasons, this case will trigger plenty of discussion during debriefing!

Clinical Vignette

You have been called to the resuscitation bay to assess an 8 year old girl who has been brought in by her mother for lethargy and confusion. She has been unwell for 3 days with excessive fatigue, a few episodes of vomiting, and mild abdominal pain.

Case Summary

An 8 year old girl who has been tired and “unwell” for several days presents to the ED with an acute decline in her mental status. She is confused and lethargic. It becomes quickly apparent that the child is in DKA and requires immediate treatment. Due to decreasing neurologic status and vomiting, she eventually requires an advanced airway. The challenge is to optimize the peri-intubation course and to appropriately ventilate to allow for compensation of her metabolic acidosis.

Download the case here: DKA Case

CXR for case found here:

Normal Post-Intubation CXR

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

ASA Overdose

This case is 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

Aspirin toxicity causes a complex array of direct and indirect physiologic effects. There are several key factors in the management of aspirin toxicity that this case reviews:

  • Urinary alkalinization is important to help renal clearance and to reduce the CNS effects of ASA
  • Altered LOC is an ominous sign that can be due to either neuroglycopenia or cerebral edema
  • Intubation of a patient with ASA toxicity is high-risk due to their requirement for a high respiratory rate. In fact, in the context of ASA overdose, intubation is an indication for dialysis.

Clinical Vignette

A 22 year-old female presents to the ED saying she just ingested 60 tablets of ASA because she wants to die. Her mom found her while she was finishing the bottle of 325mg tabs approximately 60 minutes ago and called EMS. The patient is complaining of nausea and tinnitus.

Case Summary

22 year-old female presents saying she just ingested 60 tablets of ASA because she wants to die. Her mom found her while she was finishing the bottle of 325mg tabs approximately 60 minutes ago and called EMS. The patient is complaining of nausea and tinnitus and is tachypneic. The team should consider activated charcoal and alkalinize the urine. If they do not initiate treatments, they will receive a critical VBG showing a mixed respiratory alkalosis and metabolic acidosis. The patient will then become somnolent. The team will be expected to check her blood sugar and call for dialysis. They will also need to intubate and recognize the need to hyperventilate and dialyze.

Download the case here: ASA Overdose

ECG for case found here:

Sinus tachycardia 115

(ECG source: http://en.ecgpedia.org/wiki/File:Sinustachycardia.jpg)

CXR for case found here:

normal-female-chest

(CXR source: http://radiologypics.com/2013/01/25/normal-female-chest-radiograph/)

Post-intubation CXR for case found here:

Post Intubation

Post Intubation

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

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)

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)

Severe Asthma Exacerbation

This week’s case is written by Dr. Andrew Hall. He is an Assistant Professor in the Department of Emergency Medicine at Queen’s University where he is a Simulation-based Resuscitation Rounds Instructor and runs the Simulation-based OSCE Assessment Program for EM residents. He’s also one of the advisory board members here at EMSimCases.

Why it Matters

Acute asthma exacerbations are extremely common. Most asthmatics improve quickly after basic treatment with beta-agonists, anticholinergics, and steroids. This case highlights the management of those patients who don’t respond to the basics, including the following important points:

  • Severe asthma requires immediate, continuous treatment
  • Adjuncts to treatment such as magnesium sulfate, iv epinephrine, and bipap may be required
  • Ventilation in a severe asthmatic is extremely challenging due to air trapping and the need for prolonged expiratory time

Clinical Vignette

(vignette delivered by ER RN) A patient has been brought in by EMS and triaged to a Resuscitation Room in the Emergency Department with shortness of breath. He has had an upper respiratory tract infection with cough for 4 days. He’s now been having increasing SOB and chest tightness for 12 hours. He may have had a fever yesterday. EMS was called by a housemate who found him struggling to breathe at home. He is no longer responding to ventolin (using 4 puffs q30 min) and has rapidly worsened over the last hour. EMS reported vitals are HR 140, RR 41, O2Sat 85% on 100% O2 with face mask.

Case Summary

22 y.o. male is brought by EMS to the emergency department with increasing SOB and chest tightness x12 hours with rapid deterioration over the last hour resulting from a severe asthma exacerbation. He will require multiple pharmaceutical treatments, rapid sequence intubation and proper ventilation.

Download the case here: Asthma Exacerbation

CXR for the case found here:

Hyperinflation CXR

(CXR source: http://www.mypacs.net/cases/ACUTE-SEVERE-ASTHMA-ON-31-YO-CXR-3547838.html)