Nightmares Case 3: Seizure

This is the third in a case series we will be publishing that make up “The Nightmares Course”.

The Nightmares Course at Queen’s University (Kingston, Ontario) was developed in 2011 by Drs. Dan Howes and Mike O’Connor. The course emerged organically in response to requests from first year residents wanting more training in the response to acutely unwell patients. In 2014, Dr. Tim Chaplin took over as the course director and has expanded the course to include first year residents from 14 programs and to provide both formative feedback and summative assessment. The course involves 4 sessions between August and November and a summative OSCE in December. Each session involves 4-5 residents and covers 3 simulated scenarios that are based on common calls to the floor. The course has been adapted for use at the University of Saskatchewan, the University of Manitoba, and the University of Calgary.

Why it Matters

The first few months of residency can be a stressful time with long nights on call and the adjustment to a new level of responsibility. While help should always be available, the first few minutes of managing a decompensating patient is something all junior residents must be competent at. This case series will help to accomplish that through simulation.

Clinical Vignette

It is 01:00 and you are on call covering the thoracic surgery service. You have been called to assess Mr. Wright for a seizure episode.

Case Summary

The resident is called to the ward to manage a patient who may have had a seizure. The patient is somnolent when the resident arrives. Shortly afterward, the patient seizes again. Two doses of anti-epileptic will be required to terminate the seizure. Finally, when the patient has been stabilized, the resident will be required to discuss the case with their staff on call.

Download here

Seizure

Subarachnoid Hemorrhage with Increased Intracranial Pressure

This case was written by Dr. Martin Kuuskne from McGill University. Dr. Kuuskne is a PGY4 Emergency Medicine resident and one of the editors-in-chief at EMSimCases.

Why it Matters

This case highlights three important aspects of the management of a subarachnoid hemorrhage:

  • Blood pressure control in an undifferentiated neurologic catastrophe
  • Safe approaches to intubating a patient with possible acute hydrocephalus
  • Management of a patient demonstrating signs of increased intracranial pressure

Clinical Vignette

You are working an evening shift at a tertiary care centre emergency department with full surgical capabilities. A patient is brought into the resuscitation area by ambulance with decreased mental status. The patient was at the gym lifting weights; he complained of an acute headache to his friend and suddenly fell to the ground. The patient remained unconscious with sonorous breathing. The ambulance was called.

Case Summary

A 45-year-old male who suffered an aneurysmal subarachnoid hemorrhage while weightlifting presents to the emergency department requiring intubation for airway protection and develops acute hydrocephalus requiring ICP lowering maneuvers before definitive surgical management.

Download the case here: SAH Case

ECG for case found here:

Deep cerebral t-wave inversions

(ECG source: http://cdn.lifeinthefastlane.com/wp-content/uploads/2011/12/SAH1.jpg)

CXR for case found here:

Post Intubation

Post Intubation CXR

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