This is a multi-case simulation. The initial patient will present with a STEMI. The resident will need to arrange for cardiac catheterization and provide appropriate medical treatment. The exact moment these orders are completed, a stroke activation will be called for a patient eligible for tPA. Stroke protocol needs to be followed and tPA will need to be given. As soon as tPA is pushed, the resident will be handed an EKG with signs of hyperkalemia and told that a patient with depression has checked in. The resident will need to immediately evaluate the patient with hyperkalemia and give appropriate medications or they will decline. As they are pushing the medications, a Trauma Level One will be called. The trauma will be an open book pelvic fracture with hypotension and a positive FAST. The patient will need a pelvic binder, blood products, and go immediately to the OR. At this time, the resident will need to follow up on the stroke and hyperkalemia patients before evaluating the patient presenting with depression.
48-year-old male with a recent tracheostomy presents with sudden onset respiratory distress. The patient is unable to be oxygenated or ventilated through the tracheostomy tube. The team must recognize that the tracheostomy tube is either obstructed or displaced. Attempts to correct tracheostomy obstruction with suctioning and cuff deflation are not successful. Removal of the tracheostomy tube is required, followed by either oral intubation or placement of a new tracheostomy tube. The patient improves once oral or stomal intubation is performed. If tracheostomy tube is not removed, the patient worsens and goes into cardiac arrest secondary to respiratory failure.
Pre-notification is sent about an 8-year-old with known seizure disorder coming in via EMS who has been seizing for 7 minutes and is persistently seizing despite intramuscular midazolam. The case will involve managing pediatric status epilepticus and including escalating anti-epileptics, intubation, and handing over to pediatrics.
A 67yr old male with multiple comorbidities is brought by ambulance with a 3-day history of diffuse abdominal pain. The history is vague and the differential of his symptoms remains very broad. He develops significantly worsening pain and hypotension and becomes obtunded. As the patient’s condition deteriorates, the team must initiate management of abdominal pain plus shock and support the hemodynamics with vasopressors/inotropes. The team will need to intubate to facilitate advanced imaging and definitive care.
A 44-year-old male presents to the emergency department following the ingestion of an entire bottle of metoprolol. Decontamination strategies should be utilized alongside consultation with poison control. Patient clinically deteriorates as the drug reaches peak effects, requiring IV fluids, atropine, calcium, glucagon, multi-dose vasopressors, high dose insulin, and a discussion around potential salvage therapies.
A 53 year old male with untreated hypertension presents with a history of vomiting, back pain and acute agitation. Once he is sedated, assessment will reveal an acute aortic dissection. He will require prompt treatment, intubation and disposition planning.
A femoral nerve block has just been performed on a 65-year-old male who sustained a right femoral neck fracture. The patient also sustained a laceration to the scalp which was repaired by the medical student. The patient is now complaining of blurry vision, paresthesias, and “twitchiness”. The patient progresses on to seizure followed by cardiac arrest and will need high quality ACLS care along with lipid emulsion therapy.
This case was designed during the January 2020 COVID-19 outbreak in order to assess and improve team preparedness for safely and effectively caring for a critically ill coronavirus patient from triage through to intubation.
This is a case of an elderly patient with syncope. He is found to be in third degree heart block. The team is expected to perform an initial assessment and obtain an ECG. Upon recognizing the heart block, they should ensure IV access and place pacer pads while calling for help.
A 21 year old male is brought to your tertiary care ED by EMS after being stabbed by a friend. EMS initiated spinal precautions and failed several attempts to intubate en route. On arrival, the patient is being bagged and has a single stab wound to the right posterolateral neck. He requires emergent intubation for airway protection. After intubation, his blood pressure drops but his heart rate remains in the 70s. His blood pressure will stabilize only after appropriate fluid resuscitation and vasopressor initiation.