Nightmares Case 1: Bradycardia

This is the first 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

The triage note states – Patient “fainted” while returning from the bathroom at home. He was found to be slightly more confused by his wife and complained of right elbow pain.

Case Summary

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.

Download the case here:

Bradycardia

ECG for the case found here:

Brady.jpg

Source: https://www.ecgquest.net/ecg/complete-heart-block-3/

Stab Wound to the Neck with Neurogenic Shock

This week’s case is written by Dr. Cheryl ffrench. She is the Simulation Director for Emergency Medicine at the University of Manitoba and is one of the advisory board members here at EMSimCases.

Why it Matters

Neurogenic shock is an important manifestation of spinal trauma. This case highlights several important aspects of neurogenic shock:

  • It can be difficult to recognize (especially in a multi-trauma patient)
  • At its presentation, vasopressors are often required to manage blood pressure
  • It should be suspected in trauma cases where the patient is hypotensive without tachycardia

Clinical Vignette

To be stated by EMS: “This is Jamal James. He’s a 21 year-old male who was found in his house by police after being stabbed by a friend. There was a lot of blood at the scene. We found a stab wound on his neck so we initiated spinal precautions. Before we arrived, the police started CPR briefly because they thought he didn’t have a pulse. He had a pulse when we got there but his respiratory effort was poor and he had a decreased LOC. Several attempts to intubate were unsuccessful so we bagged him on the way here. We don’t know anything about his allergies, medications, or past medical history.

Case Summary

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.

Download the case here: Stab Wound to Neck

ECG for the case found here:

normal-sinus-rhythm

(ECG source: http://lifeinthefastlane.com/ecg-library/normal-sinus-rhythm/)

CXR for the case found here:

Post Intubation

Post Intubation

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

U/S image showing no free fluid in the abdomen found here:

no FF

(U/S image courtesy of McMaster POCUS Subspecialty Training Program)

U/S showing no pericardial effusion found here:

(U/S courtesy of McMaster POCUS Subspecialty Training Program)