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

Non-Accidental Trauma

This case is written by Dr. Suzan Schneeweiss. She is a staff physician at Sick Kids Hospital in Toronto and is the Director of Education for the Division of Pediatric Emergency Medicine at the University of Toronto.

Why it Matters

The differential diagnosis for any sick neonate is always broad. This case, in particular, addresses the differential diagnosis and management of a seizing neonate. It highlights the following:

  • The need for anti-epileptics in a neonate with seizures in the context of trauma
  • The importance of including a septic work-up and broad antibiotic/antiviral coverage in the management of a seizing neonate
  • The need to consider non-accidental injury

Clinical Vignette

A 1 month-old male is brought into the ED due to poor feeding and lethargy. The baby was apparently well until this morning, when his mom noticed it was difficult to wake and feed him. There has been no fever. The baby vomited once this morning, and is voiding and stooling normally.

The nurse in triage notices abnormal movements and brings the baby in to your team in the resuscitation room.

Case Summary

The team has been called to help in the ED after a 1 month-old male is brought in seizing. The team is expected to manage the seizure, but then will subsequently realize on examination there are concerning signs for non-accidental trauma, specifically head injury. The team will be expected to establish definitive airway management and consult with PICU and local child protection services.

Download the case here: Non-Accidental Trauma

CXR for the case found here:

neonatal pneumonia

(CXR source: https://radiopaedia.org/articles/neonatal-pneumonia)

 

Newborn Sepsis with Apneas

This case is written by Dr. Rob Woods. He works in both the adult and pediatric emergency departments in Saskatoon and has been working in New Zealand for the past year. He is the founder and director of the FRCP EM residency program in Saskatchewan.

Why it Matters

This case highlights important manifestations of sepsis in a neonate. In particular, it reinforces that:

  • Apneas, hypoglycemia, and hypothermia are commonly seen as a result of systemic illness in neonates
  • Prolonged or persistent apneas with associated desaturations require management with either high-flow oxygen or intubation
  • Fluid resuscitation and broad-spectrum antibiotics are important early considerations when managing toxic neonates

Clinical Vignette

To be stated by the Paramedic with the Resus Nurse at bedside: “We picked up this term 3-day old male infant at their GPs office. Mom reports poor feeding for the past 12 hours, and two episodes of vomiting. They took him to the GPs office this morning and they found the temperature to be quite low at 33.1°C. They called us concerned about sepsis. We were only 5 minutes away so we have not obtained IV access. We did obtain a glucose level of 2.7. The child is lethargic and has very poor perfusion – peripheral cap refill is 7 seconds. We don’t have a cuff to get an accurate BP but the HR is 190.”

Case Summary

A 3-day-old term male infant is brought to the ED by EMS after being seen at their Family Physician’s office with a low temperature (33.1oC). The child has been feeding poorly for about 12 hours, and has vomited twice. He is lethargic on examination and poorly perfused with intermittent apneas lasting ~ 20 seconds. He requires immediate fluid resuscitation and broad-spectrum antibiotics. His perfusion will improve after IVF boluses, however the apneas will persist and necessitate intubation.

Download the case here: Newborn Sepsis with Apneas

Initial CXR for the case found here:

Normal neonatal CXR

(CXR source: http://emedicine.medscape.com/article/414608-overview)

Post-intubation CXR for the case found here:

Post-intubation CXR neonate

(CXR source: https://radiopaedia.org/articles/neonatal-pneumonia)

Pediatric Septic Shock

This case is written by Dr. Kyla Caners. She is a staff 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

Children with true septic shock are, thankfully, a rare presentation in the ED. However, recognition of early shock is an essential skill. This case highlights several important features of managing the critically ill child, including:

  • The need for early vascular access (whether that be intravenous or intraosseous, it must be obtained expediently)
  • The importance of monitoring for and treating resultant hypoglycemia
  • The need for early antibiotics

Clinical Vignette

A 4-year-old girl presents to your pediatric ED. Her mother states she is “not herself” and seems “lethargic.” She’s had a fever and a cough for the last three days. Today she just seems different. She was brought straight into a resus room and the charge nurse came to find you to tell you the child looks unwell.

Case Summary

A 4 year-old girl is brought to the ED because she is “not herself.” She has had 3 days of fever and cough and is previously healthy. She looks toxic on arrival with delayed capillary refill, a glazed stare, tachypnea and tachycardia. The team will be unable to obtain IV access and will need to insert an IO. Once they have access, they will need to resuscitate by pushing fluids. If they do not, the patient’s BP will drop. If a cap sugar is not checked, the patient will seize. The patient will remain listless after fluid resuscitation and will require intubation.

Download the case here: Pediatric Septic Shock

ECG for the case found here:

sinus-tachycardia

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

CXR for the case found here:

pediatric-pneumonia

(CXR source: http://radiopaedia.org/articles/round-pneumonia-1)

Coarctation of the Aorta

This case is written by Drs. Quang Ngo and Donika Orlich. Dr. Ngo is an attending emergency physician at McMaster Children’s Hospital and also serves as the Associate Program Director for the Department of Pediatrics. He is also a member of the advisory board here at EMSimCases. Dr. Orlich is a PGY5 Emergency Medicine resident at McMaster University who also completed a fellowship in Simulation and Medical Education last year.

Why it Matters

Having an approach to the toxic neonate is essential. More importantly, emergency physicians must be able to recognize subtle historical clues and physical exam features that point toward congenital heart disease in order to begin critical treatment rapidly. This case highlights the following:

  • The presentation of neonates with congenital heart disease including features like difficulty feeding, CHF, and tachypnea without increased work of breathing
  • The clinical features that may be present in a coarctation of the aorta, one specific type of congenital heart disease, and the resultant need to include four-limb BP’s as part of the work-up of toxic-appearing neonates
  • The importance of beginning a prostaglandin infusion in patients with suspected ductal-dependent congenital heart disease
  • One of the most common side effects of a prostaglandin infusion – apnea

Clinical Vignette

Your triage nurse comes to tell you about an infant she just put in the resuscitation room who she feels looks quite unwell. He is a 2 week old neonate brought to the ED by his mother. Mom was worried because he hasn’t been feeding very well and seems to just get sleepy when feeding. Now he just vomited his last feed and seems really lethargic. She thinks he just “doesn’t look the right colour”.

Case Summary

A 2-week-old neonate presents in shock requiring the learner to implement an initial broad work-up. The patient will also be hypoglycemic, and will seize if this is not promptly recognized. Physical exam and CXR findings will suggest coarctation of the aorta as the likely cause, and the learner should recognize the need for gentle fluid boluses and a prostaglandin infusion. Unless learners anticipate appropriately and intubate the patient prior to beginning the prostaglandins, the infant will become apneic after starting the infusion and require intubation.

Download the case here: Coarctation of the Aorta Case

ECG for the case found here:

coarc-ecg

(ECG source: http://www.omjournal.org/IssueText.aspx?issId=380)

Initial CXR for the case found here:

chf-neonate

(CXR source: http://www.adhb.govt.nz/newborn/TeachingResources/Radiology/CXR/HLHS/CXR-HLHS-congested.jpg)

Post-intubation CXR for the case found here:

chf-neonate-post-intubation

(CXR source: http://www.adhb.govt.nz/newborn/TeachingResources/Radiology/CXR/OtherCHF/NonstructuralCHF.jpg)

For more information on the management of Congenital Heart Disease Emergencies, see the excellent review by Emergency Medicine Cases found here.

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)

Eclampsia with Apnea Secondary to Magnesium Sulfate Administration

This case was written by Dr. Kyla Caners from McMaster University. Dr. Caners 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 managing an eclamptic patient:

  • Early administration of magnesium sulfate
  • Adding an anti-hypertensive agent if the blood pressure remains elevated after magnesium administration
  • Recognition of apnea as a side effect of magnesium administration; calcium gluconate is an antidote

Clinical Vignette

Miranda Hamm presents to your local tertiary care ED complaining of a headache. She is a 30 year old G1P0 at 32 weeks. She has had a headache since last night. This morning she started feeling nauseous and began vomiting. Now her vision feels blurred, so she came for assessment.

Case Summary

A 30 year-old female, G1P0 at 32 weeks, presents to the ED with headache, blurred vision, nausea, and vomiting. Her arrival BP is 175/115. As the team coordinates her initial workup, the patient will begin to seize. She will not stop seizing until magnesium sulfate is given. The patient will then require intubation for respiratory depression. The patient will also remain hypertensive, requiring administration of an appropriate antihypertensive agent. The case will end post intubation when the patient has been referred to OB.

Download the case here: Eclampsia Case

Post-intubation CXR for case found here:

Post Intubation

Post Intubation

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