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.
NIGHTMARES CASE 9: STEMI
We are returning to a case series that we published two years ago! This is the ninth case in a series we are publishing that make up “The Nightmares Course” - a Sim Bootcamp for new residents. It’s 5:00 am and you’ve been called to see a patient complaining of “chest discomfort”.
COVID-19: STEMI with VF Arrest
This 50-year old woman presents with typical cardiac chest pain and high suspicion for COVID-19. Her ECG shows an anterior STEMI. The team will start performing the initial work-up and management of a patient with STEMI. While this is occurring, the patient suffers a VF arrest. The team will need to go through the ACLS algorithm while taking all precautions required in caring for a patient with suspected COVID.
Chest Pain on the Ward
The case will begin with a phone call from the bedside nurse for a patient on the ward that the resident on call is covering. The resident will then arrive at the bedside to find a patient complaining of significant chest pain. The patient will be in some respiratory distress due to CHF. The patient’s initial ECG will show new T-wave inversion. The patient will prompt regarding ongoing chest pain and his ECG will evolve to show an anterolateral STEMI. The team is expected to recognize the evolving STEMI and initiate treatment and cath lab activation.
STEMI with Cardiogenic Shock
A 55-year-old man presents to the ED as a STEMI call. He is profoundly hypotensive with low O2 sats and obvious CHF. The patient’s blood pressure will transiently respond to fluid resuscitation. The ECG will show anterolateral ST elevation. The team will need to prepare for intubation while activating the cath lab. They will also need to start vasopressors. The patient will remain hypotensive until an inotrope like dobutamine is initiated. If unsafe medications are chosen for intubation, the patient will have a VT arrest.
STEMI with Bradycardia
A 65-year-old female is brought to the ED with chest tightness and SOB. On arrival, she will be found to have an inferior STEMI with resultant 3rd degree heart block and hypotension. The team will be expected to initiate vasopressor support and transcutaneous pacing. However, prior to doing so, the patient will develop a VT arrest requiring ACLS care. After ROSC, the team will need to initiate transcutaneous pacing and activate the cath lab for definitive management.
A 54-year-old male police officer presents to the ED complaining of chest pain for two hours that started after his weekend hockey game. He is feeling dizzy and short of breath upon presentation. He will have a VT arrest as he is placed on the monitor. He will require two shocks and rounds of CPR before he has ROSC. He will then loose his pulse again while the team is trying to initiate post-arrest care; this will happen several times. Finally, the team will maintain ROSC. When an ECG is performed, it is revealed that the patient has a STEMI and the team will need to call for emergent PCI.
Tumour Lysis Syndrome
A 72-year-old male is brought in as a “code STEMI” to the resuscitation bay. He was recently diagnosed with ALL and had chemotherapy 3 days ago for the first time. The patient is severely hyperkalemic, which must be initially recognized and treated, hypocalcemic and hyperuricemic as a result of Tumour Lysis Syndrome and the metabolic derangements must be stabilized until emergent hemodialysis is arranged.