PE with Bleeding

This case is written by Dr. Donika Orlich. She is a staff physician practising in the Greater Toronto Area. She completed both her Emergency Medicine training and Clinician Educator Diploma at McMaster University.

Why it Matters

Many simulation cases that deal with pulmonary embolism seem to focus on the decision to administer thrombolytics (usually upon a patient’s arrest). This case is different. While the team must administer thrombolytics to a patient with known pulmonary embolism, the catch is that they must then also recognize shock as a result of intra-abdominal bleeding. As a result, the case highlights the following:

  • The dose of thrombolytics to be used in the context of cardiac arrest
  • The importance of an approach to undifferentiated shock after ROSC. (It’s not all cardiogenic!)
  • That bleeding is a complication of thrombolysis. This is drilled into our brains as the major complication, but somehow it is diagnostically challenging to recognize.

Clinical Vignette

You are called urgently to the bedside of a patient who is in the Emergency Department awaiting medicine consultation. Your colleague saw her earlier. She is 63 years old and has a CT-confirmed pulmonary embolism. She had presented with shortness of breath on exertion in the context of a recent hysterectomy 4 weeks ago. She has been stable in the ED until she got up to go to the bathroom and suddenly developed severe shortness of breath.

Case Summary

A 63-year-old female is in the Emergency Department awaiting internal medicine consultation for a diagnosed pulmonary embolism. She suddenly becomes very short of breath while walking to the bathroom and the team is called to assess. The patent will then arrest, necessitating thrombolysis. After ROSC, she will stabilize briefly but then develop increasing vasopressor requirements. The team will need to work through the shock differential diagnosis and recognize free fluid in the abdomen as a complication of thrombolysis requiring surgical consultation and transfusion.

Download the case here: PE with Bleeding

ECG for the case found here:

Massive PE ECG

(ECG source: https://lifeinthefastlane.com/ecg-library/pulmonary-embolism/)

Initial CXR for the case found here:

normal female CXR radiopedia

(CXR source: https://radiopaedia.org/cases/normal-chest-radiograph-female-1)

Post-intubation CXR for the case found here:

normal-intubation2

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

Pericardial ultrasound for the case found here:

Normal lung ultrasound for the case found here:

Abdominal free fluid ultrasound for the case found here:

RUQ FF

(All ultrasound images are courtesy of McMaster PoCUS Subspecialty Training Program.)

Ruptured Ectopic

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

Ectopic pregnancy is a can’t miss diagnosis in Emergency Medicine. This case highlights just how sick patients with ruptured ectopic pregnancies can be. Some important learning points include:

  • The importance to having an approach to the undifferentiated patient with syncope and hypotension
  • The need to order a βHCG in women of child-bearing age who present with syncope
  • The rapid stabilization of a patient with intraperitoneal hemorrhage using massive transfusion.

Clinical Vignette

26 year old female presents after a syncopal episode at home. She immigrated from Cambodia two weeks ago to work as a live-in nanny, but has been feeling unwell for the last 3 days. The patient speaks limited English, but the family she is staying with said she has been vomiting the past few days and was unable to get out of bed this morning. When she tried, she because quite dizzy and then passed out.

Case Summary

26 year-old female, recently immigrated from Cambodia, presents after a syncopal episode at home. At the case outset, she complains of feeling “a little dizzy” and has a HR of 100 and a BP of 90/60. Once the team initiates care, the patient will say she has to vomit and then become poorly responsive and more hypotensive. The patient does not know that she is pregnant, so the team will have to consider the diagnosis early and use bedside U/S to point them in the right direction. The team will then need to initiate a massive transfusion and arrange for surgery. If the ectopic pregnancy is not recognized, the patient will become persistently more hypotensive until she has a PEA arrest.

Download the case here: Ruptured Ectopic

RUQ U/S for the case found here:

RUQ FF

Abdominal U/S with no IUP for the case found here:

(All U/S images are courtesy of McMaster PoCUS Subspecialty Training Program.)

ECG #1 for the case found here:

Sinus tachycardia

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

ECG #2 for the case found here:

normal-sinus-rhythm

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

Post-intubation CXR for the case found here:

Post-Intubation

Post Intubation

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