Breech Delivery + NRP

This case is written by Dr. Donika Orlich. She is a PGY5 Emergency Medicine resident at McMaster University who also completed a fellowship in Simulation and Medical Education last year.

Why it Matters

All deliveries in the Emergency Department are considered high risk. Further, in most departments, both delivery and neonatal resuscitation are rare events. However, Emergency physicians must be prepared to manage all presentations – including breech delivery! This case highlights several important components of managing these rare presentations, including:

  • The need to adequately prepare the room (if time permits)
  • The importance of calling for a second physician to be available to manage the neonate upon delivery
  • How to safely perform a breech delivery
  • The step-wise progression of neonatal resuscitation post-delivery

Clinical Vignette

EMS Patch: “We have a 19 F complaining of severe abdominal pain onset 1 hour ago. She denies being pregnant, but looks almost full term to us. Contractions seem to be about 1 minute apart. Patient’s Vitals as follows: HR 120, BP 140/85, RR 20, O2 100% on RA. ETA 2 minutes.”

Case Summary

A 19-year-old female presents with EMS in active labour. She denies any history of pregnancy and has had no prenatal care. On examination, infant will be in breech position. The learner must deliver the infant from breech presentation. Following this, the neonate will will present lifeless, and require resuscitation.

Download the case here: Breech + NRP

 


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)


Multi-trauma (Kicked off a Horse)

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

Management of trauma patients with multiple intercurrent injuries can be challenging. This case provides an opportunity for junior learners to stretch themselves beyond their comfort zones. In particular, this case highlights the following:

  • The need for a systematic approach to the initial assessment and ongoing re-assessment of any complex trauma patient
  • The importance of prioritizing tasks and adjusting priorities as patient status changes
  • The complexity of managing a hypotensive, head-injured patient

Clinical Vignette

A 32-year-old female presents as a trauma activation with EMS after being bucked off of her horse. Her mom witnessed the episode and called EMS because she seemed groggy. She has had a low BP with EMS on route. Her current BP is 80/40.

Case Summary

A 32-year-old female presents after being bucked off of her horse. She is brought in as a trauma team activation because of a low BP. Her primary survey will reveal a boggy hematoma over her right temporal area as well as an unstable pelvis. Her initial GCS will be 8. The team will proceed through airway management in a hypotensive, head-injured trauma patient while also binding her pelvis. The patient eventually shows signs of brain herniation, which the team will need to manage prior to consultant arrival.

Download the case here: Pelvic Fracture and SDH

ECG for the case found here:

Sinus tachycardia

(ECG source: https://i0.wp.com/lifeinthefastlane.com/wp-content/uploads/2011/12/sinus-tachycardia.jpg)

Pre-intubation CXR for the case found here:

normal female CXR radiopedia

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

PXR for the case found here:

Pelvic fracture

(PXR source: https://littlemedic.files.wordpress.com/2013/01/pelvis_0_1.jpg)

Post-intubation CXR for the case found here:

normal-intubation2

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

Ultrasound showing free fluid in RUQ found here:

RUQ FF

Ultrasound showing normal lung sliding found here:

Ultrasound showing no pericardial effusion found here:

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


lung sliding
no PCE

Multi-drug Overdose

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

Calcium channel blocker overdoses are one of the most difficult overdoses for emergency physicians to manage. Even with excellent care, these patients often progress to cardiac arrest or to needing ECMO. This case highlights some key features in management, including:

  • The use of calcium gluconate and high-d0se insulin infusions to assist with blood pressure support (in isolation or in addition to other vasopressors)
  • The use of intralipid as an end of the line rescue treatment
  • The need to consider co-ingestions and their effects on management (in this case, clonazepam that slows the patient’s respiratory rate enough to require intubation)

Clinical Vigenette

A 48-year-old female presents to the ED with an unknown overdose. She was out drinking with friends until an hour ago. Her daughter came home and found her with vomit around her, empty pill bottles, and bits of pills in her vomit.

Case Summary

A 48-year-old female presents with a possible multi-drug overdose including glyburide, clonazepam and nifedipine. She will remain hypotensive throughout the case, despite treatment with calcium, high dose insulin, and other vasopressors. She will also have progressive respiratory depression and will eventually require intubation. She will then proceed to arrest. The team will be expected to give intralipid once the patient has arrested.

Download the case here: Multi-drug (CCB) OD

ECG for the case found here:

sinus brady with 1st degree hb

(ECG source: http://lifeinthefastlane.com/ecg-library/beta-blocker-and-calcium-channel-blocker-toxicity/sb-1hb/)

Post-intubation CXR for the case found here:

normal-intubation2

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


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)