ALiEM Sim Case Series: Mass Casualty Building Bombing

disasterCase Writer:  Nikita Joshi, MD

Keywords: Mass casualty incident, building bombing, disaster, triage, ethics

Educational Objectives

Medical

  • Develop system of triage to optimize patient outcomes in prehospital disaster setting
  • Effectively utilize color coded tagging method to assist in categorizing patients
  • Develop treatment plans to address immediate emergency conditions per ATLS protocols

Communication

  • Maintain team and personnel safety precautions
  • Regularly provide updates to incident command center

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By |2019-02-19T18:08:27-08:00Jul 5, 2013|Simulation|

ALiEM Sim Case Series: Pediatric WPW

Case Writer: Nikita Joshi, MD

Keywords

Pediatrics, Syncope, Wolff Parkinson White (WPW), PALS

Educational Objectives

Medical

  • Discuss a broad differential diagnosis for pediatric syncope
  • Identify critical findings in pediatric EKG
  • Manage WPW tachycardia

Communication

  • Obtain a focused history in a pt with WPW focusing upon family history
  • Communicate as an interdisciplinary team

Case Synopsis

10 yo boy BIBEMS s/p syncope. Pt was playing on the football field, running down field when he suddenly collapsed. Bystanders quickly went to the boy and within 1 minute the pt had regained consciousness without any intervention. When EMS arrived on the scene, the boy was sitting with his mother telling everyone he wanted to go back and play.Upon arrival in the ED, pt is well appearing, however had a heart rate of 180 bpm and BP of 115/80.  EKG shows a wide complex tachycardia rhythm.  If team gives AV nodal blocking agents, the pt will devolve into a VF rhythm, and the pt will become nonresponsive. If team administers procainamide, pt will go into a rate controlled rhythm that reveals WPW and should then be placed on a procainamide drip. If team performs cardioversion, the pt will go into a rate controlled rhythm that reveals WPW. If the team does nothing, the pt will eventually go into a ventricular fibrillation cardiac arrest.

 
Peds WPW Case Flow3

Download PDF of this flowchart

Peds WPW ABEM Milestone PC1
PDF this case-specific ABEM Milestone breakdown of PC1
PDF of more detailed scenario description

Critical Actions

  1. Analyze and interpret pediatric EKG for life threatening causes of syncope
  2. Initiate PALS for tachydysrhythmia
  3. Avoid AV nodal blocking agents in undifferentiated wide complex tachycardias
  4. Cardiovert pt early to avoid further decompensation
  5. Obtain family history of WPW with ablation

Learners

  • Residents (EM, pediatrics)
  • Nurses
  • EMS providers
  • Students (medical, nursing, EMS)

Location

ED resuscitation bay

Patient

10 yo boy

Equipment

  • Advanced airway equipment
  • Airway adjuncts
  • Broselow tape
  • Cardiac monitor
  • Cardioverter / defibrillator
  • IV fluid
  • Pediatric cardiac arrest cart
  • Syringes

Moulage

  • Sports clothing for manikin

Confederates

  • EMS provider – Gives history of well appearing pt on the football field. They did not obtain vitals because pt was so well appearing upon their arrival.
  • Mother – Unconcerned of syncopal episode, not good historian, thinks her son does not require medical care
  • Nurse – Completes and executes all orders provided
  • PICU attending (voice) – Discusses case with team over phone
  • Pediatric cardiology attending (voice) – Discusses case with team over phone

Supporting Files / Media

  • CXR – normal
  • EKG 1 – wide complex tachycardia, irregularly irregular
  • EKG 2 – VF
  • Echocardiography – normal, no effusion, good ejection fraction

Translation

AV = atrioventricular
BIBEMS = brought in by EMS
BP = blood pressure
CXR = chest x-ray
HR = heart rate
IV = intravenous
LOC = loss of consciousness
neg = negative
RR = respiratory rate
pt = patient
s/p = status post
T = temperature
WPW = Wolff Parkinson White
US = ultrasound
VF = ventricular fibrillation
yo = year old


References

  1. Boren SD. Commotio cordis. N Engl J Med. 2010. 362(23):2229-30. PMID: 20568311
  2. Fischer JWJ. Cho CS. Pediatric Syncope: Cases from the Emergency Department. Emergency Medicine Clinics of North America. 2010. 28;3. PMID 20709241
  3. Life in the Fast Lane Blog Post:  http://lifeinthefastlane.com/ecg-library/pre-excitation-syndromes/
  4. Mottram AR. Svenson JE. Rhythm Disturbances. Emergency Medicine Clinics of North America. 2011. 29;4. PMID 22040704

By |2019-02-19T18:02:41-08:00May 17, 2013|Pediatrics, Simulation|

Sim Case Series: Incorporating ABEM Milestones

In this week’s simulation case, you will notice the addition of a table which is a description of ABEM Milestone #9 – General approach to Procedures (PC9). I created this table after attending a workshop from Dr. Danielle Hart (Assistant Residency Director and Director of Simulation at Hennepin County Medical Center). During the 2013 CORD assembly in Denver, Dr. Hart held a session in which she described a novel method by which to incorporate the ABEM milestones into simulation cases. This would accomplish two things:

  1. Provide an evaluation tool for the learners
  2. Easily incorporate milestones to evaluate residents

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By |2016-11-17T12:34:30-08:00Apr 17, 2013|Medical Education, Simulation|

Sim Case: Cocaine toxicity and placental abruption

Case Synopsis

17 yo girl, 24 weeks pregnant, is brought to the ED with an overbearing, controlling, and older boyfriend (BF). The chief complaint is abdominal discomfort and vaginal spotting. The patient is initially reluctant and quiet, but then gets hysterical as the case progresses. Upon questioning, the patient admits that she took cocaine prior to arrival to induce an abortion, because her BF is married and does not want her to keep the baby.

The patient becomes altered and goes into a shock state from significant vaginal bleeding. Blood work shows significant anemia, acute renal failure, and coagulopathy. The team needs to recognize cocaine toxicity, discuss and manage placental abruption, intubate the patient, control acute hemorrhage, and get a stat OB consult to take the patient to OR for management of placenta abruption and emergent c-section. The team needs to recognize signs of domestic violence and consult the social worker.

Case Writer:  Nikita Joshi, MD
Keywords: Cocaine toxicity, placental abruption, domestic violence

UPDATE: 6-22-23 – The PDF is no longer available.

Educational Objectives

Medical:

  1. Recognize and manage cocaine toxicity
  2. Identify causes of 2nd trimester vaginal bleeding
  3. Manage emergency airway
  4. Recognize signs and symptoms of domestic violence

Communication:

  1. Assess for unsafe environment due to hostile family
  2. Crowd management
  3. Resource utilization
 

Critical Actions

  1. Recognize cocaine toxicity
  2. Recognize severe hemorrhage and impending fetal demise due to placental abruption
  3. Give blood products immediately
  4. Intubate unstable patient
  5. Recognize potential for domestic violence and treat appropriately

Learners

  • ED residents
  • ED nurses
  • Medical students

Location

ED resuscitation bay

Patient

17 yo female teenager who is 24 weeks pregnant

Equipment

  • Advanced airway equipment
  • Airway adjuncts
  • Bedside ultrasound
  • Fake blood
  • IV fluid
  • pRBCs
  • Stretcher with sheets

Moulage

  • Manikin capable of showing pregnancy and pelvic bleeding
  • Fake blood around pelvic area (initially covered by sheet)
  • Ace bandage wrapped around the right wrist (“old” broken wrist)
  • Abrasions and healing bruises of various stages over body

Confederates

  • Patient (voice) – hysterical, sobbing, at times rapid speech, denies bruises are related to trauma, laughs it off when asked about her poorly healing broken right wrist, initially says she just has abdominal pain and vaginal bleeding, finally admits the cocaine use after questioning. She says she loves her boyfriend and would never do anything to compromise the relationship, and perhaps this baby would risk their relationship.
  • Boyfriend – older man, overbearing, hovering, questions everything that the team does, refuses to leave the bedside, denies hurting her.
  • Nurse – helpful, asks about bruises, asks about wrist deformity.
  • Security – arrives when asked by team; escorts the boyfriend away.
  • OB (voice) – calls when asked by team, discusses case with team.

Supporting Files and Media

  • Bedside ultrasound images of fetus with fetal heart movement
  • CXR post intubation with correct ETT placement
  • CBC – very low hemoglobin and hematocrit
  • BMP – elevated creatinine
  • Coagulation profile – elevated INR
  • Beta HCG
  • Urine tox – positive for cocaine
  • Type and screen and/or cross

References

  • Deak TM, Moskovitz JB. Hypertension and pregnancy. Emerg Med Clin North Am. 2012 Nov;30(4):903-17. PMID 23137402
  • Selvidge R, Dart R. Emergencies in the second and third trimesters: hypertensive disorders and antepartum hemorrhage. Emergency Medicine Practice. Dec 2004. Website
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By |2023-06-22T11:22:52-07:00Mar 29, 2013|Medical Education, Simulation|
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