The patient’s chest and clavicular radiographs showed a comminuted displaced acute fracture of the right mid-clavicle (green, blue, yellow). The clavicular fracture was also visible on the chest computed tomography (CT). The remainder of his trauma workup was negative for acute findings.
Radiographs of the left elbow and wrist were obtained. Left elbow radiographs showed simple posterolateral dislocation of the olecranon (red) without fracture of the olecranon (red) or trochlea (blue). Left wrist lateral radiographs demonstrated DRUJ dislocation with dorsal displacement of the distal ulna (green) without fracture or widening of the radioulnar joint (purple). Post-reduction radiographs demonstrated appropriate alignment of the elbow with the trochlea seated in the olecranon and improved alignment of the DRUJ.
On examination, the patient was alert and oriented but in mild distress. Suprapubic fullness was noted upon abdominal palpation. Point of care ultrasound of the bladder showed two enlarged “bladders” with a central communication. Bedside total bladder volume was measured to be 1288 cm3 (the top “bladder” was measured to be 1011 cm3, while the bottom “diverticulum” was measured to be 277 cm3) by ultrasound.
The POCUS stills of the patient’s bladder demonstrated the bladder (red arrow) and bladder diverticulum (yellow arrow) with a central communication (blue arrow) in the transverse and sagittal views.
Plain radiograph of the patient’s abdomen revealed a gaseous distention of the colon. This is demonstrated as noted in the abdominal x-ray as gaseous distention, most notably in the large bowel (arrows) including the rectal region (large circle). Follow up computed tomography (CT) scan affirmed severe pancolonic gaseous distention measuring up to 11.2 cm, compatible with colonic pseudo-obstruction as noted by the large red arrows. No anatomical lesion or mechanical obstruction was observed, as well as no evidence of malignancy or other acute process.
The CT image demonstrates a “whirl sign” (red arrow) which is indicative of a volvulus. This image occurs when bowel, mesentery and vasculature rotate around a transition point causing an image similar to a hurricane on a weather map. When seen on a CT scan, a whirl sign suggests a high likelihood of either a closed loop bowel obstruction or volvulus in the cecum, sigmoid or midgut. In any of the cases, seeing a whirl sign strongly increases the need for emergent surgical management.
In route, it was proposed that this patient was suffering from a dysrhythmia due to the transient episodes of syncope with lack of ventricular activity on telemetry. Upon close examination of the rhythm strips as well as the ECG, P waves can be visualized without any accompanying QRS complexes lasting multiple seconds (ED ECG blue arrows). Additionally, the rhythm has an intrinsic rate of 100 beats per minute and has a consistent morphology with no evidence of ventricular activity due to the lack of QRS complexes. As a result, the rhythm likely originates in the atria with no passage of impulses into the ventricles through the atrioventricular (AV) node versus an accelerated ventricular rhythm where QRS complexes would be seen.8 These rhythm strips demonstrate an example of VS. There is preserved native atrial automaticity, with an intact sinoatrial (SA) node, with a complete lack of ventricular electrical activity
By the end of this simulation session, learners will be able to: (1) recognize worsening respiratory status of a patient with hemoptysis and intervene appropriately, (2) manage a patient with severe hemoptysis and perform appropriate ventilator management, (3) manage sinus tachycardia with QT prolongation on the ECG caused by cocaine and hypomagnesemia, (4) address various etiologies of hemoptysis, (5) discuss the causes of massive hemoptysis and management options, and (6) review ventilation strategies in an intubated hypoxic patient.
At the conclusion of the simulation session, learners will be able to: 1) Understand the need to notify team members of a planned COVID intubation including: physician, respiratory therapist, pharmacist, nurse(s), and ED technician. 2) Distinguish between in-room and out-of-room personnel during high-risk aerosolizing procedures. 3) Distinguish between in-room and out-of-room equipment during high-risk aerosolizing procedures to minimize contamination. 4) Appropriately select oxygenation therapies and avoid high-risk aerosolizing procedures. 5) Manage high risk scenarios such as hypotension or failed intubation and be prepared to give push-dose vasoactive medications or place a rescue device such as an I-gel®.
