November 2010



MedEd Portal/ POGOe

Human Patient Simulation

• Title: Altered Mental Status

• Target Audience: Medical Students, Residents

• Learning Objectives:

- Primary

– Identification and treatment of beta-blocker toxicity

- Secondary

– Management of altered mental status in the elderly

– Discuss the differential for the patient presenting with bradycardia and hypotension

– Different methods of treating beta-blocker toxicity

– Identifying major depression and suicidal risk factors in the elderly

- Critical Actions Checklist

 Obtain further history from the patient’s son

 Accucheck

 Electrocardiogram (EKG)

 Glucagon, repeat doses, and a glucagon drip

 Intravenous fluids

 Creatine kinase ( rhabdomyolysis

 Discuss with patient’s primary doctor to obtain old records

 Involuntary commitment

 Consult psychiatry

 Admit to the Intensive Care Unit

• Environment:

- Environment

– Emergency Department in a Tertiary Care Hospital

- Manikin Set Up

– Adult Manikin

- Props

– Pill bottle in Manikin’s pocket – Lorazepam

– EKG – bradycardia

– Chest X-ray – within normal limits

- Distractors

– Lorazepam

• Actors: (All roles may be played by residents participating)

• Case Narrative:

- Chief Complaint

– Altered Mental Status

- History

– Pt is a 76 year old male who presents with his son to the Emergency Department by private vehicle for evaluation of altered mental status. His son went to check on him this morning and found him lying on the ground in the living room next to his couch. His son states he last talked to his father yesterday and knows he has a history of coronary artery disease, prior myocardial infarction, depression, and hypertension. The patient is very lethargic and cannot provide any substantial history.

- Additional history given only if asked

– The patient lives alone and his wife died two weeks ago.

– The patient told his son yesterday he was “thinking above giving up.”

– The patient’s son will offer to drive back home and get the patient’s medications. The son will find an empty bottle of metoprolol 25 mg #60 filled 2 days ago.

- Past Medical History

– Hypertension, Hyperlipidemia, Hypothyroidism, Depression, Coronary Artery Disease, Myocardial Infarction years ago

- Social History

– The patient lives at home with his wife. He is a retired police officer.

- Medications

– His son does not know the name of all of his medications.

– The patient has a bottle of lorazepam with the appropriate amount missing (not an overdose amount missing)

– ***The patient’s son will provide contact information to the patient’s pharmacy or the primary care doctor. If the nurse or other ancillary staff is instructed to call either of these contacts, they will discover the patient takes metoprolol. If the patient’s son is asked to go back to the house, he will locate an empty bottle of metoprolol that was filled 2 days ago.

- Surgical History

– Negative

- Allergies

– Unknown

- Review of Systems

– Unable to obtain secondary to patient’s condition

- Physical Exam

– Blood Pressure 79/45, Heart Rate 34, Respiratory Rate 22, Oxygen Saturation 97%, Glucose 82

– General – lethargic, drowsy, altered

– Head, Eyes, Ears, Nose and Throat – dry mucous membranes, pupils are equally reactive and responsive to light and accommodation, no meningismus

– Respiratory – clear to auscultation bilaterally with no wheezes, rales, or rhonchi

– Cardiovascular – bradycardia, no murmurs, rubs, or gallops, regular rhythm, no peripheral pulses

– Abdomen – soft, non-tender, non-distended, no palpable pulsatile mass, no organomegaly

– Extremities – No obvious deformities or edema

– Skin – No mottling or cyanosis

– Neurological – Glasgow Coma Scale 13 (eyes 3, verbal 4, movement 5), Cranial Nerves 2-12 intact, motor intact, sensation intact, cerebellar intact

- Scenario Branch Points

– The patient will present with altered mental status. The resident needs to immediately assess vitals and treat appropriately with intravenous access, oxygen, monitor, and accucheck. The resident will need to give intravenous fluids and atropine. Atropine will not work and the resident should begin other methods of treating hypotension and bradycardia.

– If asked, the resident will discover the patient takes metoprolol and has a history of depression which makes his presentation suspicious for beta blocker overdose.

– The electrocardiogram will show sinus bradycardia with no conduction blocks

– The patient’s blood pressure and heart rate will improve intermittently with repeat bolus doses of glucagon, but ultimately the patient will need to be started on a glucagon drip. Once placed on a drip, the patient will become more responsive with improvement in vitals signs and mental status.

– He will ultimately return to being bradycardic and hypotensive.

– He must be treated with either of the below interventions:

• High dose insulin therapy

• Transcutaenous or transvenous pacing

– The patient will also state that he has left sided body pain because he has been lying on the ground for approximately 24 hours. He won’t have any fractures, but he will be in rhabdomyolysis and needs to be treated with intravenous fluids.

– He will admit to an intentional overdose.

– He will need admission to the Intensive Care Unit.

– He will need to be Voluntarily or Involuntarily Committed with a psychiatry consult.

• Instructors Notes:

- Tips to Keep the Scenario Flowing

– Lorazepam is supposed to be a distracter. The patient has not taken an overdose of benzodiazepines. He does not need to be intubated. He will not respond to flumazenil

– The patient will not respond to atropine.

– The patient will temporarily respond to glucagon and then have recurrent hypotension and bradycardia. This will still occur despite being on an infusion of glucagon.

– The resident should use ancillary staff and family to obtain history of metoprolol overdose.

– The resident will need to be placed on high dose insulin, or undergo cardiac pacing to improve.

– The patient should persistently complain of left sided body pain and the resident should remain vigilant for rhabdomyolysis.

– Do not let the patient be transferred out of the Emergency Department unless he is stabilized with the above interventions.

– The poison control center is a good resource for help managing the B Blocker overdose.

- Tips to Direct Actors

- Scenario Steps

– Optimal Management Path

• Creating a differential for the hypotensive and bradycardic patient

• Intervening with:

o Intravenous Fluids

o Atropine

o Glucagon

o High Dose Insulin

o Cardiac Pacing

• Intravenous Fluids for rhabdomyolysis

• Stabilizing patient

• Admit to the Intensive Care Unit

• Consult Psychiatry

– Potential Complications Path

• Not recognizing beta-blocker overdose

• Not progressing down the treatment pathway and the patient will remain hypotensive

• Not recognizing rhabdomyolysis

• Not admitting the patient to the Intensive Care Unit

• Not consulting psychiatry

– Potential Errors Path

• Not recognizing beta blocker overdose

• Treating patient only with flumazenil

- Imaging and Labs

– Electrocardiogram

• Sinus bradycardia

• Normal sinus rhythm

– Suicide Note in pocket

– Lorazepam bottle

• Debriefing Plan:

- Topics to discuss

– Differential of the hypotensive and bradycardic patient

– Signs and symptoms of beta-blocker overdose

– Methods of treatment for beta-blocker overdose

– Depression and suicide in the elderly

• Pilot Testing and Revision:

- Number of Participants – 4

– Directing Physician

– Nurse

– Family Member

– Consulting Psychiatrist and Intensive Care Unit physician and Poison Control

- Anticipated Management Mistakes –

– Not recognizing beta-blocker overdose

– Not progressing down the correct intervention algorithm

- Evaluation form for participants – generic handout

• Authors:

- John B. Seymour, MD. University of North Carolina Department of Emergency Medicine.

- Rochelle Chijioke, MD. University of North Carolina Department of Emergency Medicine.

- Amar Patel, MS. Director of the Center for Innovative Learning at WakeMed Health & Hospitals.

- Graham Snyder, MD. Assistant Professor and Medical Director of the Center for Innovative Learning at WakeMed Health & Hospitals

- Kevin Biese. MD, MAT. University of North Carolina Department of Emergency Medicine, Assistant Professor and Residency Director

- Jan Busby-Whitehead, MD. University of North Carolina Professor & Chief, Division of Geriatric Medicine; Director, Center for Aging and Health.

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