MedEd Portal
Human Patient Simulation
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Title: Altered Mental Status
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Target Audience: Medical Students, Residents
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Learning Objectives:
Primary
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Identification and Treatment of Beta-blocker toxicity
Secondary
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Management of Altered Mental Status in the Elderly
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Discuss the differential for the patient presenting with bradycardia and hypotension
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Different methods of treating beta-blocker toxicity
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Identifying major depression and suicidal risk factors in the elderly
– Diagnosing delirium
Critical Actions Checklist
 Obtain further history from pt.’s son

Accucheck

EKG

Glucagon, repeat doses and eventually a glucagon drip.
 IV fluids

CK

rhabdomyolysis
 Discuss with patient’s primary doctor for old records
 Involuntary commitment

Consult psychiatry

Admit to ICU
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Environment:
Environment
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Emergency department in a tertiary care hospital
Manikin Set Up
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Adult manikin
Props
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Pill bottle in manikin’s pocket – Lorazepam
– CAM – ICU worksheet
Distractors
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Lorazepam

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Actors: (All roles may be played by residents participating)
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Case Narrative:
Chief Complaint
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Altered Mental Status
History
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Pt is a 76 y/o male who presents with his son to the ER 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. The son states he last talked to his father yesterday and knows he has a history of CAD, MI, depression, and HTN. The patient is very lethargic and cannot provide any substantial history.
Additional history given only if asked
– Pt lives alone because his wife just died 2 weeks ago
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Pt told son yesterday he was “thinking above giving up”
– The patient’s son will offer to drive back home and get the patient’s medications.
PMHx
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HTN, Hyperlipidemia, Hypothyroidism, Depression, CAD, MI years ago
Social Hx
– The patient lives at home with his wife. He is a retired police officer.
Meds
– His son doesn’t know the name of all of his medications.
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The patient has a bottle of lorazepam with the appropriate amount is missing.
– ***If the patient’s son is asked, he will provide contact information to the patient’s pharmacy or the primary care doctor and if the nurse is instructed to call either of these contacts, then they will find that the patient takes metoprolol. If the patient is asked to go back to the house, they will find an empty bottle of metoprolol.
Surgical Hx
–
Negative
Allergies
–
Unknown

ROS
– Unable to obtain secondary to patient’s condition
Physical Exam
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BP 79/45, HR 32, RR 22, O2 – 97%, Glucose 82
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General – lethargic, drowsy, altered
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HEENT – dry mucous membranes, PERRLA, no meningismus
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Pulmonary – CTA bilaterally
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CVS – bradycardia, no m/r/g, regular rhythm, no peripheral pulses
– Abdomen – soft, non-tender, non-distended, no palpable pulsatile mass, no organomegaly
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Ext – No obvious deformities, edema,
– Skin – No mottling or cyanosis
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Neuro – GCS 13 (eyes 3, verbal 4, movement 5), CN intact, motor/sensation intact, cerebellar intact
Scenario Branch Points
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Pt will present with altered mental status. The resident needs to immediately assess vitals and treat appropriately with IV, O2, monitor, and Accucheck. The resident will need to give IV fluids and atropine. Atropine will not work and the resident should begin other methods of treating hypotension and bradycardia.
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If the resident specifically asks the family or calls the pharmacy for the medication history, the resident will discover the patient takes metoprolol and has a history of depression which makes his presentation suspicious for B blocker overdose.
– The EKG will show sinus bradycardia with no conduction blocks
– The patient’s blood pressure and heart rate will improve intermittently with repeat glucagons boluses, 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.
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He will ultimately return to being bradycardic and hypotensive.
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He must be treated with either of the below interventions:
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High dose insulin therapy
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Dopamine or Norepinephrine infusions
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Transcutaneous or transvenous pacing
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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 IVF.
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He will admit to an intentional overdose.
– He will need admission to the ICU.

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He will need to be voluntarily or involuntarily committed with a psychiatry consult.
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Instructors Notes:
Tips to Keep the Scenario Flowing
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Lorazepam is supposed to be a distracter as the patient has not taken an overdose of benzodiazepines. He does not need to be intubated. He will not respond to flumazenil
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The patient will not respond to atropine.
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The patient will temporarily respond to glucagon and then have recurrent hypotension and bradycardia. This will still occur despite being on an infusion.
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The resident should use ancillary staff and family to obtain history of metoprolol overdose.
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The patient will need to be placed on vasopressors, high dose insulin, or undergo cardiac pacing to improve.
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Not recognizing rhabdomyolysis
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Do not let the patient be transferred out of the ER unless he is stabilized with the above interventions.
Tips to Direct Actors
Scenario Steps
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Optimal Management Path
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Creating a differential for the hypotensive and bradycardic patient
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Intervening with: o IV fluids o Atropine o Glucagon o Dopamine or Norepinephrine o High Dose Insulin o Cardiac Pacing
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Intravenous Fluids for rhabdomyolysis
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Stabilizing patient
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Admit to the ICU
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Consult Psychiatry
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Potential Complications Path
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Not recognizing beta-blocker overdose
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Not progressing down the treatment pathway and the patient will remain hypotensive
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Not recognizing rhabdomyolysis

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Not admitting the patient to the ICU
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Not consulting psychiatry
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Not diagnosing delirium
– Potential Errors Path
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Not recognizing beta blocker overdose
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Treating patient only with flumazenil
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Not recognizing attempts at self-harm in the elderly
Imaging and Labs
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EKG
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Lorazepam bottle
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Debriefing Plan:
Topics to discuss
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Differential of the hypotensive and bradycardic patient
– Signs and symptoms of beta-blocker overdose
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Methods of treatment for beta-blocker overdose
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Suicide risk factors in the elderly
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Pilot Testing and Revision:
Number of Participants – 4
– Directing Physician
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Nurse
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Family Member
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Consulting psychiatrist and ICU physician
Anticipated Management Mistakes –
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Not recognizing beta-blocker overdose
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Not progressing down the correct intervention algorithm
Evaluation form for participants – generic handout

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Authors:
John B. Seymour M.D. University of North Carolina Department of
Emergency Medicine, PGY – 3
Rochelle Chijioke M.D. University of North Carolina Department of
Emergency Medicine, PGY – 2
Kevin Biese M.D. University of North Carolina Department of Emergency
Medicine, Associate Professor and Residency Director
Graham Snyder M.D. Wake Med Health and Hospitals Department of
Emergency Medicine, Assistant Program Director and Simulation Director
Jan Busby-Whitehead M.D. University of North Carolina Division of
Geriatric Medicine/ Institute on Aging, Professor and Chief
Copyright © 2011 The University of North Carolina School of Medicine