I.Title: Altered Mental Status in an Adolescent Patient

(Intentional Clonidine Overdose)

II.Date Created / Catalog #: March 15, 2005 (revised December 11, 2006)

  1. Category (circle one): Resident Core Curriculum; Pediatrics; Teamwork;

Toxicology

  1. Target Audience: undergraduate and graduate medical trainees and staff,

nurses, paramedics

V.Learning Objectives or Assessment Objectives

  1. Primary -

a.)recognition and management of altered mental status in a

adolescent patient

b.)recognition and management of clonidine ingestion and toxicity

c.)recognition of suicidality

d.)deployment of teamwork behaviors

e.)discussion of care with family members

  1. Secondary -

a.)appropriate airway management

b.)appropriate circulatory support

c.)appropriate use of decontamination procedures

d.)appropriate consultation and disposition

e.)proper transition of care

  1. Critical actions checklist (see Appendix A)-

1. Simple checklist of critical actions

a.)recognition of unresponsiveness

b.)recognition of respiratory dysfunction (hypoxia)

c.)recognition of circulatory dysfunction (hypotension)

d.)establishment of team structure with role assignment

e.)deployment of appropriate communications and teamwork behaviors

f.)basic airway management (100% oxygen administration with bag-valve-mask ventilation)

g.)cardiac rhythm analysis (sinus bradycardia, normal intervals)

h.)basic circulatory management (venous access, IV fluids)

i.)implementation of altered mental status protocol / treatment (naloxone, dextrose (D50), thiamine)

j.)narcotic toxidrome recognition (i.e. identifies toxidrome of miosis, bradycardia, bradypnea, hypotension in context of ingestion)

k.)narcotic toxidrome evaluation and management (implementation of specific testing and treatment- naloxone IV)

l.)recognition of recurrent / persistent deterioration of respiratory status despite naloxone treatment

m.)advanced airway management (endotracheal intubation, placement confirmation + securement, ventilator management)

n.)advanced circulatory support as needed (cardiac monitor, atropine, vasoactive agents [vasopressors])

o.)toxicology consultation

p.)institution of naloxone infusion therapy

q.)continued respiratory and circulatory support

r.)pediatric critical care medicine consultation

s.)discussion of care with family members

t.)recognizes and communicates need for adolescent psychiatric treatment (constant observation for suicidality, discusses need for psychiatry consultation with admitting team)

u.)disposition to pediatric critical care setting

2. Optimal sequence of critical actions- expected sequence as above

3. Duration to critical actions- resuscitation to be completed within

20-25 minutes of starting scenario

4. Global area ratings- see Appendix A

5. Behavioral ratings- see Appendix A

  1. ACGME Competencies Assessed
A.Patient Care
B.Medical Knowledge
  1. Interpersonal / Communication Skills

VII.Environment and Props

  1. Lab Set Up – Emergency Department in simulation center / lab
  2. Manikin Set Up –

a.) advanced medical simulation manikin

b.) male patient moulage, street clothing, bilateral 2 mm pupils

c.) lines needed: right 20 gauge IV

d.) drugs needed: altered mental status medications

(naloxone, dextrose (D50), thiamine)

rapid sequence induction medications

(etomidate, succinylcholine)

activated charcoal

  1. Props – (basic airway and code blue cart is assumed)

a.) clonidine pill bottle- empty; prescribed [10 days ago]

prescription information: for 76 year old “Roger Schultz”

clonidine 0.3mg PO BID, # 60 (sixty), 2 refills

b.) ECGs: sinus bradycardia 50s

c.) X-rays: normal chest X-ray

d.) head CT: no intracranial abnormalities

f.)laboratory values: see Appendix B

VIII.Simulation Personnel and Assigned Roles (Faculty, Actors, etc)

1 manikin controller, 1 audio-visual technician, 2+facilitators (mother;

toxicology /critical care consultant), 1+ observers

  1. Case Narrative (describes what the learner will experience)
  1. A 16 year old patient is brought to the adult ED from the affiliated pediatric section by transport / RN staff for a CT scan [the scenario assumes the scanner to be a shared resource between adult + pediatric EDs to make the case generalizable]. The patient was just brought in from home by his mother for dizziness, dehydration and pre-syncope, possibly attributed to drinking too much coffee and not getting enough sleep in preparation for his midterm exams. He had become unconscious for about two minutesjust prior to arrival(no fall or trauma), after which he became arousable and complained of a headache, so the pediatric ED treatment team arranged for a head CT scan. In transit to the adult ED CT scanner, the patient becomes obtunded and develops apnea.

After basic interventions in the adult ED [specifically, after administration of medications intended to address potential causes of altered mental status, including naloxone, dextrose (D50) and thiamine], the mother will find out that the patient’s visiting grandfather’s Catapres (clonidine) pill bottle was found empty at home by her spouse. The patient has no known past medical history, but has been suicidally depressed from home and school stressors and has actually overdosed on clonidine as part of a suicide attempt. Time of ingestion was approximately 30 minutes prior to arrival in pediatric ED. No other co-ingestions. Patient will require use of pediatric code cart for intubation, decontamination with activated charcoal, naloxone, and pediatric critical care unit admission. Toxicologic consultation will be required but will have no additional suggestions

  1. Patient presentation at scenario initiation:

1. Name/Age/Sex: David Schultz, 16 year old male

2. Mode of arrival: EMS

3. Accompanied by: mother (can be in waiting area until later)

4. Triage Note: n/a

  1. Chief Complaint: dizziness
  2. Past Medical History: none
  3. Medications and Allergies: none; no known allergies
  4. Immunizations: up-to-date
  5. Family / Social History: high school student, no drugs
  6. Patient’s Exam at start of scenario:

Vital signs: weight: 50kg

heart rate:52 / minute

blood pressure: 85 / 41 mmHg

respiratory rate:4 / minute

oxygen saturation: 90% on 2 liters NC

temperature:97.8 deg F /36.6 deg C

Airway: minimal gag, no pooled secretions

Breathing: slowed shallow respirations

Circulation: weak radial pulses, good femoral pulses,

warm extremities

Secondary Exam:teenage male

HEENT: no pooled secretions

pupils 2mm,sluggishly reactive,no papilledema

conjugate gaze and intact EOMs

Neck: no JVP noted, supple; normal thyroid

Lungs: slowed but equal clear breath sounds without

wheezes, rales or rhonchi

Cardiac: slow heart rate, no murmurs or heave

Abdomen: diminished bowel sounds

Extremities: no edema; no track marks; normal muscle tone

Skin:warm, dry without cyanosis

Neurologic: GCS 8 (E 1 V 2 M 5); intermittently awakens

briefly with painful stimulation / naloxone

Additional information:

Fingerstick blood sugar: normal

EKG: sinus rhythm 50s

CXR: normal

head CT: normal

  1. Flow diagram with branch points, times of expected interventions and reactions from SimMan with notes (see Appendix Aand C)

Case progression:

1. Despite altered mental status protocol / treatment (one dose of

0.2 - 0.4mg IV naloxone, dextrose (D50), thiamine), there is a persistent alteration in mental status

2. After initial administration of naloxone, dextrose (D50) and

thiaminetothepatient, the clonidine suicidal ingestion history will be presented through the mother

3. Repeated high doses (1mg) of naloxone will provide transient

improvements in mental status, but not enough to avert intubation and mechanical ventilation

4. Supportive interventions (endotracheal intubation, mechanical

ventilation, IV fluids +/- vasopressors), gastric decontamination, and naloxone will stabilize patient for transfer to pediatric critical care unit setting

  1. Distracters in case: n/a
  1. Trends needed: none

  1. Instructors Notes (what the instructor must do to create the experience)
  1. Tips to keep scenario flowing in lab and via computer

- presentation of patient in respiratory failure should keep the case

moving quickly and with learner stress

- lulls in activity may be broken with entry of agitated mother

  1. Tips to direct actors- as above
  2. Scenario programming- see Appendix C
  1. Optimal management path
  2. Potential complications path(s)
  3. Potential errors path(s)
  4. Program debugging
  1. Performance expectations, anticipated management mistakes

-non-recognition of toxidrome

-premature diagnostic closure

-resistance to administration of naloxone

-improper disposition

-failure to recognize and to communicate need for psychiatric care

XI.Debriefing Plan

  1. Method of debriefing

1. Debriefing Topics

a.) didactic content

- altered mental status (adolescent)

-systemic (hypotension, hypoxia, hypercarbia)

-infectious (meningitis, encephalitis, sepsis)

-metabolic (hypoglycemia, hypothyroidism, renal failure, etc.)

-neoplastic (CNS tumor mass effect)

-neurologic (seizure / post-ictal, hydrocephalus)

-psychiatric

-toxidromes (alcohols, barbiturates, benzodiazepines, beta-

blockers, calcium channel blockers, opioids, etc)

-traumatic (incl. non-accidental injury)

-vascular (CNS bleed, infarct)

- clonidine toxicity
-mechanism-

-central alpha-2 adrenergic receptor agonist, reduces

sympathetic autonomic outflow

-unclear connection between central alpha-2 activity

and opioid-like symptomatology

-some peripheral alpha-1 adrenergic agonist activity

-rapid enteral absorption and symptom onset of tablet

and transdermal preparations, significant uptake into CNS

-evaluation

-skin: can be hypothermic

-CNS: depressed mental status, hypotonia, seizures

-pupils: miosis (can have mydriasis)

-respiratory: apnea / bradypnea, hypoxia, hypercarbia

-cardiovascular: bradycardia, reduced systemic

vascular resistance (can behypertensive early)

-not detected on routine serum / urine toxicology

-treatment

-supportive

-respiratory: oxygen, mechanical ventilation

-cardiovascular: IV fluids, chronotropic and

vasopressor medications as needed for hypotension; warming for hypothermia

-decontamination

-activated charcoal

-gastric lavage controversial

-naloxone

-variable efficacy; limited duration of effect

with bolus (less than 60 minutes)

-may need large doses (1-2mg IV) or infusion

(two-thirds of dose required to reverse respiratory depression infused in IV fluid continuously every hour)

-complications: severe hypo- or hyper-tension

-consultation

-toxicology / poison control center

-disposition

-critical care unit if unstable

-telemetry unit if stable

-disposition based on other active issues (e.g.

psychiatric) if asymptomatic for 4 hours

- suicidality (see eMedicine reference)

b.) teamwork behaviors

-leadership

-resuscitation leadership establishment

-role and responsibility assignment

-collaboration

-recognition and integration of team input

-communication

-callouts of critical information

-callbacks for confirmation of information

-situational awareness

-continued patient reassessment

-plan development and execution

-task prioritization

-workload assessment

-team member cross-monitoring

-requests for assistance

-professionalism

-transitions in care

-proper patient acceptance from pediatric ED provider

-proper care transition to pediatric critical care team

XII.Pilot Testing and Revisions

A. Pilot testing- completed on-site at Rhode Island Hospital Emergency

Department, April 2, 2005 with 11 members of ED clinical staff in 2 groups. Need for at least 4 simulation faculty + personnel with proper pre-scenario briefing for successful simulation noted.

B. Scenario Revision- Minor scenario + program changes. December 11, 2006

X.Authors and their affiliations

Primary author: Leo Kobayashi, MD

Co-Director, RIHMSC

Assistant Professor, Department of Emergency Medicine,

Brown Medical School

Transportable Enhanced Simulation Technologies for Pre-

Implementation Limited Operations Testing (TESTPILOT) group, Department of Emergency Medicine, Rhode Island Hospital

Additional authors: Marc Shapiro, MD; RIHMSC, Rhode Island Hospital

X.References:

Benton TD, Lynch J. Mood disorder: depression. In eMedicine Specialties > Pediatrics > Developmental + Behavioral. Berkowitz CD, Konop R, Pataki C et al. (eds), eMedicine Web site. Updated May 20, 2005. Available at: Accessed July 23, 2005.

Henretig FM. Clonidine and central-acting antihypertensives. In: Clinical Toxicology. Ford MD, Delaney KA, Ling LJ, Erickson T (eds), Philadelphia: WB Saunders, 2001.

Riley D. Toxicity, clonidine. In eMedicine Specialties > Emergency Medicine > Toxicology. Michelson EA, VanDeVoort JT, Benitez JG et al. (eds), eMedicine Web site. Updated August 2, 2004. Available at: Accessed July 22 2005.

Suchard JR, Graeme KA. Pediatric clonidine poisoning as a result of pharmacy compounding error. Pediatric Emergency Care 2002; 18(4): 295-6.

Appendix A
Scenario Evaluation Form
Resident Name ______
Examiner ______
Case Title ______
Scenario Type Single Patient Multiple Patient

Critical Actions Checklist

Critical Action / Yes / No / Time
1 / recognition of unresponsiveness
2 / recognition of respiratory dysfunction (hypoxia)
3 / recognition of circulatory dysfunction (hypotension)
4 / establishment of team structure with role assignment
5 / deployment of appropriate communications and teamwork behaviors
6 / basic airway management (100% oxygen administration with bag-valve-mask)
7 / cardiac rhythm analysis (sinus bradycardia, normal intervals )
8 / basic circulatory management (venous access, IV fluids)
9 / implementation of altered mental status protocol / treatment (naloxone, dextrose (D50), thiamine)
10 / narcotic toxidrome recognition (i.e. identifies miosis, bradycardia, bradypnea, hypotension in context of ingestion)
11 / narcotic toxidrome evaluation +management (implementation of specific testing and treatment- repeated naloxone IV)
continued

Notes:

Rating Scale
Very poor / Poor / Marginal / Acceptable / Good / Very good / Superior
1 / 2 / 3 / 4 / 5 / 6 / 7
Critical Action / Yes / No / Time
12 / recognition of recurrent / persistent deterioration of respiratory status despite naloxone treatment
13 / advanced airway management (endotracheal intubation, placement confirmation and securement, ventilator management)
14 / advanced circulatory support as needed (cardiac monitor, atropine, vasoactive agents [vasopressors])
15 / toxicology consultation
16 / institution of naloxone infusion therapy
17 / continued respiratory and circulatory support
18 / pediatric critical care medicine consultation
19 / discussion of care with family members
20 / recognizes and communicates need for adolescent psychiatric treatment (constant observation for suicidality, discusses need for psychiatry consultation with admitting team)
21 / disposition to critical care setting

Description of Elements in RIHMSC Global Rating Scale

No / Competency / Descriptor
1 / Immediate emergency medicine actions / ● IV, O2, Monitor
● Immediate stabilization dependent on case
2 / Appropriately targeted history/physical exam / ● History and physical based on case
3 / Recognizes & manages disease process / ● Completes all critical actions based on checklist in appropriate sequence and timeframe
4 / Considers differential dx / ● Avoids premature diagnostic closure (considers at least 3 other potential etiologies for altered mental status in adolescent patient)
5 / Presentation skills/interpersonal relations / ● Quality of verbal presentation (assessment-oriented)[1] = data content, expression, organization of medical decision making, overall presentation – (AO format = patient ID, assessment & mgmt/therapeutic plan, limited justification based on H&P)
● Respectful interaction with patient
● Works effectively with ED staff
6 / Case synthesis/Cognition / ● Recognizes diagnosis
● Appropriately dispositions patient
● Obtains all appropriate consults/follow-ups
● Recognizes unresolved issues
● Avoids common cognitive errors[2]
7 / Degree of Expertise/Leadership[3] / ● fluency: does the activity run together in an integrated and uninterrupted sequence with a minimum of pauses/hesitations.
● simultaneity: ability to complete several tasks at one time
● rapidity: the ability to make an appropriate response quickly
● knowledge base
8 / Crisis Management Behaviors/Teamwork[4] / ● Anticipation and planning
● Awareness and utilization of all available resources
● Distribution of workload and mobilization of help
● Routine reevaluation of the situation
● Awareness and utilization of all available information
● Triage and prioritization
● Efficient management of multiple patients
● Effective coping with disruptions/distractions
● Can add teamwork assessment[5]
9 / Safety Behaviors / ● Safe medication ordering (asks about allergies, Knows indications/contraindications for therapy, communicates dose, route and timing, knows pt weight)
● Any potentially harmful behaviors should be noted
ACGME Competencies
Competency / Required Skill / Check
Patient Care
Caring and respectful behaviors
Interviewing
Informed decision-making
Develop & carry out patient management plans
Counsel & educate patients and families
Performance of procedures
a) Routine physical exam
b) Medical Procedures
Work within a team
Medical Knowledge
Investigatory and analytic thinking
Practice-Based Learning and Improvement
Analyze own practice for needed improvements
Use of information technology
Facilitate learning of others
Interpersonal & Communication Skills
Creation of therapeutic relationship with patients
Listening skills
Professionalism
Respectful, altruistic
Ethically sound practice
System-Based Practice
Understand interaction of their practices with the larger system
Knowledge of practice and delivery systems
Practice cost-effective care

TeamSTEPPS Instructor Guide. [TeamSTEPPS: Team Strategies & Tools to Enhance Performance and Patient Safety; developed by the Department of Defense and published by the Agency for Healthcare Research and Quality.] AHRQ Publication No. 06-0020. Rockville (MD): Agency for Healthcare Research and Quality; September 2006. Available at:

Appendix B

Case Complete blood count (CBC)

WBC (3.5-11.0) K/uL:6.5

HGB (11.0-15.0) G/DL: 14.3

HCT (32.0-45.0) %: 42.9

PLT (150-400) K/uL: 308

Case Chemistry panel (Chem7)

Na (135-145) MEQ/L:138

K (3.6-5.1) MEQ/L:4.5

Cl (98-110) MEQ/L:104

CO2 (20-30) MEQ/L:18 L

BUN (6-24) MG/DL:15

Creat (0.4-1.3) MG/DL:1.1

Glu (67-109) MG/DL:87

Case Arterial blood gas (pre-intubation)

pH (7.35-7.45):7.28 L

PCO2 (35-45) MMHG:56 H

PO2 (78-82) MMHG:68 L

O2 Sat (93-98) %:89 L

Case Urinalysis / Toxicology

U/A (dip and micro):negative

Urine drugs-of-abuse screen:negative

Serum tox screen: negative

Serum ASA (aspirin):not detected

Serum APAP (acetaminophen): not detected

Appendix C

Laerdal SimMan v2.2 scenario content

Laerdal SimMan v2.2 medication handler

Laerdal SimMan v2.2 scenario trends

clinical worsening

clinical improvement with intubation clinical improvement with supportive treatment

Laerdal SimMan v2.2 scenario trends (used by medication handler)

naloxone supplemental oxygen

etomidatesuccinylcholine

[1] Maddow CL, et. al. Efficient Communication: Assessment-Oriented Oral Case Presentation. Academic Emergency Medicine 2003; 10: 842-847.

[2] Pat Croskerry Achieving Quality in Clinical Decision Making: Cognitive Strategies and Detection of Bias Acad Emerg Med 2002 9: 1184-1204.

[3] Gellatly Angus, ed. The Skillful Mind: An Introduction to Cognitive Psychology. Open University Press,Milton Keyes England.1986

[4] Martin Reznek, Rebecca Smith-Coggins, Steven Howard, Kanthi Kiran, Phillip Harter, Yasser Sowb, David Gaba, and Thomas Krummel

Emergency Medicine Crisis Resource Management (EMCRM): Pilot Study of a Simulation-based Crisis Management Course for Emergency Medicine Acad Emerg Med 2003 10: 386-389.

[5] Gregory D. Jay, Scott D. Berns, John C. Morey, Dan T. Risser, Shawna J. Perry, and Robert Simon Formal Teamwork Training Improves Teamwork and Reduces Emergency Department Errors: Results from the MedTeams Project Acad Emerg Med 1999 6: 408-a