Simulated Patient Scenario

Septic Shock (Elderly Patient)

Scenario Details

Scenario: Elderly patient with altered mental status, suspected sepsis progressing to shock.

Simulated Patient: 82-year-old Female Mannequin or Actor

Actor/Actress: Home Care Worker / Family Member (provides collateral).

MDT Information

Urgent response - Unwell Elder / Altered Consciousness
82-year-old female, confused, lethargic
Possible infection / Sepsis
Patient not responding normally
Care worker present

On Arrival

Paramedics arrive at a residential home. A home care worker meets them, reporting the patient has become increasingly confused and difficult to rouse over the past 12 hours. She has a known history of recurrent UTIs and had urinary symptoms starting 3 days ago (dysuria, frequency). Today she refused food/fluids and has been very sleepy. Patient is found lying in bed, appears flushed, breathing rapidly, and only responds minimally to voice.

Initial Impression and Primary Survey

Category	Finding
Initial Impression	Acutely unwell, lethargic, flushed, tachypnoeic.
Response	Opens eyes to loud voice/gentle shake, moans or makes incomprehensible sounds, withdraws from painful stimuli (AVPU=V/P, GCS E3 V2 M4 = 9).
Airway	Clear currently, but at risk due to decreased LOC.
Breathing	Rapid and shallow respirations. Chest expansion appears adequate.
Circulation	Skin feels warm and flushed initially (warm shock). Tachycardic. Radial pulse present but may feel bounding initially, then weaker. Capillary refill may be normal initially or slightly delayed (< 3 sec).
Disability	Significantly altered level of consciousness (GCS 9). Pupils equal and reactive.
Exposure/Environment	Indoor home environment. Patient in bed clothes. Need to assess skin temperature, check for rashes, sources of infection.

Secondary Survey and Simulation Progression

History (Collateral from Care Worker/Family, Patient unable to provide reliable history)

Allergies	Trimethoprim (causes rash)
Medications	Furosemide, Ramipril, Bisoprolol, Apixaban, Paracetamol PRN. (Care worker unsure about recent compliance).
Past Medical History	Recurrent UTIs, Hypertension, Atrial Fibrillation, Heart Failure (NYHA II), Type 2 Diabetes (diet controlled), Mild Dementia.
Last Oral Intake	Minimal intake (sips of water) in last 12-24 hours. Refused breakfast.
Events Preceding / History of Presenting Complaint	Started complaining of dysuria and increased urinary frequency 3 days ago. Seemed slightly more confused yesterday. Today, became very lethargic, difficult to wake, confused when awake, refused food/drink/medications. Care worker noted she felt very warm and was breathing fast. No vomiting or diarrhoea reported.

Vital Signs/Assessment (Initial)

Parameter	Value (Approximate/Expected)
Resp. Rate (/min.)	28, shallow
Lung Sounds (L/R)	Clear bilaterally. (Monitor for crackles - fluid overload/ARDS).
SpO2 (%)	90% (Room Air)
EtCO2 (mmHg)	30-35 mmHg (Reflects respiratory compensation for metabolic acidosis).
Pulse Rate (/min.)	115, regular (AF controlled by Bisoprolol, rate indicates stress).
CRT (sec.)	2-3 seconds initially.
ECG rhythm	Atrial Fibrillation (controlled rate).
12-lead ECG	AF, rate ~115 bpm. No acute ischaemic changes.
BP (mmHg)	85/50 (Hypotensive - MAP < 65 mmHg).
Skin	Warm, flushed, dry.
Pain (/10)	Unable to assess reliably due to LOC. May show discomfort on abdominal palpation.
GCS (/15: E,V,M)	9/15 (E3 V2 M4)
BGL (mmol/L)	8.5 (May be elevated due to stress response/diabetes).
Pupils (mmL/mmR)	3mm L / 3mm R, Equal and Reactive
Pupil reac. (L/R)	Equal and Reactive
Temp. (°C)	39.2 (Febrile).

Physical Examination (Focused)

**General:** Lethargic, acutely unwell appearance, flushed.
**Head/Neck:** Dry mucous membranes. No neck stiffness.
**Chest:** Tachypnoeic, clear lung sounds bilaterally. Tachycardic.
**Abdomen:** Soft. May have mild suprapubic tenderness on palpation. No guarding or rebound.
**Skin:** Warm, flushed, dry. No obvious rashes or wounds. Check for pressure areas.
**Neurology:** GCS 9, moving all limbs spontaneously/to pain. No focal deficits apparent.
**Sepsis Screening:** Meets criteria based on suspected infection (UTI), fever, tachycardia, tachypnoea, altered mental status, hypotension. (e.g., qSOFA score >= 2).

Assessment and Treatment

Appropriate Management

Recognise Septic Shock (Sepsis with persistent hypotension requiring vasopressors to maintain MAP ≥65 mmHg or lactate >2 mmol/L despite adequate volume resuscitation - prehospital recognition based on Sepsis + Hypotension + Altered LOC/Tachypnoea). Likely source UTI. **Time critical emergency.**
Primary survey (ABCDE), manage immediate life threats.
**Oxygen:** High-flow oxygen via non-rebreather mask or nasal cannula to maintain SpO2 ≥94%.
**IV Access:** Establish large bore IV access x 2 if possible.
**Fluid Resuscitation:** **Administer IV crystalloid fluid bolus rapidly** (e.g., 500ml - 1000ml Sodium Chloride 0.9% or Hartmann's solution over 15-30 mins). **Use caution** given history of heart failure - monitor for signs of fluid overload (listen to lung sounds frequently). Titrate further fluids based on response (BP, HR, mental status, urine output if measurable) and signs of overload, aiming for MAP ≥ 65 mmHg (follow local guidelines).
**Antibiotics:** Early administration is crucial but typically occurs in ED. Prehospital role is recognition and rapid transport. (Do not delay transport for antibiotics unless specific local protocol exists).
**Source Control:** Identify potential source (likely UTI here). Requires hospital investigation/treatment.
**Monitoring:** Continuous monitoring of vital signs (HR, BP, RR, SpO2, Temp, GCS), EtCO2 if available. Monitor ECG. Check BGL.
**Vasopressors:** Consider if hypotensive despite initial fluid resuscitation (usually ED management, but some services may initiate prehospital per protocol).
Keep patient warm if temperature starts to drop or if becoming peripherally cool (later stages of shock).
Transport patient urgently to hospital.
**Pre-notify:** **Sepsis Alert** to receiving hospital. Provide age, suspected source (UTI), vital signs (confirming hypotension, tachycardia, fever, tachypnoea, ALOC), relevant PMHx (HF, AF, dementia), treatments given (O2, fluids - volume and response), ETA. Request sepsis pathway activation.
Documentation: Detailed record of assessment findings (including sepsis criteria met), vital signs trends, interventions (fluids, O2), response to treatment, communication with family/carer.