Simulated Patient Scenario

Anorexia Nervosa Complications

Scenario Details

Scenario: Collapse / Bradycardia secondary to Anorexia Nervosa

Simulated Patient: 18-year-old Female

Actor/Actress: Student Actor (Patient), Student Actor (Parent)

MDT Information

Urgent Response - Collapse / Faint
18-year-old female, collapsed at home
History of eating disorder
Patient now conscious but weak and dizzy
Parent on scene
Location: Home address

On Arrival

You arrive at a house where an anxious parent meets you. They lead you to the living room where the patient, an 18-year-old female, is lying pale and frail-looking on the sofa. She is awake but appears lethargic and weak. The parent states the patient fainted while trying to stand up a short while ago.

Initial Impression and Primary Survey

Category	Finding
Initial Impression	Alert but lethargic, appears cachectic, pale, unwell.
Response	Opens eyes spontaneously, responds verbally but speech is quiet and slow. Oriented. (AVPU = A)
Airway	Clear and self-maintaining.
Breathing	Rate appears slow, depth normal to shallow.
Circulation	Skin pale, cool peripheries. Radial pulse weak and slow (bradycardia). Cap refill delayed.
Disability	Alert (GCS 15), but lethargic, weak, dizzy on sitting/standing.
Exposure/Environment	Indoor home environment. Patient wearing loose clothing, appears very thin.

Secondary Survey and Simulation Progression

History (obtained from patient - may be guarded, and parent)

Allergies	NKDA (Parent confirms)
Medications	None prescribed. Parent suspects possible laxative abuse but patient denies.
Past Medical History	Diagnosed Anorexia Nervosa 2 years ago. Several previous hospital admissions for medical stabilisation and refeeding. Currently under outpatient mental health team and dietitian, but has been struggling recently. History of bradycardia and orthostatic hypotension.
Last Oral Intake	Parent reports very poor intake over last few days (e.g., half a piece of toast yesterday, sips of water). Patient states she "isn't hungry".
Events Preceding	Patient has been increasingly withdrawn and restricting intake more severely over the past week. Complained of feeling weak and dizzy this morning. Attempted to stand up from sofa ~20 minutes ago, felt very lightheaded, and fainted briefly (parent witnessed, lasted < 1 minute, no seizure activity, immediate recovery on lying flat). Has felt weak, cold, and dizzy since. Denies chest pain or palpitations specifically, but feels generally unwell.

Vital Signs/Assessment (Initial)

Parameter	Value (Supine)
Resp. Rate (/min.)	12 (Slow)
Lung Sounds (L/R)	Clear bilaterally.
SpO2 (%)	97% (Room Air)
EtCO2 (mmHg)	Not indicated unless decreased LOC/resp effort
Pulse Rate (/min.)	42, regular but weak
CRT (sec.)	3-4 sec
ECG rhythm	Sinus Bradycardia
12-lead ECG	Sinus Bradycardia. Possible prolonged QT interval, low voltage QRS, T wave flattening/inversion. No acute ischaemic changes.
BP (mmHg)	85/55 (Hypotensive)
Postural BP	Significant drop on sitting/standing attempt (e.g., >20mmHg systolic or >10mmHg diastolic drop with symptoms) - Assess cautiously.
Skin	Pale, cool peripheries, dry. Possible lanugo hair.
Pain (/10)	Denies pain. Reports weakness and dizziness.
GCS (/15: E,V,M)	15/15 (E4, V5, M6) but lethargic.
BGL (mmol/L)	3.2 (Hypoglycaemic or low-normal)
Pupils (mmL/mmR)	3mm L / 3mm R, Equal and Reactive (PERL)
Temp. (°C)	35.4 (Hypothermic)

Physical Examination

General Appearance: Cachectic, frail, lethargic, pale. Appears significantly underweight.
Cardiovascular: Marked bradycardia, hypotension. Weak peripheral pulses. Delayed capillary refill. Possible orthostatic hypotension.
Skin: Cool, dry, poor turgor. Fine downy hair (lanugo) may be present on face/arms/back. Peripheral cyanosis may be present if very cold/poor perfusion.
Neurological: GCS 15 but lethargic. Weakness. Dizziness reported.
Other: May have muscle wasting, brittle nails/hair, dental erosion (if purging history). Abdomen may be scaphoid.

Assessment and Treatment

Appropriate Management Focus

Primary Survey (ABCDE): Recognize critical illness related to anorexia complications (bradycardia, hypotension, hypothermia, potential hypoglycaemia, risk of electrolyte disturbance/arrhythmia).
ECG Acquisition & Interpretation: **Obtain 12-lead ECG early.** Look for bradycardia, prolonged QT, other T wave/QRS changes indicative of electrolyte imbalance or structural changes.
Oxygen Therapy: Apply oxygen via nasal prongs or mask if hypoxic (SpO2 < 94%) or signs of shock.
Glucose Management: Check BGL. If hypoglycaemic (<4.0 mmol/L), administer oral glucose if alert and able to swallow, or IV Dextrose / IM Glucagon per local protocols.
Temperature Management: Actively warm the patient using blankets. Prevent further heat loss.
Vascular Access: Establish IV access (may be difficult due to dehydration/cachexia).
Fluid Therapy: Administer IV fluids (e.g., Sodium Chloride 0.9%) cautiously. Start with a small bolus (e.g., 250-500mL) for hypotension/poor perfusion, reassess frequently. Avoid rapid large volumes due to risk of refeeding syndrome/fluid shifts in malnourished patients.
Monitoring: Continuous ECG monitoring is essential due to arrhythmia risk. Frequent vital signs (including temperature). Monitor mental status. Recheck BGL after treatment if initially low.
Positioning: Keep patient supine initially due to hypotension/orthostasis. Move gently.
Communication & Rapport: Approach patient with sensitivity and empathy. Avoid focus on weight/food initially. Communicate concerns clearly to patient and parent.
Transport: **Urgent transport** to an Emergency Department equipped for medical stabilisation of eating disorder complications. Pre-notify receiving hospital (CRITICAL PATIENT: Suspected severe anorexia complications - bradycardia, hypotension, hypothermia, ?hypoglycaemia, ECG findings).
Teamwork & Communication: Clear roles. Gentle handling. Sensitive communication. Clear handover emphasizing medical instability and history of anorexia.

Debrief Focus Points

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Recognizing the signs and symptoms of severe medical compromise in Anorexia Nervosa (bradycardia, hypotension, hypothermia, hypoglycaemia, cachexia).
Understanding the potential for life-threatening complications (arrhythmias, electrolyte imbalances, refeeding syndrome).
Importance of early ECG acquisition and interpretation in this patient group.
Cautious approach to IV fluid administration.
Management of hypothermia and hypoglycaemia.
Communicating sensitively with patients with eating disorders and their families.
Importance of transport to an appropriate facility for medical stabilisation.
Recognizing the limitations of prehospital assessment for underlying electrolyte disturbances.