Simulated Patient Scenario

Hypothermia (Elderly Fall)

Scenario Details

Scenario: Elderly patient found outdoors after a fall, presenting with confusion and signs of hypothermia.

Simulated Patient: 80-year-old Male Mannequin or Actor

Actor/Actress: Neighbour (found patient, provides limited info).

MDT Information

Non-urgent response initially (Welfare Check), upgraded - Fall / Exposure
80-year-old male found lying in garden by neighbour
Patient confused, cold to touch
Unknown duration of exposure
Neighbour present

On Arrival

Paramedics arrive on a cool, overcast morning (ambient temp ~10°C). The patient is found lying on his side on damp grass in the back garden, partially covered by a thin blanket provided by the neighbour. He appears pale and is shivering weakly. The neighbour reports finding him ~20 minutes ago when checking on him, unsure how long he's been there but possibly overnight after a fall.

Initial Impression and Primary Survey

Category	Finding
Initial Impression	Elderly male, pale, shivering weakly, altered mental status.
Response	Opens eyes to voice, appears confused and disoriented, speech slow and slightly slurred (AVPU=V, confused).
Airway	Clear and self-maintaining currently.
Breathing	Slow respiratory rate (bradypnoea), shallow depth.
Circulation	Skin pale, cool/cold to touch peripherally and centrally. Peripheral pulses weak, difficult to palpate. Central pulse slow (bradycardia). Capillary refill significantly delayed (>5 seconds).
Disability	Altered mental status (confusion, lethargy). GCS ~12-13 (E3 V4 M5-6). Pupils may be sluggishly reactive. Muscle rigidity may be present.
Exposure/Environment	Outdoor environment, cool ambient temperature, patient on damp ground, clothing likely damp. High risk of further heat loss.

Secondary Survey and Simulation Progression

History (Neighbour collateral, Patient input limited/unreliable)

Allergies	Unknown (Neighbour unsure)
Medications	Neighbour thinks he takes "heart and blood pressure tablets".
Past Medical History	Neighbour knows he has had heart problems and lives alone since wife died last year. Seems more forgetful recently.
Last Oral Intake	Unknown.
Events Preceding / History of Presenting Complaint	Unknown mechanism of fall or time down. Found lying in garden this morning. Patient unable to provide clear history due to confusion/hypothermia. Likely fell sometime yesterday evening or overnight and was unable to get up, leading to prolonged cold exposure.

Vital Signs/Assessment (Initial)

Parameter	Value (Approximate/Expected)
Resp. Rate (/min.)	8-10, shallow
Lung Sounds (L/R)	Clear, air entry may be poor due to shallow breathing.
SpO2 (%)	Difficult to obtain reliable reading due to poor perfusion/cold peripheries. May read low (e.g., 88-92%).
EtCO2 (mmHg)	May be elevated due to hypoventilation.
Pulse Rate (/min.)	45-55, regular or irregular (risk of AF).
CRT (sec.)	> 5 seconds.
ECG rhythm	Sinus Bradycardia. Monitor closely for Osborn (J) waves, Atrial Fibrillation, Ventricular Fibrillation, or Asystole.
12-lead ECG	Sinus bradycardia. Look for Osborn waves (positive deflection at J point), prolonged intervals (PR, QRS, QT).
BP (mmHg)	May be low (e.g., 90/60) or surprisingly normal/high initially due to vasoconstriction. Often difficult to measure accurately.
Skin	Pale, cold centrally and peripherally. Possible cyanosis.
Pain (/10)	Unable to assess reliably. May have pain from fall (e.g., hip).
GCS (/15: E,V,M)	~12-13 (E3 V4 M5-6)
BGL (mmol/L)	May be low, normal, or high. Check promptly.
Pupils (mmL/mmR)	May be dilated and sluggishly reactive.
Pupil reac. (L/R)	Sluggish.
Temp. (°C)	Crucial: Measure core temperature (tympanic, oral if possible, ideally oesophageal/rectal if equipped/protocol allows). Expected < 35°C (e.g., 32-34°C indicating moderate hypothermia).

Physical Examination (Focused)

**General:** Lethargic, confused, shivering (may be weak or absent if severe <32°C), cold to touch.
**Skin:** Pale/ashen/cyanotic, cold. Check for frostbite (unlikely at 10°C ambient unless wet/prolonged).
**Neurology:** Altered LOC, slurred speech, ataxia/poor coordination if able to move, muscle rigidity.
**Cardiovascular:** Bradycardia, hypotension (or normal BP), weak pulses.
**Respiratory:** Bradypnoea, shallow breathing.
**Trauma Assessment:** Perform head-to-toe assessment carefully (minimising movement) to identify injuries from fall (e.g., head injury, hip fracture, other fractures).

Assessment and Treatment

Appropriate Management

Recognise Moderate Hypothermia (<35°C, e.g., 32-34°C) secondary to environmental exposure after a fall. Consider underlying medical conditions/frailty as contributing factors. **Potential for cardiac instability.**
Primary survey (ABCDE), manage immediate life threats. **Handle patient gently** - rough handling can precipitate VF.
**Airway:** Maintain patent airway. Consider basic adjuncts if needed.
**Breathing:** Provide supplemental oxygen (warmed and humidified if possible) via mask to maintain SpO2 ≥94%. Assist ventilations with BVM if RR severely depressed or inadequate tidal volume.
**Circulation:**
- Continuous ECG monitoring. Be vigilant for dysrhythmias (esp. AF, VF).
- IV Access: Establish IV access if possible (may be difficult).
- **Fluid Therapy:** Administer **warmed** IV crystalloid fluids (e.g., Sodium Chloride 0.9% heated to ~40°C). Give cautiously, especially if heart failure history suspected. Primarily for volume expansion if hypotensive and to aid core rewarming.
- Treat hypotension primarily via rewarming. Vasopressors generally avoided unless refractory hypotension persists after initial rewarming/fluids.
- If VF/VT occurs, standard defibrillation attempts (may be less effective at low core temps). Follow local hypothermic cardiac arrest protocols (may involve limited shocks, delayed drugs, focus on rewarming).
**Rewarming:** **PRIORITY**.
- **Remove wet clothing** immediately.
- **Passive external rewarming:** Cover with warm, dry blankets (including head). Use space blanket/hypothermia wrap. Prevent further heat loss.
- **Active external rewarming:** Apply warming blankets (e.g., Bair Hugger) or heat packs to trunk (axillae, groin, torso) - avoid direct skin contact, avoid peripheral rewarming initially (can cause afterdrop).
- **Minimally invasive core rewarming:** Warmed IV fluids. Warmed humidified oxygen.
**Disability:** Check BGL, treat hypoglycaemia if present. Maintain spinal precautions if trauma suspected.
**Handle Gently:** Avoid unnecessary or rough movement.
Transport urgently to hospital capable of managing hypothermia and potential underlying trauma/medical issues. Minimise heat loss during transport.
**Pre-notify:** **Hypothermia Alert** to receiving hospital. Provide age, circumstances (fall, exposure time), **core temperature**, vital signs (confirming bradycardia, bradypnoea, hypotension), GCS, ECG findings (Osborn waves?), suspected injuries, rewarming measures initiated, ETA.
Documentation: Detailed record of circumstances, core temperature readings, vital signs trends, ECG findings, neurological status, rewarming methods used, fluid volumes, response to treatment.