27 y/o female presents hot and altered to the ED after cocaine binge. Learners should recognize serotonin syndrome as the likely cause. Patient will develop Torsades and require multiple management interventions.
A 27-year-old female presents hot and altered to the ED with EMS. The likely cause is serotonin syndrome, precipitated by being on citalopram and methadone in the setting of a recent cocaine binge (all increase serotonin levels). She will develop Torsades de Pointes as a complication that must be treated with MgSO4. She will become increasingly agitated and febrile, requiring IV benzodiazepines, active cooling, and consideration of intubation with paralysis to achieve normothermia.
Overall Goal: Expose learners to a hyperthermic, altered patient with serotonin syndrome
Specific Learning Objectives:
Time Recommended: 60 minutes total (10 min Setup | 20 min Scenario | 30 min Debrief)
Patient Recommendation: Mannequin w/ pacing capabilities
Medical Equipment:
Medications:
| Role | Description (Role, Behaviour, Key Moments, Script) |
| Boyfriend |
You brought the patient to the ER. You will provide collateral history for the patient, as she will be agitated and not very cooperative. History: This morning, you found your girlfriend seeming confused and warm. She has a history of opioid abuse and is currently on methadone. What's more, she's also been on an antidepressant for some time now. This past weekend she was well, though you two did "party a lot and get pretty wasted last night". If probed by learners, you will admit to cocaine use by you and your girlfriend, but you swear she hasn't done any prescription pain meds lately and has been taking her medication as prescribed. |
Moulage: Can place a female wig on the mannequin if desired. Put some water droplets on the mannequin to simulate diaphoresis.
Set-Up: Set up mannequin as though they had been brought in by EMS services at your hospital. Boyfriend in room with patient. Monitors should be attached.
Note: While prepping for your simulation, don't forget to prep for the debrief. Become comfortable with your chosen framework, review your objectives. For additional debriefing resources, see our Resources page.
Credits:
Original Author: Donika Orlich
Date: 2016
Originally published on: EM Sim Cases
Most Recent Modification: July 2021
Modified by: Mateo Orrantia
A good prebriefing is an essential component of running effective simulations, as it sets the stage for everything that comes after it1-3. An effective prebrief will create a safe container for learning, and in doing so, help participants feel more comfortable pushing their limits, sharing their thoughts and feelings, and buying into the experience. In turn, this will enhance engagement, participation, and learning. To that end, the prebriefing process needs to cover a lot of information1-5, which can make it daunting to novice or non-expert facilitators. To help, we have consulted the relevant literature and put together a prebrief guide to ensure that you have the tools you need to run an effective pre-briefing session.
Throughout the pre-brief, it is important that you convey your commitment to respecting learners and their perspective2-4, and establish and maintain the simulation as a safe space for learning1,4,5.
Prebrief Guide (Sample Phrases in Italics)
Welcome learners. Introduce yourself, your role, and your experience with simulation.
Go over the time requirements for the simulation, when breaks will occur, how learners should handle incoming calls or texts, etc.
Clarify the learning objectives for the simulation1-5. Give information on the purpose of the simulation without giving out specific actions or information that might compromise the learning experience for participants.
Explain how participants will be evaluated (formative/summative/not evaluated). Briefly discuss the debrief process that will take place at the end of the simulation.
Give details on what expectations are for the learners' behaviour during the simulation, setting basic ground rules2-5. Go over expectations for yourself as the facilitator. Reinforce the simulation as a learning environment, where mistakes aren't something to be punished but opportunities for further learning.
This could be a good place to pause and ask learners if they have any additional expectations, fears, comments, or questions about the topic for the day.
Ensure all participants agree to the confidentiality expectations of the simulation. Often, this will follow the mantra of "What happens in the simulation stays in the simulation," where learners and instructors agree not to share information on others' performance or scenario details outside of the simulation environment.
Explain that you've done what you can to make the simulation as real as possible, but acknowledge the limitations. Ask the learner to commit to doing what they can to act as if everything was real, explaining that the quality of their learning will depend on their willingness to participate as fully as possible. For the first simulation with a new group, it could be helpful to explain the importance of a mutual fiction contract.
Explain the different roles in the simulation and assign learners to them. If you have predetermined scripts for certain roles, hand them out here.
Explain the resources that will be available for the participants to use, how they should call for help in the simulation, what your role will be in providing information.
Orient participants to simulation space, equipment, manikin, etc. This can also be done by allowing participants to explore the simulation space and manikin for themselves.
Ask for questions!
References
1. Rudolph JW, Raemer DB, Simon R. Establishing a safe container for learning in simulation: the role of the presimulation briefing. Simul Healthc. 2014 Dec;9(6):339-49. doi: 10.1097/SIH.0000000000000047. PMID: 25188485.
2. Leigh G, Steuben F. Setting Learners up for Success: Presimulation and Prebriefing Strategies. Teaching and Learning in Nursing. 2018; 13(3):185-189. https://doi.org/10.1016/j.teln.2018.03.004
3. Lecomte F, Jaffrelot M. Chapter 33 - Prebriefing and Briefing. Clinical Simulation. 2019; 2nd ed.; 471-482. https://doi.org/10.1016/B978-0-12-815657-5.00034-6.
4. INACSL Standards Committee (2016, December). INACSL standards of best practice: SimulationSM Facilitation. Clinical Simulation in Nursing, 12(S), S16-S20. http://dx.doi.org/10.1016/j.ecns.2016.09.007.
5. Simon R, Raemer D, Rudolph J. Rater's handbook for the Debriefing Assessment for Simulation in Healthcare (DASH) Rater Version. 2009. http://www.harvardmedsim.org/debriefing-assesment-simulation-healthcare.php.
A 27-year-old female was found by her boyfriend this morning seeming confused and warm. He called EMS. With EMS the patient was noted to be diaphoretic, febrile and quite agitated. She is in the trauma room, and her boyfriend is with her.
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Patient Chart |
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Patient Name: Sandy Jones |
Age: 27 |
Gender: F |
Weight: 60kg |
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Presenting complaint: Fever and altered LOC |
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Temp: 39.4C |
HR: 110 |
BP: 122/75 |
RR: 18 |
O2Sat: 99% |
FiO2: |
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|
Cap glucose: 6.4 |
GCS: 14 (E4 V4 M6) |
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|
Triage Note: Brought by EMS w Fever and Altered LOC. BF says they "partied a lot" over |
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Allergies: Penicillin |
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|
Past Medical History: |
Current Medications: |
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Further History: To be provided by boyfriend - This morning, found girlfriend seeming confused and warm. She has a history of opioid abuse and is currently on methadone. What's more, she's also been on an antidepressant for some time now. This past weekend she was well, though the two did "party a lot and get pretty wasted last night". If probed, will admit to cocaine use. Is a 1 pack per day smoker.
| Physical Exam | |
| Cardio: Nil | Neuro: Confused, Not oriented. Agitated and "jumpy". |
| Resp: Nil. No recent cough. | Head & Neck: Pupils 4mm reactive bilaterally. No signs of head injury. |
| Abdo: Nil | MSK/Skin: Inducible clonus, hyper-reflexia |
| Other: Diaphoretic, Shivering | |
A 27-year-old female was found by her boyfriend this morning seeming confused and warm. He called EMS. With EMS the patient was noted to be diaphoretic, febrile and quite agitated. She is in the trauma room, and her boyfriend is with her.
|
Patient Chart |
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|
Patient Name: Sandy Jones |
Age: 27 |
Gender: F |
Weight: 60kg |
|||||||
|
Presenting complaint: Fever and altered LOC |
||||||||||
|
Temp: 39.4C |
HR: 110 |
BP: 122/75 |
RR: 18 |
O2Sat: 99% |
FiO2: |
|||||
|
Cap glucose: 6.4 |
GCS: 14 (E4 V4 M6) |
|||||||||
|
Triage Note: Brought by EMS w Fever and Altered LOC. BF says they "partied a lot" over |
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|
Allergies: Penicillin |
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|
Past Medical History: |
Current Medications: |
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Patient shivering and diaphoretic. Generally agitated.
| Patient State/Vitals | ||||||
| Rhythm: Wide QRS | HR: 110 | BP: 120/80 | RR: 18 | |||
| O2SAT: 99% | T: 39.5oC | GCS: 14 | ||||
| Expected Learner Actions | Modifiers | Triggers |
|---|---|---|
|
IV, O2, Monitors |
Antipyretic ⇒ No effect 1L IV NS ⇒ HR 105 BP 125/85 1amp NaHCO3 ⇒ narrowing of QRS |
All Actions Complete or 5 mins⇒ 2. Torsades |
This ECG shows a marked widening of the QRS with tachycardia and a positive R' wave in aVR
This ECG shows a QTc of 510ms, which is associated with an increased risk of torsades
This CXR shows a normal chest
| Patient State/Vitals | ||||||
| Rhythm: Wide QRS | HR: 110 | BP: 120/80 | RR: 18 | |||
| O2SAT: 99% | T: 39.5oC | GCS: 14 | ||||
Patient begins moaning. GCS drops to 8.
Facilitator Note: Patient is now in Torsades des Pointes
| Patient State/Vitals | ||||||
| Rhythm: Torsades | HR: 180 (↓) | BP: 60/30 (↓) | RR: 18 | |||
| O2SAT: 93% (↓) | T: 40.5o C | GCS: 8 (↓) | ||||
| Expected Learner Actions | Modifiers | Triggers |
|---|---|---|
|
Cardioversion 100-200J |
Cardioversion before MgSO4 ⇒ Brief NSR |
MgSO4 given ⇒ 4. More Agitated No MgSO4 by 3 mins ⇒ 3. Arrest |
This ECG shows a Torsades des Pointes - a key indicator of this is the irregularity of the rhythm and the dramatic rotation of the electrical axis.
| Patient State/Vitals | ||||||
|
Torsades |
HR: 180 (↓) | BP: 60/30 (↓) | RR: 18 | |||
| O2SAT: 93% (↓) | T: 40.5o C | GCS: 8 (↓) | ||||
Patient loses pulse
| Patient State/Vitals | ||||||
| Rhythm: Torsades | HR: 180 | BP: 0 (↓) | RR: 0 (↓) | |||
| O2SAT: ??? | T: 40.5oC | GCS: 8 | ||||
| Expected Learner Actions | Modifiers | Triggers |
|---|---|---|
|
IV MgSO4 |
Defibrillation only ⇒ No ROSC |
| Patient State/Vitals | ||||||
| Rhythm: Torsades | HR: 180 | BP: 0 (↓) | RR: 0 (↓) | |||
| O2SAT: ??? | T: 40.5oC | GCS: 8 | ||||
Patient GCS 13 and very jumpy. Speaking nonsense.
| Patient State/Vitals | ||||||
| Rhythm: NSR | HR: 120 (↑) | BP: 140/90 (↑) | RR: 16 (↑) | |||
| O2SAT: 99% | T: 40.5oC | GCS: 13 (↑) | ||||
| Expected Learner Actions | Modifiers | Triggers |
|---|---|---|
|
IV Benzos until more calm |
1st dose benzos ⇒ HR 110 |
| Patient State/Vitals | ||||||
| Rhythm: NSR | HR: 120 (↑) | BP: 140/90 (↑) | RR: 16 (↑) | |||
| O2SAT: 99% | T: 40.5oC | GCS: 13 (↑) | ||||
Give lab results at beginning of stage
| Patient State/Vitals | ||||||
| Rhythm: NSR | HR: 100 (↓) | BP: 130/80 (↓) | RR: 16 | |||
| O2SAT: 99% | T: 39oC | GCS: 13 | ||||
| Expected Learner Actions | Modifiers | Triggers |
|---|---|---|
|
Consider cyproheptadine (if available) |
No Modifiers for This Stage |
Transfer arranged/Consultation Complete ⇒ Debrief End Case PRN ⇒ Debrief |
These lab results show elevated tox levels.
| Sandy Jones | |||||
| MRN: 1234-567-890 | Age: 27 | ||||
| Complete Blood Count | |||||
| WBC | 14 | x109L | H | ||
| Hgb | 122 | g/L | L | ||
| Hct | 0.4 | ||||
| Plt | 300 | x109L | |||
| Electrolytes | |||||
| Na | 138 | mmol/L | |||
| K | 4.5 | mmol/L | |||
| HCO3 | 22 | mmol/L | L | ||
| Cl | 102 | mmol/L | |||
| Urea | 6 | mmol/L | |||
| Cr | 70 | µmol/L | L | ||
| Glucose | 6.8 | mmol/L | |||
| Venous Blood Gas | |||||
| pH | 7.28 | L | |||
| pCO2 | 30 | mmHg | L | ||
| PO2 | 100 | mmHg | H | ||
| HCO3 | 18 | meQ/L | L | ||
| Lactate | 3.4 | mmol/L | H | ||
| TSH | |||||
| TSH | 0.5 | mIU | Normal | ||
| CK | |||||
| CK | 100 | U/L | Normal | ||
| Tox | |||||
| EtOH | 46 | mmol/L | H | ||
| ASA | 2.4 | mmol/L | H | ||
| Tylenol | <66 | mcg/mL | |||
| Osm | 300 | mOsm/kg | H | ||
This x-ray shows a normal post-intubation chest.
| Patient State/Vitals | ||||||
| Rhythm: NSR | HR: 100 (↓) | BP: 130/80 (↓) | RR: 16 | |||
| O2SAT: 99% | T: 39oC | GCS: 13 | ||||
| Sandy Jones | ||||||
| MRN: 1234-567-890 | Age: 27 | |||||
| Complete Blood Count | ||||||
| WBC | 14 | x109L | H | |||
| Hgb | 122 | g/L | L | |||
| Hct | 0.4 | |||||
| Plt | 300 | x109L | ||||
| Electrolytes | ||||||
| Na | 138 | mmol/L | ||||
| K | 4.5 | mmol/L | ||||
| HCO3 | 22 | mmol/L | L | |||
| Cl | 102 | mmol/L | ||||
| Urea | 6 | mmol/L | ||||
| Cr | 70 | µmol/L | L | |||
| Glucose | 6.8 | mmol/L | ||||
| Venous Blood Gas | ||||||
| pH | 7.28 | L | ||||
| pCO2 | 30 | mmHg | L | |||
| PO2 | 100 | mmHg | H | |||
| HCO3 | 18 | meQ/L | L | |||
| Lactate | 3.4 | mmol/L | H | |||
| TSH | ||||||
| TSH | 0.5 | mIU | Normal | |||
| CK | ||||||
| CK | 100 | U/L | Normal | |||
| Tox | ||||||
| EtOH | 46 | mmol/L | H | |||
| ASA | 2.4 | mmol/L | H | |||
| Tylenol | <66 | mcg/mL | ||||
| Osm | 300 | mOsm/kg | H | |||
Choosing a Debrief Framework:
A good debrief has been identified in the literature as the most important part of a successful simulation experience. If you're a novice or inexperienced facilitator, use this table to help you choose which debrief framework you want to use, just tap the button on their name and you will be directed to the appropriate aids or scripts. While we recommend the PEARLS framework, take a look to see if there may be another that is a better fit for your situation.
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Time |
Facilitator Level |
Prep Time |
Scenario Type |
Flexibility |
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Moderate |
Novice |
Moderate |
Any |
High |
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Short-Moderate |
Novice |
Low |
Short w/ Clear Objectives |
Low |
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Moderate |
Novice |
Moderate |
Any, esp. Team-focused |
Moderate |
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Very Short |
No experience |
None |
Any |
Low |
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Short |
Novice |
Low |
Low number of non-technical skills |
Low |
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Very Short |
No experience |
None |
Any |
Moderate |
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Moderate-Long |
Novice |
Moderate |
Any |
Moderate |
(To learn more about this debriefing framework, visit our page on Debriefing resources)
If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic
|
Phase |
Objective |
Task |
Sample Phrases |
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|
1. Setting the Scene |
Create a safe context for learning |
State the goal of debriefing; articulate the basic assumption |
“Let’s spend X minutes debriefing. Our goal is to improve how we work together and care for our patients.” “Everyone here is intelligent and wants to improve”
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|
2. Reactions |
Explore feelings |
Solicit initial reactions and emotions
|
“Any initial reactions?” “How are you feeling?” |
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3. Description |
Clarify Facts |
Develop a shared understanding of the case |
“Can you please share a short summary of the case?” “What was the working diagnosis? Does everyone agree?”
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|
4. Analysis |
Explore a variety of performance domains:
|
See bottom of guide for details on the analysis phase |
For each item to be debriefed: 1. Preview Statement: (to introduce topic)
2. Pick Analysis method + Analyze: (see below for more info on each method)
3. Mini Summary: (to summarize discussion of topic)
Phase Wrap-up: "Any outstanding issues or concerns before we start to close?" |
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5. Application or Summary |
Identify take-aways |
Can be learner- or instructor-centered |
Learner-centered: “What are some takeaways from this discussion for our clinical practice?”
Instructor-centered: “The key learning points for the case were [insert learning points]”
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|
Analysis Phase Details |
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Choose an analysis approach (Different approaches can be used for different topics within the same analysis stage): |
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Approach |
Objective |
Sample Phrases |
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Learner Self-Assessment
|
Promote reflection by asking learners to assess their own performance |
“What aspects were managed well and why?”
“What aspects do you want to change and why?”
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Focused Facilitation
|
Probe deeper on key aspects of performance, uncover mental frames guiding performance |
Use Advocacy-Inquiry Method Advocacy: "I saw [observation], I think [your point-of-view]” "I noticed [observation] I liked that/I was concerned..." Inquiry: “How do you see it? What were your thoughts at the time?” |
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Provide Information
|
Teach to close clear knowledge gaps as they emerge and provide directive feedback as needed |
“I noticed[behaviour]. Next time you may want to consider [suggested behaviour], because [rationale]” |
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PDF from debrief2learn.org: Here
Visual Guide: debrief2learn.org
Alternative Script: Here
Originally Created by: Bajaj K, Meguerdichian M, Thoma B, Huang S, Eppich W, Cheng A. The PEARLS Healthcare Debriefing Tool. Acad Med. 2018, 93(2), 336.
(To learn more about this debriefing framework, visit our page on Debriefing resources)
If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic
|
Phase |
Goal |
Actions |
Possible Scripts |
|
Gather (Listen)
25% |
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How do you feel? |
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How do you think it went? Can you tell me what happened? |
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Can anyone add anything to that account? |
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Analyze (Guide Reflection)
50% |
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I noticed… |
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I noticed…. What was the thought process behind…. When….happened, I saw….What do you think….. I saw…I think….How do you see it? |
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Tell me more about… How did you feel about…. I understand, but tell me about X aspect of the scenario |
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Summarize (Help gather Conclusions)
25%
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What are two things that you thought were effective or went well? |
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What do you think are some areas you/your team need to work on? |
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In today’s session, we…. Going forward, we should…. |
References/Adapted From:
(To learn more about this debriefing framework, visit our page on Debriefing resources)
If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic
Instructions:
|
Actions |
Gather |
Analyze |
Summarize |
|
Closed-loop communication
Clear Messages
Clear Roles
Knowing one’s limitations
Knowledge Sharing
Constructive Intervention
Reevaluation and Summarizing
Mutual Respect
|
Student Observations
Instructor Observations
|
Done Well
Needs Improvement
|
Student-led Summary
Instructor-led Summary
|
References/Adapted from:
(To learn more about this debriefing framework, visit our page on Debriefing resources)
If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic
|
|
Set learning objectives |
|
After Case |
How did it go? Address Concerns Review learning points Plan ahead |
Framework from:
(To learn more about this debriefing framework, visit our page on Debriefing resources)
If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic
|
Diamond Debrief: Sample Phrases |
|
Description |
|
“So what happened?...and then what happened next?”
Continue asking until confident that the details of the scenario have been raised by the learners
“Let’s not judge our performance now, let’s just focus on what happened” |
|
Transition |
|
“This scenario was designed to show…”
“Let’s address technical and clinical questions. What is the protocol for…?”
“How do we normally deal with this clinical situation?”
“Everyone ok with that?” |
|
Analysis |
|
“How did that make you feel?” To participants, then group “Why?” Then use silence
“How did you/they do that exactly?” “Why did you respond in that way? “ or “Why did you take that action?”
“It feels like…was an issue. Did it feel like that to you?” What I’m hearing from you is…is that correct?”
“This is part of…” (identify the non-technical skill/human factor) “We refer to that as a human factor or non-technical skill, which means…” |
|
Transition |
|
“So, what we’ve talked about in this scenario is…” “What have we agreed we could do?” |
|
Application |
|
“What other kinds of situations might you face that might be similar? How are they similar?”
“How might these skills we discussed play out in those situations?”
“What are you going to do differently in your practice going forward?” |
|
Underlying Principles |
|
Description |
|
Reinforce a safe learning environment. Situate the debrief in the shared and meaningful activity that occurred. Keep the focus dispassionate—discuss what happened but avoid focus on emotions. Listen for emotional responses but resist the temptation to discuss emotions. Make sure everyone shares the same understanding of what happened.
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|
Transition |
|
Transition into analysis by clarifying any technical and clinical issues |
|
Analysis |
|
Spend most of your time in Analysis. Deconstruct behaviours into specific actions, and explore what happened in detail. Ask about affective responses and validate them. Analyze and interpret the activity by applying appropriate frameworks or lenses (such as non-technical skills, or the clinical context surrounding the scenario). Keep discussion positive, and avoid the temptation to focus on “strengths and weaknesses”. Reflect responses back, allowing participants to amend or augment. |
|
Transition |
|
Transition into Application by reinforcing learning. |
|
Application |
|
Focus on moving from the specifics of the scenario to the more general world of practice. Break behaviours down into specific actions. Explore the other kinds of situations that these might apply to. Ask what participants will do differently in their practice. |
Adapted From: Jaye P, Thomas L, Reedy G (2015). 'The Diamond': a structure for simulation debrief. The Clinical Teacher 12(1). 171-175. onlinelibrary.wiley.com/doi/full/10.1111/tct.12300
If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic
Pluses:
Deltas:
|
Plus (+) |
Delta (∆) |
References:
((To learn more about this debriefing framework, visit our page on Debriefing resources)
If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic
|
Phase |
Purpose |
Process |
Sample Phrases |
|
Reactions |
|
|
How are you feeling? What are some initial reactions to what just happened? So, in that scenario… |
|
Analysis |
|
1. Observe an event or result. Comment on the observation.
2. Advocate for your position |
I saw that… I think… I noticed that…To me…
I saw…I’m concerned that… |
|
3. Investigate basis for learner’s thinking that led to the observed event or result |
What do you think? Why do you think that happened? How do you see it? What was the thought process behind….? |
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|
4. Close the gap through discussion and didactics |
I hear…. What would it take for you to do this next time? How could we do this differently next time? I think a few good ideas that came up were… I’d like to say a little bit about…from my experience/literature |
||
|
Summary |
|
|
What are some takeaways from today? What went well today? What would you do differently next time?
In today’s session, we…. Going forward, we should… |
Adapted from:
1. Administer MgSO4 for patients in Torsades
2. Serotonin Syndrome often occurs through the inadvertent interaction of several serotonergic medications, rather than a singular full-blown overdose.
