This simulation-based educational activity is designed to train learners in the recognition and management of acute lower gastrointestinal (GI) bleeding in the setting of abnormal coagulation due to rodenticide ingestion (superwarfarin toxicity). The case presents a 58-year-old patient in hemorrhagic shock with brisk rectal bleeding and elevated INR secondary to intentional ingestion of anticoagulant rodenticide. Learners must rapidly assess the patient, organize a care team, differentiate the source of bleeding, initiate appropriate resuscitation, and reverse anticoagulation using vitamin K and blood products such as fresh frozen plasma or prothrombin complex concentrate. The simulation emphasizes early recognition of hemorrhagic shock, coordinated team-based resuscitation, and appropriate consultant involvement. The activity has been implemented within an emergency medicine residency curriculum and was rated as both realistic and educationally useful by the majority of participants.
Target Learners
- Emergency Medicine Residents (primary audience)
- Internal Medicine Residents
- Senior Medical Students (optional participants)
- Interprofessional learners (e.g., nursing staff in simulation roles)
No prerequisite knowledge is required, although a foundational understanding of resuscitation principles is beneficial.
Equipment Needed
Simulation Platform
- High-fidelity mannequin (e.g., SimMom or SimMan)
- Cardiac monitor
- Defibrillator
- Access to simulated laboratory testing and imaging
IV and Airway Supplies
- Angiocaths
- IV tubing
- Normal saline
- Non-rebreather mask
- Nasal cannula
- Laryngoscope
- Bag-valve mask
- Endotracheal tube
- Stylet
- Orogastric or nasogastric tube
Medications
- Etomidate
- Succinylcholine
- Lorazepam
- Epinephrine
- Atropine
- Haloperidol
- Vitamin K (for anticoagulation reversal)
Blood Products (Simulated)
- Packed red blood cells (PRBCs)
- Fresh frozen plasma (FFP)
- Platelets
- Cryoprecipitate
- Prothrombin complex concentrate (PCC)
Moulage and Miscellaneous
- Simulated blood/stool for hematochezia
- Pale skin or ecchymosis visual cues
- Gloves
- Skin prep (e.g., alcohol or chlorhexidine)
Estimated Time to Complete Activity
- Simulation Scenario: ~15–20 minutes
- Post-Scenario Debriefing: ~10–20 minutes
- Total Time per Learner Group: ~30–40 minutes
This activity is typically delivered within a rotating simulation conference block (e.g., four cases run within a 55-minute session).