{
  "scenario": {
    "id": "hypothermia-elderly-01",
    "name": "Elderly Hypothermia with Bradycardia \u2014 Rewarming Recovery",
    "description": "81-year-old female found outdoors in winter with core temp 33.5\u00b0C on arrival. Presents with hypothermia-induced bradycardia, hypotension, and altered mentation. Gradual active rewarming over 4 hours with warm IV fluids and warming blankets leads to full recovery of vitals and consciousness.",
    "durationMinutes": 240,
    "tags": [
      "hypothermia",
      "bradycardia",
      "elderly",
      "rewarming",
      "recovery",
      "emergency",
      "winter"
    ]
  },
  "patient": {
    "firstName": "Margaret",
    "lastName": "Thornton",
    "dateOfBirth": "1945-01-14",
    "gender": "Female"
  },
  "encounter": {
    "department": "Emergency",
    "encounterType": "Emergency",
    "attendingPhysician": "Dr. Elena Vasquez",
    "roomBed": "ED-03A",
    "admissionReason": "Found unresponsive outdoors in winter, hypothermia, bradycardia"
  },
  "events": [
    {
      "offsetMinutes": 0,
      "type": "observation",
      "data": {
        "code": "HEART_RATE",
        "value": 48,
        "unit": "bpm",
        "source": "Device"
      },
      "note": "Arrival \u2014 severe hypothermia, bradycardia, altered mentation. NEWS2=14 (EMERGENCY)"
    },
    {
      "offsetMinutes": 0,
      "type": "observation",
      "data": {
        "code": "RESP_RATE",
        "value": 10,
        "unit": "/min",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 0,
      "type": "observation",
      "data": {
        "code": "SYSTOLIC_BP",
        "value": 96,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 0,
      "type": "observation",
      "data": {
        "code": "DIASTOLIC_BP",
        "value": 54,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 0,
      "type": "observation",
      "data": {
        "code": "TEMP_C",
        "value": 33.5,
        "unit": "\u00b0C",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 0,
      "type": "observation",
      "data": {
        "code": "SPO2",
        "value": 93,
        "unit": "%",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 0,
      "type": "observation",
      "data": {
        "code": "AVPU",
        "value": 1,
        "unit": "score",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 0,
      "type": "observation",
      "data": {
        "code": "SUPPLEMENTAL_O2",
        "value": 1,
        "unit": "flag",
        "source": "Manual"
      },
      "note": "Nasal cannula 2L/min started on arrival"
    },
    {
      "offsetMinutes": 1,
      "type": "observation",
      "data": {
        "code": "GCS_EYE",
        "value": 4,
        "unit": "score",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 1,
      "type": "observation",
      "data": {
        "code": "GCS_VERBAL",
        "value": 4,
        "unit": "score",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 1,
      "type": "observation",
      "data": {
        "code": "GCS_MOTOR",
        "value": 5,
        "unit": "score",
        "source": "Manual"
      },
      "note": "GCS 13 — sluggish, confused from hypothermia"
    },
    {
      "offsetMinutes": 0,
      "type": "order",
      "data": {
        "orderType": "Procedure",
        "description": "Active warming protocol \u2014 forced-air warming blanket",
        "orderedBy": "Dr. Elena Vasquez"
      }
    },
    {
      "offsetMinutes": 5,
      "type": "order_result",
      "data": {
        "orderDescription": "Active warming protocol \u2014 forced-air warming blanket",
        "resultSummary": "Bair Hugger warming blanket applied, set to 43\u00b0C"
      },
      "note": "Warming blanket order initiated"
    },
    {
      "offsetMinutes": 8,
      "type": "medication",
      "data": {
        "drugName": "sodium chloride 0.9% (warmed to 40\u00b0C)",
        "dose": 1000,
        "doseUnit": "mL",
        "route": "IV",
        "administeredBy": "nurse-rn-2"
      },
      "note": "Warm IV fluids \u2014 first bolus for active core rewarming and volume support"
    },
    {
      "offsetMinutes": 15,
      "type": "observation",
      "data": {
        "code": "GLUCOSE_MG_DL",
        "value": 74,
        "unit": "mg/dL",
        "source": "Lab"
      },
      "note": "Initial labs \u2014 glucose low-normal, potassium borderline high (hypothermia shifts K+ extracellularly)"
    },
    {
      "offsetMinutes": 15,
      "type": "observation",
      "data": {
        "code": "POTASSIUM_MEQ_L",
        "value": 5.4,
        "unit": "mEq/L",
        "source": "Lab"
      }
    },
    {
      "offsetMinutes": 15,
      "type": "observation",
      "data": {
        "code": "LACTATE_MMOL_L",
        "value": 2.3,
        "unit": "mmol/L",
        "source": "Lab"
      }
    },
    {
      "offsetMinutes": 20,
      "type": "observation",
      "data": {
        "code": "HEART_RATE",
        "value": 47,
        "unit": "bpm",
        "source": "Device"
      },
      "note": "Minimal change \u2014 rewarming just started. NEWS2=14 (EMERGENCY)"
    },
    {
      "offsetMinutes": 20,
      "type": "observation",
      "data": {
        "code": "RESP_RATE",
        "value": 10,
        "unit": "/min",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 20,
      "type": "observation",
      "data": {
        "code": "SYSTOLIC_BP",
        "value": 94,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 20,
      "type": "observation",
      "data": {
        "code": "DIASTOLIC_BP",
        "value": 53,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 20,
      "type": "observation",
      "data": {
        "code": "TEMP_C",
        "value": 33.7,
        "unit": "\u00b0C",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 20,
      "type": "observation",
      "data": {
        "code": "SPO2",
        "value": 93,
        "unit": "%",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 20,
      "type": "observation",
      "data": {
        "code": "AVPU",
        "value": 1,
        "unit": "score",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 20,
      "type": "observation",
      "data": {
        "code": "SUPPLEMENTAL_O2",
        "value": 1,
        "unit": "flag",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 45,
      "type": "observation",
      "data": {
        "code": "HEART_RATE",
        "value": 46,
        "unit": "bpm",
        "source": "Device"
      },
      "note": "Slow rewarming \u2014 temp barely above 34\u00b0C. SpO2 slightly improved with O2. NEWS2=13 (EMERGENCY)"
    },
    {
      "offsetMinutes": 45,
      "type": "observation",
      "data": {
        "code": "RESP_RATE",
        "value": 11,
        "unit": "/min",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 45,
      "type": "observation",
      "data": {
        "code": "SYSTOLIC_BP",
        "value": 95,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 45,
      "type": "observation",
      "data": {
        "code": "DIASTOLIC_BP",
        "value": 55,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 45,
      "type": "observation",
      "data": {
        "code": "TEMP_C",
        "value": 34.0,
        "unit": "\u00b0C",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 45,
      "type": "observation",
      "data": {
        "code": "SPO2",
        "value": 94,
        "unit": "%",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 45,
      "type": "observation",
      "data": {
        "code": "AVPU",
        "value": 1,
        "unit": "score",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 45,
      "type": "observation",
      "data": {
        "code": "SUPPLEMENTAL_O2",
        "value": 1,
        "unit": "flag",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 50,
      "type": "medication",
      "data": {
        "drugName": "sodium chloride 0.9% (warmed to 40\u00b0C)",
        "dose": 500,
        "doseUnit": "mL",
        "route": "IV",
        "administeredBy": "nurse-rn-2"
      },
      "note": "Second warm IV fluid bolus \u2014 continued active rewarming"
    },
    {
      "offsetMinutes": 60,
      "type": "observation",
      "data": {
        "code": "HEART_RATE",
        "value": 48,
        "unit": "bpm",
        "source": "Device"
      },
      "note": "One hour into rewarming \u2014 temp 34.3\u00b0C, still bradycardic. NEWS2=13 (EMERGENCY)"
    },
    {
      "offsetMinutes": 60,
      "type": "observation",
      "data": {
        "code": "RESP_RATE",
        "value": 11,
        "unit": "/min",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 60,
      "type": "observation",
      "data": {
        "code": "SYSTOLIC_BP",
        "value": 97,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 60,
      "type": "observation",
      "data": {
        "code": "DIASTOLIC_BP",
        "value": 56,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 60,
      "type": "observation",
      "data": {
        "code": "TEMP_C",
        "value": 34.3,
        "unit": "\u00b0C",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 60,
      "type": "observation",
      "data": {
        "code": "SPO2",
        "value": 94,
        "unit": "%",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 60,
      "type": "observation",
      "data": {
        "code": "AVPU",
        "value": 1,
        "unit": "score",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 60,
      "type": "observation",
      "data": {
        "code": "SUPPLEMENTAL_O2",
        "value": 1,
        "unit": "flag",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 90,
      "type": "observation",
      "data": {
        "code": "HEART_RATE",
        "value": 50,
        "unit": "bpm",
        "source": "Device"
      },
      "note": "Temp approaching 35\u00b0C \u2014 HR and RR beginning to improve. NEWS2=12 (EMERGENCY)"
    },
    {
      "offsetMinutes": 90,
      "type": "observation",
      "data": {
        "code": "RESP_RATE",
        "value": 12,
        "unit": "/min",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 90,
      "type": "observation",
      "data": {
        "code": "SYSTOLIC_BP",
        "value": 100,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 90,
      "type": "observation",
      "data": {
        "code": "DIASTOLIC_BP",
        "value": 58,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 90,
      "type": "observation",
      "data": {
        "code": "TEMP_C",
        "value": 34.8,
        "unit": "\u00b0C",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 90,
      "type": "observation",
      "data": {
        "code": "SPO2",
        "value": 95,
        "unit": "%",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 90,
      "type": "observation",
      "data": {
        "code": "AVPU",
        "value": 1,
        "unit": "score",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 90,
      "type": "observation",
      "data": {
        "code": "SUPPLEMENTAL_O2",
        "value": 1,
        "unit": "flag",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 120,
      "type": "observation",
      "data": {
        "code": "HEART_RATE",
        "value": 54,
        "unit": "bpm",
        "source": "Device"
      },
      "note": "Temp crosses 35\u00b0C threshold \u2014 major improvement. HR normalizing, BP improving. NEWS2=7 (EMERGENCY \u2014 AVPU still 3)"
    },
    {
      "offsetMinutes": 120,
      "type": "observation",
      "data": {
        "code": "RESP_RATE",
        "value": 13,
        "unit": "/min",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 120,
      "type": "observation",
      "data": {
        "code": "SYSTOLIC_BP",
        "value": 104,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 120,
      "type": "observation",
      "data": {
        "code": "DIASTOLIC_BP",
        "value": 62,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 120,
      "type": "observation",
      "data": {
        "code": "TEMP_C",
        "value": 35.2,
        "unit": "\u00b0C",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 120,
      "type": "observation",
      "data": {
        "code": "SPO2",
        "value": 96,
        "unit": "%",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 120,
      "type": "observation",
      "data": {
        "code": "AVPU",
        "value": 1,
        "unit": "score",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 120,
      "type": "observation",
      "data": {
        "code": "SUPPLEMENTAL_O2",
        "value": 1,
        "unit": "flag",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 125,
      "type": "observation",
      "data": {
        "code": "GLUCOSE_MG_DL",
        "value": 88,
        "unit": "mg/dL",
        "source": "Lab"
      },
      "note": "Repeat labs at T+120 \u2014 glucose normalizing, potassium trending down as rewarming drives K+ intracellularly"
    },
    {
      "offsetMinutes": 125,
      "type": "observation",
      "data": {
        "code": "POTASSIUM_MEQ_L",
        "value": 4.6,
        "unit": "mEq/L",
        "source": "Lab"
      }
    },
    {
      "offsetMinutes": 125,
      "type": "observation",
      "data": {
        "code": "LACTATE_MMOL_L",
        "value": 1.7,
        "unit": "mmol/L",
        "source": "Lab"
      }
    },
    {
      "offsetMinutes": 150,
      "type": "observation",
      "data": {
        "code": "HEART_RATE",
        "value": 58,
        "unit": "bpm",
        "source": "Device"
      },
      "note": "Significant recovery \u2014 patient responding to name, temp 35.8\u00b0C. NEWS2=4 (below WARNING threshold)"
    },
    {
      "offsetMinutes": 150,
      "type": "observation",
      "data": {
        "code": "RESP_RATE",
        "value": 14,
        "unit": "/min",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 150,
      "type": "observation",
      "data": {
        "code": "SYSTOLIC_BP",
        "value": 108,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 150,
      "type": "observation",
      "data": {
        "code": "DIASTOLIC_BP",
        "value": 65,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 150,
      "type": "observation",
      "data": {
        "code": "TEMP_C",
        "value": 35.8,
        "unit": "\u00b0C",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 150,
      "type": "observation",
      "data": {
        "code": "SPO2",
        "value": 97,
        "unit": "%",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 150,
      "type": "observation",
      "data": {
        "code": "AVPU",
        "value": 0,
        "unit": "score",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 150,
      "type": "observation",
      "data": {
        "code": "SUPPLEMENTAL_O2",
        "value": 1,
        "unit": "flag",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 180,
      "type": "observation",
      "data": {
        "code": "HEART_RATE",
        "value": 62,
        "unit": "bpm",
        "source": "Device"
      },
      "note": "Temp in normal range \u2014 all vitals normalizing. O2 weaned off. NEWS2=0"
    },
    {
      "offsetMinutes": 180,
      "type": "observation",
      "data": {
        "code": "RESP_RATE",
        "value": 15,
        "unit": "/min",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 180,
      "type": "observation",
      "data": {
        "code": "SYSTOLIC_BP",
        "value": 112,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 180,
      "type": "observation",
      "data": {
        "code": "DIASTOLIC_BP",
        "value": 68,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 180,
      "type": "observation",
      "data": {
        "code": "TEMP_C",
        "value": 36.2,
        "unit": "\u00b0C",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 180,
      "type": "observation",
      "data": {
        "code": "SPO2",
        "value": 97,
        "unit": "%",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 180,
      "type": "observation",
      "data": {
        "code": "AVPU",
        "value": 0,
        "unit": "score",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 210,
      "type": "observation",
      "data": {
        "code": "HEART_RATE",
        "value": 65,
        "unit": "bpm",
        "source": "Device"
      },
      "note": "Continued monitoring \u2014 stable, fully alert. NEWS2=0"
    },
    {
      "offsetMinutes": 210,
      "type": "observation",
      "data": {
        "code": "RESP_RATE",
        "value": 15,
        "unit": "/min",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 210,
      "type": "observation",
      "data": {
        "code": "SYSTOLIC_BP",
        "value": 118,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 210,
      "type": "observation",
      "data": {
        "code": "DIASTOLIC_BP",
        "value": 70,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 210,
      "type": "observation",
      "data": {
        "code": "TEMP_C",
        "value": 36.4,
        "unit": "\u00b0C",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 210,
      "type": "observation",
      "data": {
        "code": "SPO2",
        "value": 98,
        "unit": "%",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 210,
      "type": "observation",
      "data": {
        "code": "AVPU",
        "value": 0,
        "unit": "score",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 240,
      "type": "observation",
      "data": {
        "code": "HEART_RATE",
        "value": 68,
        "unit": "bpm",
        "source": "Device"
      },
      "note": "End of scenario \u2014 near-normal vitals, temp 36.5\u00b0C. Full recovery. NEWS2=0"
    },
    {
      "offsetMinutes": 240,
      "type": "observation",
      "data": {
        "code": "RESP_RATE",
        "value": 16,
        "unit": "/min",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 240,
      "type": "observation",
      "data": {
        "code": "SYSTOLIC_BP",
        "value": 122,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 240,
      "type": "observation",
      "data": {
        "code": "DIASTOLIC_BP",
        "value": 72,
        "unit": "mmHg",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 240,
      "type": "observation",
      "data": {
        "code": "TEMP_C",
        "value": 36.5,
        "unit": "\u00b0C",
        "source": "Manual"
      }
    },
    {
      "offsetMinutes": 240,
      "type": "observation",
      "data": {
        "code": "SPO2",
        "value": 98,
        "unit": "%",
        "source": "Device"
      }
    },
    {
      "offsetMinutes": 240,
      "type": "observation",
      "data": {
        "code": "AVPU",
        "value": 0,
        "unit": "score",
        "source": "Manual"
      }
    }
  ],
  "expectedOutcomes": [
    {
      "afterOffsetMinutes": 0,
      "type": "alert",
      "alertType": "NEWS2_EMERGENCY",
      "description": "NEWS2=14 on arrival: Temp 33.5\u21923, HR 48\u21921, SBP 96\u21922, RR 10\u21921, SpO2 93\u21922, AVPU 1\u21923, O2\u21922. Total \u22657 with multiple single-param 3s"
    },
    {
      "afterOffsetMinutes": 0,
      "type": "score",
      "scoreType": "NEWS2",
      "expectedMinimum": 14,
      "description": "Initial NEWS2 of 14 \u2014 critically elevated due to severe hypothermia with multi-organ effects"
    },
    {
      "afterOffsetMinutes": 0,
      "type": "alert",
      "alertType": "WARNING_HEART_RATE",
      "description": "HR 48 bpm in warning range (41-50) \u2014 hypothermia-induced bradycardia"
    },
    {
      "afterOffsetMinutes": 0,
      "type": "alert",
      "alertType": "WARNING_POTASSIUM",
      "description": "Potassium 5.4 mEq/L \u2014 borderline high (warning range 5.1-5.5) due to hypothermic cellular shifts"
    },
    {
      "afterOffsetMinutes": 90,
      "type": "score",
      "scoreType": "NEWS2",
      "expectedMinimum": 12,
      "description": "NEWS2 decreasing to 12 at T+90: Temp 34.8\u21923, HR 50\u21921, SBP 100\u21922, RR 12\u21920, SpO2 95\u21921, AVPU 1\u21923, O2\u21922. Still EMERGENCY"
    },
    {
      "afterOffsetMinutes": 120,
      "type": "score",
      "scoreType": "NEWS2",
      "expectedMinimum": 7,
      "description": "NEWS2 drops to 7 at T+120: Temp 35.2\u21921, HR 54\u21920, SBP 104\u21921, RR 13\u21920, SpO2 96\u21920, AVPU 1\u21923, O2\u21922. Still EMERGENCY due to AVPU=3"
    },
    {
      "afterOffsetMinutes": 120,
      "type": "alert",
      "alertType": "NEWS2_EMERGENCY",
      "description": "NEWS2 still \u22657 at T+120 \u2014 AVPU single-param score of 3 alone triggers EMERGENCY even as other parameters normalize"
    },
    {
      "afterOffsetMinutes": 150,
      "type": "score",
      "scoreType": "NEWS2",
      "expectedMinimum": 0,
      "description": "NEWS2 drops to 4 at T+150: Temp 35.8\u21921, HR 58\u21920, SBP 108\u21921, RR 14\u21920, SpO2 97\u21920, AVPU 0\u21920, O2\u21922. Below WARNING threshold \u2014 recovery evident"
    },
    {
      "afterOffsetMinutes": 180,
      "type": "score",
      "scoreType": "NEWS2",
      "expectedMinimum": 0,
      "description": "NEWS2 drops to 0 at T+180: all vitals in normal range, O2 weaned off. Full recovery from hypothermia"
    },
    {
      "afterOffsetMinutes": 240,
      "type": "score",
      "scoreType": "NEWS2",
      "expectedMinimum": 0,
      "description": "NEWS2 remains 0 at end of scenario \u2014 sustained normothermia at 36.5\u00b0C with normal hemodynamics"
    }
  ]
}