Neurological

Acute Behavioural Disturbance — Agitated female at music festival

Intermediate

Adult · 35yr · female

Patient Information

Dispatch	You are called to the medical tent at the Southside Music Festival. Security staff have brought in a 35YO female (Natalie Pearce) who is behaving erratically and was found wandering near the main stage. She is conscious but very agitated and not making sense.
Patient	Natalie Pearce — 35yr (65kg)
Incident History	Security found pt pacing near the main stage, shouting at bystanders and attempting to climb the barrier. Pt has been at the festival since midday. No witnessed trauma or collapse. Pt is holding her head intermittently and appears confused.
Emergency Contact	Dean Pearce (Husband) — 0412 883 647

Initial Rapid Assessment

Response	Alert
Airway	Patent. Pt speaking loudly. No stridor or airway obstruction noted.
Breathing	Breathing appears fast and shallow. No cyanosis. Able to speak in full sentences although content is disorganised.
Circulation	Radial pulse rapid and strong. Skin flushed and diaphoretic. No visible external bleeding.
Disability	GCS 13 (E4V3M6). Not orientated to time, place or person. Agitated. Intermittently grabbing at own head.
Exposure	No visible external trauma. No rashes. Pupils appear dilated bilaterally. Skin warm and dry. No medic alert jewellery noted.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	97% (RA)	Mild	22	118	148/94	<2s	13	6 6 SL	37.9	5.8 mmol/L	–
10 mins	97% (RA)	Mild	20	112	144/90	<2s	13	6 6 SL	37.9	5.8 mmol/L	–

History Taking

Treatment Response

Diagnosis

This patient is suffering from Acute Behavioural Disturbance of uncertain aetiology — differential diagnoses include sympathomimetic toxidrome (suspected illicit substance ingestion such as MDMA or amphetamines), alcohol intoxication with agitation, and organic cause such as hypoglycaemia or head injury that must be actively excluded.

Facilitator Triggers — if trainees miss a critical step

! (If trainees do not perform BGL within the first 3 minutes — pt becomes increasingly agitated and attempts to stand up and leave. Facilitator prompts: 'She keeps pulling at her arm and saying she needs to get back to her friends. What organic causes do you need to exclude?')
! (If trainees do not consider organic causes such as head injury, hypoglycaemia, or hypoxia before attributing behaviour to alcohol or drugs — facilitator prompts: 'Her pupils are dilated and her skin is warm and dry. Does this change your thinking about what might be causing this?')
! (If de-escalation is not attempted and restraint is applied immediately — facilitator states: 'She becomes more agitated with physical contact and starts shouting. Security are asking if they should help hold her down. What is your approach?')
! (If trainees attempt to administer any sedative medication — facilitator states: 'That medication is not within EHS scope of practice. What can you do at your level of care to manage this patient?')
! (If trainees do not contact the Clinical Support Paramedic in SOC for guidance within 5 minutes of assessment — facilitator prompts after 10 minutes: 'Her behaviour has not improved and she has attempted to leave twice. Who can you contact for advice on this patient?')
! (If patient is placed supine and left unattended — facilitator states: 'She rolls towards the edge of the stretcher and starts to vomit. What position should she be in?')

Treatment Objectives

1. Ensure scene and personal safety before approaching — confirm security presence and position self with clear egress route
2. Perform Primary Survey — airway patent, breathing present, radial pulse present, no catastrophic haemorrhage
3. Apply non-confrontational approach and de-escalation techniques — calm voice, open body language, maintain personal space, avoid physical contact unless essential
4. Perform BGL — result 5.8 mmol/L, hypoglycaemia excluded as primary cause
5. Apply pulse oximetry — SpO2 97% on room air
6. Obtain tympanic temperature — 37.9°C, does not meet heat stroke threshold but note warm dry skin and tachycardia
7. Attempt full Vital Sign Survey including BP, HR, RR, and GCS — document RASS score (RASS +3 initially, reassess following de-escalation)
8. Actively exclude organic causes: head injury (no visible trauma, no history of fall reported), hypoglycaemia (BGL 5.8 mmol/L — excluded), hypoxia (SpO2 97% — excluded), stroke (consider but FAST assessment outside EHS scope — maintain high suspicion)
9. Note clinical features consistent with sympathomimetic toxidrome: dilated pupils, tachycardia, hypertension, diaphoresis, agitation, hyperthermia — do not diagnose but document and communicate findings
10. Do NOT administer any sedative medication — this is outside EHS Primary Care scope
11. Do NOT restrain unless essential to prevent immediate harm to patient or crew — if restraint is necessary use minimum force in a safe position (not prone, not supine)
12. Do NOT leave patient unattended — if patient expresses suicidal ideation, maintain constant observation
13. Position patient in a seated or lateral position — do NOT transport in supine position
14. Contact Clinical Support Paramedic (CSP) in State Operations Centre for advice and to request Advanced Care backup given altered conscious state of uncertain aetiology
15. Maintain continuous monitoring — repeat vital signs every 10 minutes (or 5 minutes if condition deteriorates)
16. Arrange Priority 1 transport to hospital with pre-notification
17. Scenario ends on arrival of ambulance and IMISTAMBO handover
18. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Disturbed & Abnormal Behaviour · Unconsciousness · Hypoglycaemia · Poisons & Overdoses

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Signs/Symptoms	Confusion, agitation, disorganised speech, intermittent head-holding. Pt intermittently states 'everything is moving' and 'my heart is racing'.
Allergies	Unable to obtain reliably from pt. No information from bystanders.
Medications	Unknown — pt unable to provide history. No medications visible on person.
Pertinent History	Unknown. Husband (Dean) contacted by security — states pt has no known medical conditions and does not take regular medications. He is not on site.
Last Oral Intake	Pt states she has been drinking alcohol since around 1pm. Unable to confirm food or water intake. Festival started at 11am.
Events Leading	Pt attended the festival with friends who have since lost track of her. She was found alone near the main stage behaving erratically. Friends have not been located.
Treatment Prior	Nil treatment prior to EHS arrival. Security staff did not administer anything.

Onset	Security reports behaviour has been escalating over the past 45 minutes. Pt was seen drinking alcohol earlier in the afternoon.
Pain	Pt intermittently holds head — when asked directly she says 'my head is spinning' but cannot localise or rate pain consistently.
Quality	Disorganised speech. Pt intermittently lucid for seconds then becomes loud and agitated again.
Radiates	Nil reported.
Severity	Unable to obtain reliable pain score due to altered conscious state.