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Scenario — Chest pain at the footy — suspected ACS in elderly male
Patient Information
Dispatch
You are called to an elderly male (Brian Carmichael, 75YO) seated in the grandstand at Optus Stadium. A bystander reports he has been complaining of chest tightness for the last 20 minutes and looks pale and unwell.
Incident History
Pt was watching the AFL game with his son when he developed central chest tightness and pressure approximately 20 minutes ago. He initially thought it was indigestion but the pain has not settled with rest. He looks pale and is sweating.
Emergency Contact
David Carmichael (Son (present on scene)) 0412 348 921
Initial Rapid Assessment
Response
Alert
Airway
Patent. Nil airway obstruction. Nil stridor. Speaking in full sentences but short of breath.
Breathing
Slightly laboured. RR elevated. Nil audible wheeze or crackles.
Circulation
Radial pulse present — regular, moderate strength. Skin pale, cool and diaphoretic. Nil external bleeding.
Disability
GCS 15 (E4V5M6). Orientated to time, place and person. Mild distress.
Exposure
No rashes, no visible trauma. Pt clutching centre of chest. Diaphoretic.
Vitals
Time SpO2 Resp Dist RR Pulse BP CRT GCS PERL Temp BGL Pain
Initial 95% (RA) Mild 20 96 148/92 <2s 15 4 4 ++ 36.9 6.4 mmol/L 7
10 mins 97% (O2 NRB 10L) Nil 17 88 136/84 <2s 15 4 4 ++ 36.9 6.4 mmol/L 4
History Taking
Signs/Symptoms
Central chest tightness described as a heavy pressure. Associated mild shortness of breath, nausea and diaphoresis. No palpitations reported.
Onset
Sudden onset approximately 20 minutes ago while seated watching the game. No precipitating exertion.
Pain
Central chest — heavy, tight, crushing sensation.
Quality
Pressure-like, constant, not pleuritic.
Radiates
Radiates to left shoulder and jaw.
Severity
7/10 at rest.
Allergies
NKDA — no known drug allergies.
Medications
Perindopril 5mg daily (hypertension). Atorvastatin 40mg nocte. Metformin 500mg BD (Type 2 diabetes). Aspirin 100mg daily (already taken this morning).
Pertinent History
Known hypertension and Type 2 diabetes. Previous cardiac stent inserted 6 years ago. Non-smoker. Denies use of sildenafil, tadalafil or any erectile dysfunction medications.
Last Oral Intake
Ate a meat pie and soft drink approximately 1 hour ago.
Treatment
Son gave him a sip of water. No other treatment prior to EHS arrival.
Events Leading
Pt was seated watching the AFL game. No physical exertion. Pain came on spontaneously and has not resolved with rest over 20 minutes.
Scenario Progression and Treatment Objectives

((If trainees do not ask about erectile dysfunction medications or PDE5 inhibitors before administering GTN — patient reveals he took sildenafil 'about 12 hours ago' — GTN is now contraindicated; trainees must withhold GTN and proceed to Methoxyflurane for analgesia.))

((If trainees do not administer aspirin within 5 minutes — patient's pain escalates to 9/10 and he becomes increasingly distressed and diaphoretic; his SpO2 drops to 93% on room air.))

((If oxygen is not applied within 3 minutes — SpO2 drops to 92% on room air and patient becomes more anxious and reports worsening breathlessness.))

((If trainees fail to limit patient exertion or attempt to walk Brian to the FAP — patient becomes markedly diaphoretic and pale; pulse rises to 110 bpm.))

((If trainees do not perform a full history including current medications — they may attempt to give a second aspirin dose; facilitator notes Brian already took aspirin 100mg this morning; current CPG states aspirin should still be administered even if taken that day — trainees must administer 300mg aspirin regardless.))

((If pain remains >3/10 after 1 spray of GTN and trainees do not offer Methoxyflurane — patient states 'the pain is still really bad, can you do anything else?' to prompt consideration of analgesia.))

This patient is suffering from a suspected Acute Coronary Syndrome (ACS) — likely NSTEMI or unstable angina — presenting with prolonged central chest pressure, radiation to the left shoulder and jaw, diaphoresis, and nausea in a 75-year-old male with known hypertension, Type 2 diabetes, and prior cardiac stent.

  • Ensure scene safety and don appropriate PPE.
  • Perform Primary Survey — confirm airway patent, breathing adequate, radial pulse present, GCS 15.
  • Position patient seated or semi-recumbent in current location — do NOT walk the patient to the FAP.
  • Perform Vital Sign Survey — HR, RR, BP, SpO2, BGL, temperature, pain score.
  • Apply oxygen via non-rebreather mask at 10–15 L/min — titrate to target SpO2 94–98%.
  • Obtain IMISTAMBO history — specifically ask about PDE5 inhibitor use (sildenafil, tadalafil, vardenafil, avanafil) before administering GTN.
  • Administer Aspirin 300mg oral (chewed) — indicated for suspected ACS; administer even though patient took aspirin 100mg earlier today. Confirm 6 medication rights: right patient, right drug, right dose, right route, right time, right documentation.
  • Confirm GTN is NOT contraindicated: SBP >90 mmHg ✓, HR 50–150 bpm ✓, no PDE5 inhibitor use in last 24 hours (sildenafil/vardenafil/avanafil) or 3 days (tadalafil) — confirm verbally with patient.
  • Administer GTN 400 microg (1 spray) sublingually — patient must be seated or semi-recumbent, do not shake bottle. Confirm 6 medication rights: right patient, right drug, right dose, right route, right time, right documentation.
  • Reassess pain score and BP after 5 minutes.
  • If pain >3/10 after first GTN spray and no contraindications: administer second GTN spray 400 microg sublingually at 5-minute interval.
  • If pain remains >3/10 post GTN: administer Methoxyflurane (Penthrox) 3 mL via inhaler — patient self-administers; record pain score pre and post.
  • Administer Ondansetron 4 mg sublingual tablet if patient reports nausea or vomiting — may repeat after 15 minutes if remains symptomatic (max 8mg in 8 hours). Confirm 6 medication rights: right patient, right drug, right dose, right route, right time, right documentation.
  • Record full observations every 10 minutes.
  • Request urgent ambulance via CSP response immediately — do not delay for treatment completion.
  • Continuously reassure patient and keep son (David) informed.
  • Prepare for potential deterioration — position defibrillator (AED) nearby and be prepared to commence CPR if cardiac arrest occurs.
  • Scenario ends on arrival of ambulance and IMISTAMBO handover.
  • Attention to hand hygiene will be given throughout the scenario.

Clinical references: Chest Pain / Acute Coronary Syndrome · Glyceryl Trinitrate (GTN, Nitroglycerin) · Aspirin (Disprin, Disprin Direct, Aspro Clear) · Methoxyflurane (Penthrox) · Ondansetron · Oxygen