((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 or dissolved in small amount of water) — indicated for suspected ACS; administer even though patient took aspirin 100mg earlier today.
• 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.
• 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 oral wafer if patient reports nausea or vomiting — may repeat after 15 minutes if remains symptomatic (max 8mg in 8 hours).
• Record full observations every 10 minutes.
• Request Priority 1 ambulance 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