Scenario — Sudden onset palpitations and near-syncope at community fair

intermediate Cardiac · Elderly · 75yr · female

Patient Information

Dispatch	You are called to a 75YO female (Dorothy Hennessey) at the Rockingham Community Fair who is sitting near the craft stalls feeling very unwell, complaining of a racing heart and nearly fainting.
Patient	Dorothy Hennessey — 75yr (60kg)
Incident History	Pt was browsing craft stalls when she suddenly felt her heart 'go haywire', became dizzy and nearly fell. A bystander helped her to a chair and called the FAP.
Emergency Contact	Margaret Hennessey (Daughter) — 0412 774 203

Initial Rapid Assessment

Response	Alert
Airway	Patent. Nil airway obstruction. Nil stridor. Self-maintaining.
Breathing	Slightly increased rate. No accessory muscle use. No wheeze or crackles audible. Able to speak in short sentences.
Circulation	Rapid and irregular weak radial pulse. Skin pale and diaphoretic. No visible haemorrhage.
Disability	GCS 14 (E4V4M6). Orientated to person and place, mildly confused about recent events. Complains of dizziness and light-headedness.
Exposure	No visible rash, wounds or swelling. Patient is seated. No obvious injury from near-fall.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	95% (RA)	Mild	20	148	88/60	3s	14	3 3 ++	36.8	6.4 mmol/L	3
10 mins	98% (O2 simple face mask 6L/min)	Nil	17	142	100/68	2s	15	3 3 ++	36.8	6.4 mmol/L	2

History Taking

Scenario Progression and Treatment Objectives

Diagnosis

This patient is suffering from an acute episode of cardiac dysrhythmia — rapid ventricular rate with signs of haemodynamic compromise (hypotension, diaphoresis, altered GCS, reduced CRT), consistent with her known history of paroxysmal atrial fibrillation.

Facilitator Triggers — if trainees miss a critical step

! (If the trainee does not measure blood pressure within the first 3 minutes, Dorothy becomes increasingly pale and GCS drops to 13 — she says 'I feel like I'm going to pass out again')
! (If oxygen is not applied within 3 minutes of assessment, SpO2 drops to 92% on room air and respiratory distress escalates to Moderate)
! (If the trainee attempts to administer GTN without checking blood pressure first, the facilitator reminds them: 'What is Dorothy's current blood pressure?' — BP is 88 systolic, which is a contraindication to GTN)
! (If the trainee attempts to administer GTN despite confirmed BP <90 mmHg, Dorothy develops sudden severe dizziness and GCS drops to 12 — state: 'GTN is contraindicated in hypotension <90 mmHg')
! (If patient is not positioned appropriately — i.e. allowed to stand or walk — Dorothy nearly collapses and must be assisted back to seated position)
! (If the trainee does not arrange urgent transport within 5 minutes of assessment, Dorothy's BP drops further to 82 systolic and she becomes more confused — GCS 13)

Treatment Objectives

1. Ensure scene safety and don appropriate PPE
2. Perform Primary Survey — confirm patent airway, assess breathing rate and quality, palpate radial pulse and assess quality
3. Position patient seated or semi-recumbent — do NOT allow patient to stand or walk given haemodynamic compromise
4. Apply SpO2 monitoring — initial reading 95% RA
5. Administer Oxygen via simple face mask at 5–8 L/min titrated to maintain SpO2 94–98%
6. Perform Vital Signs Survey — obtain BP, pulse, RR, GCS, BGL, temp, pain score
7. Recognise hypotension (BP 88 systolic) and rapid irregular pulse (148 bpm) as signs of haemodynamically unstable tachycardia
8. Recognise GTN is CONTRAINDICATED due to BP <90 mmHg — do not administer GTN
9. Obtain a focused IMISTAMBO-structured history including known AF, warfarin use, and current medications
10. Assess and document BGL (6.4 mmol/L — normal, not a contributing factor)
11. Reassure patient continuously throughout assessment and treatment
12. Limit patient exertion — assist patient to remain seated, do not allow ambulation
13. Monitor patient persistently, recording full observations every 10 minutes
14. Recognise this presentation as time critical (unstable tachycardia with hypotension and altered GCS) — arrange Priority 1 transport with ambulance upgrade and pre-notify receiving ED
15. Contact CSPSOC for advice given haemodynamically compromised dysrhythmia and anticoagulant medication
16. Do not attempt rhythm management interventions (cardioversion, Amiodarone, Modified Valsalva) — these are outside EHS scope
17. Perform reassessment of vitals at 10 minutes — note partial improvement with oxygen and positioning (SpO2 98%, BP 100/68, GCS 15) confirming correct management
18. Prepare for deterioration and potential peri-arrest state — have AED/defibrillator and BVM readily accessible
19. Scenario ends on arrival of ambulance and IMISTAMBO handover
20. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Cardiac Dysrhythmia · Chest Pain / Acute Coronary Syndrome · Oxygen Delivery · Blood Pressure · Primary Survey · Secondary & CNS Survey · Pulse Oximetry

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Signs/Symptoms	Sudden onset rapid irregular heartbeat, dizziness, light-headedness, near-syncope, mild shortness of breath, mild chest discomfort described as a fluttering sensation.
Allergies	Penicillin — rash. No known allergy to aspirin or NSAIDs.
Medications	Warfarin (for known atrial fibrillation), Metoprolol 25mg daily, Perindopril 5mg daily.
Pertinent History	Known history of paroxysmal atrial fibrillation diagnosed 3 years ago. Last episode was 8 months ago and self-resolved. No prior cardioversion. Hypertension. No history of recent chest infection or illness.
Last Oral Intake	Had a cup of tea and a scone approximately 1 hour ago.
Events Leading	Patient was walking at a leisurely pace around the craft stalls at the Rockingham Community Fair when the palpitations started suddenly with no clear precipitant.
Treatment Prior	Nil. No self-administration of additional medications. Bystander provided a chair and kept patient calm.

Onset	Sudden onset approximately 20 minutes ago while walking between stalls.
Pain	Mild chest fluttering/discomfort rated 3/10. No crushing or squeezing pain.
Quality	Fluttering, racing sensation in chest. Not sharp or burning.
Radiates	Nil radiation.
Severity	3/10 chest discomfort. Patient describes dizziness as 8/10.