Unstable bradycardia at the Anzac Day march

Patient Information

Dispatch: You are called to a 75YO male (Don Hartley) who has sat down on the curb during the Anzac Day march and is complaining of dizziness and feeling faint. Bystanders report he briefly lost consciousness.
Patient: Don Hartley — 75yr (75kg)
Incident History: Pt was marching in the Anzac Day parade when he felt dizzy and nearly fainted. Bystanders assisted him to sit on the curb. He is pale and diaphoretic. Denies chest pain currently.
Emergency Contact: Margaret Hartley (Wife) — 0412 554 871

Initial Rapid Assessment

Response: Alert
Airway: Patent. Nil airway obstruction. Nil stridor.
Breathing: Slightly laboured. RR elevated. Nil audible wheeze or crackles.
Circulation: Pulse weak, slow and irregular. Skin pale, cool and diaphoretic. Nil active bleeding.
Disability: GCS 14 (E4V4M6). Orientated to person and place; mildly confused about events. Mild diaphoresis.
Exposure: Nil rashes, wounds or obvious injuries. Wearing full Anzac Day dress uniform.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	93% (RA)	Mild	20	38	82/58	3s	14	3 3 ++	36.6	5.8 mmol/L	2
10 mins	97% (O2 NRB 10L/min)	Nil	16	42	90/62	2s	15	3 3 ++	36.6	5.8 mmol/L	1

History Taking

Treatment Response

Diagnosis

This patient is suffering from unstable bradycardia with adverse signs including symptomatic hypotension (SBP 82 mmHg), near-syncope with transient loss of consciousness, diaphoresis, and altered conscious state — likely exacerbated by his beta-blocker (Metoprolol) use and prolonged exertion in the heat.

Facilitator Triggers — if trainees miss a critical step

! (If the trainee does not position the patient supine within the first 2 minutes, the patient's GCS drops to 12 and he becomes less responsive — facilitator states: 'Don's eyes are closing and he's becoming harder to rouse')
! (If oxygen is not applied within 3 minutes, SpO2 drops to 89% on room air and respiratory distress increases to Moderate)
! (If the trainee does not take a medication history and misses the Metoprolol, facilitator prompts: 'Don's wife arrives and mentions he takes a tablet for his heart rate every morning — she has the Webster-pak in her bag')
! (If the trainee attempts to sit the patient upright or allow him to stand, the patient becomes dizzy and near-syncopal again — facilitator states: 'Don grabs your arm and says everything has gone grey')
! (If the trainee does not identify this as time critical and does not request ambulance within 5 minutes, the patient's pulse drops to 32 and his GCS drops to 13)

Treatment Objectives

1 Ensure scene safety and don appropriate PPE.
2 Perform Primary Survey — confirm patent airway, assess breathing and circulation, identify slow/weak pulse as immediate priority.
3 Position patient supine immediately to address symptomatic hypotension and near-syncope — do NOT allow patient to remain sitting upright or attempt to stand.
4 Apply oxygen via Non-Rebreather Mask (NRB) at 10–15 L/min targeting SpO2 94–98%.
5 Perform Vital Sign Survey — record BP (noting SBP <90 mmHg), pulse rate (noting bradycardia <60 bpm), SpO2, RR, GCS, BGL, temperature.
6 Perform Blood Glucose Level (BGL) test — result 5.8 mmol/L, no hypoglycaemia treatment required.
7 Obtain IMISTAMBO history — specifically identify Metoprolol use (beta-blocker) as a contributing factor to bradycardia, prior 'funny heart episode', and penicillin allergy.
8 Recognise adverse signs of unstable bradycardia: SBP 82 mmHg (hypotension), near-syncope, diaphoresis, and altered conscious state — this patient is TIME CRITICAL.
9 Request ambulance (urgent ambulance) immediately via CSP — unstable bradycardia with adverse signs is beyond EHS Primary Care treatment scope; notify of pre-alert.
10 Perform reassurance continuously — maintain calm communication with the patient and explain all actions.
11 Limit patient exertion entirely — do not allow patient to walk, change position independently, or exert himself.
12 Perform Secondary Survey as time permits — assess for distracting injuries or other contributing causes.
13 Perform ongoing vital signs monitoring every 5 minutes given time-critical status, noting any improvement or deterioration in GCS, BP, and pulse rate.
14 Maintain supine position with legs slightly elevated if tolerated and if no contraindications (no TBI, no respiratory compromise at rest) to support venous return.
15 Prepare for possible deterioration to cardiac arrest — ensure AED is immediately accessible and CPR equipment is ready.
16 Perform IMISTAMBO handover to ambulance crew, including: medication history (Metoprolol), prior cardiac history, adverse signs on arrival (SBP 82, HR 38, near-syncope), interventions performed, and trending vitals.
17 Scenario ends on arrival of ambulance and IMISTAMBO handover.
18 Attention to hand hygiene will be given throughout the scenario.

Clinical references: Cardiac Dysrhythmia · Transient Loss of Consciousness (Fainting / Syncope) · Chest Pain / Acute Coronary Syndrome · Primary Survey · Oxygen Delivery · Blood Glucose Monitor · Blood Pressure · Pulse & Respirations

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