Acute asthma exacerbation at a fun run

Patient Information

Dispatch: You are called to a 28-year-old female who has come to the FAP during the City to Surf Fun Run. She is sitting upright and appears short of breath. (Sarah Nolan)
Patient: Sarah Nolan — 28yr (65kg)
Incident History: Pt was approximately 8km into the fun run when she developed increasing shortness of breath, chest tightness and audible wheeze. She walked herself to the FAP.
Emergency Contact: Marcus Nolan (Husband) — 0412 773 405

Initial Rapid Assessment

Response: Alert
Airway: Patent. Nil obstruction. Nil stridor.
Breathing: Increased work of breathing. Audible expiratory wheeze. Unable to speak in full sentences. RR 26. SpO2 91% on room air.
Circulation: Radial pulse present, regular, slightly elevated. Skin warm and diaphoretic. Nil active bleeding.
Disability: GCS 15 (E4V5M6). Alert and oriented to time, place and person. Appears anxious.
Exposure: No rashes, urticaria or angioedema visible. No signs of trauma.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	91% (RA)	Severe	26	112	128/82	<2s	15	4 4 ++	37.1	–	4
10 mins	96% (O2 simple mask 6L/min)	Mild	18	98	122/78	<2s	15	4 4 ++	37.1	–	2

History Taking

Treatment Response

Diagnosis

This patient is suffering from a severe acute asthma exacerbation triggered by exercise.

Facilitator Triggers — if trainees miss a critical step

! (If trainees do not sit the patient upright or allow her to adopt a position of comfort within the first 2 minutes, increase the patient's distress — she becomes more anxious and SpO2 drops to 89%.)
! (If oxygen is not applied within 3 minutes of assessment, RR increases to 30 and SpO2 drops to 88% on room air.)
! (If trainees attempt to use the patient's own Ventolin MDI without a spacer, remind them that MDI must be administered via spacer as per CPG — prompt: 'Do you have a spacer available?')
! (If salbutamol via spacer is not administered within 5 minutes of recognising severe wheeze, the patient becomes unable to speak in more than 2-word sentences and SpO2 drops to 87%.)
! (If trainees consider anaphylaxis — correct them only if they do NOT also check for urticaria, angioedema or other anaphylaxis features; if they check and rule it out, this is appropriate clinical reasoning.)
! (If trainees ask about prior asthma severity or risk factors, reward this as good history-taking — no change to scenario.)

Treatment Objectives

1 Ensure scene safety and don appropriate PPE.
2 Perform Primary Survey — identify severe respiratory distress with audible wheeze and SpO2 91% on room air.
3 Position patient sitting upright or in a position of comfort — do not lay patient flat.
4 Apply oxygen via simple face mask at 5–8 L/min titrated to target SpO2 92–95%.
5 Perform Vital Sign Survey including RR, SpO2, HR, BP, GCS and pain score.
6 Take IMISTAMBO history — confirm known asthma, current medications, allergies, prior severity, and events leading to presentation.
7 Determine asthma severity — classify as SEVERE based on: unable to complete sentences, accessory muscle use, SpO2 90–94%, RR >25.
8 Assess for anaphylaxis — confirm no urticaria, angioedema, stridor or other allergic features before proceeding with asthma management.
9 Prepare Salbutamol (Ventolin) MDI with spacer (Space Chamber or Lite Aire spacer).
10 Administer Salbutamol 400–1200 microg (4–12 puffs) via MDI and spacer — for severe exacerbation administer up to 12 puffs (1200 microg) via spacer. Confirm 6 medication rights: right patient, right drug, right dose, right route, right time, right documentation.
11 Reassess SpO2, RR and work of breathing 5 minutes post salbutamol administration.
12 Repeat Salbutamol 400–1200 microg (4–12 puffs) via MDI and spacer every 20 minutes as clinically indicated if bronchospasm persists.
13 Record full observations every 10 minutes (or 5 minutes if time critical).
14 Be alert for rapid deterioration — reassess severity classification after each intervention.
15 Arrange transport to hospital — call for ambulance if patient does not respond to initial treatment or is time critical.
16 Scenario ends on arrival of ambulance and IMISTAMBO handover.
17 Attention to hand hygiene will be given throughout the scenario.

Clinical references: Asthma exacerbation · Salbutamol Sulphate · Oxygen · MDI & Space Chamber

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