Congestive Cardiac Failure — Acute Presentation

Patient Information

Dispatch: You are called to a 48-year-old male (Marcus Donnelly) at the Perth Royal Show who is sitting on a bench outside the main pavilion, extremely short of breath and refusing to walk to the FAP.
Patient: Marcus Donnelly — 48yr (80kg)
Incident History: Pt was walking through the show with his family when he became severely short of breath. Bystanders noticed him sitting down, sweating heavily and struggling to breathe. Pt states this has been getting worse for the last 30 minutes.
Emergency Contact: Sarah Donnelly (Wife) — 0412 774 391

Initial Rapid Assessment

Response: Alert
Airway: Patent. Nil foreign body or obstruction. No stridor. Mild frothy secretions visible at lips.
Breathing: Markedly laboured. Accessory muscle use noted. Audible crackles bilaterally. RR 28. Unable to complete full sentences.
Circulation: Rapid and weak radial pulse. Skin pale, cool and diaphoretic. Bilateral ankle oedema noted. Distended jugular veins visible.
Disability: GCS 14 (E4V4M6). Alert but anxious and restless. Orientated to person and place, mildly confused about events.
Exposure: Bilateral pitting ankle oedema to mid-shin. No visible wounds or rashes. Sacral area not assessed in field. Lips mildly cyanotic.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	88% (RA)	Severe	28	118	88/60	3s	14	4 4 ++	36.8	6.4 mmol/L	3
10 mins	94% (O2 NRB 15L)	Moderate	22	108	90/64	2s	14	4 4 ++	36.8	6.4 mmol/L	2

History Taking

Treatment Response

Diagnosis

This patient is suffering from an acute exacerbation of congestive cardiac failure (right and left heart failure) with hypoxia, hypotension, and moderate-to-severe respiratory distress, likely precipitated by missed medications, physical exertion, and dietary indiscretion.

Facilitator Triggers — if trainees miss a critical step

! (If oxygen is not applied within 2 minutes of arrival, patient becomes increasingly agitated and restless, GCS drops to 13, and SpO2 falls to 84% — facilitator states: 'The patient is pushing your hands away and saying he doesn't need oxygen.')
! (If the trainee attempts to walk the patient or stand him up to move to the FAP, facilitator states: 'As you assist the patient to his feet, he becomes pale, his legs buckle and he nearly collapses — his wife screams.')
! (If trainee administers GTN, facilitator states: 'The patient's blood pressure drops suddenly to 72/40 — he becomes pale and diaphoretic, eyes rolling back.' — Prompt: GTN is contraindicated in CCF and must not be given.)
! (If trainee does not identify jugular venous distension and ankle oedema during exposure, facilitator prompts: 'The patient's wife says — he's had really swollen legs all week and he can't sleep lying flat anymore.')
! (If BGL is not checked, facilitator prompts after 5 minutes: 'The patient is confused — are there any other causes you should be ruling out?')

Treatment Objectives

1 Ensure scene safety and don appropriate PPE.
2 Perform Primary Survey — identify severe respiratory distress, hypoxia, and hypotension as immediate life threats.
3 DO NOT walk the patient — bring equipment to the patient and coordinate transport to FAP on stretcher.
4 Position patient sitting upright or semi-recumbent with legs in a dependent position (hanging down) — do NOT lay flat as this will worsen respiratory distress.
5 Administer Oxygen via Non-Rebreather Mask at 10–15 L/min — titrate to achieve SpO2 94–98%. Confirm 6 medication rights: right patient, right drug, right dose, right route, right time, right documentation.
6 Continuously reassure patient — explain all actions calmly; patient may be hypoxic and anxious.
7 Perform full Vital Signs Survey — GCS, SpO2, RR, BP, HR, CRT, BGL, temperature.
8 Take BGL — result 6.4 mmol/L, no treatment required.
9 Take IMISTAMBO history — identify known cardiomyopathy, current cardiac medications (furosemide, carvedilol, ramipril), and missed morning doses.
10 Perform secondary survey — identify bilateral ankle oedema, jugular venous distension, and mildly cyanotic lips consistent with CCF exacerbation.
11 DO NOT administer GTN — GTN is contraindicated in congestive cardiac failure as it reduces preload and may worsen cardiac output and precipitate severe hypotension.
12 Monitor patient persistently — record full observations every 10 minutes.
13 Contact CSP to advise of time-critical patient and request urgent ambulance via CSP with IMISTAMBO handover.
14 Ensure resuscitation equipment (AED, BVM, suction) is immediately available at the patient's side — patient is at risk of deterioration and cardiac arrest.
15 Reassess SpO2 and respiratory effort every 5 minutes — if SpO2 cannot be maintained above 90% on NRB, ensure assisted ventilation via BVM is ready.
16 Scenario ends on arrival of ambulance and IMISTAMBO handover.
17 Attention to hand hygiene will be given throughout the scenario.

Clinical references: Congestive Cardiac Failure · Oxygen Delivery · Primary Survey · Blood Glucose Monitor · Pulse Oximetry · Blood Pressure · Cardiac Dysrhythmia

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