Scenario — Congestive Cardiac Failure — Acute Presentation

intermediate Cardiac · Adult · 35yr · male

Patient Information

Dispatch	You are called to a 35-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 — 35yr (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

Scenario Progression and Treatment Objectives

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%.
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 State Operations Centre (SOC) to advise of time-critical patient and request Priority 1 ambulance with pre-notification.
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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Signs/Symptoms	Severe shortness of breath, chest heaviness rated 3/10, unable to speak in full sentences, swollen ankles, generalised fatigue and weakness for several days.
Allergies	Nil known drug allergies.
Medications	Furosemide 40mg daily (diuretic), Carvedilol 6.25mg twice daily (beta-blocker), Ramipril 5mg daily (ACE inhibitor). States he missed his morning medications today.
Pertinent History	Known dilated cardiomyopathy diagnosed 2 years ago. Has had two previous hospital admissions for heart failure exacerbations. Non-smoker. Nil alcohol. No recent illnesses.
Last Oral Intake	Ate a large meal approximately 1 hour ago. Did not take morning medications.
Events Leading	Walking through the Royal Show with his wife and two children. Had been on his feet for approximately 3 hours in warm weather when breathlessness rapidly worsened.
Treatment Prior	Nil. Wife tried to encourage him to sit and rest.

Onset	Acute worsening over the last 30 minutes during exertion at the show. Pt reports worsening breathlessness over the past week, especially when lying flat at night.
Pain	Mild chest heaviness 3/10. No crushing or radiating chest pain.
Quality	Pressure-like chest heaviness. Breathlessness described as 'can't get enough air in'.
Radiates	Nil radiation.
Severity	Breathlessness 9/10. Chest heaviness 3/10.