Congestive Cardiac Failure — elderly female at community fair

Patient Information

Dispatch: You are called to a 75-year-old female (Margaret Holloway) who is sitting outside the main tent at the Kalamunda Community Fair, complaining of difficulty breathing and feeling 'very tired'. A bystander reports she has been struggling for the last 20 minutes.
Patient: Margaret Holloway — 75yr (60kg)
Incident History: Pt reports progressive shortness of breath over the past 20 minutes. Pt states she has been sitting in the sun watching the entertainment and started to feel increasingly breathless. She denies chest pain. Bystander notes her ankles look 'very puffy'.
Emergency Contact: Susan Holloway (Daughter) — 0412 774 391

Initial Rapid Assessment

Response: Alert
Airway: Patent. Nil airway obstruction. Nil stridor. Able to speak in short sentences only.
Breathing: Laboured. Increased work of breathing. Audible crackles bilaterally at lung bases. RR 26. SpO2 88% on room air. Nil wheeze.
Circulation: Pulse rapid and regular. Skin cool and mildly diaphoretic centrally. Bilateral ankle and lower leg oedema noted. Mild peripheral cyanosis to fingertips. CRT 3s.
Disability: GCS 14 (E4V4M6). Alert but mildly confused — not fully oriented to time. No focal neurological deficit.
Exposure: Bilateral pitting ankle oedema to mid-calf. No rashes or visible injuries. Distended neck veins noted when patient is semi-recumbent. No sacral oedema assessed (patient seated).

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	88% (RA)	Moderate	26	108	160/100	3s	14	3 3 ++	37.1	6.4 mmol/L	2
10 mins	95% (O2 simple face mask 6L/min)	Mild	20	98	155/95	2s	15	3 3 ++	37.1	6.4 mmol/L	1

History Taking

Treatment Response

Diagnosis

This patient is suffering from an acute exacerbation of congestive cardiac failure (right and left heart failure), most likely precipitated by a missed diuretic dose.

Facilitator Triggers — if trainees miss a critical step

! (If oxygen is not applied within 3 minutes of arrival, patient's SpO2 drops to 85% on RA and confusion worsens — GCS drops to 13 (E3V4M6). Patient becomes more agitated and begins to resist assessment.)
! (If the trainee attempts to walk the patient to the stretcher rather than bringing the stretcher to the patient, the patient becomes significantly more breathless and SpO2 drops to 84%. Facilitator states: 'Margaret says she feels much worse and grabs your arm — she looks frightened.')
! (If GTN is considered or prepared, facilitator prompts: 'You check your medication references — is GTN indicated here?' GTN is contraindicated in CCF. Trainee should recognise this and NOT administer GTN.)
! (If history of missed frusemide is not elicited, facilitator provides cue: Margaret's daughter says quietly 'She forgot to take her water tablet this morning — is that important?')
! (If patient is positioned supine rather than sitting/semi-recumbent with legs down, patient states 'I can't breathe lying flat, please sit me up' and breathlessness visibly worsens.)
! (If the trainee does not reassess vitals at 10 minutes, facilitator states: 'It has been 10 minutes since your last set of observations — what are you going to do now?')

Treatment Objectives

1 Ensure scene safety and don appropriate PPE.
2 Perform Primary Survey — confirm patent airway, identify laboured breathing and signs of circulatory compromise.
3 Position patient sitting upright or semi-recumbent with legs hanging down — do NOT walk the patient; bring the stretcher/chair to the patient.
4 Apply Pulse Oximetry monitoring.
5 Administer Oxygen via simple face mask at 5–8 L/min targeting SpO2 94–98%. Titrate flow to maintain target saturations. Do NOT use a non-rebreather mask as first line unless SpO2 does not respond to simple face mask. Confirm 6 medication rights: right patient, right drug, right dose, right route, right time, right documentation.
6 Perform Full Vital Signs Survey: GCS, BGL, SpO2, RR, BP, pulse, CRT, temperature, pain score.
7 Perform Secondary Survey including assessment for neck vein distension, and assessment of lower limb oedema.
8 Obtain IMISTAMBO history: elicit missed frusemide dose, known CCF, current medications (Frusemide, Ramipril, Bisoprolol, Atorvastatin), nil known allergies.
9 Recognise GTN is CONTRAINDICATED in CCF — do not administer GTN.
10 Reassess and document full observations every 10 minutes.
11 Prepare for transport — request ambulance (urgent given patient is time critical with hypoxia and altered GCS on arrival).
12 Continuous reassurance to patient and family throughout.
13 Monitor patient persistently for clinical deterioration including worsening hypoxia, decreasing GCS, increasing respiratory distress, or haemodynamic instability.
14 Scenario ends on arrival of ambulance and IMISTAMBO handover.
15 Attention to hand hygiene will be given throughout the scenario.

Clinical references: Congestive Cardiac Failure · Oxygen Delivery · Primary Survey · Auscultation · Blood Glucose Monitor · Pulse Oximetry · Blood Pressure · Pulse & Respirations · Glasgow Coma Scale (GCS)

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