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Scenario — 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.
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 on auscultation. 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
Signs/Symptoms
Progressive shortness of breath, fatigue, mild confusion, bilateral ankle swelling, feeling of heaviness in her legs.
Onset
Gradual onset over the past 20–30 minutes at the fair. Daughter states breathing has been 'not quite right' for the past two days at home.
Pain
Denies chest pain. Reports mild discomfort from ankle swelling — 2/10.
Quality
Breathlessness described as 'can't catch my breath' and 'tight in my chest when I breathe in'.
Radiates
Nil radiation.
Severity
Breathlessness 7/10 at presentation.
Allergies
Nil known drug allergies.
Medications
Frusemide 40mg daily, Ramipril 5mg daily, Bisoprolol 5mg daily, Atorvastatin 40mg at night. States she 'forgot' her frusemide this morning.
Pertinent History
Known congestive cardiac failure diagnosed 3 years ago. Previous admission to Midland Public Hospital for CCF exacerbation 8 months ago. Hypertension. No known COPD or asthma.
Last Oral Intake
Light sandwich and a cup of tea approximately 2 hours ago.
Treatment
Nil self-treatment. No GTN or other medications taken today aside from regular medications (missing frusemide dose today).
Events Leading
Patient attended the Kalamunda Community Fair with her daughter to watch the entertainment. Had been seated for approximately 1 hour when breathing difficulty began. Daughter became concerned when patient became unable to speak in full sentences and appeared confused.
Scenario Progression and Treatment Objectives

((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?'))

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.

  • Ensure scene safety and don appropriate PPE.
  • Perform Primary Survey — confirm patent airway, identify laboured breathing and signs of circulatory compromise.
  • Position patient sitting upright or semi-recumbent with legs hanging down — do NOT walk the patient; bring the stretcher/chair to the patient.
  • Apply Pulse Oximetry monitoring.
  • 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.
  • Perform Full Vital Signs Survey: GCS, BGL, SpO2, RR, BP, pulse, CRT, temperature, pain score.
  • Perform Secondary Survey including auscultation of lung bases for crackles, assessment of neck vein distension, and assessment of lower limb oedema.
  • Obtain IMISTAMBO history: elicit missed frusemide dose, known CCF, current medications (Frusemide, Ramipril, Bisoprolol, Atorvastatin), nil known allergies.
  • Recognise GTN is CONTRAINDICATED in CCF — do not administer GTN.
  • Reassess and document full observations every 10 minutes.
  • Prepare for transport — request ambulance (Priority 1 given patient is time critical with hypoxia and altered GCS on arrival).
  • Continuous reassurance to patient and family throughout.
  • Monitor patient persistently for clinical deterioration including worsening hypoxia, decreasing GCS, increasing respiratory distress, or haemodynamic instability.
  • Scenario ends on arrival of ambulance and IMISTAMBO handover.
  • 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)