Heat Stroke with declining GCS and alcohol intoxication at festival

Patient Information

Dispatch: You are called to a patient (Melissa Hartley, 42YO female) who has been found unresponsive near the main stage at the Southbank Summer Music Festival. Bystanders report she has been dancing in the sun for several hours and became increasingly confused before collapsing.
Patient: Melissa Hartley — 42yr (65kg)
Incident History: Pt found seated on the ground, leaning against a barrier, not responding appropriately to bystanders. Bystanders state she was 'acting strangely' and stumbling before sitting down. Pt has been in direct sun for approximately 3 hours in 38°C heat. Strong odour of alcohol noted on approach.
Emergency Contact: Brooke Hartley (Sister) — 0412 774 391

Initial Rapid Assessment

Response: Voice
Airway: Patent. No visible obstruction. No stridor. Airway at risk given declining GCS — monitor closely.
Breathing: Breathing present, rate increased. Shallow. No audible wheeze or crackles.
Circulation: Pulse rapid and strong. Skin hot, dry, flushed. No active bleeding. CRT 2s.
Disability: GCS 11 (E3V3M5). Not oriented to time, place or person. Confused, intermittently agitated. Pupils equal and reactive.
Exposure: Clothing soaked in sweat. Hot, dry skin to touch on torso. No rash or visible injuries. Strong odour of alcohol. Temperature 40.8°C tympanic.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	95% (RA)	Mild	24	122	100/68	2s	11	4 4 ++	40.8	3.6 mmol/L	–
10 mins	98% (O2 NRB 15L)	Nil	18	106	108/72	<2s	13	4 4 ++	39.4	3.6 mmol/L	–

History Taking

Treatment Response

Diagnosis

This patient is suffering from Heat Stroke with significantly elevated core temperature (>40°C), declining GCS secondary to thermoregulatory failure, and concurrent alcohol intoxication which is masking and compounding the presentation.

Facilitator Triggers — if trainees miss a critical step

! (If the trainee attributes altered GCS solely to alcohol and does not initiate active cooling within 2 minutes — patient's GCS drops to 9 (E2V2M5), RR increases to 28, SpO2 falls to 91% on RA. Facilitator states: 'The patient is becoming increasingly unresponsive and her breathing is laboured.')
! (If BGL of 3.6 mmol/L is not identified and acted upon — patient becomes diaphoretic and GCS drops a further point. Facilitator states: 'The patient is now less responsive and sweating profusely.' Trainee should recognise borderline hypoglycaemia and administer Glucose Oral Gel 15g orally if GCS permits safe swallowing.)
! (If active cooling is not initiated — temperature remains 40.8°C at 10-minute reassessment. Facilitator states: 'The patient is no longer responding to voice and her skin remains extremely hot and dry.' GCS falls to 9.)
! (If patient is not positioned laterally or airway is not monitored given declining GCS — facilitator states: 'The patient vomits.' Trainee must manage airway immediately with lateral position and suction.)
! (If alcohol intoxication is used as a reason to withhold oxygen — facilitator prompts: 'Her SpO2 is 95% on room air and she is breathing 24 times per minute — what would you like to do about her oxygen?')

Treatment Objectives

1 Ensure scene safety — confirm patient is in shade or move to cool environment; festival environment, 38°C ambient temperature
2 Don appropriate PPE — gloves and eye protection given altered GCS and vomiting risk
3 Perform Primary Survey — airway patent, breathing present but increased WOB, circulation intact, GCS 11 (E3V3M5)
4 Recognise this is NOT a simple alcohol intoxication — hot dry flushed skin, tachycardia, tympanic temperature 40.8°C, and CNS dysfunction in heat = Heat Stroke until proven otherwise
5 Apply oxygen via Non-Rebreather Mask (NRB) at 10–15 L/min — titrate to maintain SpO2 94–98%
6 Perform Vital Sign Survey — GCS, temperature (tympanic), BGL, SpO2, RR, BP, HR, CRT
7 Identify BGL 3.6 mmol/L — borderline, monitor closely; if GCS permits safe swallowing consider Glucose Oral Gel 15g orally to prevent hypoglycaemia
8 Initiate active cooling immediately — STRIP clothing, SOAK with tepid water, FAN patient continuously, apply ice packs to neck, groin and armpits
9 Position patient supine if tolerating, ensure airway positioning — given GCS 11 be prepared to place in left lateral position if vomiting risk increases
10 Consider delaying transport by approximately 15 minutes to achieve adequate cooling at scene before transport — reassess temperature and GCS at 10 minutes
11 Reassess GCS and temperature at 10 minutes — target temperature reduction and GCS improvement confirm cooling is effective
12 Consider Ondansetron 4mg sublingual tablet for nausea/vomiting IF patient is GCS 15 and able to safely swallow — at GCS 11 do NOT administer sublingual tablet; defer to ambulance crew
13 Continue cooling during transport — wet cloths, fan, remove from heat source
14 Request ambulance (urgent ambulance) — time-critical patient with GCS 11, temperature 40.8°C, and declining conscious state
15 Reassess every 5 minutes given time-critical status
16 Monitor for seizure activity throughout — manage as per Seizures CPG if seizure occurs while continuing active cooling
17 Do NOT attribute altered GCS to alcohol alone — heat stroke is the working diagnosis; alcohol is a compounding factor
18 Scenario ends on arrival of ambulance and IMISTAMBO handover
19 Attention to hand hygiene will be given throughout the scenario.

Clinical references: Heat Stroke · Hypoglycaemia · Glucose Oral Gel · Oxygen · Seizures · Unconsciousness · Ondansetron

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