Heat Stroke with declining GCS and alcohol intoxication

Patient Information

Dispatch: You are called to a patient (Marcus Doyle, 38YO male) who has collapsed near the main stage at the Summernova Music Festival, Joondalup. Bystanders report he was dancing in full sun for several hours and is now confused and not making sense.
Patient: Marcus Doyle — 38yr (80kg)
Incident History: Pt was dancing in direct sun for approximately 3 hours in 38°C heat. Friends state he consumed 'at least 8 beers' across the afternoon. Pt initially became unsteady on his feet, then sat down and became increasingly confused before collapsing. He has not had any water in the last 2 hours.
Emergency Contact: Tara Doyle (Wife) — 0412 774 391

Initial Rapid Assessment

Response: Voice
Airway: Airway patent at present. No stridor. No vomit visible. Airway at risk — GCS declining and alcohol on breath.
Breathing: Rapid, shallow breathing. Increased work of breathing noted. RR elevated.
Circulation: Rapid, bounding pulse. Skin hot, dry and flushed. No external haemorrhage.
Disability: GCS 11 (E3V3M5). Not oriented to time, place or person. Pupils equal and reactive to light. Slurred speech. Combative when touched.
Exposure: Skin hot, dry and flushed across entire body. No rash, no trauma noted. Clothing fully intact and on. Temperature 40.8°C (tympanic).

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	94% (RA)	Moderate	26	128	100/60	3s	11	4 4 ++	40.8	3.6 mmol/L	–
10 mins	97% (O2 NRB 15L/min)	Mild	20	112	108/66	2s	13	4 4 ++	39.4	3.6 mmol/L	–

History Taking

Treatment Response

Diagnosis

This patient is suffering from Heat Stroke with a declining GCS secondary to excessive core temperature elevation (40.8°C), complicated by significant alcohol intoxication which masks the clinical picture and increases aspiration risk.

Facilitator Triggers — if trainees miss a critical step

! (If trainees attribute altered GCS solely to alcohol intoxication and do not take temperature — patient's GCS drops to 9 (E2V2M5) at the 5-minute mark, representing ongoing thermoregulatory failure. Facilitator states: 'The patient stops responding to voice and begins to make grunting sounds.')
! (If STRIP and SOAK cooling is not commenced within 3 minutes of scene arrival — temperature rises to 41.2°C at 5-minute mark. Facilitator states: 'The patient begins to have tonic-clonic limb movements consistent with a seizure.' Manage as per Seizures CPG while continuing active cooling.)
! (If BGL is not checked and hypoglycaemia is not identified — BGL is 3.6 mmol/L. While not yet below 4 mmol/L, trainees should note the borderline BGL in the context of alcohol consumption and prolonged exertion. If BGL is not monitored and patient deteriorates further, facilitator states: 'BGL now reads 3.2 mmol/L.' Prompt trainees to consider oral glucose gel if GCS allows safe administration.)
! (If patient is not placed supine and airway is not monitored — at 7 minutes facilitator states: 'The patient begins to retch. There is a risk of aspiration.' Trainees should be directed to lateral position to protect airway.)
! (If oxygen is not applied — SpO2 drops to 91% RA at 5 minutes. Facilitator states: 'The patient's lips appear slightly dusky. SpO2 is now 91%.')

Treatment Objectives

1 Scene safety — confirm ambient environment is safe; move patient to shade or cool area immediately
2 Don appropriate PPE including gloves
3 Perform Primary Survey — establish AVPU/GCS, airway patency, breathing, circulation, exposure
4 Position patient supine on a flat surface
5 STRIP — remove all clothing to maximise heat loss (preserve dignity where possible)
6 SOAK — apply tepid water liberally across entire body surface using available water/spray
7 FAN — fan patient continuously to promote evaporative heat loss
8 Apply ice packs to neck, axillae and groin if available at FAP
9 Administer Oxygen via non-rebreather mask at 10–15 L/min, titrate to SpO2 94–98%. Confirm 6 medication rights: right patient, right drug, right dose, right route, right time, right documentation.
10 Obtain tympanic temperature — document 40.8°C; repeat every 5 minutes to monitor cooling effectiveness
11 Perform BGL — document 3.6 mmol/L; monitor closely given alcohol intake and borderline BGL
12 Perform full Vital Sign Survey including GCS, SpO2, RR, pulse, BP, temp, BGL
13 Recognise alcohol intoxication as a complicating factor — do NOT attribute all altered GCS to alcohol; temperature confirms heat stroke diagnosis
14 Monitor airway continuously — patient is at high aspiration risk due to reduced GCS and alcohol intoxication; be prepared to place in lateral position if GCS drops further or vomiting occurs
15 Consider Ondansetron 4 mg sublingual tablet if patient has sufficient GCS (15/15) to safely ingest; if GCS does not support safe oral administration, withhold oral medications and monitor
16 Do NOT administer oral glucose gel at BGL 3.6 mmol/L as BGL is above 4 mmol/L threshold — continue to monitor BGL closely
17 Consider delaying transport by up to 15 minutes to allow active cooling to take effect — reassess GCS and temperature trend before and during transport decision
18 Continue active cooling during transport to hospital
19 Record full observations every 5 minutes given time-critical presentation
20 Request urgent ambulance via CSP with IMISTAMBO handover to CSP
21 Scenario ends on arrival of ambulance and IMISTAMBO handover
22 Attention to hand hygiene will be given throughout the scenario.

Clinical references: Heat Stroke · Seizures · Oxygen · Hypoglycaemia · Ondansetron · Glucose Oral Gel · Unconsciousness · Disturbed & Abnormal Behaviour

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