Heat Stroke with declining GCS and alcohol intoxication in elderly female

Patient Information

Dispatch: You are called to an elderly female (Margaret Hollis, DOB 14/03/1950) found slumped in her chair at the Ascot Racecourse Summer Racing Carnival. Bystanders report she has been in the sun all afternoon and 'isn't making sense.'
Patient: Margaret Hollis — 75yr (60kg)
Incident History: Pt found slumped in chair in outdoor grandstand. Bystanders report she has been drinking champagne since midday, sitting in direct sun for 3+ hours. She was talking normally an hour ago but is now confused, not responding to questions properly, and her skin is hot and dry to touch.
Emergency Contact: Sandra Hollis (Daughter) — 0412 774 309

Initial Rapid Assessment

Response: Voice
Airway: Patent. No obstruction. No vomiting at this time. Airway at risk if GCS continues to decline.
Breathing: Breathing present, rapid and shallow. Increased respiratory rate noted. No wheeze or crackles.
Circulation: Rapid and weak radial pulse. Skin hot, dry and flushed. No external bleeding.
Disability: GCS 12 (E3V4M5). Confused — not orientated to time or place. Slurred speech. Pupils equal and reactive to light.
Exposure: Clothing intact. Skin hot, dry, flushed across face, neck and arms. No rash. No evidence of trauma.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	95% (RA)	Mild	22	118	98/60	3s	12	4 4 ++	40.8	4.2 mmol/L	2
10 mins	97% (O2 NRB 15L)	Nil	18	104	106/68	2s	14	4 4 ++	39.4	4.2 mmol/L	1

History Taking

Treatment Response

Diagnosis

This patient is suffering from Heat Stroke with declining GCS secondary to a core temperature exceeding 40°C, compounded by alcohol intoxication and elderly physiology, presenting with hyperthermia, CNS dysfunction, tachycardia, and hypotension at a racecourse event.

Facilitator Triggers — if trainees miss a critical step

! (If the trainee does not move the patient to a cool environment or shade immediately — bystanders ask 'Should we move her?' and the patient's GCS drops to 11, E3V3M5, with more pronounced slurring. Facilitator cues: 'The sun is still directly on the patient.')
! (If the trainee does not initiate active cooling within 3 minutes — patient begins to shiver briefly then stops, temperature reading re-checked shows 41.1°C, and patient becomes more difficult to rouse to Voice only.)
! (If the trainee attempts to give oral fluids without confirming GCS 15 — patient coughs and partially aspirates. Facilitator cues: 'She tries to drink but the fluid spills and she coughs.' The trainee must immediately reassess airway and consider lateral position.)
! (If the trainee attributes ALL signs purely to alcohol intoxication and does not take temperature — facilitator prompts: 'A bystander mentions she hasn't been to the bathroom all afternoon and her skin is bone dry.' Temperature must be taken to identify hyperthermia as the primary driver.)
! (If oxygen is not applied within 3 minutes of assessment — SpO2 drops to 92% RA. Facilitator cues: 'She looks a bit blue around the lips.')
! (If the trainee does not monitor BGL — facilitator prompts: 'She's diabetic, isn't she? Did you check her sugar?' BGL is 4.2 — within normal range but must be checked and documented given altered GCS.)
! (If the trainee does not consider lateral position or airway safety as GCS declines below 14 — patient vomits a small amount. Facilitator cues: 'She gags and you notice vomit at the corner of her mouth.' Trainee must manage airway immediately.)
! (If the trainee does not monitor for seizure — facilitator prompts at 8-minute mark: 'Her left arm starts twitching briefly.' Trainee must manage as per Seizures CPG while continuing active cooling.)

Treatment Objectives

1 Ensure scene safety — confirm patient is not at risk of further sun exposure; direct bystanders to assist in creating shade or assist moving patient to cool area
2 Perform Primary Survey — assess ABCDE; note GCS 12, airway at risk, hot dry skin, tachycardia, tachypnoea
3 Move patient to cool environment or shade immediately — this is the single most important initial intervention
4 Apply oxygen via Non-Rebreather Mask at 10–15 L/min — titrate to target SpO2 94–98%
5 Do NOT give oral fluids — GCS is 12 (not 15); oral fluids are only safe with GCS 15 and fully conscious patient
6 Initiate active cooling immediately — STRIP outer clothing (hat, jacket, cardigan), SOAK skin with tepid water, FAN patient continuously, apply ice packs to neck, groin and axillae
7 Obtain tympanic temperature — document 40.8°C; this confirms Heat Stroke (not simple heat exhaustion)
8 Perform Vital Sign Survey — GCS, BGL, SpO2, BP, HR, RR, temperature; document all
9 Check BGL — document 4.2 mmol/L; not hypoglycaemic but must be checked in all altered GCS patients
10 Recognise complicating factor: alcohol intoxication — do NOT attribute confusion solely to alcohol; temperature and clinical picture confirm Heat Stroke as primary diagnosis
11 Position patient supine with airway monitoring — given declining GCS, be prepared to place in lateral position if GCS continues to fall or vomiting occurs
12 Consider ondansetron — if active vomiting occurs AND GCS allows safe sublingual administration (GCS 15), administer Ondansetron 4mg sublingual tablet. If GCS does not permit sublingual administration, position laterally and escalate to CSP.
13 Consider delaying transport to achieve adequate cooling — approximately 15 minutes of active cooling prior to transport is recommended; reassess GCS and temperature at 10-minute mark
14 Continue active cooling during transport — do not cease cooling interventions once in ambulance
15 Monitor closely for seizure activity — if seizure occurs manage as per Seizures CPG while maintaining active cooling
16 Monitor persistently — repeat full observations every 5 minutes given time-critical presentation (GCS < 14, temp > 40°C, haemodynamic compromise)
17 Recognise time-critical status — declining GCS, temperature > 40°C, tachycardia, hypotension in elderly patient constitutes a time-critical presentation requiring urgent ambulance support via CSP — IMISTAMBO handover to CSP
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 · Unconsciousness · Seizures · Hypoglycaemia · Oxygen Delivery · Tympanic Thermometer · Blood Glucose Monitor · Lateral Position · Primary Survey

How did you go?