Environmental

Heat Stroke with declining GCS and alcohol intoxication — elderly male

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Elderly · 75yr · male

Patient Information

Dispatch	You are called to a patient (Reg Calloway, 75YO male) who has been found slumped on a bench near the main stage at the Fremantle Summer Festival. Bystanders report he looks unwell and is difficult to rouse.
Patient	Reg Calloway — 75yr (75kg)
Incident History	Pt found slumped on a bench in direct sun. Skin is hot and dry to touch. Bystanders state he had been sitting in the sun for several hours and has been drinking beer throughout the afternoon. He briefly responded to his name but is now increasingly confused and difficult to keep awake.
Emergency Contact	Margaret Calloway (Wife) — 0412 773 094

Initial Rapid Assessment

Response	Voice
Airway	Patent. No visible obstruction. No stridor. Able to maintain own airway currently but at risk given declining GCS.
Breathing	Rapid and shallow. Increased work of breathing noted. No audible wheeze or crackles. Skin flushed and dry.
Circulation	Rapid, weak radial pulse. Skin hot and dry. Flushed. No active bleeding. Peripheries warm.
Disability	GCS 11 (E3V3M5). Confused and disoriented. Not orientated to time, place or person. Slurred speech. Pupils equal and reactive to light.
Exposure	Wearing shorts and polo shirt. Skin hot and dry throughout. No rashes or urticaria. No visible trauma. Strong smell of alcohol noted.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	93% (RA)	Mild	24	118	100/64	2s	11	4 4 ++	40.4	4.8 mmol/L	–
10 mins	97% (O2 NRB 15L)	Nil	18	102	108/70	2s	14	4 4 ++	39.1	4.8 mmol/L	–

History Taking

Treatment Response

Diagnosis

This patient is suffering from Heat Stroke, complicated by significant alcohol consumption and a declining GCS secondary to core temperature above 40°C in an elderly male.

Facilitator Triggers — if trainees miss a critical step

! (If trainees do not move the patient out of the sun and into shade or a cool environment within the first 2 minutes — patient's GCS drops to 9 (E2V2M5) and RR increases to 28. Facilitator states: 'Reg becomes increasingly difficult to rouse and his breathing becomes more laboured.')
! (If trainees do not commence active cooling — STRIP, SOAK, FAN — within 4 minutes, temperature remains at 40.4°C at 10-minute vitals and GCS does not improve. BP drops to 90/58. Facilitator states: 'Reg is not improving. His skin remains hot and dry. His wife is becoming distressed.')
! (If trainees attribute the altered GCS solely to alcohol intoxication and do not measure temperature — facilitator prompts: 'The patient's wife says he has drunk before and never been like this. Could something else be going on?')
! (If trainees attempt to give oral fluids to a patient with GCS below 14 — facilitator states: 'Reg is unable to safely swallow. He coughs and some fluid dribbles out.' Prompt trainees to reassess airway and reconsider route of fluid administration given oral route is unsafe.)
! (If patient is not placed in lateral position as GCS declines below 12 — facilitator states: 'Reg vomits a small amount. His airway is at risk.' Trainees must suction and/or reposition.)
! (If ondansetron is considered — trainees should note no oral wafer route is safe at GCS 11. IM ondansetron 4mg is the appropriate route if vomiting occurs and is within EHS scope. Facilitator prompts if trainee attempts oral wafer: 'Is the oral route safe for this patient?')

Treatment Objectives

1. Ensure scene safety — confirm ambient temperature, assess for ongoing sun/heat exposure hazard
2. Don appropriate PPE including gloves
3. Perform Primary Survey — open, clear and maintain airway; assess breathing, circulation, disability and exposure
4. Move patient immediately out of direct sun into a cool environment or shade — this is a priority intervention
5. Position patient supine
6. Apply SpO2 monitoring and tympanic thermometer — record temperature (expected ≥ 40°C)
7. Perform BGL — rule out hypoglycaemia as a contributing cause of altered GCS (expected BGL 4.8 mmol/L — no glucose gel required)
8. Administer Oxygen via Non-Rebreather Mask at 15L/min — titrate to target SpO2 94–98%
9. Commence active cooling immediately — STRIP clothing, SOAK with tepid water, FAN patient, apply ice packs to neck, groin and armpits
10. Reassess GCS every 5 minutes — as GCS is 11, patient is at risk of airway compromise; prepare suction and OPA
11. Do NOT give oral fluids — GCS 11 renders oral intake unsafe; aspiration risk is high
12. Consider lateral position if GCS drops below 12 or if vomiting occurs — use left lateral if no spinal concerns
13. Reassess temperature at 10 minutes — target progressive reduction; if no improvement escalate cooling
14. If vomiting occurs — suction airway, maintain lateral position, consider Ondansetron 4mg IM injection (not oral wafer — unsafe at this GCS)
15. Note and document alcohol intoxication as a confounding factor — do NOT attribute altered GCS to alcohol alone; temperature and clinical picture must guide assessment
16. Consider delaying transport by up to 15 minutes to ensure active cooling is initiated and effective; continue cooling during transport
17. Monitor for seizure activity — if seizure occurs, manage as per Seizures CPG while active cooling continues
18. Record full vital signs every 5 minutes given time-critical presentation
19. Ensure ambulance is called early given declining GCS and need for higher-scope management (IV fluids, cardiac monitoring)
20. Scenario ends on arrival of ambulance and IMISTAMBO handover
21. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Heat Stroke · Unconsciousness · Seizures · Hypoglycaemia · Oxygen Delivery · Suction · Lateral Position · Tympanic Thermometer · Blood Glucose Monitor · Primary Survey

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Signs/Symptoms	Confusion, hot and dry skin, slurred speech, rapid breathing, rapid weak pulse. Smell of alcohol.
Allergies	Wife states Nil known drug allergies.
Medications	Wife states patient takes Ramipril 5mg daily (for hypertension) and Atorvastatin 40mg nightly. No insulin or diabetes medications.
Pertinent History	Known hypertension. No known cardiac conditions. No known diabetes. Wife states he 'never drinks this much normally' but it was a celebration. No prior history of heat illness.
Last Oral Intake	Wife states he had several beers throughout the afternoon — approximately 4–5 standard drinks over 3 hours. Minimal food since midday. Limited water intake.
Events Leading	Patient was attending the Fremantle Summer Festival with his wife. She left briefly to get food. On return approximately 40 minutes later, she found him slumped and barely responsive on a bench in direct sun. Ambient temperature approximately 38°C.
Treatment Prior	Bystanders moved him into partial shade approximately 10 minutes prior to EHS arrival. No other treatment.

Onset	Bystanders report he had been sitting in direct sun for approximately 2–3 hours during the afternoon. Wife (via phone) states he has been unwell and increasingly confused over the last 30–40 minutes.
Pain	Unable to clearly assess due to altered consciousness. Pt moans when moved.
Quality	Not clearly obtainable. Pt mumbles incoherently when questioned.
Radiates	Nil
Severity	Unable to reliably assess — GCS 11 on arrival.