Scenario — Hypertensive Emergency — Severe Headache and Visual Disturbance

advanced Circulation · Elderly · 75yr · female

Patient Information

Dispatch	You are called to a patient (Margaret Sutton, 75YO female) at the Perth Royal Show who is seated near the main grandstand, reporting a severe headache and saying she 'can't see properly'. A bystander states she looked unwell and sat herself down.
Patient	Margaret Sutton — 75yr (60kg)
Incident History	Pt was walking through the showgrounds when she developed a sudden, severe headache and noticed blurred vision in both eyes. She sat down on a bench and a bystander called for EHS. Pt states she ran out of her blood pressure tablets two days ago.
Emergency Contact	David Sutton (Husband) — 0412 874 331

Initial Rapid Assessment

Response	Alert
Airway	Patent. Nil obstruction. Nil stridor. Patient speaking in full sentences.
Breathing	Adequate. RR 18. Nil increased work of breathing. Nil accessory muscle use.
Circulation	Radial pulse present — strong and regular. Skin warm and dry. Nil active bleeding.
Disability	GCS 15 (E4V5M6). Alert and oriented to time, place and person. Reporting severe headache 9/10 and bilateral blurred vision. PERL 3mm bilaterally, brisk.
Exposure	Nil rashes, nil facial asymmetry on inspection. No visible injury. Patient seated on bench, no fall reported.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	97% (RA)	Nil	18	88	218/124	<2s	15	3 3 ++	36.8	6.4 mmol/L	9
10 mins	97% (RA)	Nil	17	86	216/122	<2s	15	3 3 ++	36.8	6.4 mmol/L	9

History Taking

Scenario Progression and Treatment Objectives

Diagnosis

This patient is suffering from a hypertensive emergency with associated severe headache and bilateral visual disturbance, most likely precipitated by two missed doses of her antihypertensive medication (amlodipine), representing a potentially life-threatening end-organ threatening event.

Facilitator Triggers — if trainees miss a critical step

! (If the trainee does not perform a BGL — facilitator prompts: 'The patient asks you if her sugar could be causing this — she thinks her friend had similar symptoms once.')
! (If the trainee does not specifically ask about missed medications — facilitator prompts: 'The patient's husband taps you on the shoulder and says: she ran out of her blood pressure tablets a couple of days ago, does that matter?')
! (If the trainee does not consider stroke as a differential and fails to assess for facial asymmetry, limb weakness, or speech disturbance — facilitator prompts: 'The patient suddenly says: my right hand feels a bit tingly — is that normal?')
! (If oxygen is administered unnecessarily to a normoxic patient (SpO2 97% RA) — facilitator prompts trainee: 'What is your target SpO2 for this patient and is supplemental oxygen indicated here?')
! (If the trainee attempts to administer GTN — facilitator states: 'GTN is not indicated here — what is the authorised indication for GTN in this patient? Check the CPG.')
! (If the trainee fails to keep the patient seated and calm and instead attempts to walk her to the FAP — facilitator prompts: 'The patient says she feels dizzy when she stands — what is your positioning priority here?')
! (If the trainee does not call for ambulance transport within 5 minutes — at the 7-minute mark, patient's GCS drops to 14 (E3V5M6), she becomes more confused, and reports her headache is now a 10/10 — facilitator states: 'She grabs your arm and says everything looks really dark now.')

Treatment Objectives

1. Scene safety assessment and don appropriate PPE.
2. Perform Primary Survey — confirm patent airway, adequate breathing, circulation, GCS 15.
3. Position patient seated and calm — do NOT mobilise or walk patient given hypertensive emergency and visual disturbance. Minimise exertion.
4. Perform full Vital Sign Survey — including BP (bilateral if possible), SpO2, RR, HR, BGL, temperature, GCS, PERL.
5. Document BP: 218/124 mmHg — recognise this as a hypertensive emergency with suspected end-organ involvement (neurological symptoms).
6. Perform BGL — result 6.4 mmol/L, within normal range, rules out hypoglycaemia as primary cause.
7. Assess for stroke differential — inspect for facial asymmetry, assess upper limb movement and sensation bilaterally, assess speech clarity. Document findings.
8. Administer oxygen ONLY if SpO2 falls below 94% — SpO2 97% on room air, therefore supplemental oxygen is NOT indicated at this time.
9. Do NOT administer GTN — GTN is not authorised for hypertensive emergency in EHS scope; GTN indications are chest pain/ACS, ACPO, autonomic dysreflexia and Irukandji sting only.
10. Provide continuous reassurance — keep patient calm and seated to prevent further elevation in BP.
11. Call for ambulance (Priority 1) immediately — this patient has hypertensive emergency with neurological symptoms (severe headache and visual disturbance) representing a time-critical condition beyond EHS treatment scope. Pre-notify receiving facility.
12. Perform Secondary Survey and CNS Survey as time permits whilst awaiting ambulance — assess pupils, limb sensation and strength, speech.
13. Monitor and record full observations every 5 minutes given time-critical status.
14. If GCS drops or patient loses consciousness: place patient in lateral position, insert airway adjunct as tolerated (OPA or NPA), apply oxygen via non-rebreather mask at 10–15 L/min targeting SpO2 94–98%, prepare BVM.
15. Scenario ends on arrival of ambulance and IMISTAMBO handover.
16. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Chest Pain / Acute Coronary Syndrome · Stroke (Cerebrovascular Accident) · Unconsciousness · Autonomic Dysreflexia · Transient Loss of Consciousness (Fainting / Syncope) · Primary Survey · Secondary & CNS Survey · Blood Pressure · Glasgow Coma Scale (GCS) · Blood Glucose Monitor · Pulse Oximetry · Oxygen Delivery

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Signs/Symptoms	Sudden severe headache, bilateral blurred vision, feeling of pressure in her head. No chest pain, no neck stiffness, no nausea or vomiting at this stage.
Allergies	NKDA
Medications	Amlodipine 5mg daily (antihypertensive) — last taken 2 days ago. Also takes Atorvastatin 40mg at night. No PDE5 inhibitors reported.
Pertinent History	Known hypertension — diagnosed approximately 10 years ago. No known cardiac history. No prior stroke or TIA. No known diabetes. Lives independently with husband.
Last Oral Intake	Cup of tea and toast approximately 2 hours ago.
Events Leading	Patient was walking with husband through the Perth Royal Show when she developed the headache and blurred vision. She denied any fall or head trauma. Husband states she has been well this week but did mention she had run out of her blood pressure tablets.
Treatment Prior	Nil. No medications taken today.

Onset	Approximately 30 minutes ago whilst walking through the showgrounds.
Pain	Severe headache — described as the worst she has ever had, like a pressure squeezing her whole head. 9/10.
Quality	Constant, pressure-like, global headache. No radiation.
Radiates	Nil radiation reported.
Severity	9/10