Scenario — Hypertensive emergency with headache and visual disturbance at AFL match

advanced Cardiac · Elderly · 75yr · male

Patient Information

Dispatch	You are called to a 75YO male patron (Graeme Hutchinson) in the grandstand seating area at Perth's Optus Stadium who is complaining of a severe headache and is reporting he cannot see properly. Security has seated him and his wife is with him.
Patient	Graeme Hutchinson — 75yr (75kg)
Incident History	Pt was watching the AFL match and told his wife he developed a sudden severe headache approximately 20 minutes ago. Wife reports he has been 'acting a bit strange' and his vision has been blurred since the headache started. Pt is known to have hypertension and takes daily blood pressure medication — wife confirms he ran out of tablets two days ago.
Emergency Contact	Maureen Hutchinson (Wife) — 0412 553 887

Initial Rapid Assessment

Response	Alert
Airway	Patent. No obstruction. No stridor. Able to speak in full sentences.
Breathing	Adequate. RR 18. No increased work of breathing. No accessory muscle use. Chest rise equal bilaterally.
Circulation	Strong, bounding radial pulse. Skin warm and flushed to touch. No diaphoresis. No external bleeding.
Disability	GCS 14 (E3V5M6). Oriented to person and place, mildly confused to time. Complaining of severe throbbing headache. Reports blurred vision bilaterally. No facial droop. No obvious limb weakness on inspection.
Exposure	No rashes, no injuries. Well dressed. No medic alert bracelet noted. No obvious signs of trauma.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	97% (RA)	Nil	18	88	218/124	<2s	14	4 4 SL	37.2	6.4 mmol/L	8
10 mins	96% (RA)	Nil	20	92	224/130	<2s	13	4 4 SL	37.2	6.4 mmol/L	9

History Taking

Scenario Progression and Treatment Objectives

Diagnosis

This patient is suffering from a hypertensive emergency (severely elevated BP ≥180/120 mmHg with evidence of end-organ involvement — neurological symptoms including severe headache and visual disturbance), in the context of missed antihypertensive medication for two days. The clinical picture raises concern for hypertensive encephalopathy and must be differentiated from acute stroke.

Facilitator Triggers — if trainees miss a critical step

! (If trainees do not perform a BGL — remind them any patient with altered GCS requires a BGL. Patient remains at 6.4 mmol/L — no hypoglycaemia.)
! (If trainees do not ask about medications or identify the missed antihypertensive doses — wife becomes visibly distressed and volunteers: 'He ran out of his blood pressure pills two days ago — could that be it?')
! (If trainees do not identify visual disturbance as a neurological end-organ symptom — patient begins to describe 'a dark patch' in the upper right field of his left eye at the 8-minute mark.)
! (If oxygen is applied unnecessarily to a normoxic patient — redirect trainees: SpO2 is 97% on RA and patient does not meet criteria for supplemental oxygen; titrate oxygen only if SpO2 drops below 94%.)
! (If trainees attempt to administer GTN — this is a critical error. GTN is NOT indicated for hypertensive emergency without ACS or other authorised indication. GTN is contraindicated without a confirmed cardiac indication. Facilitator states: 'What specific CPG indication authorises GTN here? There is no chest pain and no confirmed cardiac event.')
! (If trainees fail to place the patient appropriately — patient should be positioned sitting or semi-recumbent. Remind trainees that head elevation assists cerebral venous drainage. Do NOT lay patient flat.)
! (If trainees do not identify this as a time-critical presentation requiring urgent transport — at 12 minutes the patient's GCS drops to 13 and he reports his headache is now 9/10 and he is struggling to identify the correct year. Expedite transport.)
! (If trainees do not reassess BP after initial vital signs — BP has risen to 224/130 at 10 minutes, reinforcing the time-critical nature of the presentation.)

Treatment Objectives

1. Ensure scene safety and don appropriate PPE.
2. Perform Primary Survey — confirm patent airway, adequate breathing, bounding circulation, GCS 14.
3. Perform Vital Sign Survey — obtain BP (both arms if possible), HR, RR, SpO2, BGL, temperature, GCS, pain score, pupils.
4. Document BP of 218/124 mmHg — identify as severely elevated with neurological end-organ symptoms (headache, visual disturbance, GCS change).
5. Perform BGL — result 6.4 mmol/L, ruling out hypoglycaemia as cause of altered GCS.
6. Assess and document pupils — PERL 4mm bilaterally, sluggish light response.
7. Elicit focused history using SAMPLER/IMISTAMBO framework — identify missed amlodipine for 2 days as precipitating factor.
8. Screen for stroke using available history — note: FAST assessment and RACE score are outside EHS Primary Care scope; however maintain high suspicion for CVA and document time of symptom onset (approximately 20–25 minutes prior to EHS arrival — within 9-hour thrombolysis window).
9. Position patient sitting or semi-recumbent — do NOT lay flat; 30° head elevation preferred to promote cerebral venous drainage.
10. Do NOT administer GTN — there is no authorised EHS CPG indication for GTN in hypertensive emergency without confirmed ACS, ACPO, autonomic dysreflexia, or Irukandji sting.
11. Do NOT administer aspirin — there is no confirmed ACS, and aspirin is contraindicated where intracranial haemorrhage cannot be excluded.
12. Administer supplemental oxygen ONLY if SpO2 drops below 94% — titrate to 94–98% via nasal cannula or simple face mask. Do NOT hyperoxigenate.
13. Minimise patient exertion — do not walk the patient; use a wheelchair or stretcher to transport within the venue.
14. Provide continuous reassurance — reduce patient and carer anxiety.
15. Perform repeat vital signs at 10 minutes — BP 224/130, GCS 13, pain 9/10 confirms clinical deterioration.
16. Classify as TIME CRITICAL — deteriorating GCS, escalating BP with neurological symptoms.
17. Arrange Priority 1 transport — contact State Operations Centre, request ambulance upgrade, pre-notify receiving emergency department of: 75YO male, hypertensive emergency, BP 224/130, GCS 13, severe headache and visual disturbance, suspected hypertensive encephalopathy vs acute stroke, symptom onset approximately 25 minutes ago.
18. Perform secondary and CNS survey during transport preparation — assess facial symmetry, upper and lower limb power, speech quality, gait (do not mobilise), pupil response.
19. Continue monitoring and document all vital signs every 5 minutes given time-critical status.
20. Prepare for potential deterioration — have BVM, OPA/NPA, suction, and defibrillator available at bedside.
21. Scenario ends on arrival of ambulance and IMISTAMBO handover.
22. Attention to hand hygiene will be given throughout the scenario.

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

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Signs/Symptoms	Severe throbbing headache (8/10, worst in the back of the head), blurred vision bilaterally, mild confusion. No chest pain. No shortness of breath. No nausea at present.
Allergies	Nil known.
Medications	Amlodipine 5mg daily (antihypertensive — wife confirms last dose was two days ago when he ran out). No other regular medications reported.
Pertinent History	Known hypertension for 12 years. Wife reports BP has been 'well controlled' on medication. No known history of stroke, cardiac disease, or diabetes. No history of similar headaches previously.
Last Oral Intake	Ate a meat pie and had a soft drink approximately 1.5 hours ago.
Events Leading	Pt was seated in the grandstand watching an AFL game at Optus Stadium. He had been there for approximately 2 hours prior to symptom onset. No physical exertion, no crowd crush. Wife became concerned when he said 'everything looks fuzzy' and grabbed his head.
Treatment Prior	Nil. Wife tried to give him a glass of water. No self-administered medications.

Onset	Sudden onset approximately 20–25 minutes ago during the AFL match. Wife states it came on without warning.
Pain	Severe throbbing occipital headache, 8/10. Pt describes it as the worst headache he has had in years.
Quality	Throbbing, constant, described as 'like pressure building in my head'.
Radiates	Radiates to the back of the neck.
Severity	8/10 at initial assessment, escalating.