Scenario — Unresponsive female — suspected opioid overdose

intermediate Toxicology · Adult · 35yr · female

Patient Information

Dispatch	You are called to the First Aid Post at Ascot Racecourse. A female has been found unresponsive in the public amenities block by event security. (Sarah Donoghue, 35YO female)
Patient	Sarah Donoghue — 35yr (65kg)
Incident History	Security found Pt slumped on the floor of a toilet cubicle, unresponsive. A small zip-lock bag and a used syringe were found near the patient. Pt is breathing but slowly.
Emergency Contact	Mel Donoghue (Sister) — 0412 883 447

Initial Rapid Assessment

Response	Pain
Airway	Partially obstructed — gurgling/snoring respirations. Tongue relaxed against posterior pharynx. Secretions visible in oropharynx. Suction required.
Breathing	Slow, shallow, irregular. RR 6. Minimal chest rise. Cyanotic lips noted. No wheeze or stridor.
Circulation	Slow, weak radial pulse. Skin pale, cool and clammy centrally. No external haemorrhage. Track marks noted to left antecubital fossa.
Disability	GCS 6 (E1V2M3). Not orientated. No purposeful movement. Pinpoint pupils bilaterally.
Exposure	Used syringe found adjacent to patient. Zip-lock bag with residual white powder. No obvious trauma. No medic alert identified.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	82% (RA)	Severe	6	52	88/54	4s	6	2 2 —	35.8	4.6 mmol/L	–
10 mins	96% (O2 NRB 15L/min)	Moderate	10	64	96/60	3s	8	2 2 —	35.8	4.6 mmol/L	–

History Taking

Scenario Progression and Treatment Objectives

Diagnosis

This patient is suffering from opioid toxicity (overdose), presenting with the classic opioid toxidrome: decreased conscious state (GCS 6), pinpoint pupils, severe respiratory depression (RR 6), hypoxia (SpO2 82% RA), bradycardia, and hypotension. A used syringe at scene strongly supports IV opioid administration as the cause.

Facilitator Triggers — if trainees miss a critical step

! (If the trainee does not suction and clear the airway within 60 seconds of arrival — the patient's gurgling worsens and SpO2 drops to 76%. Prompt: 'You can hear a loud gurgling noise with each breath.')
! (If the trainee does not insert an OPA or NPA to maintain the airway after suctioning — the airway obstructs again and SpO2 fails to improve above 86% despite oxygen application.)
! (If high-flow oxygen via NRB mask is not applied within 2 minutes — cyanosis deepens and GCS drops to 4 (E1V1M2). Prompt: 'The patient's lips appear darker blue and her breathing has slowed further.')
! (If the trainee does not perform a BGL — facilitator prompts: 'You want to rule out other causes of altered conscious state. What else might be contributing?')
! (If the trainee does not collect the syringe and bag as evidence for the ambulance crew — facilitator prompts at handover: 'The paramedic asks if there were any clues about what the patient may have taken.')
! (If the trainee does not position patient in the lateral position once airway is managed — patient vomits and there is a risk of aspiration. Prompt: 'The patient begins to retch.')
! (If BVM ventilation is not considered or commenced despite RR of 6 and SpO2 not improving above 90% on NRB — facilitator prompts: 'Despite high-flow oxygen, her saturations remain at 88% and her chest rise is barely visible. What else can you do to support her breathing?')

Treatment Objectives

1. Ensure scene safety — don appropriate PPE including gloves and eye protection given presence of used syringe and unknown substance at scene.
2. Perform Primary Survey — identify immediately life-threatening airway obstruction and severe respiratory depression.
3. Suction the oropharynx using Yankauer catheter to clear secretions — maximum 5 seconds per pass.
4. Insert an appropriately sized oropharyngeal airway (OPA) — measure from centre of lips to angle of mandible — to maintain airway patency.
5. Administer high-flow oxygen via Non-Rebreather Mask (NRB) at 15 L/min — target SpO2 94–98%.
6. If SpO2 does not improve above 90% or RR remains ≤6 with inadequate tidal volume — commence assisted BVM ventilation at 10–12 breaths per minute with high-flow oxygen at 15 L/min.
7. Place patient in lateral position (left lateral) once airway is secured and adjunct in place — to reduce aspiration risk and maintain drainage.
8. Perform Vital Signs Survey — GCS, SpO2, RR, pulse, BP, skin signs, pupils, temperature.
9. Perform blood glucose level (BGL) test — rule out hypoglycaemia as contributing cause of altered conscious state. Result: 4.6 mmol/L — no glucose treatment required.
10. Assess pupils — pinpoint bilateral pupils consistent with opioid toxidrome. Document finding.
11. Inspect scene — safely collect used syringe (place in sharps container if available), zip-lock bag with residue, and any other medications or substances. Place in patient medications bag and hand over to ambulance crew.
12. Repeat vital signs at 10 minutes — document response to oxygenation and airway management.
13. Note: Naloxone administration is outside EHS scope of practice. Do not attempt to administer naloxone. Maintain supportive airway management and oxygenation until ambulance arrival.
14. Maintain continuous monitoring — observe for vomiting, further deterioration in GCS, or respiratory arrest. Prepare to commence CPR as per Cardiac Arrest CPG if patient loses pulse or ceases breathing.
15. Brief ambulance crew on IMISTAMBO handover — include toxidrome findings (pinpoint pupils, RR 6, GCS 6), scene evidence collected, interventions performed, and response to treatment.
16. Scenario ends on arrival of ambulance and IMISTAMBO handover.
17. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Poisons & Overdoses · Unconsciousness · Oropharyngeal Airway · Nasopharyngeal Airway · Suction · Bag Valve Mask Ventilation · Oxygen Delivery · Lateral Position · Blood Glucose Monitor · Primary Survey · Secondary & CNS Survey

How did you go?

← Prev ← → navigate · Space reveal

🖨 Export PDF Next →

Signs/Symptoms	Unresponsive, snoring respirations, pinpoint pupils, pale and clammy skin, cyanotic lips.
Allergies	Unknown — patient unable to provide history. No medic alert identified.
Medications	Unknown. Used syringe and white powder residue at scene suggestive of illicit opioid use.
Pertinent History	No history obtainable from patient. Security advises Pt was attending the event alone. No witnesses to the incident.
Last Oral Intake	Unknown.
Events Leading	Pt was attending the horse racing event as a patron. Found alone, unresponsive in a locked toilet cubicle. Security used an emergency release to gain access.
Treatment Prior	Nil — no bystander treatment prior to EHS arrival. Security did not attempt any first aid.

Onset	Security last walked past amenities block approximately 20 minutes ago — Pt was not found at that time. Estimated down-time unknown, potentially 15–25 minutes.
Pain	Nil — patient unresponsive to verbal stimuli, responds only to pain.
Quality	Decreased conscious state with respiratory depression consistent with opioid toxidrome.
Radiates	Nil
Severity	GCS 6. Critical presentation.