Scenario — Suspected opioid overdose at music festival

intermediate Toxicology · Adult · 35yr · male

Patient Information

Dispatch	You are called to the general camping area at Fairgrounds Music Festival — a bystander has reported a 35YO male who is unresponsive and 'won't wake up' near the tent area. (Marcus Delgado)
Patient	Marcus Delgado — 35yr (80kg)
Incident History	Pt found slumped against a tent pole by friends approximately 5 minutes ago. Friends state he was 'using something' earlier in the evening and became increasingly drowsy before becoming unresponsive. Empty blister packs nearby — unknown substance.
Emergency Contact	Brodie Delgado (Brother) — 0412 387 651

Initial Rapid Assessment

Response	Pain
Airway	Partially obstructed — jaw relaxed, tongue falling posteriorly. Audible gurgling with slow, shallow breaths. No foreign body visible. No stridor.
Breathing	Slow and shallow. RR 6/min. Minimal chest rise. Cyanotic lips noted. SpO2 82% on room air.
Circulation	Pulse present — slow, weak, regular. Radial pulse difficult to locate; carotid identified. Skin cool, pale, slightly diaphoretic. No external haemorrhage.
Disability	GCS 7 (E1V2M4). Not orientated to time, place or person. Pinpoint pupils bilaterally.
Exposure	No obvious trauma. Track marks noted to bilateral antecubital fossae. No rashes. Nil incontinence noted.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	82% (RA)	Severe	6	52	88/54	3s	7	2 2 —	35.6	4.8 mmol/L	–
10 mins	96% (O2 NRB 15L/min)	Mild	12	68	102/66	<2s	11	2 2 SL	35.6	4.8 mmol/L	–

History Taking

Scenario Progression and Treatment Objectives

Diagnosis

This patient is suffering from suspected opioid toxicity resulting in CNS depression, respiratory depression, and airway compromise consistent with the opioid toxidrome: pinpoint pupils, reduced GCS, slow shallow respirations, and haemodynamic instability.

Facilitator Triggers — if trainees miss a critical step

! (If the trainee does not immediately position the airway — lateral position or jaw thrust — within 60 seconds, the gurgling worsens and SpO2 drops to 76%. Prompt: 'The patient's breathing sounds worse and his lips are turning more blue.')
! (If the trainee does not apply high-flow oxygen within 2 minutes, SpO2 remains at 82% and RR drops to 4/min. Prompt: 'His chest is barely moving now.')
! (If the trainee does not insert an OPA or NPA to maintain airway patency, the airway re-obstructs when manual positioning is released. Prompt: 'As soon as you release your hand from his jaw, the gurgling returns immediately.')
! (If BVM ventilation is not initiated despite RR of 6 and SpO2 below 85%, GCS drops to 5 within 3 minutes. Prompt: 'He is barely breathing at all now.')
! (If BGL is not checked, facilitator prompts at the 5-minute mark: 'One of the friends asks — could it be his diabetes? He was diagnosed last year.' — this introduces clinical uncertainty requiring BGL testing to exclude hypoglycaemia as a concurrent cause.)
! (If the trainee does not request backup / ambulance urgently within the first 2 minutes, prompt: 'Your partner asks — should we call for an advanced crew?')

Treatment Objectives

1. Ensure scene safety — approach from upwind, assess for ongoing hazards, don appropriate PPE including gloves.
2. Perform Primary Survey — identify unresponsive male with compromised airway and inadequate respiratory effort.
3. Position patient in lateral position to protect airway from secretions and passive regurgitation — left lateral preferred.
4. Open and clear airway using jaw thrust and suction if available — clear gurgling secretions from oropharynx.
5. Insert Oropharyngeal Airway (OPA) — measure from centre of lips to angle of mandible, insert with rotation technique to maintain airway patency.
6. Apply oxygen via Non-Rebreather Mask (NRB) at 10–15 litres per minute — target SpO2 94–98%.
7. Initiate BVM ventilation — RR 6/min is inadequate; provide assisted ventilations at approximately 10–12 breaths/min using gentle tidal volume, avoid hyperventilation. Two-person BVM technique preferred.
8. Perform Vital Sign Survey — GCS, RR, SpO2, BP, pulse, CRT, BGL, temperature, pupils.
9. Perform BGL — result 4.8 mmol/L, normoglycaemic, no glucose gel indicated.
10. Call for urgent backup — request Advanced Care / Paramedic response given suspected opioid toxicity requiring naloxone (outside EHS scope) and potential for rapid deterioration.
11. Collect medication packaging from scene and place in patient medications bag for handover to ambulance crew.
12. Maintain lateral position or BVM-assisted ventilation continuously — do not leave patient unattended.
13. Reassess vitals at 10 minutes — with correct airway management and BVM-assisted ventilation and oxygen, expect GCS improvement to 11, SpO2 96% on O2, RR 12, BP improvement to 102/66.
14. Keep patient warm — apply blanket, monitor for hypothermia (temperature 35.6°C — mild hypothermia risk).
15. Record full observations every 5 minutes given time-critical presentation.
16. Note: Naloxone administration is outside EHS scope of practice — this must be handed over to the incoming Paramedic crew as a priority treatment.
17. Prepare IMISTAMBO handover — include mechanism (suspected opioid toxicity), GCS on arrival (7), interventions performed (lateral position, OPA, BVM ventilation, O2 NRB 15L/min), current vitals, and need for naloxone.
18. Scenario ends on arrival of ambulance and IMISTAMBO handover.
19. Attention to hand hygiene will be given throughout the scenario.

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

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Signs/Symptoms	Unresponsive to voice. Responds to painful stimuli only. Pinpoint pupils. Slow, shallow respirations. Gurgling airway. Cool pale skin.
Allergies	Unknown — patient unable to communicate. Friends state 'he doesn't have any that we know of.'
Medications	Unknown — friends unaware of regular medications. Empty blister packs on scene, illegible branding.
Pertinent History	Friends report patient has a history of recreational drug use. No known medical conditions volunteered by friends. No medic alert bracelet visible.
Last Oral Intake	Friends state he was drinking alcohol earlier in the afternoon — approximately 5–6 standard drinks. Last food unknown.
Events Leading	Patient was socialising with friends at the campsite earlier in the evening. Friends noticed him becoming very quiet and drowsy approximately 45 minutes ago. When they were unable to rouse him approximately 10 minutes ago, they called for help.
Treatment Prior	Nil. Friends placed him in a sitting position against the tent pole. No other intervention prior to EHS arrival.

Onset	Friends state patient became drowsy approximately 45 minutes ago, then unresponsive 10–15 minutes ago.
Pain	Nil reported — patient unable to self-report.
Quality	Nil reported.
Radiates	Nil
Severity	Unable to assess — GCS 7.