Scenario — Seizure in elderly female at community event

foundation Neurological · Elderly · 75yr · female

Patient Information

Dispatch	You are called to an elderly female (Margaret Hollis, 75YO) who has been found unresponsive on the ground near the community hall at the Fremantle Community Fair.
Patient	Margaret Hollis — 75yr (60kg)
Incident History	Bystanders report the patient suddenly fell to the ground and began shaking her arms and legs. Shaking has now stopped. Patient is not yet responsive.
Emergency Contact	Susan Hollis (Daughter) — 0412 774 331

Initial Rapid Assessment

Response	Pain
Airway	Partially obstructed — jaw relaxed, tongue fallen back. Saliva pooling at corner of mouth. No foreign body visible. No stridor.
Breathing	Present but shallow and irregular. RR approximately 10. Accessory muscle use noted. SpO2 88% on room air.
Circulation	Radial pulse weak and regular. Skin pale, warm and slightly diaphoretic. No external bleeding visible.
Disability	GCS 8 (E2V2M4). Not orientated to time, place or person. Post-ictal state suspected.
Exposure	No visible injuries or rashes. Patient is incontinent of urine. No medical alert bracelet visible on initial inspection.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	88% (RA)	Moderate	10	102	138/88	<2s	8	3 3 ++	37.2	5.4 mmol/L	–
10 mins	97% (O2 NRB 15L)	Mild	14	94	136/86	<2s	12	3 3 ++	37.2	5.4 mmol/L	2

History Taking

Scenario Progression and Treatment Objectives

Diagnosis

This patient is suffering from a generalised tonic-clonic seizure (now post-ictal), most likely secondary to sub-therapeutic anticonvulsant levels due to missed Lamotrigine doses.

Facilitator Triggers — if trainees miss a critical step

! (If airway is not opened and patient not repositioned within 60 seconds, SpO2 drops further to 84% and patient develops audible gurgling — facilitator prompts: 'The patient's breathing sounds noisy and wet.')
! (If BGL is not checked within the first 5 minutes, facilitator states: 'The patient appears restless and is not improving as expected — what else do you want to assess?')
! (If oxygen is not applied within 2 minutes of arrival, RR decreases to 8 and skin colour becomes mildly cyanotic around the lips.)
! (If the patient is not placed in the lateral position while unconscious, facilitator states: 'You notice saliva beginning to pool near the patient's mouth — what is your concern?')
! (If trainees do not reassess GCS at 10 minutes, facilitator prompts: 'The patient appears to be moving more — what do you want to do now?')

Treatment Objectives

1. Ensure scene safety — confirm no ongoing hazards at the community fair, don PPE.
2. Perform Primary Survey: approach, assess for dangers, call for response.
3. Open and clear the airway using the triple airway manoeuvre (head tilt, jaw thrust, open mouth) — no spinal concern in this presentation.
4. Suction airway if required to clear pooled saliva.
5. Place patient in the lateral (recovery) position to protect airway and allow drainage of secretions.
6. Insert an Oropharyngeal Airway (OPA) — measure from centre of lips to angle of mandible, insert with rotation technique.
7. Apply oxygen via Non-Rebreather Mask (NRB) at 10–15 L/min — titrate to target SpO2 94–98%.
8. Assist ventilations via BVM if respiratory effort remains inadequate (RR <8 or SpO2 not improving).
9. Perform Vital Signs Survey: GCS, BGL, SpO2, RR, HR, BP, Temperature.
10. Check BGL — result 5.4 mmol/L, no glucose gel required.
11. Protect patient from injury — pad beneath head, move hazardous objects away, do not restrain unless injury risk.
12. Reassess airway patency continuously and after any patient movement.
13. Obtain SAMPLE history from patient (as she regains consciousness) and bystanders — identify known epilepsy and missed Lamotrigine doses.
14. Repeat vital signs every 10 minutes (or 5 minutes if time critical).
15. Complete Secondary and CNS Survey once seizure has terminated and patient is more responsive — assess for tongue laceration, check pupils, assess limb movement and sensation.
16. Monitor for recurrent seizure activity — if second seizure occurs or seizure lasts >5 minutes, classify as time critical and escalate.
17. Request ambulance attendance — transport Priority 1 with pre-notification if seizure recurs or patient remains time critical.
18. Scenario ends on arrival of ambulance and IMISTAMBO handover.
19. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Seizures · Oropharyngeal Airway · Nasopharyngeal Airway · Lateral Position · Suction · Bag Valve Mask Ventilation · Oxygen Delivery · Blood Glucose Monitor · Primary Survey · Secondary & CNS Survey · Glasgow Coma Scale (GCS) · Pulse Oximetry

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Signs/Symptoms	Patient is post-ictal and confused. Complains of mild headache and generalised fatigue as she regains consciousness. Tongue slightly bitten on left side.
Allergies	Penicillin — rash.
Medications	Metoprolol (for hypertension), Citalopram (for depression), Lamotrigine (for epilepsy).
Pertinent History	Known epilepsy — diagnosed 8 years ago. Daughter (via phone) states patient ran out of Lamotrigine two days ago and had not yet been able to fill her prescription. No recent illness or fever. No recent head injury.
Last Oral Intake	Light breakfast approximately 3 hours ago. Has had water since.
Events Leading	Patient was walking through the community fair with her daughter when she suddenly stopped, became rigid, then fell to the ground and began shaking. Daughter was not present at the exact moment of collapse — was at a nearby stall.
Treatment Prior	Bystanders placed patient in recovery position and called for EHS. No medications administered.

Onset	Sudden onset — bystanders report approximately 3 minutes of tonic-clonic shaking before it self-terminated approximately 2 minutes prior to EHS arrival.
Pain	Mild headache, 2/10, generalised. Denies chest pain or focal limb pain.
Quality	Dull aching headache. No neck stiffness reported.
Radiates	Nil
Severity	2/10