Sepsis with delayed recognition — COPD background

Patient Information

Dispatch: You are called to a patient (Marcus Bellingham, 47-year-old male) at the volunteer first aid tent at the Perth River Festival. Bystanders report he has been sitting in the shade for 20 minutes feeling unwell after the crowd crush. Staff initially thought it was heat exhaustion.
Patient: Marcus Bellingham — 47yr (80kg)
Incident History: Pt reports feeling increasingly unwell over the past 2 days with productive cough and fevers at home, but attended the event as a volunteer. Became confused and short of breath approximately 30 minutes ago. Initially assessed by a bystander first aider as heat exhaustion and given water.
Emergency Contact: Diane Bellingham (Wife) — 0412 773 091

Initial Rapid Assessment

Response: Voice
Airway: Patent. No visible obstruction. Nil stridor. Pt able to speak in short sentences only.
Breathing: Laboured. Increased work of breathing. Accessory muscle use visible. Audible wheeze. RR elevated. SpO2 88% on room air.
Circulation: Radial pulse rapid and weak. Skin warm, flushed, diaphoretic. CRT 3 seconds. No external haemorrhage.
Disability: GCS 13 (E3V4M6). Confused — not oriented to time or place. Oriented to person only.
Exposure: No rash or obvious trauma. No non-blanching rash. Pt appears generally unwell and fatigued. Wearing volunteer vest. Feels warm to touch.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	88% (RA)	Moderate	26	134	88/58	3s	13	4 4 SL	38.9	4.1 mmol/L	4
10 mins	92% (O2 NRB 15L)	Mild	23	128	92/60	3s	14	4 4 SL	38.9	4.1 mmol/L	3

History Taking

Treatment Response

Diagnosis

This patient is suffering from Red Flag Sepsis secondary to a lower respiratory tract infection (likely pneumonia), complicated by underlying COPD.

Facilitator Triggers — if trainees miss a critical step

! (If trainees continue to manage as heat exhaustion and do not reassess vitals within 2 minutes — patient becomes more confused, GCS drops to 11, RR increases to 30. Facilitator cue: 'He seems to be getting worse despite being in the shade.')
! (If oxygen is not applied within 3 minutes of initial assessment — SpO2 drops to 85% on room air, patient becomes more agitated and difficult to assess. Remind trainees of COPD target saturations 88–92%.)
! (If trainees administer high-flow oxygen via NRB without considering COPD target saturations — facilitate a question from a bystander: 'Is he on oxygen at home? Does he have a lung condition?' Prompt trainees to reassess oxygen delivery and titrate to 88–92%.)
! (If trainees do not identify Red Flag Sepsis criteria — patient's BP drops to 84 systolic at the 5-minute mark. Facilitator prompts: 'His wife has arrived and says he had a temperature of 39 degrees at home last night and has been coughing up green phlegm for 2 days.')
! (If trainees do not call for ambulance early — patient's GCS drops to 11 at 8 minutes. Facilitator states: 'His wife is asking why you haven't called an ambulance yet.')
! (If trainees attempt to walk the patient to the ambulance — patient becomes bradycardic and more hypotensive. State: 'As you help him stand, he becomes extremely unsteady and more confused.')

Treatment Objectives

1 Ensure scene safety and don appropriate PPE including gloves and mask given infective respiratory presentation.
2 Perform Primary Survey — identify airway patent, breathing laboured with accessory muscle use, circulation compromised (rapid weak pulse, CRT 3s, hypotension), disability impaired (GCS 13, confused).
3 Apply pulse oximetry immediately — initial SpO2 88% on room air.
4 Apply oxygen via nasal cannula at 1–4 L/min initially, titrating to target SpO2 88–92% given confirmed COPD — do NOT administer uncontrolled high-flow oxygen.
5 If SpO2 cannot be maintained ≥88% on nasal cannula, upgrade to simple face mask at 5–8 L/min, continuing to titrate carefully to 88–92% target.
6 Perform Vital Signs Survey — RR 26, HR 134, BP 88/58, Temp 38.9°C, BGL 4.1 mmol/L, GCS 13.
7 Identify Red Flag Sepsis criteria: new altered mental state (GCS 13, confused), systolic BP ≤90 mmHg (88 mmHg), HR ≥130 (134 bpm), RR ≥25 (26/min), temperature ≥38°C (38.9°C), SpO2 requiring oxygen to maintain ≥88%.
8 Perform IMISTAMBO-structured history — identify 2-day productive cough, fevers, COPD background, medications (salbutamol, tiotropium), Nil known allergies.
9 Recognise this is NOT heat exhaustion — the combination of fever, productive cough, hypotension, tachycardia, elevated RR and confusion in an immunocompetent adult with COPD meets Red Flag Sepsis criteria.
10 Activate ambulance urgently via CSP — communicate Red Flag Sepsis, patient's COPD, vitals, and GCS.
11 Pre-notify receiving Emergency Department — communicate Red Flag Sepsis, COPD, vitals on arrival, treatment provided, ETA.
12 Position patient semi-recumbent or in position of comfort — do NOT ambulate patient.
13 Monitor patient persistently — record full observations every 5 minutes given time-critical status.
14 Reassess SpO2 every 5 minutes and adjust oxygen delivery to maintain 88–92% target.
15 Reassess GCS and vital signs every 5 minutes — document trends for handover.
16 Do NOT delay transport for any further interventions — minimise on-scene time.
17 Prepare for clinical deterioration — have airway adjuncts (OPA, NPA) and BVM immediately available.
18 At ambulance handover, communicate: Red Flag Sepsis, known COPD, oxygen requirement and titrated target (88–92%), vital sign trends, treatment administered, medication history.
19 Scenario ends on arrival of ambulance and IMISTAMBO handover.
20 Attention to hand hygiene will be given throughout the scenario.

Clinical references: Sepsis · Chronic Obstructive Pulmonary Disease (COPD) — Acute Exacerbation · Oxygen Delivery · Primary Survey · Pulse Oximetry

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