Cardiac Advanced
STEMI with claimed aspirin allergy and concurrent COPD
Adult · 57yr · female
Patient Information
- Dispatch
- You are called to a patient (Sarah Kowalski, 57YO female) at the First Aid Post during the Fremantle Folk Festival. Her husband says she has had jaw pain, nausea, and has been getting increasingly breathless for the past 20 minutes — he is very worried.
- Patient
- Sarah Kowalski — 57yr (65kg)
- Incident History
- Pt was walking between festival stages when she told her husband her jaw was aching and she felt sick to her stomach. She then became increasingly breathless and profusely sweaty. Husband initially thought she was overheated, but when symptoms worsened he brought her to the FAP. She has NOT reported classic chest pain. Pt has a history of COPD and is normally on home oxygen. No trauma.
- Emergency Contact
- Daniel Kowalski (Husband) — 0412 774 391
Initial Rapid Assessment
- Response
- Alert
- Airway
- Patent. No airway obstruction. No stridor. Speaking in short sentences.
- Breathing
- Laboured. Increased work of breathing. Accessory muscle use present. Audible mild wheeze bilaterally. RR elevated. DETECT & CORRECT — SpO2 89% on room air.
- Circulation
- Radial pulse rapid and weak. Skin pale, diaphoretic, cool peripherally. No external haemorrhage.
- Disability
- GCS 15 (E4V5M6). Orientated to time, place and person. Anxious and distressed.
- Exposure
- No rashes, no trauma. Skin pale and diaphoretic. No chest guarding — patient describes jaw aching and left arm heaviness rather than chest pain. No peripheral oedema noted on brief inspection.
Vitals
| Time | SpO2 | Resp Dist | RR | Pulse | BP | CRT | GCS | PERL | Temp | BGL | Pain |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Initial | 89% (RA) | Moderate | 24 | 108 | 98/64 | 3s | 15 | 4 4 ++ | 37.1 | 5.8 mmol/L | 8 |
| 10 mins | 92% (O2 NRB 10L/min — then titrate down to NC for COPD target 88–92%) | Mild | 20 | 98 | 102/68 | 2s | 15 | 4 4 ++ | 37.1 | 5.8 mmol/L | 5 |
History Taking
- Signs/Symptoms
- Jaw aching, left arm and shoulder heaviness, breathlessness, profound nausea, diaphoresis, dizziness. No classic chest pain — 'my jaw is really aching and my arm feels like lead.'
- Allergies
- Patient states she is 'allergic to aspirin — I got a rash when I was a kid.' No documented anaphylaxis. No other known allergies.
- Medications
- Salbutamol MDI (PRN), Tiotropium inhaler (daily). Normally uses home oxygen 2L/min via nasal cannula for COPD. No phosphodiesterase-5 inhibitors. No anticoagulants.
- Pertinent History
- Known COPD — diagnosed 4 years ago. Ex-smoker (10 pack year history). No previous cardiac history. No previous aspirin reactions as an adult. Childhood aspirin rash — no anaphylaxis documented.
- Last Oral Intake
- Ate a meat pie and water approximately 1.5 hours ago.
- Events Leading
- Patient was attending the Fremantle Folk Festival with her husband. Was walking between two performance stages when she told him her jaw was aching and she felt sick. She denied any heavy exertion, fall, or impact — and denies chest pain.
- Treatment Prior
- Nil. Husband guided her to the FAP immediately.
- Onset
- Approximately 20 minutes ago while walking between stages at a normal pace. Jaw ache and nausea came first, breathlessness followed.
- Pain
- Jaw aching — heavy, pressure-like. Left arm and shoulder feel heavy and 'not right'. Vague mild upper chest discomfort. Patient does not describe it as chest pain.
- Quality
- Heavy, aching jaw with left arm and shoulder heaviness. Constant. No crushing sensation.
- Radiates
- Jaw ache with heaviness spreading to the left arm and shoulder — patient does not identify a focal point of chest pain.
- Severity
- 8/10 at rest.
Treatment Response
Diagnosis
This patient is suffering from a suspected ST-Elevation Myocardial Infarction (STEMI) with an ATYPICAL female presentation — jaw pain, left arm heaviness, nausea, breathlessness, and diaphoresis WITHOUT classic crushing chest pain. Additionally complicated by concurrent COPD contributing to hypoxia, and patient reluctance to accept aspirin due to a reported childhood allergy. Facilitator note: female STEMI commonly presents without classic chest pain. Trainees must recognise jaw/arm/back discomfort, nausea, and diaphoresis as potential ACS in a female patient even when she does not complain of chest pain.
Facilitator Triggers — if trainees miss a critical step
- ! (If trainees do not consider a cardiac cause because classic chest pain is absent — jaw aching and diaphoresis worsen. Facilitator prompts at 3 minutes: 'She is getting more sweaty and her husband says she has never felt like this before. What are you considering?' Expected: trainees should recognise atypical female ACS presentation and proceed with cardiac assessment — aspirin, GTN criteria check, SpO2, vital signs.)
- ! (If the trainee does not ask about the nature of the aspirin 'allergy' — patient becomes more distressed and insists she 'cannot' take aspirin. Prompt: husband adds 'she's never actually had a serious reaction — it was a rash on her arm when she was about six'.) Facilitator note: the CPG states aspirin is administered even if the patient reports a prior reaction, unless hypersensitivity to aspirin/salicylates/NSAIDs is confirmed. A childhood rash does not constitute confirmed anaphylaxis or hypersensitivity. Trainee must recognise this distinction and administer aspirin.
- ! (If the trainee administers high-flow oxygen via NRB mask and does not titrate down toward 88–92% SpO2 target for COPD — patient's husband states 'she always uses low-flow oxygen at home, her doctor said too much is bad for her'. Facilitator note: COPD patients require controlled oxygen. Target SpO2 88–92%. Uncontrolled high-flow oxygen risks CO2 retention. Trainee must titrate oxygen appropriately.)
- ! (If GTN is administered without first confirming blood pressure ≥90 mmHg systolic — patient's BP is 98 systolic, which is borderline. Trainee must confirm BP before each GTN dose and recognise that BP is within the threshold. Facilitator note: GTN is indicated here — systolic >90 mmHg. However, the trainee must verbally confirm BP is adequate before each dose.)
- ! (If aspirin is not administered within the first 5 minutes of clinical contact — patient's pain score escalates to 9/10 and she becomes more diaphoretic. Facilitator note: aspirin administration should not be delayed in suspected ACS. Prompt trainees to address the allergy concern and administer.)
- ! (If the trainee does not request ambulance upgrade/urgent ambulance via CSP — patient's GCS drops to 14 at 8 minutes, becoming confused. Facilitator note: this is a time-critical cardiac presentation. Early IMISTAMBO handover to CSP and urgent ambulance via CSP are essential.)
- ! (If pain score remains >3/10 after first GTN spray and Methoxyflurane is not offered — patient states 'the spray didn't do much, I'm still in a lot of pain'. Facilitator note: per the CPG, if pain >3/10 after 1 spray of GTN, Methoxyflurane should be administered as per ACS protocol.)
Treatment Objectives
- 1 Ensure scene safety and don appropriate PPE. Attention to hand hygiene will be given throughout the scenario.
- 2 Perform Primary Survey — establish patent airway, assess breathing and circulation, confirm GCS 15.
- 3 Position patient seated or semi-recumbent — limit exertion, do not allow patient to walk.
- 4 Apply SpO2 monitoring immediately — initial reading 89% on room air.
- 5 Administer oxygen — initiate via nasal cannula at 1–2 L/min targeting SpO2 88–92% given known COPD. If unable to achieve target via nasal cannula, upgrade to simple face mask 5–8 L/min. Do NOT administer high-flow uncontrolled oxygen to a COPD patient. Confirm 6 medication rights: right patient, right drug, right dose, right route, right time, right documentation.
- 6 Complete Vital Sign Survey — HR 108, BP 98/64, RR 24, SpO2 89% RA, GCS 15, BGL 5.8 mmol/L, Temp 37.1°C, CRT 3s, Pain 8/10.
- 7 Conduct SAMPLE / IMISTAMBO history — specifically explore the nature of the aspirin 'allergy' (childhood rash, no anaphylaxis — not a confirmed hypersensitivity reaction).
- 8 Administer Aspirin 300 mg orally (chewed) — the CPG states aspirin is administered even if the patient reports prior aspirin use or is on anticoagulants; a childhood rash without confirmed anaphylaxis/hypersensitivity does not constitute a contraindication. Explain clearly to the patient why it is important. Confirm 6 medication rights: right patient, right drug, right dose, right route, right time, right documentation.
- 9 Confirm GTN is not contraindicated: systolic BP 98 mmHg (≥90 mmHg — threshold met), HR 108 bpm (50–150 bpm — threshold met), no PDE5 inhibitor use in previous 24–72 hours.
- 10 Administer GTN 400 microg (1 spray) sublingually — patient must be seated or semi-recumbent. Do not shake GTN bottle prior to use. Confirm 6 medication rights: right patient, right drug, right dose, right route, right time, right documentation.
- 11 Reassess pain score 5 minutes post GTN — if pain >3/10 and BP maintained ≥90 mmHg, administer second GTN 400 microg (1 spray) sublingually.
- 12 If pain remains >3/10 after first GTN spray: prepare and administer Methoxyflurane (Penthrox) 3 mL via Penthrox inhaler — patient self-administers intermittently to maintain analgesia. Reassess pain score.
- 13 Reassess BP before every GTN dose — confirm systolic ≥90 mmHg prior to each administration.
- 14 Consider Ondansetron 4 mg sublingual tablet if patient reports nausea or vomiting — confirm no contraindications (no apomorphine use).
- 15 Continuously reassure patient — maintain calm demeanour, keep patient still and supported.
- 16 Record full observations every 5 minutes given time-critical presentation.
- 17 Call CSP for urgent ambulance support transport with IMISTAMBO handover to CSP (suspected STEMI). Provide IMISTAMBO handover to transporting crew including: aspirin administered, GTN dose/s administered, Methoxyflurane initiated if given, COPD with controlled oxygen in use, aspirin allergy discussion documented.
- 18 Scenario ends on arrival of ambulance and IMISTAMBO handover.
Clinical references: Chest Pain / Acute Coronary Syndrome · Oxygen · Aspirin · Glyceryl Trinitrate (GTN) · Methoxyflurane · Ondansetron · Chronic Obstructive Pulmonary Disease (COPD) — Acute Exacerbation · Primary Survey · Pain Assessment
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