Cardiac Advanced
STEMI with claimed aspirin allergy and concurrent COPD
Adult · 51yr · male
Patient Information
- Dispatch
- You are called to a 51YO male (Darren Murchison) who is sitting outside the medical tent at Fremantle Dockers v West Coast Eagles AFL game, complaining of chest pain and difficulty breathing.
- Patient
- Darren Murchison — 51yr (80kg)
- Incident History
- Pt was in his seat watching the game when he developed a crushing central chest pain radiating to his left arm approximately 20 minutes ago. Pain has not improved with rest. His mate walked him to the FAP.
- Emergency Contact
- Kylie Murchison (Wife) — 0412 883 047
Initial Rapid Assessment
- Response
- Alert
- Airway
- Patent. Nil airway obstruction. Nil stridor.
- Breathing
- Shallow and slightly laboured. Accessory muscle use visible. RR 22. Audible mild wheeze bilaterally on expiration.
- Circulation
- Pulse rapid and weak at radial. Skin pale and diaphoretic. Nil external haemorrhage.
- Disability
- GCS 15 (E4V5M6). Orientated to time, place and person. Anxious and distressed.
- Exposure
- No rashes or urticaria visible. Pt clutching centre of chest with both hands. Nasal cannula in situ from personal home oxygen supply (not currently connected — left at seat).
Vitals
| Time | SpO2 | Resp Dist | RR | Pulse | BP | CRT | GCS | PERL | Temp | BGL | Pain |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Initial | 91% (RA) | Moderate | 22 | 108 | 148/92 | 3s | 15 | 4 4 ++ | 36.8 | 5.4 mmol/L | 8 |
| 10 mins | 94% (O2 nasal cannula 2L/min) | Mild | 18 | 98 | 136/84 | 2s | 15 | 4 4 ++ | 36.8 | 5.4 mmol/L | 5 |
History Taking
- Signs/Symptoms
- Crushing central chest pain radiating to left arm and jaw. Shortness of breath. Diaphoresis. Mild nausea. Bilateral expiratory wheeze.
- Allergies
- Pt states allergy to aspirin — 'I came out in a rash as a kid when my mum gave me some'. No anaphylaxis, no respiratory symptoms, no documented diagnosis of aspirin-exacerbated respiratory disease. No known NSAID allergy. No known salicylate allergy documented by a doctor.
- Medications
- Salbutamol MDI (PRN). Tiotropium inhaler (daily). Home oxygen via nasal cannula 2L/min PRN. No phosphodiesterase-5 inhibitors. No anticoagulants.
- Pertinent History
- Known COPD — moderate severity. Smoker — 15 pack years. No known cardiac history. No prior ACS. Father had heart attack at age 52.
- Last Oral Intake
- Meat pie and beer approximately 45 minutes ago.
- Events Leading
- Pt was seated in his bay at the stadium watching the game. No exertion. Sudden onset of chest pain during the second quarter. Walked approximately 50 metres to the FAP with assistance — should not have been walked.
- Treatment Prior
- Nil. Pt's mate wanted to give him some Disprin but pt refused due to claimed allergy.
- Onset
- Sudden onset approximately 20 minutes ago while seated watching the game. No exertion at onset.
- Pain
- Central crushing chest pain, radiates to left arm and jaw.
- Quality
- Crushing, heavy. Pt states 'like someone is sitting on my chest'.
- Radiates
- Left arm and jaw.
- Severity
- 8/10
Treatment Response
Diagnosis
This patient is suffering from a suspected ST-Elevation Myocardial Infarction (STEMI) with concurrent moderate COPD, complicated by a claimed childhood aspirin rash and hypoxia requiring careful oxygen titration.
Facilitator Triggers — if trainees miss a critical step
- ! (If trainees fail to sit the patient down and insist on walking him further into the FAP — pt becomes more diaphoretic and pain increases to 9/10. Facilitator states: 'He looks like he is about to faint'.)
- ! (If trainees accept the aspirin allergy and withhold aspirin without challenge — pt's mate asks 'Isn't he supposed to get a blood thinner or something?' Escalate: pain remains 8/10 at 5 minutes and pt asks 'Is there anything you can do for the pain?')
- ! (If trainees apply high-flow oxygen via NRB mask without titrating to COPD target — facilitator states: 'SpO2 is now 99% on NRB. Patient seems a little drowsy and his breathing has slowed.' GCS drops to 14.)
- ! (If GTN is administered without checking BP first — facilitator states: 'What is the patient's blood pressure?' Prompt trainees to reassess BP before each dose.)
- ! (If trainees do not ask about phosphodiesterase-5 inhibitor use before GTN — facilitator states: 'Have you checked if he has taken anything for erectile dysfunction in the last 24–72 hours?')
- ! (If Methoxyflurane is offered before GTN has been trialled — facilitator prompts: 'What is the first analgesic indicated in suspected ACS?' Direct trainees to GTN protocol order.)
- ! (If trainees do not consider nausea management — pt begins to gag and states 'I feel like I am going to be sick'. Prompt Ondansetron consideration.)
Treatment Objectives
- 1 Ensure scene safety and don appropriate PPE.
- 2 Immediately limit patient exertion — seat patient in a comfortable semi-recumbent position. Do NOT walk patient further. Note: patient has already walked to the FAP — this was incorrect and should be identified.
- 3 Perform Primary Survey — confirm patent airway, assess breathing (note wheeze and accessory muscle use), assess circulation (pale, diaphoretic, weak rapid pulse), confirm GCS 15.
- 4 Apply SpO2 monitoring. Initial SpO2 91% on RA.
- 5 Titrate oxygen to target SpO2 88–92% (COPD patient): commence nasal cannula at 2L/min (FiO2 approximately 28%). Reassess SpO2 after 2 minutes and titrate. Do NOT apply high-flow NRB without clinical justification — risk of hypercapnic respiratory failure in COPD.
- 6 Perform Vital Sign Survey — BP 148/92, HR 108, RR 22, BGL 5.4 mmol/L, GCS 15, pain 8/10.
- 7 Take IMISTAMBO history. Identify onset, character, radiation, severity, medications, pertinent history.
- 8 Identify and address claimed aspirin allergy: Childhood rash does NOT constitute an absolute contraindication. A true aspirin hypersensitivity causing anaphylaxis or NSAID-exacerbated respiratory disease (NSAID-EERD) would be relevant, but a childhood rash is not a documented allergy to aspirin/salicylates. Aspirin CPG states it is administered 'even if patient has taken aspirin that day or on anticoagulants'. Officer should explain benefit vs risk and administer aspirin unless patient refuses after full information.
- 9 Administer Aspirin 300mg oral — chewed — for suspected ACS. Document patient's stated allergy and clinical decision to administer in ePCR. Confirm 6 medication rights: right patient, right drug, right dose, right route, right time, right documentation.
- 10 (If patient refuses aspirin after full explanation — document informed refusal. Do not administer against explicit refusal. Notify CSP.)
- 11 Administer GTN 400 microg (1 spray) sublingually for ongoing chest pain — BP 148/92 confirms systolic >90mmHg. HR 108 confirms within 50–150 bpm range. Confirm no PDE5 inhibitor use in last 24–72 hours before administering. Confirm 6 medication rights: right patient, right drug, right dose, right route, right time, right documentation.
- 12 Reassess BP before each subsequent GTN dose. Reassess pain score 5 minutes after first GTN dose.
- 13 If pain remains >3/10 after first GTN spray: administer second GTN 400 microg sublingual at 5 minutes — confirm BP maintained.
- 14 If pain remains >3/10 post second GTN: administer Methoxyflurane (Penthrox) 3mL via inhaler device for analgesia — patient self-administers. Reassess pain score.
- 15 Consider Ondansetron 4mg sublingual tablet for nausea if patient reports nausea or vomiting — confirm no contraindications.
- 16 Record full observations every 5 minutes given time-critical presentation.
- 17 Prepare patient for urgent ambulance via CSP to nearest ED with IMISTAMBO handover. Provide IMISTAMBO handover to incoming ambulance crew including: suspected STEMI, COPD, oxygen titration in use, aspirin administered (with allergy documentation), GTN doses given, Methoxyflurane if administered, BP trend.
- 18 Ensure defibrillation equipment (AED) is immediately available at the FAP throughout the episode — peri-arrest risk.
- 19 Maintain continuous reassurance. Restrict patient movement at all times.
- 20 Scenario ends on arrival of ambulance and IMISTAMBO handover.
- 21 Attention to hand hygiene will be given throughout the scenario.
Clinical references: Chest Pain / Acute Coronary Syndrome · Chronic Obstructive Pulmonary Disease (COPD) — Acute Exacerbation · Aspirin · Glyceryl Trinitrate (GTN) · Methoxyflurane · Ondansetron · Oxygen
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