Cardiac Advanced
Atypical STEMI with claimed aspirin allergy and concurrent COPD
Elderly · 75yr · female
Patient Information
- Dispatch
- You are called to a 75-year-old female at the Anzac Day community morning tea, Fremantle Town Hall. Patient reports feeling unwell with jaw pain and nausea — no chest pain reported. (Margaret Holt)
- Patient
- Margaret Holt — 75yr (60kg)
- Incident History
- Pt seated at morning tea event when she began feeling nauseated and noticed a tight, heavy feeling in her jaw and left arm. Denies chest pain. Has a history of COPD and is on home oxygen. Bystander called for EHS assistance.
- Emergency Contact
- David Holt (Husband) — 0412 883 047
Initial Rapid Assessment
- Response
- Alert
- Airway
- Patent. Nil airway obstruction. Nil stridor. Patient speaking in short sentences.
- Breathing
- Mild increased work of breathing. Faint audible bilateral expiratory wheeze. RR 20. SpO2 88% on room air.
- Circulation
- Radial pulse weak and irregular. Skin pale, cool and diaphoretic. Nil external bleeding.
- Disability
- GCS 15 (E4V5M6). Alert and orientated to time, place and person. Mild anxiety noted.
- Exposure
- Nil rash or urticaria. Nil visible trauma. Patient well dressed, seated in chair at event.
Vitals
| Time | SpO2 | Resp Dist | RR | Pulse | BP | CRT | GCS | PERL | Temp | BGL | Pain |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Initial | 88% (RA) | Mild | 20 | 98 | 98/64 | 3s | 15 | 3 3 ++ | 36.8 | 6.4 mmol/L | 5 |
| 10 mins | 91% (O2 NC 2L/min) | Mild | 18 | 104 | 94/60 | 3s | 15 | 3 3 ++ | 36.8 | 6.4 mmol/L | 4 |
History Taking
- Signs/Symptoms
- Tight, heavy sensation in jaw and left arm. Nausea. Mild shortness of breath. Diaphoresis. Denies chest pain. Feels 'generally unwell and off colour'.
- Allergies
- Patient states she is allergic to aspirin — 'I came up in a rash when I was a little girl, the doctor said never take it again.' No documented anaphylaxis. No respiratory symptoms with the reported reaction.
- Medications
- Salbutamol MDI (PRN), Tiotropium inhaler (daily), Prednisolone 5mg oral (daily — maintenance dose), home oxygen 2L/min via nasal cannula at night. No phosphodiesterase-5 inhibitors. No anticoagulants.
- Pertinent History
- Known COPD — moderate severity, on home oxygen overnight. No prior cardiac history. Non-smoker for 20 years (ex-smoker 30 pack years). Hypertension managed with diet.
- Last Oral Intake
- Morning tea — cup of tea and a scone approximately 30 minutes ago.
- Events Leading
- Patient was seated attending the Anzac Day morning tea when she began to feel nauseated. Her husband noticed she was pale and sweating and called for help.
- Treatment Prior
- Nil. Husband rubbed her back. No medications taken today other than morning Tiotropium.
- Onset
- Approximately 25 minutes ago, gradual onset while seated at event.
- Pain
- Heavy, tight sensation radiating from jaw to left arm. No central chest pain reported.
- Quality
- Heavy and tight — 'like something pressing on my jaw'. Constant.
- Radiates
- Jaw to left arm.
- Severity
- 5/10
Treatment Response
Diagnosis
This patient is suffering from a suspected STEMI (acute ST-elevation myocardial infarction) presenting atypically with jaw and left arm pain, nausea, and diaphoresis — no classic central chest pain. She has concurrent COPD requiring carefully titrated oxygen therapy, and is resistant to aspirin due to a childhood rash that is consistent with a mild hypersensitivity reaction rather than true anaphylaxis or NSAID-sensitive asthma.
Facilitator Triggers — if trainees miss a critical step
- ! (If trainees fail to recognise atypical ACS presentation due to absence of chest pain — patient begins to clutch her left arm more firmly and becomes increasingly pale and diaphoretic. Ask the trainee: 'What other conditions could cause jaw pain, left arm heaviness, nausea, and diaphoresis in a 75-year-old female?')
- ! (If oxygen is not applied within 3 minutes OR if high-flow oxygen is administered without titration — patient's SpO2 rises above 94% briefly then the facilitator prompts: 'Remember Margaret has COPD — what are your oxygen targets for this patient and why does that matter?')
- ! (If trainee accepts the aspirin allergy claim without clinical reasoning and withholds aspirin — patient's pain score increases to 7/10 at 8 minutes and facilitator prompts: 'The CPG states aspirin is administered even if hypersensitivity is claimed — what does the CPG say about a childhood rash versus a true contraindication? Are there absolute contraindications listed for aspirin in ACS?')
- ! (If GTN is administered without checking blood pressure first — facilitator states: 'Margaret's BP is 98/64. What does the GTN CPG say about systolic BP and administration?')
- ! (If trainee attempts to administer GTN with BP 98 systolic — facilitator confirms BP again and asks trainee to reconsider the contraindication threshold.)
- ! (If Methoxyflurane is considered before GTN — facilitator prompts: 'What is the first-line analgesic for cardiac chest pain in the ACS CPG, and does the patient's blood pressure allow it?')
- ! (If patient is not positioned correctly — she stands up to find her handbag. Facilitator states: 'Margaret has stood up. What positioning does the ACS CPG recommend and why?')
Treatment Objectives
- 1 Ensure scene safety and don appropriate PPE.
- 2 Perform Primary Survey — confirm patent airway, note increased work of breathing and wheeze, assess circulation (weak irregular pulse, pallor, diaphoresis).
- 3 Apply SpO2 monitoring immediately — note 88% on room air.
- 4 Apply oxygen via nasal cannula at 1–2 L/min (FiO2 approximately 24–28%) — titrate to target SpO2 88–92% as per COPD CPG. DO NOT apply non-rebreather mask or high-flow oxygen without reassessment.
- 5 Position patient seated or semi-recumbent — do not allow patient to stand or walk.
- 6 Perform Vital Sign Survey — BP 98/64, HR 98 irregular, RR 20, SpO2 88% RA, GCS 15, BGL 6.4 mmol/L, Temp 36.8°C.
- 7 Conduct focused history using IMISTAMBO — identify atypical ACS features: jaw pain, left arm heaviness, nausea, diaphoresis, no chest pain.
- 8 Take comprehensive medication and allergy history — identify claimed aspirin allergy (childhood rash only, no anaphylaxis, no respiratory component).
- 9 Administer Aspirin 300mg oral (chewed) — the CPG states aspirin is administered even if the patient has taken aspirin that day or is on anticoagulants. A childhood rash is not a documented absolute contraindication (no hypersensitivity to salicylates/NSAIDs resulting in anaphylaxis or bronchospasm confirmed). Clearly explain to Margaret: 'The clinical evidence strongly supports giving this medication to protect your heart. A rash as a child is different to a true allergy. I am recommending we give it.'. Confirm 6 medication rights: right patient, right drug, right dose, right route, right time, right documentation.
- 10 Reassess BP before considering GTN — BP is 98 systolic. GTN is CONTRAINDICATED as systolic BP is below 90mmHg threshold. DO NOT administer GTN.
- 11 Consider Methoxyflurane (Penthrox) 3mL via inhaler for pain score 5/10 — confirm patient is alert, oriented, and able to self-administer. Not affected by alcohol or illicit drugs. Administer as per Penthrox Inhaler Administration clinical skill.
- 12 Administer Ondansetron 4mg sublingual tablet for nausea — confirm no contraindications (patient not on apomorphine, no hypersensitivity). Patient is alert and able to take oral medication safely. Confirm 6 medication rights: right patient, right drug, right dose, right route, right time, right documentation.
- 13 Reassess vitals at 10 minutes — expect mild SpO2 improvement to 90–92% on nasal cannula O2. BP likely to remain low or worsen. Escalate to urgent ambulance via CSP urgently.
- 14 Prepare for cardiac arrest — ensure AED/defibrillator is at hand given suspected STEMI with hypotension and irregular pulse.
- 15 Call for ambulance (SJWA) immediately — this is a urgent time-critical patient. Provide IMISTAMBO handover: suspected atypical STEMI, 75YO female, HR irregular, BP 98 systolic, COPD, SpO2 88% on RA now on 2L NC.
- 16 Continue monitoring every 5 minutes given time-critical status — GCS, BP, HR, SpO2, pain score, respiratory status.
- 17 Do not leave patient unattended. Reassure continuously.
- 18 Scenario ends on arrival of ambulance and IMISTAMBO handover.
- 19 Attention to hand hygiene will be given throughout the scenario.
Clinical references: Chest Pain / Acute Coronary Syndrome · Chronic Obstructive Pulmonary Disease (COPD) — Acute Exacerbation · Oxygen · Aspirin · Glyceryl Trinitrate (GTN) · Methoxyflurane · Ondansetron · Primary Survey · Blood Pressure · Pulse Oximetry · Pain Assessment
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