Scenario — Atypical STEMI with claimed aspirin allergy and concurrent COPD

advanced Cardiac · 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. Bilateral reduced air entry with faint expiratory wheeze on auscultation. 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

Scenario Progression and Treatment Objectives

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 or dissolved) — 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.'
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 oral wafer for nausea — confirm no contraindications (patient not on apomorphine, no hypersensitivity). Patient is alert and able to take oral medication safely.
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 Priority 1 transport 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 Priority 1 time-critical patient. Provide pre-notification: 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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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