Scenario — STEMI with Aspirin Allergy Claim and COPD on Home Oxygen

advanced Cardiac · Elderly · 75yr · male

Patient Information

Dispatch	You are called to the corporate hospitality area at Optus Stadium during an AFL match. A 75YO male (Graham Whitfield) is seated and clutching his chest. Staff report he has been unwell for approximately 20 minutes.
Patient	Graham Whitfield — 75yr (75kg)
Incident History	Pt states he developed a heavy, crushing sensation across his chest approximately 20 minutes ago during the first quarter. He initially thought it was indigestion. He is pale, diaphoretic, and reports the pain is not improving with rest. He has his home oxygen concentrator bag with him.
Emergency Contact	Margaret Whitfield (Wife) — 0412 883 047

Initial Rapid Assessment

Response	Alert
Airway	Patent. Nil obstruction. Nil stridor. Patient speaking in short sentences.
Breathing	Laboured. Accessory muscle use noted. Audible mild wheeze bilaterally. RR elevated. Patient on home oxygen — concentrator not available at venue. Currently on room air.
Circulation	Radial pulse rapid and weak. Skin pale, cool and diaphoretic. Nil external bleeding.
Disability	GCS 15 (E4V5M6). Orientated to time, place and person. Complaining of severe chest pain.
Exposure	No rashes or urticaria visible. No obvious trauma. Patient dressed in formal attire. Diaphoresis noted to forehead and neck.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	91% (RA)	Moderate	22	108	94/60	3s	15	3 3 ++	36.8	6.8 mmol/L	8
10 mins	94% (O2 NRB 10L/min — titrated to 88–92% if COPD confirmed; correct mask selected)	Mild	18	102	96/62	2s	15	3 3 ++	36.8	6.8 mmol/L	5

History Taking

Scenario Progression and Treatment Objectives

Diagnosis

This patient is suffering from a suspected ST-elevation myocardial infarction (STEMI) with concurrent COPD requiring carefully titrated oxygen therapy, and a claimed childhood aspirin rash that does not constitute an absolute contraindication to aspirin administration.

Facilitator Triggers — if trainees miss a critical step

! (If trainees apply high-flow oxygen at 15L/min without consideration of COPD: the patient's SpO2 rises to 98% and he becomes drowsy with slowed respiratory rate — facilitator states 'His breathing seems to be slowing down and he looks more sleepy.' Prompt trainees to reassess oxygen delivery and titrate to 88–92%.)
! (If trainees decline to administer aspirin citing allergy without further questioning: patient's pain remains at 8/10 and facilitator states 'He's still in a lot of pain and says it's getting worse.' Prompt trainees to review aspirin CPG — childhood rash is not an absolute contraindication; aspirin is administered even if patient has taken aspirin that day or is on anticoagulants; only true hypersensitivity to aspirin/salicylates/NSAIDs is a contraindication.)
! (If trainees administer GTN without checking blood pressure first: facilitator states BP is 84/56 — patient becomes very dizzy and says 'I feel like I'm going to pass out.' GTN is contraindicated below systolic 90mmHg. Trainees must check BP before every dose.)
! (If trainees do not limit patient exertion and allow him to stand or walk: patient becomes more diaphoretic and says his chest pain is worse — 9/10. Remind trainees to keep patient seated or semi-recumbent and minimise all exertion.)
! (If Methoxyflurane is not offered after GTN contraindicated due to hypotension: patient reports pain remains severe at 8/10. Trainees should recognise GTN is now contraindicated and consider Methoxyflurane for analgesia.)
! (If oxygen is not applied within 3 minutes of initial contact: SpO2 drops to 88% on room air and patient becomes more distressed — 'I really can't catch my breath.')

Treatment Objectives

1. Ensure scene safety and don appropriate PPE.
2. Perform Primary Survey — confirm patent airway, assess breathing with wheeze noted, assess circulation with weak rapid pulse and diaphoresis.
3. Position patient semi-recumbent — do NOT allow patient to stand or walk; limit all exertion.
4. Apply pulse oximetry immediately — note SpO2 91% on room air.
5. Administer Oxygen via nasal cannula at 1–2L/min initially, titrating to target SpO2 88–92% given known COPD — do NOT apply high-flow non-rebreather mask without clinical justification; reassess SpO2 continuously.
6. If SpO2 cannot be maintained at 88–92% on nasal cannula, step up to simple face mask at 5–8L/min, reassessing with each change.
7. Perform Vital Signs Survey — note BP 94/60, HR 108, RR 22, SpO2 91% RA, pain 8/10.
8. Perform Secondary Survey — confirm chest pain radiating to left arm and jaw, diaphoresis, nausea, mild wheeze; no rash or urticaria.
9. Take IMISTAMBO/SAMPLE history — specifically clarify nature of claimed aspirin allergy (childhood rash — not documented anaphylaxis, no NSAID allergy confirmed).
10. Administer Aspirin 300mg orally (chewed) — the claimed childhood rash does NOT constitute a contraindication per CPG; hypersensitivity to aspirin/salicylates/NSAIDs is the contraindication, not a historical rash; explain clinical rationale to patient and gain verbal consent.
11. Assess GTN eligibility — BP is 94/60 (systolic < 90mmHg at first check is borderline; REASSESS BP after patient is positioned and settled). If systolic BP confirmed below 90mmHg, GTN is CONTRAINDICATED — do not administer. Document decision.
12. If systolic BP rises above 90mmHg on reassessment and no PDE5 inhibitor use in previous 24–72 hours confirmed: Administer GTN 400mcg (1 spray) sublingually — reassess BP before every dose; administer in seated or semi-recumbent position.
13. If GTN is contraindicated due to hypotension OR pain remains >3/10 after GTN: Administer Methoxyflurane (Penthrox) 3mL via inhaler — patient self-administers; monitor for over-sedation.
14. Assess for nausea — if present, administer Ondansetron 4mg oral wafer; may repeat after 15 minutes if symptoms persist (max 8mg in 8 hours).
15. Reassess vitals every 5 minutes given time-critical presentation — document pain scores pre- and post-intervention.
16. Prepare for cardiac arrest — have AED/defibrillator immediately accessible and pads ready.
17. Arrange Priority 1 transport — pre-notify receiving facility with patient details, suspected STEMI, current treatment, and COPD with controlled oxygen requirement.
18. Maintain continuous reassurance throughout.
19. Scenario ends on arrival of ambulance and IMISTAMBO handover.
20. 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 · Primary Survey · Pain Assessment

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Signs/Symptoms	Severe crushing chest pain radiating to left arm and jaw. Shortness of breath. Diaphoresis. Nausea. Mild wheeze.
Allergies	Patient claims allergy to aspirin — reports developing a rash as a child after taking aspirin. Has not taken aspirin as an adult. No documented anaphylaxis. No allergy to NSAIDs confirmed. No other known allergies.
Medications	Salbutamol MDI (PRN), Tiotropium (daily), home oxygen concentrator (2L/min at rest). Reports no use of Viagra, Cialis or similar medications. No anticoagulants. No regular aspirin.
Pertinent History	Known COPD diagnosed 8 years ago. Ex-smoker (40 pack years, ceased 10 years ago). No prior cardiac history documented. Hypertension managed with diet only.
Last Oral Intake	Meat pie and a soft drink approximately 45 minutes ago.
Events Leading	Patient was seated in corporate hospitality box watching the AFL match. Developed sudden onset chest pain and shortness of breath with no strenuous activity. Companion called for help after patient became pale and diaphoretic.
Treatment Prior	Nil. Staff offered water but no medications given prior to EHS arrival.

Onset	Approximately 20 minutes ago, sudden onset during the first quarter of the game. No clear precipitating activity — was seated watching the match.
Pain	Heavy, crushing sensation across the centre of the chest radiating to the left arm and jaw.
Quality	Crushing, pressure-like. Patient says 'like an elephant sitting on my chest.'
Radiates	Left arm and jaw.
Severity	8/10