Scenario — Sudden onset facial droop and arm weakness in elderly female

intermediate Neurological · Elderly · 75yr · female

Patient Information

Dispatch	You are called to the First Aid Post at the Perth Royal Show. A 75-year-old female has been brought in by her family — they say she suddenly started slurring her words and her face looks droopy.
Patient	Margaret Hollis — 75yr (60kg)
Incident History	Pt was walking through the pavilion with family when she suddenly stopped mid-sentence. Family noticed her face dropped on the right side and her right arm went weak. Family walked her to the FAP approximately 10 minutes ago. No fall, no head strike.
Emergency Contact	David Hollis (Son) — 0412 338 901

Initial Rapid Assessment

Response	Alert
Airway	Patent. Nil obstruction. Nil stridor. Pt able to maintain own airway. Mild drooling noted from right side of mouth.
Breathing	Adequate. RR 16. Nil increased work of breathing. Nil accessory muscle use. Bilateral air entry present.
Circulation	Radial pulse present, regular, moderate strength. Skin warm and dry centrally. No active bleeding.
Disability	GCS 13 (E4V3M6). Oriented to person only. Confused and unable to name location or today's date. Right-sided facial droop noted. Right arm weakness on assessment — unable to hold arm up against gravity.
Exposure	No rashes, no visible injuries, no medic alert bracelet. Right arm visibly weaker than left on inspection.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	96% (RA)	Nil	16	88	162/94	<2s	13	4 4 ++	36.8	6.4 mmol/L	2
10 mins	95% (O2 simple face mask 6L/min)	Nil	17	90	168/96	<2s	12	4 4 ++	36.8	6.4 mmol/L	2

History Taking

Scenario Progression and Treatment Objectives

Diagnosis

This patient is suffering from a suspected acute ischaemic stroke with right-sided facial droop, right arm weakness (hemiparesis), and expressive dysphasia — symptom onset confirmed within the last 25–30 minutes, well within the 9-hour stroke bypass window.

Facilitator Triggers — if trainees miss a critical step

! (If BGL is not checked within the first 3 minutes — patient becomes increasingly confused and family become agitated demanding to know what is wrong. Facilitator prompts: 'The family ask — is it her sugar? She's not diabetic but could it be?')
! (If oxygen is not applied — SpO2 drifts to 93% at 5 minutes and patient reports feeling 'more foggy'. Facilitator prompts: 'Patient closes her eyes and does not respond to voice immediately.')
! (If the time of symptom onset is not clearly established and documented — facilitator prompts son David to say: 'Does it matter when it started? Is she going to be okay?'. Trainees must recognise this and confirm onset time to determine stroke bypass eligibility.)
! (If trainees attempt to give aspirin — remind them that aspirin is NOT indicated for suspected stroke in EHS scope. Aspirin is an ACS medication and should not be administered here. If trainee asks about her regular aspirin, note she has already taken her morning dose.)
! (If trainees do not arrange urgent ambulance transport and pre-notification within 5 minutes — GCS drops to 12 and right-sided weakness becomes more pronounced. Facilitator states: 'Margaret tries to stand and cannot support her right leg.')

Treatment Objectives

1. Ensure scene safety and don PPE.
2. Perform Primary Survey — open, clear and maintain airway; note right-sided drooling; position patient seated or semi-recumbent in position of comfort.
3. Perform Blood Glucose Level (BGL) test — result 6.4 mmol/L; this excludes hypoglycaemia as a cause of altered conscious state.
4. Administer Oxygen via simple face mask at 5–8 L/min targeting SpO2 94–98%.
5. Perform Vital Sign Survey — GCS 13, BP 162/94, HR 88, RR 16, SpO2 96% RA, Temp 36.8°C.
6. Assess pupils — PERL 4mm bilaterally.
7. Establish and clearly document time of symptom onset — confirmed approximately 25 minutes ago (well within 9-hour window).
8. Maintain high index of clinical suspicion for acute stroke based on: sudden onset unilateral facial droop, unilateral arm weakness, slurred speech/dysphasia, known hypertension, and previous TIA history.
9. Do NOT administer Aspirin — aspirin is indicated for suspected ACS only and is NOT an EHS treatment for suspected stroke.
10. Limit on-scene time — do not delay for further assessment once stroke is suspected.
11. Request urgent ambulance (Priority 1) via State Operations Centre and pre-notify receiving facility of suspected acute stroke with time of symptom onset.
12. Reassess GCS and neurological status every 5 minutes — document any deterioration.
13. Keep patient calm and reassured; minimise exertion; do not allow patient to walk.
14. Brief son David (emergency contact) on situation and that ambulance is en route.
15. Scenario ends on arrival of ambulance and IMISTAMBO handover — include: patient name and age, time of symptom onset (~25 minutes), FAST-positive features (facial droop, arm weakness, speech difficulty), BGL 6.4 mmol/L, known TIA history, current medications including Ramipril and Aspirin, allergy to Penicillin, and current GCS.
16. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Stroke (Cerebrovascular Accident) · Unconsciousness · Hypoglycaemia · Oxygen Delivery · Blood Glucose Monitor · Primary Survey · Glasgow Coma Scale (GCS)

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Signs/Symptoms	Right-sided facial droop, right arm weakness, slurred speech, mild confusion. Denies headache, visual disturbance, chest pain, or dizziness.
Allergies	Penicillin — rash.
Medications	Ramipril 5mg daily (hypertension). Atorvastatin 40mg nocte. Aspirin 100mg daily (previously prescribed post-TIA 3 years ago).
Pertinent History	Known hypertension. Previous TIA 3 years ago — recovered fully. Non-smoker. No recent illness or fever. No anticoagulation medications other than low-dose aspirin.
Last Oral Intake	Light lunch approximately 2 hours ago — sandwich and water.
Events Leading	Patient was walking with family through the show pavilion, stopped speaking mid-sentence, and family noticed facial drooping and right arm weakness immediately. No fall, no loss of consciousness, no seizure activity witnessed.
Treatment Prior	Nil. Family brought her directly to FAP.

Onset	Sudden onset approximately 25 minutes ago while walking through the Royal Show pavilion. Family confirm she was completely well beforehand.
Pain	Mild generalised head pressure 2/10. Denies severe or thunderclap headache.
Quality	Weakness described as 'arm feels like it doesn't belong to me'. Speech slurred — pt aware she cannot get words out correctly.
Radiates	Nil radiation of symptoms reported.
Severity	2/10 head pressure. Weakness and speech difficulty causing significant distress to patient.