Scenario — Syncope at community bowls carnival

foundation Neurological · Elderly · 75yr · male

Patient Information

Dispatch	A 75YO male who has collapsed at the bowls green and briefly lost consciousness. Bystanders report he recovered quickly but is now sitting on the ground looking pale and sweaty. (Ron Hutchinson)
Patient	Ron Hutchinson — 75yr (75kg)
Incident History	Pt was playing in the Veterans Bowls Carnival on a warm morning. He stood up quickly after crouching to measure a bowl, felt dizzy, and fell to the ground. Witnesses say he was unconscious for approximately 20–30 seconds before coming around on his own.
Emergency Contact	Margaret Hutchinson (Wife) — 0412 774 391

Initial Rapid Assessment

Response	Alert
Airway	Patent. Nil airway obstructions. Nil stridor or secretions.
Breathing	Self-ventilating. RR slightly elevated. Nil audible wheeze or crackles.
Circulation	Radial pulse present — regular, slightly weak. Skin pale, cool and diaphoretic. Nil external bleeding. Small graze to right knee from fall.
Disability	GCS 15 (E4V5M6). Orientated to time, place and person. Denies chest pain currently. Complains of residual dizziness.
Exposure	Small superficial graze to right knee. No other visible injuries. Wearing light clothing appropriate for warm morning conditions.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	97% (RA)	Nil	18	58	90/60	3s	15	3 3 ++	36.6	5.2 mmol/L	1
10 mins	98% (RA)	Nil	16	64	108/70	2s	15	3 3 ++	36.6	5.2 mmol/L	0

History Taking

Scenario Progression and Treatment Objectives

Diagnosis

This patient is suffering from vasovagal syncope (transient loss of consciousness) likely precipitated by postural hypotension, physical exertion, mild dehydration, and prolonged standing in warm conditions.

Facilitator Triggers — if trainees miss a critical step

! (If the trainee does not lay the patient supine or semi-recumbent within the first 2 minutes, the patient reports worsening dizziness and nearly faints again — prompt trainee to consider positioning.)
! (If BGL is not checked, the facilitator should prompt: 'The patient mentions he takes blood pressure tablets — what other assessment might be relevant given his presentation?')
! (If the trainee does not ask about cardiac history or current medications, the patient volunteers: 'I do take a tablet for my blood pressure — is that important?')
! (If the trainee does not reassess BP after positioning, the facilitator notes BP remains low at 90/60 and prompts: 'Your partner is asking if there's anything more you want to check before considering transport.')
! (If the trainee attempts to stand the patient up to walk him to the FAP without first reassessing BP and ensuring clinical stability, the patient becomes acutely dizzy and nearly collapses — reinforce that any patient over 40 with no prior syncope history requires transport.)

Treatment Objectives

1. Ensure scene safety and don appropriate PPE prior to patient contact.
2. Perform Primary Survey — confirm airway patent, breathing adequate, no life-threatening haemorrhage.
3. Position patient supine (lying flat) to improve cerebral perfusion — do not allow patient to remain seated or stand.
4. Apply SpO2 monitoring and assess baseline oxygen saturation.
5. Assess oxygen saturation — SpO2 97% on room air, nil indication for supplemental oxygen at this time. Titrate if saturation drops below 94%.
6. Perform Vital Sign Survey — record BP, HR, RR, GCS, SpO2, temperature, BGL, pain score.
7. Perform Blood Glucose Level (BGL) test — result 5.2 mmol/L, nil hypoglycaemia present.
8. Identify postural hypotension as contributing factor — BP 90/60 on initial assessment, HR 58 (may be blunted by beta-blocker Metoprolol).
9. Conduct SAMPLE history — identify metoprolol and perindopril use, no prior syncope history, no chest pain, no neurological symptoms, no palpitations prior to event.
10. Perform Secondary/CNS Survey — assess for signs of trauma from fall, inspect right knee graze.
11. Manage minor wound — clean and dress right knee graze using Minor Wound Management procedure.
12. Reassess vital signs at 10 minutes — BP improving to 108/70, HR 64, GCS 15, SpO2 98% RA, dizziness resolving.
13. Recognise red flags requiring transport: patient is over 40 years of age, no prior history of syncope, taking antihypertensive medications — transport to hospital is indicated regardless of recovery.
14. Advise patient he requires transport for medical assessment — explain that at his age and with no prior syncopal episodes, an underlying cause must be excluded.
15. Provide reassurance continuously throughout the scenario.
16. Scenario ends on arrival of ambulance and IMISTAMBO handover.
17. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Transient Loss of Consciousness (Fainting / Syncope) · Primary Survey · Blood Glucose Monitor · Blood Pressure · Pulse Oximetry · Secondary & CNS Survey · Minor Wound Management · Oxygen Delivery

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Signs/Symptoms	Dizziness, pallor, diaphoresis, brief loss of consciousness approximately 20–30 seconds. Now alert with residual light-headedness. Small graze to right knee.
Allergies	Nil known drug allergies.
Medications	Metoprolol 50mg daily (for high blood pressure), Perindopril 5mg daily. No phosphodiesterase inhibitors reported.
Pertinent History	Known hypertension — well controlled. No prior episodes of syncope. No known cardiac history, diabetes, or neurological conditions. Had a similar near-faint two years ago in the heat, not investigated.
Last Oral Intake	Cup of tea and two pieces of toast approximately 2.5 hours ago. Minimal water intake during the morning.
Events Leading	Pt had been playing competitive bowls for approximately 90 minutes on a warm morning. Crouched low to measure a bowl, then stood up quickly. Immediately felt dizzy and collapsed.
Treatment Prior	Nil. Bystanders placed him in seated position on the ground and called for EHS.

Onset	Sudden onset after standing up quickly from a crouched position during bowls play.
Pain	Mild knee discomfort from graze. Denies chest pain, headache or abdominal pain.
Quality	Brief blackout, felt dizzy before going down. No warning palpitations described.
Radiates	Nil
Severity	1/10 — knee graze only. Dizziness resolving.