Scenario — Atypical ACS presentation — elderly female

intermediate Cardiac · Elderly · 75yr · female

Patient Information

Dispatch	You are called to the First Aid Post at the Perth Royal Show where a 75YO female (Margaret Hollis) has been brought in by a family member. She is sitting in a chair complaining of feeling unwell with nausea and upper back discomfort.
Patient	Margaret Hollis — 75yr (60kg)
Incident History	Pt was walking through the showgrounds with family when she began to feel increasingly nauseated and noticed an aching discomfort between her shoulder blades. Family became concerned when she appeared pale and short of breath and brought her directly to the FAP.
Emergency Contact	David Hollis (Son) — 0412 774 391

Initial Rapid Assessment

Response	Alert
Airway	Patent. Nil airway obstruction. Nil stridor. Speaking in short sentences.
Breathing	Mildly increased work of breathing. RR elevated. Nil audible wheeze or crackles. Shallow effort noted.
Circulation	Radial pulse present — rapid, weak. Skin pale, cool and diaphoretic. Nil external bleeding.
Disability	GCS 14 (E4V4M6). Orientated to person and place; mildly confused about current events. Denies chest pain — reports inter-scapular aching and nausea.
Exposure	No rash, no visible injuries. Mild diaphoresis across forehead and upper chest. No ankle oedema noted.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	93% (RA)	Mild	22	108	98/64	3s	14	3 3 ++	36.8	6.4 mmol/L	4
10 mins	97% (O2 NRB 10L/min)	Nil	18	96	104/70	2s	15	3 3 ++	36.8	6.4 mmol/L	3

History Taking

Scenario Progression and Treatment Objectives

Diagnosis

This patient is suffering from a suspected Acute Coronary Syndrome (ACS) presenting atypically — inter-scapular pain, nausea, diaphoresis and dyspnoea without classic central chest pain, in a 75-year-old female with diabetes and hypertension.

Facilitator Triggers — if trainees miss a critical step

! (If the EHS officer accepts the absence of chest pain as reassurance and does not treat as potential ACS — patient's GCS drops to 13, diaphoresis worsens, and she reports the back pain is now 7/10. Facilitator states: 'The patient looks increasingly unwell. Her skin is grey and clammy.')
! (If oxygen is not applied within 3 minutes of arrival — SpO2 drops to 90% on RA and patient becomes more breathless, RR increases to 26.)
! (If BGL is not checked — facilitator prompts: 'The patient tells you she is a diabetic. Do you want to check her blood sugar?')
! (If aspirin is not administered despite no contraindication — facilitator prompts after 7 minutes: 'The patient asks if there is anything you can give her for the discomfort.')
! (If the EHS officer notes the patient already took aspirin this morning and withholds the dose — remind trainee via facilitator note that aspirin is administered even if patient has taken aspirin that day, as per CPG.)
! (If GTN is considered — trainee must check BP before administration. If BP check is skipped and GTN is given without checking, facilitator states BP was 98 systolic — GTN is contraindicated at SBP <90 but note BP is borderline; discuss clinical reasoning. At initial BP of 98 systolic, GTN may be appropriate with close monitoring as BP is above 90 — facilitate discussion rather than rigid rule.)
! (If patient is asked to walk to the stretcher — facilitator intervenes: 'The patient begins to stand. Is this appropriate given her presentation?')

Treatment Objectives

1. Ensure scene safety and don appropriate PPE.
2. Perform Primary Survey — confirm patent airway, assess breathing and circulation.
3. Position patient seated or semi-recumbent — do NOT ask patient to walk; limit exertion.
4. Apply oxygen via non-rebreather mask at 10–15 L/min — titrate to target SpO2 94–98%.
5. Perform Vital Sign Survey including BGL, SpO2, BP, HR, RR, GCS, pain score, temperature.
6. Perform Secondary Survey including auscultation of lung fields.
7. Obtain IMISTAMBO-structured history — note atypical presentation (inter-scapular pain, nausea, no classic chest pain) in elderly diabetic female.
8. Recognise atypical ACS presentation: inter-scapular pain + nausea + diaphoresis + dyspnoea + left arm heaviness = high suspicion for ACS despite absence of classic chest pain.
9. Administer Aspirin (Disprin) 300mg oral — chewed or dissolved in small amount of water. Administer even though patient has taken 100mg aspirin today.
10. Reassess BP before considering GTN. BP is 98 systolic — GTN is not contraindicated (SBP >90mmHg) but is borderline. If administering GTN: administer Glyceryl Trinitrate (GTN) 400 microg (1 spray) sublingually with patient seated or semi-recumbent. Reassess BP every 5 minutes before repeat doses.
11. If pain remains >3/10 after 1 spray of GTN: Administer Methoxyflurane (Penthrox) 3mL inhaled via Penthrox inhaler device — patient self-administers.
12. Administer Ondansetron 4mg oral wafer for active nausea if indicated.
13. Monitor patient continuously — record full observations every 10 minutes (5 minutes if time critical).
14. Activate Priority 1 transport — contact State Operations Centre, pre-notify receiving Emergency Department.
15. Prepare for potential deterioration — have AED/defibrillator immediately available.
16. Scenario ends on arrival of ambulance and IMISTAMBO handover.
17. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Chest Pain / Acute Coronary Syndrome · Glyceryl Trinitrate (GTN, Nitroglycerin) · Aspirin (Disprin, Disprin Direct, Aspro Clear) · Methoxyflurane (Penthrox) · Ondansetron · Oxygen

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Signs/Symptoms	Inter-scapular aching discomfort rated 4/10, nausea, shortness of breath, generalised weakness and malaise. Denies central chest pain or crushing sensation.
Allergies	Nil known drug allergies.
Medications	Metoprolol 25mg daily (for hypertension). Atorvastatin 40mg nocte. Aspirin 100mg daily (already taken this morning).
Pertinent History	Known hypertension — well controlled. Type 2 diabetes diagnosed 8 years ago — managed with diet only. No prior cardiac history. Non-smoker. Lives independently at home.
Last Oral Intake	Light breakfast approximately 4 hours ago. Water during the morning.
Events Leading	Patient was walking slowly through the Royal Show pavilions with her son and daughter-in-law. Had been on her feet for approximately 90 minutes before symptoms developed.
Treatment Prior	Son gave her a glass of water and had her sit down. No other treatment prior to EHS arrival.

Onset	Symptoms began approximately 30 minutes prior to arrival at FAP. Gradual onset whilst walking.
Pain	Aching discomfort between shoulder blades — patient does not describe it as 'chest pain'. Reports it feels like a 'heavy pressure in my back'.
Quality	Constant, dull, aching, pressure-like. Not sharp or pleuritic.
Radiates	Discomfort radiates from inter-scapular region into left upper arm. Patient mentions left arm feels heavy.
Severity	4/10 currently. Was 6/10 at onset.