((If the trainee does not identify hypotension on the initial BP and fails to administer adrenaline within 2 minutes — patient becomes increasingly distressed, GCS drops to 12, stridor becomes louder and more pronounced, BP drops to 78 systolic. Facilitator prompts: 'Barry is telling you his throat feels like it is closing.'))

((If the trainee attempts to administer Loratadine (antihistamine) instead of adrenaline — facilitator reminds trainee that antihistamines have no role in the treatment of anaphylaxis with respiratory or cardiovascular involvement and that adrenaline must be administered first.))

((If the trainee positions the patient upright or allows the patient to stand/walk — facilitator states: 'Barry attempts to stand up, saying he feels a bit better.' Trainee must instruct patient to remain supine with legs outstretched and not mobilise.))

((If oxygen is not applied after adrenaline administration — SpO2 remains at 91% at the 5-minute reassessment and the trainee should be prompted to reassess oxygen delivery.))

((If the trainee does not reassess BP and pulse after adrenaline administration — facilitator prompts: 'Your partner asks if you want to check obs again after the injection.'))

((If the trainee does not advise that the patient must not walk or stand for a minimum of one hour following adrenaline and must be transported to hospital for 4-hour observation — facilitator prompts: 'Barry says he feels much better and wants to go back and find his wife.'))

This patient is suffering from anaphylaxis secondary to shellfish (prawn) ingestion, presenting with multi-system involvement including respiratory (wheeze, stridor, dyspnoea), cardiovascular (hypotension, tachycardia), and cutaneous (urticaria, angioedema) features.

• Ensure scene safety and don appropriate PPE.
• Perform Primary Survey — identify patent airway with stridor, increased work of breathing with wheeze, hypotension and tachycardia, urticarial rash indicating multi-system anaphylaxis.
• Recognise anaphylaxis: multi-system involvement (respiratory + cardiovascular + cutaneous) following allergen exposure (shellfish ingestion).
• Position patient supine with legs outstretched — do NOT allow patient to sit upright in a chair, stand or walk. If respiratory distress is severe, allow semi-recumbent with legs still outstretched.
• Administer Adrenaline Auto-Injector (EpiPen 300 MICROg) IM into outer mid-thigh — indication: anaphylaxis with hypotension, wheeze, stridor and urticaria.
• Apply oxygen via Non-Rebreather Mask at 10–15 litres per minute — titrate to SpO2 target 94–98%.
• Perform Vital Sign Survey — record BP, HR, RR, SpO2, GCS, skin findings.
• Reassess BP before considering any further treatment. Document pre- and post-intervention vitals.
• If symptoms not significantly improved at 5 minutes and BP permits, prepare second EpiPen (300 MICROg IM) for administration at 5-minute interval if available.
• Contact CSPSOC for further advice and to arrange Priority 1 ambulance transport.
• Monitor patient persistently — record full observations every 5 minutes given time-critical presentation.
• Advise patient he must not stand or walk. Explain he requires monitoring at hospital for a minimum of 4 hours after last dose of adrenaline due to risk of biphasic reaction.
• Do NOT administer Loratadine — antihistamines have no role in treatment of anaphylaxis with respiratory or cardiovascular involvement.
• Note: Ramipril (ACE inhibitor) may potentiate anaphylaxis severity — communicate to receiving hospital at handover.
• Scenario ends on arrival of ambulance and IMISTAMBO handover.
• Attention to hand hygiene will be given throughout the scenario.

Clinical references: Anaphylaxis · Adrenaline Auto-Injector (EpiPen) · Oxygen · Loratadine