Scenario — Congestive Cardiac Failure — elderly female at community fair

intermediate Cardiac · Elderly · 75yr · female

Patient Information

Dispatch	You are called to a 75-year-old female (Margaret Holloway) who is sitting outside the main tent at the Kalamunda Community Fair, complaining of difficulty breathing and feeling 'very tired'. A bystander reports she has been struggling for the last 20 minutes.
Patient	Margaret Holloway — 75yr (60kg)
Incident History	Pt reports progressive shortness of breath over the past 20 minutes. Pt states she has been sitting in the sun watching the entertainment and started to feel increasingly breathless. She denies chest pain. Bystander notes her ankles look 'very puffy'.
Emergency Contact	Susan Holloway (Daughter) — 0412 774 391

Initial Rapid Assessment

Response	Alert
Airway	Patent. Nil airway obstruction. Nil stridor. Able to speak in short sentences only.
Breathing	Laboured. Increased work of breathing. Audible crackles bilaterally at lung bases on auscultation. RR 26. SpO2 88% on room air. Nil wheeze.
Circulation	Pulse rapid and regular. Skin cool and mildly diaphoretic centrally. Bilateral ankle and lower leg oedema noted. Mild peripheral cyanosis to fingertips. CRT 3s.
Disability	GCS 14 (E4V4M6). Alert but mildly confused — not fully oriented to time. No focal neurological deficit.
Exposure	Bilateral pitting ankle oedema to mid-calf. No rashes or visible injuries. Distended neck veins noted when patient is semi-recumbent. No sacral oedema assessed (patient seated).

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	88% (RA)	Moderate	26	108	160/100	3s	14	3 3 ++	37.1	6.4 mmol/L	2
10 mins	95% (O2 simple face mask 6L/min)	Mild	20	98	155/95	2s	15	3 3 ++	37.1	6.4 mmol/L	1

History Taking

Scenario Progression and Treatment Objectives

Diagnosis

This patient is suffering from an acute exacerbation of congestive cardiac failure (right and left heart failure), most likely precipitated by a missed diuretic dose.

Facilitator Triggers — if trainees miss a critical step

! (If oxygen is not applied within 3 minutes of arrival, patient's SpO2 drops to 85% on RA and confusion worsens — GCS drops to 13 (E3V4M6). Patient becomes more agitated and begins to resist assessment.)
! (If the trainee attempts to walk the patient to the stretcher rather than bringing the stretcher to the patient, the patient becomes significantly more breathless and SpO2 drops to 84%. Facilitator states: 'Margaret says she feels much worse and grabs your arm — she looks frightened.')
! (If GTN is considered or prepared, facilitator prompts: 'You check your medication references — is GTN indicated here?' GTN is contraindicated in CCF. Trainee should recognise this and NOT administer GTN.)
! (If history of missed frusemide is not elicited, facilitator provides cue: Margaret's daughter says quietly 'She forgot to take her water tablet this morning — is that important?')
! (If patient is positioned supine rather than sitting/semi-recumbent with legs down, patient states 'I can't breathe lying flat, please sit me up' and breathlessness visibly worsens.)
! (If the trainee does not reassess vitals at 10 minutes, facilitator states: 'It has been 10 minutes since your last set of observations — what are you going to do now?')

Treatment Objectives

1. Ensure scene safety and don appropriate PPE.
2. Perform Primary Survey — confirm patent airway, identify laboured breathing and signs of circulatory compromise.
3. Position patient sitting upright or semi-recumbent with legs hanging down — do NOT walk the patient; bring the stretcher/chair to the patient.
4. Apply Pulse Oximetry monitoring.
5. Administer Oxygen via simple face mask at 5–8 L/min targeting SpO2 94–98%. Titrate flow to maintain target saturations. Do NOT use a non-rebreather mask as first line unless SpO2 does not respond to simple face mask.
6. Perform Full Vital Signs Survey: GCS, BGL, SpO2, RR, BP, pulse, CRT, temperature, pain score.
7. Perform Secondary Survey including auscultation of lung bases for crackles, assessment of neck vein distension, and assessment of lower limb oedema.
8. Obtain IMISTAMBO history: elicit missed frusemide dose, known CCF, current medications (Frusemide, Ramipril, Bisoprolol, Atorvastatin), nil known allergies.
9. Recognise GTN is CONTRAINDICATED in CCF — do not administer GTN.
10. Reassess and document full observations every 10 minutes.
11. Prepare for transport — request ambulance (Priority 1 given patient is time critical with hypoxia and altered GCS on arrival).
12. Continuous reassurance to patient and family throughout.
13. Monitor patient persistently for clinical deterioration including worsening hypoxia, decreasing GCS, increasing respiratory distress, or haemodynamic instability.
14. Scenario ends on arrival of ambulance and IMISTAMBO handover.
15. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Congestive Cardiac Failure · Oxygen Delivery · Primary Survey · Auscultation · Blood Glucose Monitor · Pulse Oximetry · Blood Pressure · Pulse & Respirations · Glasgow Coma Scale (GCS)

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Signs/Symptoms	Progressive shortness of breath, fatigue, mild confusion, bilateral ankle swelling, feeling of heaviness in her legs.
Allergies	Nil known drug allergies.
Medications	Frusemide 40mg daily, Ramipril 5mg daily, Bisoprolol 5mg daily, Atorvastatin 40mg at night. States she 'forgot' her frusemide this morning.
Pertinent History	Known congestive cardiac failure diagnosed 3 years ago. Previous admission to Midland Public Hospital for CCF exacerbation 8 months ago. Hypertension. No known COPD or asthma.
Last Oral Intake	Light sandwich and a cup of tea approximately 2 hours ago.
Events Leading	Patient attended the Kalamunda Community Fair with her daughter to watch the entertainment. Had been seated for approximately 1 hour when breathing difficulty began. Daughter became concerned when patient became unable to speak in full sentences and appeared confused.
Treatment Prior	Nil self-treatment. No GTN or other medications taken today aside from regular medications (missing frusemide dose today).

Onset	Gradual onset over the past 20–30 minutes at the fair. Daughter states breathing has been 'not quite right' for the past two days at home.
Pain	Denies chest pain. Reports mild discomfort from ankle swelling — 2/10.
Quality	Breathlessness described as 'can't catch my breath' and 'tight in my chest when I breathe in'.
Radiates	Nil radiation.
Severity	Breathlessness 7/10 at presentation.