((If trainees do not move the patient out of the sun and into shade or a cool environment within the first 2 minutes — patient's GCS drops to 9 (E2V2M5) and RR increases to 28. Facilitator states: 'Reg becomes increasingly difficult to rouse and his breathing becomes more laboured.'))

((If trainees do not commence active cooling — STRIP, SOAK, FAN — within 4 minutes, temperature remains at 40.4°C at 10-minute vitals and GCS does not improve. BP drops to 90/58. Facilitator states: 'Reg is not improving. His skin remains hot and dry. His wife is becoming distressed.'))

((If trainees attribute the altered GCS solely to alcohol intoxication and do not measure temperature — facilitator prompts: 'The patient's wife says he has drunk before and never been like this. Could something else be going on?'))

((If trainees attempt to give oral fluids to a patient with GCS below 14 — facilitator states: 'Reg is unable to safely swallow. He coughs and some fluid dribbles out.' Prompt trainees to reassess airway and reconsider route of fluid administration given oral route is unsafe.))

((If patient is not placed in lateral position as GCS declines below 12 — facilitator states: 'Reg vomits a small amount. His airway is at risk.' Trainees must suction and/or reposition.))

((If ondansetron is considered — trainees should note no oral wafer route is safe at GCS 11. IM ondansetron 4mg is the appropriate route if vomiting occurs and is within EHS scope. Facilitator prompts if trainee attempts oral wafer: 'Is the oral route safe for this patient?'))

This patient is suffering from Heat Stroke, complicated by significant alcohol consumption and a declining GCS secondary to core temperature above 40°C in an elderly male.

• Ensure scene safety — confirm ambient temperature, assess for ongoing sun/heat exposure hazard
• Don appropriate PPE including gloves
• Perform Primary Survey — open, clear and maintain airway; assess breathing, circulation, disability and exposure
• Move patient immediately out of direct sun into a cool environment or shade — this is a priority intervention
• Position patient supine
• Apply SpO2 monitoring and tympanic thermometer — record temperature (expected ≥ 40°C)
• Perform BGL — rule out hypoglycaemia as a contributing cause of altered GCS (expected BGL 4.8 mmol/L — no glucose gel required)
• Administer Oxygen via Non-Rebreather Mask at 15L/min — titrate to target SpO2 94–98%
• Commence active cooling immediately — STRIP clothing, SOAK with tepid water, FAN patient, apply ice packs to neck, groin and armpits
• Reassess GCS every 5 minutes — as GCS is 11, patient is at risk of airway compromise; prepare suction and OPA
• Do NOT give oral fluids — GCS 11 renders oral intake unsafe; aspiration risk is high
• Consider lateral position if GCS drops below 12 or if vomiting occurs — use left lateral if no spinal concerns
• Reassess temperature at 10 minutes — target progressive reduction; if no improvement escalate cooling
• If vomiting occurs — suction airway, maintain lateral position, consider Ondansetron 4mg IM injection (not oral wafer — unsafe at this GCS)
• Note and document alcohol intoxication as a confounding factor — do NOT attribute altered GCS to alcohol alone; temperature and clinical picture must guide assessment
• Consider delaying transport by up to 15 minutes to ensure active cooling is initiated and effective; continue cooling during transport
• Monitor for seizure activity — if seizure occurs, manage as per Seizures CPG while active cooling continues
• Record full vital signs every 5 minutes given time-critical presentation
• Ensure ambulance is called early given declining GCS and need for higher-scope management (IV fluids, cardiac monitoring)
• Scenario ends on arrival of ambulance and IMISTAMBO handover
• Attention to hand hygiene will be given throughout the scenario.

Clinical references: Heat Stroke · Unconsciousness · Seizures · Hypoglycaemia · Oxygen Delivery · Suction · Lateral Position · Tympanic Thermometer · Blood Glucose Monitor · Primary Survey