Scenario — Severe headache and visual disturbance at outdoor music festival

advanced Medical · Adult · 35yr · female

Patient Information

Dispatch	You are called to the medical tent at the Sunset Sounds outdoor music festival. A 35YO female, Priya Sharma, has presented to the FAP with a severe headache and is reporting blurred vision. Bystanders assisted her to the FAP from the main stage.
Patient	Priya Sharma — 35yr (65kg)
Incident History	Pt reports sudden onset severe headache approximately 30 minutes ago while watching a performance. She describes it as the worst headache of her life, associated with blurred vision and a feeling of pressure behind her eyes. She became unsteady on her feet and friends brought her to the FAP. No loss of consciousness. Has a known history of hypertension and reports she forgot to take her medication for the past two days.
Emergency Contact	Rohan Sharma (Husband) — 0412 774 391

Initial Rapid Assessment

Response	Alert
Airway	Patent. Self-maintaining. Nil obstruction, stridor or swelling.
Breathing	Adequate rate and depth. Nil accessory muscle use. Nil audible wheeze or crackles. SpO2 97% on room air.
Circulation	Radial pulse strong and regular. Skin warm and dry. No external bleeding. CRT <2s.
Disability	GCS 15 (E4V5M6). Alert and orientated to time, place and person. Complaining of severe occipital headache 9/10. Reports blurred vision bilaterally — 'things look fuzzy at the edges'. Pupils equal and reactive bilaterally.
Exposure	No visible rashes, no facial asymmetry noted on inspection. No peripheral oedema. No focal neurological deficit on brief assessment — grip strength equal bilaterally, facial droop absent, speech clear.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	97% (RA)	Nil	18	92	218/126	<2s	15	4 4 ++	37.1	5.8 mmol/L	9
10 mins	97% (RA)	Nil	16	88	214/122	<2s	15	4 4 ++	37.1	5.8 mmol/L	8

History Taking

Scenario Progression and Treatment Objectives

Diagnosis

This patient is suffering from a hypertensive emergency (hypertensive crisis) with associated severe headache and visual disturbance, likely secondary to two days of missed antihypertensive medication in a patient with known hypertension.

Facilitator Triggers — if trainees miss a critical step

! (If the trainee does not obtain a blood pressure within the first 2 minutes of assessment, the patient begins to complain that her vision is getting worse and she feels increasingly nauseous — prompt by saying 'I feel like something is really wrong, my eyes aren't right.')
! (If the trainee does not identify the missed antihypertensive medication as a critical complicating factor during history taking, the patient volunteers the information: 'I did forget to take my blood pressure tablet… I left it at home. It's been two days now.')
! (If the trainee fails to perform a brief neurological assessment — facial symmetry, upper limb grip strength, speech — escalate: patient develops a mild right-hand grip weakness and begins to slur slightly — this represents a neurological deterioration warning sign requiring immediate escalation and urgent transport.)
! (If the trainee attempts to administer GTN for the elevated BP: remind them that GTN is only indicated by EHS CPG for chest pain/ACS, ACPO, Autonomic Dysreflexia and Irukandji sting — not hypertensive emergency in isolation. GTN is NOT indicated here. The trainee should not administer GTN.)
! (If oxygen is applied without clinical indication — SpO2 is 97% on room air — challenge the trainee: 'Why are you applying oxygen? What is her SpO2?' Oxygen is NOT indicated in this scenario at this SpO2 level.)
! (If the trainee does not recognise this as time-critical and does not call for ambulance backup promptly, the patient's GCS drops to 14 (E4V4M6) at 8 minutes — patient becomes confused and does not know what year it is — indicating neurological deterioration requiring immediate Priority 1 transport and pre-notification.)

Treatment Objectives

1. Ensure scene safety and don appropriate PPE — infection control throughout.
2. Perform Primary Survey — confirm patent airway, adequate breathing, circulation, GCS 15.
3. Obtain blood pressure bilaterally if possible — initial reading 218/126 mmHg confirms severe hypertension.
4. Perform brief neurological assessment — assess facial symmetry, upper limb grip strength equality, speech clarity, and pupil reactivity — document all findings.
5. Perform BGL — result 5.8 mmol/L, within normal range.
6. Take full SAMPLE history — identify known hypertension and critically, the 2-day missed antihypertensive medication as the precipitating cause.
7. Screen for contraindications to GTN (sildenafil/tadalafil/vardenafil/avanafil/riociguat use) — confirm none present — however DO NOT administer GTN as hypertensive emergency without end-organ target symptoms from ACS, ACPO, Autonomic Dysreflexia or Irukandji is NOT a CPG-listed GTN indication for EHS.
8. Do NOT administer supplemental oxygen — SpO2 is 97% on room air, oxygen is not indicated.
9. Position patient semi-recumbent or seated in a position of comfort — minimise exertion, do not allow patient to walk.
10. Provide continuous reassurance — keep patient calm to avoid further BP elevation from anxiety.
11. Reassess full observations every 5 minutes given time-critical nature — monitor GCS, BP, neurological status, and pain score.
12. Recognise this presentation as BEYOND EHS scope of independent management — this is a hypertensive emergency with neurological features (visual disturbance, severe headache) indicating possible end-organ involvement and risk of stroke.
13. Activate ambulance backup immediately via State Operations Centre — this patient requires Priority 1 transport with pre-notification of receiving facility.
14. Monitor for neurological deterioration (GCS drop, new facial droop, unilateral weakness, speech changes) — if any deterioration occurs, manage as per Unconsciousness CPG and Stroke CPG principles at Primary Care level.
15. Maintain airway and ventilatory support if GCS drops — insert OPA/NPA if required and apply oxygen if SpO2 falls below 94%.
16. Perform handover to attending ambulance crew using IMISTAMBO — include BP readings, neurological findings, missed medication history, and timeline of symptom onset.
17. Scenario ends on arrival of ambulance and IMISTAMBO handover.
18. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Chest Pain / Acute Coronary Syndrome · Stroke (Cerebrovascular Accident) · Unconsciousness · Autonomic Dysreflexia · Transient Loss of Consciousness (Fainting / Syncope) · Primary Survey · Secondary & CNS Survey · Blood Pressure · Glasgow Coma Scale (GCS) · Blood Glucose Monitor · Pain Assessment · Oxygen Delivery

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Signs/Symptoms	Severe throbbing occipital headache 9/10, bilateral blurred vision ('edges of my vision are fuzzy'), mild nausea, feeling of pressure behind the eyes. No vomiting at this time. No chest pain. No shortness of breath.
Allergies	NKDA
Medications	Amlodipine 10 mg daily (antihypertensive) — last taken 2 days ago. No other regular medications. No Sildenafil, Vardenafil, Tadalafil, Avanafil or Riociguat use.
Pertinent History	Known hypertension diagnosed 3 years ago, well-controlled on Amlodipine. Missed last two doses due to festival attendance. No history of stroke, TIA, or cardiac disease. Non-smoker. Occasional alcohol. No recent illness.
Last Oral Intake	2 hours ago — food and water at the festival.
Events Leading	Patient was standing at the main stage watching a performance. Reports it was hot and she had been on her feet for several hours. Sudden onset severe headache prompted friends to escort her to the FAP.
Treatment Prior	Nil. No analgesia taken today.

Onset	Approximately 30 minutes ago — sudden onset while standing at main stage. Pt describes it as coming on very quickly over 2–3 minutes.
Pain	Severe throbbing occipital headache, 9/10. Pt states it is the worst headache she has ever had.
Quality	Throbbing, pressure-like. Located at the back of the head and behind the eyes.
Radiates	Radiates from occipital region behind both eyes.
Severity	9/10