((If the trainee does not immediately position the airway — lateral position or jaw thrust — within 60 seconds, the gurgling worsens and SpO2 drops to 76%. Prompt: 'The patient's breathing sounds worse and his lips are turning more blue.'))

((If the trainee does not apply high-flow oxygen within 2 minutes, SpO2 remains at 82% and RR drops to 4/min. Prompt: 'His chest is barely moving now.'))

((If the trainee does not insert an OPA or NPA to maintain airway patency, the airway re-obstructs when manual positioning is released. Prompt: 'As soon as you release your hand from his jaw, the gurgling returns immediately.'))

((If BVM ventilation is not initiated despite RR of 6 and SpO2 below 85%, GCS drops to 5 within 3 minutes. Prompt: 'He is barely breathing at all now.'))

((If BGL is not checked, facilitator prompts at the 5-minute mark: 'One of the friends asks — could it be his diabetes? He was diagnosed last year.' — this introduces clinical uncertainty requiring BGL testing to exclude hypoglycaemia as a concurrent cause.))

((If the trainee does not request backup / ambulance urgently within the first 2 minutes, prompt: 'Your partner asks — should we call for an advanced crew?'))

This patient is suffering from suspected opioid toxicity resulting in CNS depression, respiratory depression, and airway compromise consistent with the opioid toxidrome: pinpoint pupils, reduced GCS, slow shallow respirations, and haemodynamic instability.

• Ensure scene safety — approach from upwind, assess for ongoing hazards, don appropriate PPE including gloves.
• Perform Primary Survey — identify unresponsive male with compromised airway and inadequate respiratory effort.
• Position patient in lateral position to protect airway from secretions and passive regurgitation — left lateral preferred.
• Open and clear airway using jaw thrust and suction if available — clear gurgling secretions from oropharynx.
• Insert Oropharyngeal Airway (OPA) — measure from centre of lips to angle of mandible, insert with rotation technique to maintain airway patency.
• Apply oxygen via Non-Rebreather Mask (NRB) at 10–15 litres per minute — target SpO2 94–98%.
• Initiate BVM ventilation — RR 6/min is inadequate; provide assisted ventilations at approximately 10–12 breaths/min using gentle tidal volume, avoid hyperventilation. Two-person BVM technique preferred.
• Perform Vital Sign Survey — GCS, RR, SpO2, BP, pulse, CRT, BGL, temperature, pupils.
• Perform BGL — result 4.8 mmol/L, normoglycaemic, no glucose gel indicated.
• Call for urgent backup — request Advanced Care / Paramedic response given suspected opioid toxicity requiring naloxone (outside EHS scope) and potential for rapid deterioration.
• Collect medication packaging from scene and place in patient medications bag for handover to ambulance crew.
• Maintain lateral position or BVM-assisted ventilation continuously — do not leave patient unattended.
• Reassess vitals at 10 minutes — with correct airway management and BVM-assisted ventilation and oxygen, expect GCS improvement to 11, SpO2 96% on O2, RR 12, BP improvement to 102/66.
• Keep patient warm — apply blanket, monitor for hypothermia (temperature 35.6°C — mild hypothermia risk).
• Record full observations every 5 minutes given time-critical presentation.
• Note: Naloxone administration is outside EHS scope of practice — this must be handed over to the incoming Paramedic crew as a priority treatment.
• Prepare IMISTAMBO handover — include mechanism (suspected opioid toxicity), GCS on arrival (7), interventions performed (lateral position, OPA, BVM ventilation, O2 NRB 15L/min), current vitals, and need for naloxone.
• Scenario ends on arrival of ambulance and IMISTAMBO handover.
• Attention to hand hygiene will be given throughout the scenario.

Clinical references: Poisons & Overdoses · Unconsciousness · Principles of Essential Airway Management · Oropharyngeal Airway · Bag Valve Mask Ventilation · Oxygen Delivery · Suction · Lateral Position · Blood Glucose Monitor · Primary Survey · Secondary & CNS Survey