Scenario — Stimulant overdose at music festival

intermediate Toxicology · Adult · 35yr · female

Patient Information

Dispatch	You are called to a patient (Mia Carlson, 35-year-old female) who has been brought to the FAP by friends at the Southbound Music Festival. Friends state she has taken 'something' and is behaving erratically and is very agitated.
Patient	Mia Carlson — 35yr (65kg)
Incident History	Pt's friends state she took an unknown pill approximately 90 minutes ago at the festival. She has become increasingly agitated, confused, and is sweating heavily. Friends deny any alcohol intake.
Emergency Contact	Tara Carlson (Sister) — 0412 874 331

Initial Rapid Assessment

Response	Alert
Airway	Patent. Nil airway obstruction. Nil stridor. Patient able to vocalise.
Breathing	Rapid and shallow. Increased work of breathing noted. No audible wheeze or crackles.
Circulation	Pulse rapid and strong. Skin flushed and diaphoretic. No external haemorrhage identified.
Disability	GCS 13 (E3V4M6). Not orientated to time or place. Agitated and combative. Pupils dilated bilaterally.
Exposure	Diaphoresis noted across trunk and face. No visible wounds or rashes. Temperature elevated to touch.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	97% (RA)	Mild	24	132	158/100	<2s	13	6 6 SL	38.8	5.4 mmol/L	3
10 mins	95% (O2 NRB 15L)	Moderate	28	148	162/104	<2s	11	6 6 SL	39.4	5.2 mmol/L	5

History Taking

Scenario Progression and Treatment Objectives

Diagnosis

This patient is suffering from sympathomimetic toxicity consistent with stimulant (MDMA/methamphetamine-type) overdose, presenting with tachycardia, hypertension, hyperthermia, dilated pupils, agitation, diaphoresis, and deteriorating GCS.

Facilitator Triggers — if trainees miss a critical step

! (If scene safety and personal safety are not considered first — patient becomes more combative and attempts to leave the FAP. Prompt trainee: 'What is your priority before approaching this patient?')
! (If temperature is not assessed within the first 5 minutes — patient begins to shiver then becomes more confused. Facilitator states: 'The patient's skin now feels extremely hot to touch and she is less responsive.')
! (If BGL is not checked — facilitator prompts: 'What other assessment should you perform given her altered GCS?')
! (If the trainee attempts to administer any oral medication while GCS is 13 and patient is agitated — remind trainee that safe oral ingestion requires GCS 15/15 and patient cooperation.)
! (If cooling measures are not initiated within 5 minutes of temperature assessment — GCS drops to 11 and RR increases to 28 at the 10-minute vitals mark.)
! (If trainee attempts to administer a medication outside EHS scope such as a sedative or IV fluid — facilitator states: 'That medication/intervention is outside your scope. What can you do within your authorised scope?')
! (If an IMISTAMBO handover is not prepared as ambulance arrives — facilitator prompts: 'The ambulance crew is here. What information do you hand over?')

Treatment Objectives

1. Ensure personal safety and scene safety — approach only when patient is seated and not posing immediate danger to self or crew. Request Police assistance via State Operations Centre if patient becomes violently combative.
2. Perform Primary Survey — airway patent, breathing rapid but adequate, circulation intact with tachycardia, disability GCS 13 with dilated pupils, expose for diaphoresis and temperature assessment.
3. Apply pulse oximetry monitoring continuously.
4. Administer Oxygen via non-rebreather mask at 10–15 litres per minute — titrate to maintain SpO2 94–98%.
5. Perform full Vital Signs Survey including tympanic temperature — document tachycardia HR 132, hypertension BP 158/100, elevated temp 38.8°C, RR 24, GCS 13.
6. Perform blood glucose level (BGL) — result 5.4 mmol/L, no treatment required for hypoglycaemia.
7. Attempt to identify the agent involved — question friends for description of the pill, time of ingestion, dose, and any other substances taken. Place any packaging in patient medications bag if available.
8. Initiate active cooling measures — remove excess clothing, apply cool wet cloths to neck, groin and axilla, fan the patient. Do NOT immerse in ice bath at this temperature (38.8°C), but prepare for escalation if temperature rises.
9. Position patient in a position of comfort — seated or semi-recumbent. Do NOT restrain unless essential to prevent injury to patient or crew. Use minimum force necessary if restraint is required.
10. Use de-escalation techniques continuously — calm, quiet communication. Reassure patient and reduce stimulation in the environment.
11. Perform ongoing monitoring — repeat full observations every 5 minutes given potential for rapid deterioration. Document deteriorating GCS to 11 at 10 minutes.
12. Contact State Operations Centre / Clinical Support Paramedic early — advise of suspected stimulant toxicity, deteriorating GCS, hyperthermia, and request Priority 1 ambulance with pre-notification to receiving ED.
13. Do NOT administer any oral medication — patient GCS and agitation preclude safe oral administration. Methoxyflurane is contraindicated as patient is unable to cooperate and has altered conscious state.
14. Do NOT induce vomiting.
15. Collect all medication packaging and personal effects — place in green and white patient medications bag.
16. Prepare IMISTAMBO handover for ambulance crew — include: suspected sympathomimetic toxicity, unknown pill ~90 min ago, HR 148, BP 162/104, temp 39.4°C, GCS 11, cooling initiated, no medications administered by EHS.
17. Scenario ends on arrival of ambulance and IMISTAMBO handover.
18. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Poisons & Overdoses · Disturbed & Abnormal Behaviour · Heat Stroke · Unconsciousness · Primary Survey

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Signs/Symptoms	Agitation, confusion, sweating heavily, headache, palpitations. Friends note she has been grinding her teeth.
Allergies	NKDA.
Medications	Oral contraceptive pill. No other regular medications.
Pertinent History	No known cardiac or psychiatric history. Occasional recreational drug use at festivals per friends.
Last Oral Intake	Ate a meal approximately 3 hours ago. Limited fluid intake during the day. No alcohol.
Events Leading	Patient was dancing at the main stage when friends noticed she became increasingly agitated and confused approximately 90 minutes after taking an unknown pill.
Treatment Prior	Nil treatment prior to EHS arrival. Friends encouraged her to sit down and brought her to the FAP.

Onset	Approximately 90 minutes ago following ingestion of an unknown pill described as 'white and small'.
Pain	Complaining of headache rated 5/10. Diffuse chest tightness 3/10.
Quality	Headache described as throbbing. Chest tightness diffuse and non-radiating.
Radiates	Nil radiation of chest discomfort.
Severity	Headache 5/10. Chest tightness 3/10.