((If temperature is not assessed within 5 minutes, advise the facilitator to inform trainees that the patient begins complaining of feeling 'really hot' and starts to remove clothing — prompt temperature reassessment.))

((If trainees attempt to administer any medication other than those within EHS scope — e.g. attempt to give patient their own medication, benzodiazepines, or other agents — remind trainees that EHS scope is Primary Care only and no specific antidote or sedative is authorised for EHS.))

((If de-escalation and positioning are not addressed and the patient's agitation is not managed, the patient becomes more aggressive — RASS escalates to +3 — and trainees must consider calling for police/security via SOC.))

((If trainees do not reassess vitals at 10 minutes, advise that the patient's HR has increased to 142 and temperature has risen to 39.1°C — prompt trainees to consider active cooling and Priority 1 transport.))

((If cooling measures are not initiated — i.e. trainees do not remove excess clothing and attempt to cool the patient — temperature rises to 39.4°C at 15 minutes and patient develops a brief generalised tremor, prompting discussion of seizure risk.))

This patient is suffering from sympathomimetic toxicity consistent with stimulant overdose (suspected MDMA or methamphetamine ingestion).

• Ensure scene safety — assess for risks from the agitated patient and the festival environment before approaching.
• Don appropriate PPE.
• Perform Primary Survey — assess DRSABCD, establish GCS.
• Apply pulse oximetry and obtain initial vital signs including temperature and BGL.
• Attempt de-escalation — approach calmly, use non-confrontational tone, reduce external stimuli where possible (move away from loud music/crowd).
• Position patient in a cool, shaded area. Have patient sit or lie down to reduce exertion.
• Assess toxidrome — recognise sympathomimetic features: dilated pupils, tachycardia, hypertension, diaphoresis, agitation, elevated temperature.
• Collect all available information — ask friends about substance taken, time of ingestion, amount, and any other substances including alcohol.
• Active cooling: remove excess clothing, apply cool packs to neck, axillae and groin, fan patient, provide water to drink if GCS 15 and able to tolerate safely.
• Administer Oxygen via nasal cannula at 1–4 L/min to maintain SpO2 94–98% — titrate to clinical response.
• Do NOT induce vomiting.
• Do NOT attempt to administer any medication beyond EHS scope (no sedation, no antiemetics unless nausea/vomiting present — if vomiting develops, consider Ondansetron 4mg oral wafer).
• Reassess vital signs every 10 minutes — monitor HR, BP, temperature, GCS, and SpO2.
• Contact SOC CSP for advice and to arrange Priority 1 ambulance response given tachycardia, hypertension, elevated temperature and deteriorating GCS.
• Monitor for seizure activity — if seizure occurs, manage airway, protect from injury, and manage as per Seizures CPG.
• Maintain calm, reassuring communication with patient throughout.
• Scenario ends on arrival of ambulance and IMISTAMBO handover.
• Attention to hand hygiene will be given throughout the scenario.

Clinical references: Poisons & Overdoses · Heat Stroke · Seizures · Disturbed & Abnormal Behaviour · Oxygen · Ondansetron