Scenario — Suspected paracetamol overdose at a community festival

intermediate Toxicology · Adult · 35yr · female

Patient Information

Dispatch	You are called to a patient (Sarah Nguyen, 35YO female) who has been found by her friend sitting on the ground behind the main stage at the Fremantle Summer Festival, unresponsive to her friend's voice. Friend reports Sarah has been 'acting strange' and they found an empty blister pack of Panadol next to her.
Patient	Sarah Nguyen — 35yr (65kg)
Incident History	Pt found seated on ground behind main stage. Friend states Sarah was upset earlier in the day following an argument with her partner. Found approximately 20 minutes ago. Empty blister pack of Panadol 500mg (16 tablets) found next to patient. Unknown if any alcohol has been consumed. Friend unsure exactly when tablets were taken.
Emergency Contact	Michael Nguyen (Husband) — 0412 338 774

Initial Rapid Assessment

Response	Voice
Airway	Patent. No visible obstruction. No stridor. No vomiting or secretions noted at this time.
Breathing	Breathing present and self-maintaining. Rate slightly slow. No accessory muscle use. No wheeze or stridor.
Circulation	Radial pulse present, regular, normal strength. Skin warm and dry. No external haemorrhage.
Disability	GCS 13 (E3V4M6). Oriented to person only. Confused, slow to respond. Denies pain when asked. Pupils equal and reactive to light.
Exposure	No rashes, no urticaria. No visible trauma. Empty Panadol 500mg blister pack (16-count) on ground beside patient. Mild nausea reported by patient.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	97% (RA)	Nil	13	88	108/70	<2s	13	4 4 ++	36.8	4.8 mmol/L	2
10 mins	98% (O2 NRB 10L/min)	Nil	14	86	110/72	<2s	13	4 4 ++	36.8	4.8 mmol/L	2

History Taking

Scenario Progression and Treatment Objectives

Diagnosis

This patient is suffering from a suspected intentional paracetamol overdose (approximately 8g — 16 x 500mg tablets) of unknown exact timing, with an altered conscious state secondary to possible co-ingestion or emotional distress, requiring urgent supportive management, scene safety assessment, agent/dose/time documentation, and Priority 1 transport to ED.

Facilitator Triggers — if trainees miss a critical step

! (If trainees do not collect and bag the blister pack for dose/agent identification — patient's friend reports 'she had more tablets in her bag earlier, I don't know if there were any more packs' — prompt trainees to search the immediate area and secure all medication packaging in the green and white patient medications bag)
! (If trainees attempt to induce vomiting — the patient begins to gag but no vomit is produced; facilitator states firmly: 'Do not induce vomiting — this is contraindicated in poisoning management')
! (If trainees do not assess BGL in a patient with altered GCS — patient's confusion worsens slightly and she becomes more drowsy, GCS drops to 12 — prompting trainees to complete the full vital signs survey including BGL)
! (If trainees do not attempt to clarify the agent, dose, and time of ingestion — the friend volunteers: 'I think she might have taken some other tablets too but I'm not sure' — prompting a thorough SAMPLE history and medication search)
! (If oxygen is not applied within 4 minutes — SpO2 drifts to 94% RA and RR increases to 16, prompting trainees to apply supplemental oxygen)
! (If trainees do not consider the intentional nature of the overdose and patient safety — facilitator prompts: 'The patient becomes tearful and says she just wanted everything to stop for a while' — trainees must not leave the patient alone and must address the emotional context in their management)

Treatment Objectives

1. Ensure scene safety — approach from a safe position, check for additional hazards (other substances, unsafe environment behind stage)
2. Don appropriate PPE including gloves prior to patient contact
3. Perform Primary Survey — assess DRSABCD systematically
4. Open and maintain airway — confirm patent, no suction required at this time
5. Apply oxygen via non-rebreather mask at 10–15 litres per minute — titrate to maintain SpO2 94–98%
6. Assess and record GCS — document as GCS 13 (E3V4M6)
7. Perform full Vital Signs Survey — HR, BP, RR, SpO2, BGL, temperature, pain score, pupils
8. Conduct BGL — result 4.8 mmol/L, within normal range, no glucose gel indicated
9. Perform Secondary Survey — assess for additional injuries, rashes, or signs of co-ingestion toxidromes
10. Obtain IMISTAMBO history — identify Agent (paracetamol 500mg), Dose (estimated 8g — 16 tablets), Route (oral), Time since ingestion (estimated 1–2 hours), and Clinical Features
11. Do NOT induce vomiting — contraindicated in poisoning management
12. Do NOT attempt to neutralise or dilute the substance at this stage — beyond 10-minute window guidance applies only to corrosives/acids
13. Collect all medication packaging — place in green and white patient medications bag for dose/agent calculation at ED
14. Remain with patient at all times — do not leave unattended given suspected intentional ingestion and emotional distress
15. Remove contaminated clothing if indicated — not required in this scenario (oral ingestion only)
16. Position patient in lateral position if conscious state deteriorates further (GCS drops below manageable level) — currently GCS 13, maintain seated or semi-recumbent position with airway monitoring
17. Repeat vital signs every 10 minutes — document trends and monitor for deterioration
18. Contact State Operations Centre to advise of suspected intentional overdose — consider WAPOL notification for patient welfare if clinically appropriate
19. Consider contacting Australian Poisons Information Centre (PIC) on 13 11 26 for specific paracetamol overdose guidance if transport is delayed
20. Reassure patient continuously — address distress sensitively, do not leave patient alone
21. Prepare for Priority 1 transport — pre-notify receiving ED of: 35YO female, suspected intentional paracetamol overdose approximately 8g (16 x 500mg tablets), timing uncertain 1–2 hours ago, GCS 13, haemodynamically stable, no vomiting, BGL 4.8, oxygen applied
22. Scenario ends on arrival of ambulance and IMISTAMBO handover
23. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Poisons & Overdoses · Unconsciousness · Oxygen Delivery · Primary Survey · Secondary & CNS Survey · Blood Glucose Monitor · Pulse Oximetry · Lateral Position

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Signs/Symptoms	Confusion, nausea, mild abdominal discomfort. Slow to respond. Denies vomiting at this stage.
Allergies	NKDA
Medications	Oral contraceptive pill. No regular paracetamol use. No other regular medications reported.
Pertinent History	Friend reports Sarah has been under significant stress recently. Had an argument with her partner earlier today. No known history of mental health conditions reported by friend. No prior overdose history known to friend.
Last Oral Intake	Ate a small meal approximately 2 hours ago at the festival food stalls.
Events Leading	Patient was attending the Fremantle Summer Festival with a group of friends. Became upset after a phone argument with her partner. Friends noticed her behaviour change and found her sitting alone behind the main stage with the empty blister pack beside her.
Treatment Prior	No treatment given prior to EHS arrival. Friend stayed with patient and called for help.

Onset	Friend states Sarah was acting strangely approximately 30–40 minutes ago. Exact time of ingestion unknown — estimated within the last 1–2 hours based on when friend last saw her well.
Pain	Mild epigastric discomfort, 2/10. No chest pain. No headache.
Quality	Dull, diffuse abdominal discomfort.
Radiates	Nil
Severity	2/10