Scenario — Red Flag Sepsis — elderly male with COPD misidentified as heat exhaustion

advanced Medical · Elderly · 75yr · male

Patient Information

Dispatch	You are called to the first aid tent at the Perth Royal Show. A 75-year-old male has been brought in by his family, who say he 'overheated' walking around the grounds. He looks unwell and has been deteriorating over the last hour.
Patient	Raymond Hastings — 75yr (75kg)
Incident History	Pt was walking around the showgrounds with family when he became increasingly confused and short of breath. Family initially attributed symptoms to the heat, giving him water and sitting him in the shade for 45 minutes with no improvement. Family now concerned and brought him to the FAP.
Emergency Contact	Carol Hastings (Wife) — 0412 847 391

Initial Rapid Assessment

Response	Voice
Airway	Patent. No obstruction. No stridor. Gurgling secretions audible in upper airway. Mouth breathing.
Breathing	Increased work of breathing. Accessory muscle use present. Tachypnoeic. Bilateral wheeze audible on auscultation. RR 28/min.
Circulation	Rapid, weak radial pulse. Skin mottled and clammy over lower limbs. Peripherally cool. Central capillary refill 3 seconds.
Disability	GCS 12 (E3V4M5). Confused — not orientated to time or place. Orientated to person only. Pupils equal and reactive to light.
Exposure	No rash visible. No trauma. Appears unwell. Temperature elevated at 38.4°C. Urinary catheter in situ per wife — has not passed urine since this morning (approx. 6 hours ago).

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	88% (RA)	Moderate	28	132	88/54	3s (central)	12	4 4 ++	38.4	4.2 mmol/L	3
10 mins	93% (O2 NRB 15L/min)	Moderate	24	138	86/50	3s (central)	12	4 4 ++	38.4	4.2 mmol/L	3

History Taking

Scenario Progression and Treatment Objectives

Diagnosis

This patient is suffering from Red Flag Sepsis secondary to a lower respiratory tract infection (pneumonia/infective COPD exacerbation), complicated by underlying COPD and significantly delayed recognition due to initial misidentification as heat exhaustion.

Facilitator Triggers — if trainees miss a critical step

! (If trainee does not perform a full vital signs survey including temperature, BGL, and respiratory rate within the first 3 minutes — wife becomes increasingly distressed and states: 'He has been getting worse for an hour — why isn't anyone doing anything?')
! (If trainee accepts the family's heat exhaustion history and begins heat stroke management without further assessment — patient's GCS drops to 10 at the 5-minute mark, and wife reveals the productive green cough for the last 3 days)
! (If oxygen is not applied within 3 minutes of patient contact — SpO2 drops to 85% on room air and RR increases to 32/min)
! (If trainee applies a non-rebreather mask at 15L without considering COPD target saturations of 88–92% — facilitator prompts: 'You note from the history that Raymond is a known COPD patient on home oxygen. Does this change your oxygen delivery strategy?')
! (If trainee does not identify Red Flag Sepsis criteria (HR ≥130, SBP ≤90, RR ≥25, altered mental state, not passed urine in 6+ hours) — facilitator prompts after vitals are read: 'Looking at these observations together, what pattern do you recognise?')
! (If trainee does not pre-notify the receiving ED — facilitator at 8-minute mark states: 'Ambulance is 10 minutes away. Is there anything you should be communicating to the receiving hospital right now?')
! (If trainee does not document or verbalise Red Flag Sepsis at handover — facilitator prompts: 'What specific clinical flag will you communicate to the paramedic crew on handover?')

Treatment Objectives

1. Ensure scene and personal safety — don appropriate PPE including gloves and eye protection.
2. Perform Primary Survey — confirm airway patent, identify increased work of breathing, identify circulatory compromise (rapid weak pulse, mottled cool peripheries, CRT 3s).
3. Apply oxygen therapy — titrate carefully to target SpO2 88–92% given known COPD. Commence nasal cannula 2–4L/min; if SpO2 remains below 88%, step up to simple face mask 5–8L/min. Avoid uncontrolled high-flow oxygen to minimise CO2 retention risk.
4. Perform full Vital Signs Survey — record GCS 12, RR 28, HR 132, BP 88/54, SpO2 88% RA, Temp 38.4°C, CRT 3s, BGL 4.2 mmol/L.
5. Identify Red Flag Sepsis criteria in this patient: HR ≥130 (132), SBP ≤90 (88 mmHg), RR ≥25 (28), objective altered mental state (GCS 12, confused), not passed urine in ≥18 hours (6+ hours with catheter in situ — clinically significant), requires O2 to maintain SpO2 ≥88%.
6. Formally identify and verbalise RED FLAG SEPSIS diagnosis — communicate clearly to crew and document on ePCR.
7. Position patient semi-recumbent (position of comfort) — do NOT position flat due to respiratory compromise.
8. Do NOT administer salbutamol at this stage — bronchospasm/wheeze is likely infection-driven. Salbutamol is outside EHS scope for COPD exacerbation (Intermediate Care and above). Provide supportive oxygen therapy only.
9. Reassess vitals at 10 minutes — BP remains low at 86/50, HR has increased to 138, SpO2 improved to 93% on O2 NRB 15L but note patient is COPD — adjust oxygen delivery if SpO2 exceeds 92%.
10. Pre-notify receiving ED immediately via State Operations Centre — communicate: patient identity, age, Red Flag Sepsis, haemodynamic compromise (BP 88, HR 132), altered GCS 12, COPD background, allergy to penicillin, estimated time of arrival.
11. Ensure continuous patient monitoring — repeat full observations every 5 minutes given time critical status. Monitor for deterioration in GCS, increasing respiratory distress, cardiac arrest.
12. Keep patient warm — use blanket to prevent hypothermia given peripheral shutdown.
13. Reassure patient and wife continuously throughout — explain actions in calm, simple language.
14. On ambulance arrival — perform IMISTAMBO handover explicitly communicating RED FLAG SEPSIS, haemodynamic instability, COPD background, penicillin allergy, and delayed recognition history.
15. Scenario ends on arrival of ambulance and IMISTAMBO handover.
16. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Sepsis · Chronic Obstructive Pulmonary Disease (COPD) — Acute Exacerbation · Oxygen · Primary Survey · Pulse Oximetry · Glasgow Coma Scale (GCS) · Blood Pressure · Tympanic Thermometer · Blood Glucose Monitor

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Signs/Symptoms	Confusion, increasing shortness of breath, generalised weakness, bilateral wheeze. Wife reports he has been 'not himself' since yesterday evening — reduced appetite, felt hot and achy. No chest pain reported.
Allergies	Penicillin — rash.
Medications	Salbutamol MDI (PRN), Tiotropium inhaler (daily), Prednisolone (short course — completed 5 days ago), Aspirin 100mg (daily), Ramipril 5mg (daily).
Pertinent History	Known COPD — on home oxygen at night (2L/min via nasal cannula). Two hospital admissions in last 12 months for COPD exacerbation. Lives at home with wife. No recent surgery. GP last seen 3 weeks ago. Wife reports he had a productive cough with green sputum starting 3 days ago that he 'ignored'.
Last Oral Intake	Minimal fluid intake today. Small breakfast this morning. No alcohol.
Events Leading	Patient was walking the showgrounds with wife and two adult children. After approximately one hour walking he became progressively more confused and short of breath. Family did not call for help immediately as they believed he was overheated.
Treatment Prior	Family gave him water and had him rest in shade for 45 minutes before bringing to FAP. No medications given at scene.

Onset	Gradual onset over the past 24 hours. Acutely worsened during walk around showgrounds in the last 2 hours. Family attributed to heat for first 45 minutes.
Pain	Mild generalised chest tightness 3/10. No pleuritic pain.
Quality	Constant, dull chest tightness. Generalised malaise and weakness.
Radiates	Nil radiation.
Severity	3/10 chest discomfort. Overall condition: severely unwell.