Scenario — STEMI with claimed aspirin allergy and concurrent COPD

advanced Cardiac · Adult · 35yr · female

Patient Information

Dispatch	You are called to a patient (Sarah Kowalski, 35YO female) at the First Aid Post during the Fremantle Folk Festival. Bystanders report she walked in clutching her chest saying she feels 'really unwell'.
Patient	Sarah Kowalski — 35yr (65kg)
Incident History	Pt was walking between stages when she developed sudden onset crushing central chest pain radiating to her left arm approximately 20 minutes ago. Pt has a history of COPD and is normally on home oxygen. Pt denies trauma.
Emergency Contact	Daniel Kowalski (Husband) — 0412 774 391

Initial Rapid Assessment

Response	Alert
Airway	Patent. No airway obstruction. No stridor. Speaking in short sentences.
Breathing	Laboured. Increased work of breathing. Accessory muscle use present. Audible mild wheeze bilaterally. RR elevated. DETECT & CORRECT — SpO2 89% on room air.
Circulation	Radial pulse rapid and weak. Skin pale, diaphoretic, cool peripherally. No external haemorrhage.
Disability	GCS 15 (E4V5M6). Orientated to time, place and person. Anxious and distressed.
Exposure	No rashes, no trauma. Central chest — patient guarding with hand over sternum. No peripheral oedema noted on brief inspection.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	89% (RA)	Moderate	24	108	98/64	3s	15	4 4 ++	37.1	5.8 mmol/L	8
10 mins	92% (O2 NRB 10L/min — then titrate down to NC for COPD target 88–92%)	Mild	20	98	102/68	2s	15	4 4 ++	37.1	5.8 mmol/L	5

History Taking

Scenario Progression and Treatment Objectives

Diagnosis

This patient is suffering from a suspected ST-Elevation Myocardial Infarction (STEMI) with a concurrent COPD exacerbation contributing to hypoxia, compounded by patient reluctance to accept aspirin due to a reported childhood allergy.

Facilitator Triggers — if trainees miss a critical step

! (If the trainee does not ask about the nature of the aspirin 'allergy' — patient becomes more distressed and insists she 'cannot' take aspirin. Prompt: husband adds 'she's never actually had a serious reaction — it was a rash on her arm when she was about six'.) Facilitator note: the CPG states aspirin is administered even if the patient reports a prior reaction, unless hypersensitivity to aspirin/salicylates/NSAIDs is confirmed. A childhood rash does not constitute confirmed anaphylaxis or hypersensitivity. Trainee must recognise this distinction and administer aspirin.
! (If the trainee administers high-flow oxygen via NRB mask and does not titrate down toward 88–92% SpO2 target for COPD — patient's husband states 'she always uses low-flow oxygen at home, her doctor said too much is bad for her'. Facilitator note: COPD patients require controlled oxygen. Target SpO2 88–92%. Uncontrolled high-flow oxygen risks CO2 retention. Trainee must titrate oxygen appropriately.)
! (If GTN is administered without first confirming blood pressure ≥90 mmHg systolic — patient's BP is 98 systolic, which is borderline. Trainee must confirm BP before each GTN dose and recognise that BP is within the threshold. Facilitator note: GTN is indicated here — systolic >90 mmHg. However, the trainee must verbally confirm BP is adequate before each dose.)
! (If aspirin is not administered within the first 5 minutes of clinical contact — patient's pain score escalates to 9/10 and she becomes more diaphoretic. Facilitator note: aspirin administration should not be delayed in suspected ACS. Prompt trainees to address the allergy concern and administer.)
! (If the trainee does not request ambulance upgrade/Priority 1 transport — patient's GCS drops to 14 at 8 minutes, becoming confused. Facilitator note: this is a time-critical cardiac presentation. Early pre-notification of receiving facility and Priority 1 transport are essential.)
! (If pain score remains >3/10 after first GTN spray and Methoxyflurane is not offered — patient states 'the spray didn't do much, I'm still in a lot of pain'. Facilitator note: per the CPG, if pain >3/10 after 1 spray of GTN, Methoxyflurane should be administered as per ACS protocol.)

Treatment Objectives

1. Ensure scene safety and don appropriate PPE. Attention to hand hygiene will be given throughout the scenario.
2. Perform Primary Survey — establish patent airway, assess breathing and circulation, confirm GCS 15.
3. Position patient seated or semi-recumbent — limit exertion, do not allow patient to walk.
4. Apply SpO2 monitoring immediately — initial reading 89% on room air.
5. Administer oxygen — initiate via nasal cannula at 1–2 L/min targeting SpO2 88–92% given known COPD. If unable to achieve target via nasal cannula, upgrade to simple face mask 5–8 L/min. Do NOT administer high-flow uncontrolled oxygen to a COPD patient.
6. Complete Vital Sign Survey — HR 108, BP 98/64, RR 24, SpO2 89% RA, GCS 15, BGL 5.8 mmol/L, Temp 37.1°C, CRT 3s, Pain 8/10.
7. Conduct SAMPLE / IMISTAMBO history — specifically explore the nature of the aspirin 'allergy' (childhood rash, no anaphylaxis — not a confirmed hypersensitivity reaction).
8. Administer Aspirin 300 mg orally (chewed or dissolved in a small amount of water) — the CPG states aspirin is administered even if the patient reports prior aspirin use or is on anticoagulants; a childhood rash without confirmed anaphylaxis/hypersensitivity does not constitute a contraindication. Explain clearly to the patient why it is important.
9. Confirm GTN is not contraindicated: systolic BP 98 mmHg (≥90 mmHg — threshold met), HR 108 bpm (50–150 bpm — threshold met), no PDE5 inhibitor use in previous 24–72 hours.
10. Administer GTN 400 microg (1 spray) sublingually — patient must be seated or semi-recumbent. Do not shake GTN bottle prior to use.
11. Reassess pain score 5 minutes post GTN — if pain >3/10 and BP maintained ≥90 mmHg, administer second GTN 400 microg (1 spray) sublingually.
12. If pain remains >3/10 after first GTN spray: prepare and administer Methoxyflurane (Penthrox) 3 mL via Penthrox inhaler — patient self-administers intermittently to maintain analgesia. Reassess pain score.
13. Reassess BP before every GTN dose — confirm systolic ≥90 mmHg prior to each administration.
14. Consider Ondansetron 4 mg oral wafer if patient reports nausea or vomiting — confirm no contraindications (no apomorphine use).
15. Continuously reassure patient — maintain calm demeanour, keep patient still and supported.
16. Record full observations every 5 minutes given time-critical presentation.
17. Arrange Priority 1 ambulance transport with pre-notification of receiving facility (suspected STEMI). Provide IMISTAMBO handover to transporting crew including: aspirin administered, GTN dose/s administered, Methoxyflurane initiated if given, COPD with controlled oxygen in use, aspirin allergy discussion documented.
18. Scenario ends on arrival of ambulance and IMISTAMBO handover.

Clinical references: Chest Pain / Acute Coronary Syndrome · Oxygen · Aspirin · Glyceryl Trinitrate (GTN) · Methoxyflurane · Ondansetron · Chronic Obstructive Pulmonary Disease (COPD) — Acute Exacerbation · Primary Survey · Pain Assessment

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Signs/Symptoms	Severe crushing central chest pain, shortness of breath, diaphoresis, nausea, left arm pain, dizziness.
Allergies	Patient states she is 'allergic to aspirin — I got a rash when I was a kid.' No documented anaphylaxis. No other known allergies.
Medications	Salbutamol MDI (PRN), Tiotropium inhaler (daily). Normally uses home oxygen 2L/min via nasal cannula for COPD. No phosphodiesterase-5 inhibitors. No anticoagulants.
Pertinent History	Known COPD — diagnosed 4 years ago. Ex-smoker (10 pack year history). No previous cardiac history. No previous aspirin reactions as an adult. Childhood aspirin rash — no anaphylaxis documented.
Last Oral Intake	Ate a meat pie and water approximately 1.5 hours ago.
Events Leading	Patient was attending the Fremantle Folk Festival with her husband. Was walking between two performance stages when she developed sudden onset chest pain. Denied any heavy exertion, fall, or impact.
Treatment Prior	Nil. Husband guided her to the FAP immediately.

Onset	Sudden onset approximately 20 minutes ago while walking between stages. No exertional trigger identified — was walking at a normal pace.
Pain	Central chest, crushing, heavy sensation — 'like someone is sitting on my chest'.
Quality	Crushing, pressure-like, constant.
Radiates	Radiates to left arm and jaw.
Severity	8/10 at rest.