Simulated Patient Scenario

Anxiety with Hyperventilation

Scenario Details

Scenario: Acute Anxiety / Hyperventilation Syndrome

Simulated Patient: 22-year-old Female

Actor/Actress: Student Actor (Patient), Student Actor (Friend)

MDT Information

Urgent Response - Difficulty Breathing / ?Panic Attack
22-year-old female, conscious and breathing
Rapid breathing, distressed
Location: University Library, quiet study area
Friend called, present with patient

On Arrival

You arrive at the university library and are directed to a quiet study area. You see a young woman sitting upright in a chair, breathing rapidly and shallowly. She appears highly distressed and tearful. A friend is sitting next to her, looking concerned and trying to comfort her. Several other students are nearby, looking on curiously. The patient clutches her chest intermittently.

Initial Impression and Primary Survey

Category	Finding
Initial Impression	Acutely distressed, anxious, tachypnoeic. No obvious cyanosis.
Response	Awake, alert, oriented but highly anxious and distractible. Able to speak in short sentences between breaths. (AVPU = A)
Airway	Clear and self-maintaining.
Breathing	Markedly rapid (tachypnoeic) and shallow respirations. No obvious accessory muscle use or stridor.
Circulation	Skin pale, possibly slightly cool peripherally. Radial pulse rapid and regular.
Disability	Appears highly anxious. Complains of dizziness and tingling in hands/around mouth.
Exposure/Environment	Indoor library environment. Patient wearing casual clothes. No signs of trauma.

Secondary Survey and Simulation Progression

History (obtained from patient and friend)

Allergies	NKDA
Medications	Oral contraceptive pill only.
Past Medical History	Generally healthy. Reports feeling "stressed" and having occasional "minor panicky moments" before but nothing like this. No diagnosed anxiety disorder. No history of asthma, cardiac issues, epilepsy, or recent illness/injury.
Last Oral Intake	Coffee and a muffin ~2 hours ago.
Events Preceding	Patient has major exams starting next week and has been studying intensely. Felt increasingly overwhelmed this morning. Started feeling short of breath ~30 minutes ago, which rapidly escalated. Complains of feeling like she "can't get enough air", chest tightness ("like a band around it"), dizziness, tingling in her fingers and around her lips (paraesthesia), and fear ("feel like I'm going crazy" or "going to die"). Friend confirms sudden onset while studying.

Vital Signs/Assessment (Initial)

Parameter	Value
Resp. Rate (/min.)	32 (shallow)
Lung Sounds (L/R)	Clear bilaterally, air entry good despite shallow breaths. No wheeze.
SpO2 (%)	99-100% (Room Air)
EtCO2 (mmHg)	28 mmHg (If available - indicates hypocapnia due to hyperventilation)
Pulse Rate (/min.)	120, regular
CRT (sec.)	< 2 sec
ECG rhythm	Sinus Tachycardia
12-lead ECG	Sinus Tachycardia. No ischaemic changes. Consider to rule out cardiac causes if chest pain is significant feature, but less likely here.
BP (mmHg)	138/85
Skin	Pale, peripheries slightly cool, dry.
Pain (/10)	Reports chest tightness (3/10), denies sharp pain.
GCS (/15: E,V,M)	15/15 (E4, V5, M6) - though appears highly anxious.
BGL (mmol/L)	5.5
Pupils (mmL/mmR)	4mm L / 4mm R, Equal and Reactive (PERL) - may appear slightly dilated due to anxiety.
Temp. (°C)	36.7

Physical Examination

General Appearance: Visibly anxious, distressed, tearful, restless.
Respiratory: Obvious tachypnoea, shallow breathing pattern. Chest clear on auscultation bilaterally. Normal work of breathing (no accessory muscle use, retractions, or nasal flaring). Able to speak in short sentences.
Cardiovascular: Tachycardic, pulses regular, BP slightly elevated.
Neurological: Alert and oriented (GCS 15). Complains of peripheral and perioral paraesthesia (tingling). May exhibit carpopedal spasm (hands cramping) if hyperventilation is prolonged/severe (ask patient to describe hand sensations). No focal deficits.
Other: Check for diaphoresis (may be present).

Assessment and Treatment

Appropriate Management Focus

Prioritize Safety & Calm Environment: Ensure scene safety. Try to move patient to a quieter area if possible, or ask onlookers to step back. Maintain a calm, reassuring demeanor.
Communication & Reassurance: Speak calmly and clearly. Acknowledge the patient's fear and distress ("I can see this is very frightening for you"). Explain what is happening in simple terms (related to fast breathing). Reassure them they are safe and you are there to help.
Rule Out Organic Causes: Perform thorough assessment (vitals, SpO2, BGL, basic neuro, auscultation) to exclude other potential causes of symptoms (e.g., asthma, PE, cardiac event, hypoglycaemia), although less likely given history and full clinical picture. ECG if significant chest pain/risk factors.
Breathing Coaching: Gently guide the patient to slow their breathing. Encourage slower, deeper breaths (e.g., "Try to breathe slowly with me," "Breathe in through your nose, out through your mouth"). Avoid forceful commands. Focus on slowing the rate.
Do NOT use paper bag rebreathing.
Distraction Techniques: Engage patient in simple conversation unrelated to symptoms once breathing starts to slow.
Supportive Care: Stay with the patient. Offer encouragement. Involve the friend for support if helpful.
Oxygen Therapy: Generally not indicated as SpO2 is normal/high. Can sometimes worsen anxiety.
Pharmacological Intervention: Generally not indicated pre-hospitally for anxiety/hyperventilation unless extremely severe and prolonged, and per local protocols (e.g., benzodiazepines - very rare).
Transport Decision: If symptoms resolve quickly with reassurance and breathing coaching, and no red flags identified, transport may not be mandatory BUT strongly encourage assessment by GP or mental health service. If symptoms are severe, prolonged, distressing, first presentation, or if any concerning features/uncertainty exists, transport to ED for assessment is appropriate. Discuss options with the patient.
Teamwork & Communication: Communicate plan with partner and patient/friend. Provide clear handover if transporting, including suspected diagnosis and interventions performed.

Debrief Focus Points

Recognizing hyperventilation syndrome secondary to anxiety/panic.
Differentiating anxiety from serious organic pathology.
Communication and de-escalation techniques for anxious patients.
Effective breathing coaching strategies.
Rationale for avoiding paper bag rebreathing.
Appropriate use of assessment tools (VSS, SpO2, EtCO2, ECG).
Decision-making regarding transport vs. non-transport for anxiety presentations.
Importance of recommending follow-up care.