Simulated Patient Scenario

Scenario Details

MDT Information

• Urgent response - Difficulty Breathing / Chest Pain
• 72-year-old male, severe shortness of breath
• History of heart attack
• Patient pale and sweaty
• Spouse present

On Arrival

Paramedics arrive at a house where the patient is found sitting upright in a chair, leaning forward. He is visibly dyspnoeic, pale, and diaphoretic. His spouse reports he had chest pain yesterday which resolved, but woke up this morning feeling extremely short of breath, which has rapidly worsened. He seems confused and agitated.

Initial Impression and Primary Survey

Secondary Survey and Simulation Progression

History (Spouse collateral essential, Patient input limited)

Vital Signs/Assessment (Initial)

Physical Examination (Focused Cardiovascular/Respiratory)

• **General:** Severe respiratory distress, tripod position, pale, clammy, agitated/confused.
• **Airway:** May hear gurgling.
• **Breathing:** Tachypnoea, accessory muscle use, bilateral crackles on auscultation (pulmonary oedema).
• **Circulation:** Tachycardia, hypotension, weak peripheral pulses, cool peripheries, prolonged CRT. JVD likely present. Possible peripheral oedema.
• **Neurology:** Altered mental status consistent with hypoperfusion/hypoxia.

Assessment and Treatment

Appropriate Management

• Recognise Cardiogenic Shock likely secondary to Acute Myocardial Infarction (AMI) complicated by acute heart failure/pulmonary oedema. **Time critical emergency.**
• Primary survey (ABCDE), manage immediate life threats.
• **Positioning:** Sit patient upright (legs dependent if possible) to reduce preload and aid breathing, unless profound hypotension prevents this.
• **Oxygen:** High-flow oxygen via non-rebreather mask. If inadequate response/worsening hypoxia/respiratory failure, consider assisted ventilation with BVM or early CPAP/BiPAP if available and patient can tolerate (CPAP often beneficial in cardiogenic pulmonary oedema but use cautiously with hypotension). Prepare for advanced airway management if deterioration continues.
• **ECG:** Obtain 12-lead ECG urgently to confirm/identify AMI. Transmit if possible.
• **IV Access:** Establish IV access (consider large bore, but may be difficult due to poor perfusion).
• **Pharmacological Management (Guided by BP and clinical status - complex balance):**
  • **Nitrates (e.g., GTN):** Use with **EXTREME CAUTION** or **AVOID** in definite cardiogenic shock (SBP < 90-100 mmHg or signs of shock). Can worsen hypotension. If SBP allows (e.g., >100 and signs of pulmonary oedema without shock), small doses/infusion might be considered cautiously for preload/afterload reduction.
  • **Diuretics (e.g., Furosemide):** Generally **AVOIDED** prehospital in established cardiogenic shock with hypotension, as can worsen hypovolaemia/hypotension. May be considered if severe pulmonary oedema WITH adequate BP (rare in shock).
  • **Fluids:** Generally **AVOIDED** or used with extreme caution (e.g., small 250ml bolus ONLY if clear evidence of hypovolaemia AND monitoring for overload). Fluid challenge often worsens pulmonary oedema in cardiogenic shock. Right ventricular MI is an exception where fluids may be needed.
  • **Vasopressors/Inotropes:** Required for haemodynamic support. Initiate early if hypotensive (MAP < 65) despite initial measures. Noradrenaline (Norepinephrine) is often first-line vasopressor. Dobutamine or Milrinone (inotropes) may be added/used to improve contractility (usually ED/critical care). Follow local protocols for prehospital initiation.
  • **Aspirin:** Administer if suspecting AMI and not already taken/contraindicated.
  • **Analgesia:** Cautious use of IV Morphine/Fentanyl for pain/anxiety, monitor respiratory status and BP closely.
• Treat underlying cause (AMI): Rapid transport to a hospital capable of Percutaneous Coronary Intervention (PCI) / cardiac catheterisation is crucial.
• Continuous monitoring of vital signs, ECG, SpO2, EtCO2, mental status.
• **Pre-notify:** **Cardiac Alert / Shock Alert** to receiving hospital (ideally PCI capable centre). Provide age, history, presentation (cardiogenic shock + pulmonary oedema), ECG findings (STEMI/ischaemia), vital signs (confirming hypotension, tachycardia, hypoxia), treatments given (O2, CPAP, medications, fluids - be specific), ETA.
• Documentation: Detailed record of assessment, ECG findings, vital sign trends, all interventions (meds, O2, CPAP) with timings and response, communication with receiving facility.