This can't be a hangover can it? -Training Scenario

Scenario Overview:

This scenario is all about recognising and reacting to an often deadly thunderclap headache. This needs the FAs/ambulance crew to be on their toes to react quickly and not just dismiss this as a headache or early hangover. This tests: the ability to recognise serious illness, taking a very rapid history, unconscious casualty management. Situation: You are on a booze bus duty and it has just hit 4 AM. A man who looks like he is in his 50s bursts in to the room. He is clearly distressed - he is clutching his head and lets out a scream of agony. He smells of alcohol but does not seem that drunk. Upon questioning, he says he has the worst headache he has ever had in his life and that it feels like he has been hit in the back of the head with a baseball bat.

Difficulty:

First Aider Difficult

How the scenario should progress:

Thunderclap headaches present as a 10/10 headache, 'the worst I have ever had'. They are symptomatic of a bleed on the brain called a subarachnoid haemorrhage and can kill in just a few minutes. Rapid recognition and treatment in hospital is essential. The key here is rapid 999 and taking a focussed history: has anything caused this? medical history? has this ever happened before? etc. This can yield very important information. The patient should fall unconscious in a couple of minutes, regardless of the treatment. The patient is should give the FAs good opportunity to call an ambulance, but should not wait more than 4-5 minutes. While unconscious, the patient should be totally unresponsive and, if an ambulance isn't called, die quite quickly. This is a good opportunity to check airway skills.

Patient 1:

Name: John Dobson Age: 58 Sex: Male

Medication: Statins - for cholesterol Aspirin - to thin the blood Codeine - for sore joints Propranalol - for dicky heart

Allergies: None Known

Past medical/family/social history: Heart attack a few years ago High cholesterol Arthritis Something about a dodgy blood vessel in the brain (aneurysm)

Findings on examination: John was just walking to the next bar when the headache came on suddenly. It was like being hit over the back of the head with a bat and is the worst headache he has ever had. He had been out on the town with the lads. He was taking it slow because he wanted to go to church the next day. He reckons he has has about 4 pints of normal beer. He can barely focus because of the pain. OPQRSTA: O - No knock to the head, sudden, just walking around. P - extremely bad the whole time. Nothing makes it better or worse. Q - dull. R - a bit down the neck. S - 1000/10. T - 5 minutes ago. A - quite nauseous, some double vision, some tingles around the left side of the face and fingertips. John may vomit a bit. On examination - left pupil very large and doesn't change with light. Eyes not able to follow movement very well. No signs of trauma. After a few minutes, John must go unconscious.

Possible treatment from first aiders: Primary Survey, Recognise need for 999, Quick SAMPLE history, Quick set of obs, Recovery position when unconscious. If you have more advanced skills: Oxygen, OPA maybe.

Time after start:	0	5	8
Response:	A	U	U
Airway:	Screaming	Gurgles	Gurles
Breathing?	Yes	Yes	Yes
Respirations:	18	12	8
Pulse:	60	55	45
Oxygen Sats:	99	90	88
Pain Score:	10
Blood Pressure:	170/115	170/110	175/110
Temperature:	37.1C	37.0C	37.1C
Blood Glucose:	5.1	5.0	4.5
GCS:	E4V5M6	E1V1M3	E1V1M1

Tips for the patient actors:

Make the FAs ask directly about some symptoms - don't offer the eyesight, nausea etc up readily. When you first come in, you are fully alert, just in extreme pain so are very distracted.

Scenario: This can't be a hangover can it?