Run the survey, not the label — ABCDE of the acutely ill child

Station status

This is one MedVellum formative structured clinical encounter. The scoring, prompts and performance descriptions are educational feedback tools. They are not an official college station, timing, mark allocation, pass score or reproduced examination format. The encounter assesses first-impression recognition, leadership of a hands-on ABCDE primary survey, treat-as-found stabilisation, age-appropriate oxygen, fluid and glucose decisions, communication, reassessment, escalation and safe transfer of information. [8] [9]

Candidate instructions

You are the paediatric registrar called to the acute assessment room. Assess the child from the doorway and say aloud what you see. Lead a hands-on ABCDE primary survey and treat each problem as you find it. Speak directly to the child and parent. Reassess from A after every action. Call senior, critical-care or retrieval support early. Run safeguarding alongside urgent care. Finish with a structured handover and disposition plan. Say what you would assess or do; do not perform painful or distressing manoeuvres on the actor. [9]

Room setup and observable starting state

The encounter. Sam is seven and is supported on the assessment trolley by a parent. The parent says simply, "He's not himself." Sam is drowsy, opens his eyes briefly to voice, has marked recession and nasal flaring, and looks pale with mottled knees. These are abnormalities in appearance, work of breathing and circulation to skin. The candidate should describe these signs objectively, declare concern, call for help and begin the hands-on ABCDE primary survey immediately rather than wait for a diagnosis. [1] [9]

Simulation safety. Sam remains on the trolley and is never forcibly positioned or made to hyperventilate. Cards or the assessor supply recession, breathing sounds, monitor readings and examination findings. The parent does not obstruct urgent care. [9]

Actor cues

Parent actor

• Begin with "He's not himself." If asked what has changed, answer: "Sam is usually full of energy. For two days he's had a fever and cough, hardly drunk anything, and today he's drowsy and breathing hard."
• If asked about baseline, give the card: Sam is previously healthy, fully immunised, with no allergies and no home oxygen.
• If the candidate explains what is wrong and what they will do, stay beside Sam and ask one clear question about what to expect. If the candidate dismisses the concern, repeat once: "This is not like him."
• Do not add safeguarding history unless directly and appropriately asked. [9]

Child actor

• Respond briefly to voice early in the encounter; become drowsier and harder to rouse as the scenario progresses, following the assessor's cue card.
• Do not act out a seizure until the assessor signals it. Use a hand or the picture on the cue card to indicate breathing effort, never breath-holding. [9]

Assessor cues and clinical data

Release findings as the candidate reaches each step. Reward treat-as-found behaviour and penalise surveying past an untreated threat. [9]

A - Airway

Airway is patent but the voice is weak; no stridor. There are no secretions or blood. The candidate should position the airway, give oxygen, and note that airway expertise is on standby if the airway is threatened. [9]

B - Breathing

Respiratory rate 44, marked recession, reduced bilateral air entry, oxygen saturation 90% on air with a reliable waveform. Expected strong behaviour: give high-flow oxygen because the child is in failure; state a target of 94 to 98% for this previously well child; judge effectiveness by air entry, interaction and colour, not the number alone; prepare bag and mask. [1] [9]

C - Circulation

Heart rate 150, weak central pulses, capillary refill 4 seconds, blood pressure low-normal, cool mottled limbs, reduced urine output. Expected strong behaviour: diagnose shock from the whole picture despite a non-hypotensive blood pressure; gain access; give fluid in aliquots stating the expected response, reassessing after each; state that the first-hour total is a ceiling, not a target; call for retrieval or critical care early. [3] [9]

D - Disability

Responds to voice but cannot sustain interaction; pupils equal and reactive; no seizure yet. Expected strong behaviour: screen with AVPU and plan a formal age-adapted Glasgow Coma Scale; check bedside glucose now and correct a dangerous low immediately through the local pathway without waiting for confirmation. [7] [9]

E - Exposure

No rash, no bleeding, no obvious injury; temperature 38.9 degrees. Expected strong behaviour: look while preserving warmth and dignity; note the fever and sepsis pathway; begin safeguarding documentation in parallel without delaying care. [9]

Escalation event — the tiring child

On oxygen the saturation rises to 95%, but Sam becomes quieter with less recession and noticeably reduced air entry and interaction. Expected strong behaviour: recognise respiratory muscle fatigue and impending failure, not improvement; support ventilation immediately; declare the improvement expected (better air entry and interaction); call airway and critical-care help; reassess from A. [1] [9]

Weight and escalation

The candidate must obtain a working weight for drug and device sizing. Expected strong behaviour: use a measured weight if available immediately; otherwise document a working weight from a recent reliable value, a credible parent estimate, or the trained length-and-habitus tool, and use the local paediatric cognitive aid, re-weighing at the first safe opportunity. [9]

Marking domains

Debrief prompts

• What was the failing system at each stage, and what did you expect each action to change?
• How did you decide when to escalate, and could you have called earlier?
• What would you change if this were a rural hospital with no paediatric intensive care on site?
• How did you keep the parent informed, and how did you run safeguarding in parallel without delaying care? [9]