Check the glucose, measure the brain — altered conscious state in children

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 resuscitation, securing the airway, screening with AVPU and converting to an age-adapted Glasgow Coma Scale, the bedside glucose and DEFG, treating an ongoing convulsion at five minutes, recognising raised intracranial pressure, communication, reassessment, escalation and safe transfer of information. [1] [2]

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. Secure the airway and breathing first, then run the disability assessment. Measure level of consciousness with AVPU and convert below Alert to a Glasgow Coma Scale. Check the bedside glucose now. Treat an ongoing convulsion at five minutes. Speak directly to the child and parent. Reassess 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. [2]

Room setup and observable starting state

The encounter. Maya is three and is supported on the assessment trolley by a parent. The parent says simply, "She's not waking up properly." Maya responds to voice only, has marked recession, and a purpuric rash on the lower limbs. These are abnormalities in appearance, work of breathing and circulation to skin with an altered conscious level. The candidate should describe these signs objectively, declare concern, call for help, secure the airway and breathing, and begin the disability assessment immediately rather than wait for a diagnosis. [10]

Simulation safety. Maya 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. [2]

Actor cues

Parent actor

• Begin with "She's not waking up properly." If asked what has changed, answer: "Maya had a fever yesterday and has been sleepy all morning. Now she won't wake up properly and she has this rash."
• Express rising concern as the scenario progresses, and ask whether the child is going to be all right. [2]

Child actor

• Respond briefly to voice early in the encounter; become harder to rouse and then convulse as the scenario progresses, following the assessor's cue card. [2]

Assessor cues and clinical data

Release findings as the candidate reaches each step. Reward airway-first behaviour and the bedside glucose, and penalise diagnostic-before-resuscitation behaviour. [2]

Airway and breathing

Airway is patent but the response is weak. Respiratory rate is 36, marked recession, reduced bilateral air entry, oxygen saturation 92 percent on air with a reliable waveform. Expected strong behaviour: secure the airway, give high-flow oxygen, and prepare to support ventilation; control carbon dioxide because hypercapnia raises intracranial pressure. [2]

Circulation

Heart rate 150, weak central pulses, capillary refill 3 seconds, blood pressure low-normal, cool mottled limbs. Expected strong behaviour: diagnose shock from the whole picture despite a non-hypotensive blood pressure, and treat it in parallel. [2]

Disability

Responds to voice but cannot sustain interaction; pupils equal and reactive; no seizure yet. Expected strong behaviour: screen with AVPU and convert below Alert to an age-adapted Glasgow Coma Scale, recording eye, verbal and motor components; examine pupils, posture and tone; check the bedside glucose now (DEFG) and correct a dangerous low immediately through the local pathway without waiting for confirmation. [1] [4]

Exposure

A purpuric rash on the lower limbs; temperature 39.5 degrees. Expected strong behaviour: note the rash and fever, activate the sepsis and meningitis pathway with time-critical antimicrobials, and begin safeguarding documentation in parallel without delaying care. [10]

Escalation event — the convulsion

Maya begins to convulse and the convulsion is ongoing at five minutes. Expected strong behaviour: define convulsive status epilepticus and give a first-line benzodiazepine now by the available route, protect the airway and give oxygen, reassess breathing between doses, and state the second-line plan (levetiracetam or fosphenytoin per the local pathway) informed by ESETT and EcLiPSE. [6]

Escalation event — raised intracranial pressure

After the seizure, Maya develops a unilateral dilated unreactive pupil with abnormal posture, a rising blood pressure and a falling heart rate. Expected strong behaviour: recognise raised intracranial pressure and impending herniation, raise the head, control ventilation to avoid hypercapnia, arrange urgent neuroimaging and neurosurgical input, and do not perform a lumbar puncture until raised pressure is excluded. [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. [2]

Marking domains

Debrief prompts

• What was the failing mechanism at each stage, and what did you expect each action to change?
• Why must the bedside glucose come before the imaging?
• How did you decide between diffuse encephalopathy and a focal lesion under pressure, and how did that change your plan?
• What would you do differently if the child did not recover after the seizure stopped? [2]